StandingWellBack

You can contact me at rogercdavies(atsquiggle)me.com

This blog has evolved into a review of historical and modern explosive devices, and responses to them. Links are drawn between historical activity and similar activity in the world today. Mostly I focus on what are now called IEDs but I have a loose personal definition of that and wilingly stray into discussions of more traditional munitions, the science and technology behind them, tactical employment and EOD responses. Sometimes it's just about interesting people in one form or another. Comment is welcome and encouraged but I do monitor it and reserve the right to delete inappropriate stuff. Guest posts are always welcome. Avoid any stuff that makes the enemy's job easier for them.

Misc.
Search

Entries in Modern EOD issues (20)

Wednesday
Aug242016

More Black Box Thinking

My article here , on the subject of "Black Box Thinking" and other supporting activities has now been reproduced in a number of professional journals within the EOD community, namely the C-IED Journal,  "The Detonator" (the Journal of the International Association of Bomb Technciicans and Investigators), and this month will be featured in the Journal of the Institute of Explosive Engineers.

I continue to be struck be the lessons for the EOD community that can be learned from the aviation industry. One of the most high profile proponents of what Matthew Syed calls Black Box Thinking of that activity, Captain Chesley "Sully" Sullenbeger is interviewed here and it's well worth a read.  Sully is elsewhere quoted as saying:

"Everything we know in aviation, every rule in the book, every procedure we have, we know because someone died. We have purchased at great cost, lessons bought with blood that we have to preserve as institutional knowledge."

So, a challenge. Can we in the EOD community look in the mirror and say we have valued every drop of blood spilled by our community?  Have we wrung every lesson learned dry, examined our failures and treated them as lessons to be learned by the entire community and thus honoured their sacrifice?  Can we honour and respect those named on our memorials if we don't bother to understand exactly the lessons they provide us? Do we, as a community, have exemplary post incident or post "near-miss" investigative procedures? Do our policies encourage the admission of errors without penalty?  Do we have the hard data to support our policy development or are we still doing it by seat-of-the-pants anecdote?  Are our rank structures and organisational frameworks road-blocking rational self examination?  Is it too difficult? Is it too much to ask?

We too have experience bought in blood, but have we valued it?

 

 

Monday
May162016

EOD and Black Box Thinking

 

The EOD profession is one where lives are often at risk during operations.  Many hundreds of lives have been lost over the decades on EOD operations of various kinds.  Many more have been injured. There have been an uncountable number of “near misses”.  But proportionally only a tiny few of these incidents ever get fed back to improve future EOD operations.

This article takes the position that the EOD profession’s cultural approach to risk has been, and still is, seriously flawed and much more can and should be done to develop what might be described as “open loop” reporting and “Black Box” thinking.   I believe that EOD practitioners and C-IED operators in particular deserve better - and the hurdles that seem to be actively preventing such a cultural change need to be pushed out of the way. The status quo of accepting the current flawed and dysfunctional approach to adverse incidents whether they cause casualties or are simply “near misses” is morally unsustainable.  Nobody wants to fail and we all want to succeed.  But at a collective level, if we don’t admit and learn from mistakes, and create a culture where mistakes are recognised as opportunities to learn, then we will never move forward. The benefits of such thinking are not just in human lives. EOD Operations can become more efficient and effective by rational examination of mistakes.  There is a need for a profound change.  All too often the EOD profession at best only investigates casualties if caused on an EOD operation.  Near misses generally get ignored and swept under a carpet.  Too often even if investigations occur, they are frequently closed loop investigations with limited value, and blinkered, limited outputs.

Other professions too deal with risks to lives, and they have remarkably different responses - some of them outstanding and some dreadful. The EOD profession can learn from the good and recognise weaknesses in others that have strong similarities.   In the last few years, technological developments are now able to provide systems to support a new approach and this article will touch on some of those.

Let’s look at two contrasting examples of how other professions deal with the issues of concern.

Aviation

Barely one hundred years ago, flying an aircraft was an incredibly risky activity.  Technology was new, engineering of aircraft was still exploratory and safety systems were usually non-existent. In 1912, eight of fourteen US Army pilots died in crashes.  Training schools had a 25% fatality rate.   More recently, at the end of WW2, the first British jet fighter, the Meteor, suffered about 450 crashes. It was worrying but an accepted risk.  Being a pilot of any aircraft was risky and dangerous.  Any aircraft was a risky and dangerous thing to travel in.   But in 2013 there were 36.4 million commercial flights worldwide, carrying 3 billion passengers worldwide.  Only 210 of those passengers died, at an accident rate of one accident per 2.4 million flights. The reason for that is not just improved technology. What has also happened is an entire cultural change across a global industry. That is confirmed by the fact that members of the International Air Transport Association, which has more stringent procedures, have one accident every 8.3 million take offs, using pretty much the same technology as the rest of the industry.  What is accepted in the aviation industry as a cultural norm is that errors and mistakes are reported and that errors and mistakes are an opportunity to learn and improve.   In aviation two things have combined beautifully - technology and culture. In terms of technology, information to diagnose technical faults is much improved, quality systems have ensured components are correctly fitted, and communications and IT allow 24/7 monitoring of critical systems. Culturally there is a clear recognition that it is impossible for a pilot to learn every mistake personally – and that a global reporting system allows iterative improvement of training, drills, procedures and critical incident management so that success spirals up built on the mistakes of others. The industry accepts and understands that monitoring and recognising failure leads to lives being saved. A mistake or an error is seen as an opportunity to improve. Crucially the egos and the hierarchical sensitivities of pilots and crew are being recognised, and systems adapted accordingly.

Healthcare

Mathew Syed in his recent book “Black Box Thinking” compared the healthcare industry in terms of how errors and mistakes were addressed to the aviation industry.  There are obvious differences in that only in rare cases are doctors and nurses lives put at risk.  But with some notable exceptions, the healthcare industry is prone to mistakes and generally has a poor cultural attitude to such errors and mistakes.  In 1999 the American Institute of Medicine reported that between 44,000 and 98,000 die every year as a result of preventable medical errors. A separate assessment concluded that over a million patients are injured every year during hospital treatment and that 120,000 patients a year die as a result of mistakes. A more recent study in 2014 suggests that figure may be much higher.  That’s the equivalent of a lot of jumbo jets crashing. Errors occur in a variety of ways. Misdiagnosis, application of wrong treatment, poor communication, stress and overwork are common factors.  What is becoming apparent however is that mistakes have patterns.   Certain sets of circumstances lead to increased likelihood of mistakes.  A medical error has a path or a trajectory, that if the system was able to highlight could warn medical practitioners that they were entering dangerous territory.   Healthcare has another “built-in” problem, and that’s the medical hierarchy of senior doctors, junior doctors, nurses and support staff.  It’s not suggested that this hierarchy needs doing away with but all to often medical mistakes are happening because of a poor flow of communication upwards or downwards of the clinical management chain. Importantly this hierarchy seems to lead to ineffective investigations, if they happen at all.  In healthcare competence is equated to clinical perfection.    A recent European study established that 70% of doctors recognised that they should report errors, but only 32% said they actually did so, and in reality, even that number has to be exaggerated. In healthcare around the world the culture has been one of blame and hierarchy.  I wonder how many EOD operators would willingly report an error they had made?

Now, I would posit that currently the EOD profession has much more in common with current healthcare than current aviation.    In EOD operations accidents happen for a variety of reasons. Amongst them are misdiagnosis, application of the wrong treatment, poor communication, stress, and overwork.    There are other similarities that can be drawn between EOD and healthcare with regard to investigation or inquiries. But in EOD we can also blame a proactive enemy.   Most EOD units are military or police based, with the concomitant disciplinary ethos.  This leads to adversarial investigations when things go wrong and is one of the crucial hurdles to overcome and where attitudes and culture need to change.   Investigations are strange things and I’ve participated in a number.  Most investigations tend to stop when they find the individual or group closest to the accident who could have made a different decision, apportion the blame there and then close the investigation.   There is rarely an understanding that mistakes are made due to much more complex contexts or series of events, and little effort is made to define that pathway of context in such a way that it can be characterised and used in the future as a “flag”, warning when circumstances begin to lead down the wrong path.     A key issue is the fact that there is confusion and too often a dysfunctional link between an investigation to find the cause of an accident and the disciplinary requirement to apportion blame to an individual.  This is the nub of the issue and the EOD community will always belong to strictly hierarchical organisations which are naturally inclined to require the apportion of blame.  Somehow we have to change that attitude and recognise that there is a greater good than the need to blame individuals.  In EOD, strangely, competence is also equated with perfection, and that’s simply unrealistic. That attitude is not even applied with rigour – with perfection being defined as “nobody got hurt this time”.  As a community we have to address that attitude.

One particular technique that has been introduced in the aviation industry over the years, and is slowly being adopted in the healthcare profession is called “Crew Resource Management” or CRM.  CRM is the careful use of a number of strategies to improve dynamic dialogue within a small team during a crisis.  To me, the small team of an EOD response team working at an incident is directly analogous to the aircrew on a flight deck, or a surgical team in an operating theatre.   The stresses are the same, the hierarchy is similar and the need for an effective dialogue between the team members is crucial.  CRM addresses situational awareness, self awareness, leadership, assertiveness, decision making, flexibility and adaptability within the team.   If one studies the nature of crises in aircraft and in operating theatres and match these, where possible, with the situations seen at IED response situations, there are startling similarities.

In a crisis, perception narrows. This is a standard physiological response to high stress. It is seen on flight decks and in operating theatres where key members of the team (such as the pilot or lead surgeon) become engrossed with solving a particular problem, ignoring other factors, especially time. Awareness of other issues affecting the incident drops sometimes remarkably.  I’ve seen it personally in the command posts of an IED response incidents.  CRM can address this issue by teaching other team members to intervene effectively, forcing, appropriately a broader view on the team leader.  It is not easy and it requires training and the use of a few key techniques.  But I’m excited by the potential of CRM to have a significant impact on improving safety and indeed the broader efficiency of EOD operations.

Historically EOD procedures have evolved, of course, by some form of analysis of previous successes and failures.  I’m not suggesting that the profession should throw the baby out with the bath water and start afresh.  But these historical developments were rarely built on volumes of validated data.  They were usually built by careful consideration of a mix of actual reports from first and second hand sources, from instinct, from conjecture, and without the hard data that perhaps we can utilise today. There is an opportunity to be seized today, that modern technology can facilitate for us. Many years ago, I was one of these people working out procedures for the EOD unit I had operated in and then commanded. I did my best, I learned from the experience of others, I thought. But looking back my abilities were lacking in terms of understanding the limitations of human psychology. And I also lacked primary data sources.   At best I had the reports of the operators themselves, completed “after the operation”, when a narrative cognitive bias or fallacy had time to establish itself in the mind of the operator. Addressing such human cognitive biases is tricky, and frankly my own understanding of such things limited the value of my task.   It worries me that it has taken me nearly 20 years since I commanded that Unit to learn enough lessons about human psychology to realise I did a sub-optimal job back in the day.

So, here are suggested four measures which if introduced could bring to the EOD profession a measure of the Black Box thinking from which much could be learned and lives saved:

1.   CRM could be easily introduced as a training culture.  I accept that finding any time for training is easier said than done, but it appears the benefits would be clear. CRM training methodologies are already refined and ready for easy adaptation into the EOD community.  I don’t doubt that the hierarchy of rank and experience is an issue that will need careful handling in certain EOD units. Conversely I have seen a more collegiate response of “equals” in a bomb squad also deteriorate into a self justifying loop. CRM should address this too.  Introducing CRM will vary in its challenges between the different cultures in different EOD environments.   CRM can, I believe, also incorporate referral to outside entities for technical support and authorisation – again training here might better enable the operator to brief his commander and seek authority for an off-SOP approach – and technology too can assist this with video and images.

2.    There are already technical solutions to the “Black Box” concept on the market.  The “Scimitar” system is a good example, the principle of “the internet of things” makes it inevitable that all component systems of an EOD operation, including communications, CREW/ECM, video, audio, GPS, tools and indeed operator physiology will be fitted with sensors reporting (securely) to a data repository for subsequent analysis. The Scimitar tool (see image) gathers a range of geo and sensory data from individuals, and equipment within an EOD operation, as well as communications logs and videos. So the operator and No2 are geo located with a personal tag, as is the ROV, along with its video stream. The data is presented in a variety of ways. The image shows a map overlay showing assets deployed to an EOD operation with various thumbnails presented of different video images. Along the horizontal is a timeline showing sensor captured events.  This is, in effect, a black box for a bomb squad.  It can be used as a post event tool, or even as a live briefing tool. Clearly, establishing such data collection in an EOD team must not be a logistic drag, and the intensity of certain EOD engagements on military operations in recent years has been remarkable – but all the more need to capture data automatically in these scenarios.  Analytical tools will be able to spot error signatures and feed that back into debriefings, training and corrective procedural measures.  Investigations will pin-point those errors which can be eliminated giving the operator and other operators value from the mistakes that he made.  This can be done with relative ease with technology such as this. There are benefits too for the manufacturers who facilitate or provide this – they too can improve their products by careful analysis of the data. Aviation has a system which modern technology now allows to be a data-rich arena of information. Aviation safety has recognised this and optimised it, and continues to develop this concept. Now is the time for the EOD community to recognise that with some modern technology, an EOD operation can become a data rich environment, full of useful data and consequently lessons to be learned.  I fully expect such lessons to assist a broader improvement in operational efficiency rather than just concentrating on safety issues.  I suspect that the “Return on Investment” will be surprisingly good.

3.    Developing a common and radical post-incident investigation toolbox will of course be difficult to achieve, but I sense that very few EOD organisations have recently looked objectively at the the way they conduct such investigations. There is much to learn from other industries and developments in the psychological understanding of how individuals respond in stressful environments has much to offer.   There is no reason why this revision should not be embraced by a number of national and international organisations and provided pro-bono globally.  Thus, even if an issue cannot be shared internationally for reasons of security sensitivity at least a commonly accepted “best practice” of investigation will be applied that might be able to be of use. And the “best practice” should proactively identity where such information can and should be shared outside the unit and even internationally for the benefit of other bomb technicians.

4.    The last of course, is the most difficult to achieve, that of changing cultures from the top to the bottom.  There will be plenty who balk at them all citing hurdles such as security.  But there have been some steps. The IED IMPACT program (www.IEDIMPACT.net) gives EOD warriors the opportunity to pass back their lessons learned in frank and candid ways.  These wounded warriors, having suffered, really don’t want others to repeat their errors and their testimonies are powerful and moving. No-one thinks any the less of them for being involved in an incident. We think all the more of them because they are prepared to stand up and point out how things could have been done better. International organisations such as IABTI and the Institute of Explosives Engineers can pick up this thread and drive it forward internationally.  Leadership is needed not just from these organisations but from within the current leadership of all EOD units and national authorities.  This wont be easy – look how poor we are as an international community on sharing technical intelligence on IEDs – but we must strive to bypass these parochial hurdles.

Learn from the mistakes of others. You can’t live long enough to make them all yourself.

 

(This article was first published in “Counter-IED Report, Winter 2015/2016” and is reproduced here by kind permission of the Editor.)

 

Sunday
Sep292013

Near-Misses - Lessons from WW2, and a danger highlighted

I’m returning once again to the issue of the need for “near-miss” reporting in the EOD community.  My previous post on the subject is here.

I’ve been digging further and found an interesting study done by a famous Cambridge University psychologist, J T MacCurdy in the 1940s.  MacCurdy studied “The Structure of Morale” as it affected the British population and military during the first part of WW2. One subset he looked at were those who experienced the “Blitz” in London in 1940 and 1941.

MacCurdy theorized that people affected by the blitz fell into three categories:

  • Those who were killed.
  • Those who experienced very closely a bomb explosion. They are in the immediate vicinity – they feel the blast, see the destruction, are horrified by the carnage, perhaps they are wounded, but they survive. They are deeply “impressed” in the sense that there is a powerful reinforcement of the natural fear reaction. The psychological experience is of being faced by death, and the fear is reinforced.
  • The next category, who MacCurdy describes as the “remote-miss” group are one step further removed.  They hear the sirens, they hear the enemy planes, they hear the explosion. But they are unharmed. Psychologically the remote miss is different – the fact that they escaped injury and escaped the devastation lessens fear – the catastrophe was physically remote and so fear is put to one side. In many there builds a feeling of invulnerability and indeed excitement.

Now, while such feelings experienced by the "remote-miss" category were probably instrumental in reducing the effects of the Blitz on the population in Britain at the time, my position is that if you took those three categories and applied them to EOD operators on modern day EOD operations, then the same categories might present themselves.

  • Those operators who are killed. There will, inevitably, be some form of reporting and investigation.
  • Those operators who are injured or actually witness an unintended explosion. Usually there will be some form of investigation.
  • Those operators who experience a near miss, make a mistake but no explosive event occurs. I think this is analogous to MacCurdy’s “remote-miss” group.  Such events are usually not reported or investigated.  Not only does the mistake remain unaddressed, but the operator, perhaps begins to feel invulnerable and that can lead to tragedy, of course.

Instinct and a little experience tells me that that this psychological phenomena of an EOD operator feeling invulnerable after a series of "near misses" may be true.  I believe that an appropriate near miss reporting system could mitigate against this danger. 

Some other broader points about near-miss reporting:

  • In terms of human lives, near misses are cheap, sometimes  almost zero-cost learning tools that can be used to prevent injury and death.
  • The number of near misses, compared to fatalities is significant. Typically the aviation industry finds about 600 near-miss incidents to one fatal incident. That’s a hugely useful data set that is currently being ignored in the EOD community and not even collected.

I accept the issue of non-punitive reporting is the nub of the challenge as it faces the EOD community but:  

  • The aviation community has confidential near miss reporting systems. 
  • The US fire and rescue community has an anonymous near-miss reporting system.  
  • There are near-miss reporting systems for nurses and doctors in the healthcare community
  • The British railways system has had a near miss reporting system since 2006.

If these industries and professions can manage such systems, why can't we?  Are our egos too big?

Friday
Jul192013

Domino Theory and EOD "Near Miss" investigations

I’ve blogged before about the view that the EOD community should have and embrace a “near miss” reporting process for incidents that don’t result in death or injury but might have.  In conversation with other figures in the EOD world, I sense that the view that such a process should be looked at and encouraged, at last, is growing in momentum.

Other industries such as aviation and the nuclear industry have such processes and a culture that supports it.   The EOD community (normally) only has such a process when injury or death occurs.  My personal view is that that is wrong and means that organizational we don’t benefit from others mistakes. I think it means people die unnecessarily and I think it reflects poorly on our thinking and on the leadership within the community, and is morally untenable.

I know there are contrary views, and I respect them, if not understand them.  I know that the biggest hurdle is cultural and the issues of a career foul if an EOD technician self reports a failure is significant. That’s a key issue that needs addressing. I know that a near miss system also requires a vigorous and effective command and control system to implement and manage this, and leaders, managers, investigator and professionals with deep levels of skill (and pure leadership and moral courage) to implement. I know a “near miss” reporting and investigation system isn’t going to be easy, and will have tricky engagement elements whichever branch of the EOD world it applies to. 

Perhaps there are preliminary steps. Perhaps a training course in accident and near accident investigation for EOD unit commanders is a first step.  Ken Falke has developed an excellent concept in the IMPACT program and that perhaps sets a template that might be used for ear misses too.

Everyone has an opinion on this and many of the community are resistant to such radical concepts  - and I do admit that the concept will require radical change.

I don’t think that such a system can be introduced over night, as a diktat.  I think it needs a lot of thought and that a whole lot of work needs doing first. My understanding is that some of the professional institutes are interested in funding some academic work, maybe a PhD, to analyse this more carefully, hopefully resulting in recommendations that would inform future systems, and that would be great. I think there’s a lot of work than can be done to extend and build on the work being done to improve the current investigative and lessons learned processes that apply to injuries and deaths into those that are “near misses”.

A “near miss” is simply an accident that occurred but by perhaps chance caused no injury. Who can honestly claim that they don’t want to know the causes of that accident, whether it caused an injury or not?  Let me address one point here. It is very rare, I think, that accidents and near misses of any kind are caused by single point failure. There’s a sort of “domino” theory of accidents, with a whole chain of faults or failures, often, before the final step.  As EOD professionals I think it a greater awareness of the context of a near miss, of the other dominos in the chain which resulted in either a fatality or an accident OR a near miss are vitally important.  Those other dominos might involve:

-       Poor quality of training (content , design or delivery)

-       Ineffective tool capability (hence identifying equipment requirements)

-       Procedural inadequacies

-       Unknown technical challenges presented by ordnance or IEDs

-       Poor operator choices, mental or physical condition

-       Poor operational command issues

-       Poor communications

-       Poor intelligence

-       Contributing causes from a whole host of other areas.

So almost all the time , risks to EOD technicians and operators are complex and are not simply a direct relationship to operator capability.  Identification and characterization of all the other contributing causes for accidents and near accidents I think can valuably lead to improved professionalism and save lives.

This is an important an emotive issue, and I’m very open to publishing alternate views from others in the community, as is, with no edit from me. Fire away.

Thursday
Jan032013

Syrian FSA EOD techniques

Oh dear!   

 

No comment.