Deadly Fire Truck Accident Blamed on Poor Training. What We Can Learn From the Tragedy.

It is not always enough to know something. Often people must respond immediately to circumstances. Often they must respond under stress and distraction. To be able to do this, they need to develop a cognitive link between situational cues and action.

On January 9^th 2009, firefighter Robert O’Neill was at the wheel of a 22-ton fire truck as it headed down a steep street in Boston. When O’Neill attempted to apply the brakes, nothing happened. As the truck gained speed heading straight for a large brick wall, O’Neill made frantic attempts to pump the brakes and shift into another gear—ultimately shifting into neutral. His efforts went to no avail and the truck crashed through the brick wall into an apartment building injuring several children in an afterschool program and killing his colleague, firefighter Lieutenant Kevin M. Kelley who was riding beside O’Neill in the truck’s passenger seat.

Photo from Boston Globe Story

After an 11-month investigation, District Attorney Daniel Conley reported that O’Neill received “limited classroom instruction and no driver training in the proper use of air brakes in downhill and emergency circumstances.” What’s really tragic is that O’Neill’s actions in that time of panic may have actually made things worse. As the Boston Globe reported:

The driver did not know to check brake pressure before he got behind the wheel that day and then, when the brakes failed, did not know how to engage secondary braking systems. Instead, he pumped the brakes, releasing any remaining air pressure from the brake system, and put the truck into neutral, preventing the secondary brakes from engaging.

Many things might have prevented this tragedy. The truck could have been better maintained. A job aid that forced drivers to do routine safety check might have been used to ensure brake pressure. Management oversight might have prompted the drivers to actually engage safety routines. Training that helped drivers understand how air brakes worked might have helped—just before the accident the driver turned the truck around in a parking lot releasing air pressure in the braking system. Finally, the driver could have been trained to spontaneously remember what do when facing such a situation.

Ideally, when someone is in an emergency situation, the cues from that situation ought to remind them of what to do. As learning professionals we want to help our learners engage in spontaneous remembering. To do this, we need to help our learners make links between situational cues and actions. It can help to teach these links, but it is even better to have learners practice these links.

Research on general context-alignment effects shows the benefits of making such links (for reviews see Bjork & Richardson-Klavehn, 1989; Smith, 1988; Smith & Vela, 2001; Eich, 1980; Roediger & Guynn, 1996; Davies, 1986). Research on retrieval practice shows us the benefits of retrieval practice in automating such responding (for reviews on retrieval practice see Roediger & Karpicke, 2006a; Pashler, Rohrer, Cepeda, & Carpenter, 2007; Bjork, 1988; Crooks, 1988). Finally, recent research on implementation intentions shows how powerful it can be to help learners link situational cues to action (for review see Gollwitzer & Sheeran, 2006).

If firefighter O’Neill had been properly trained, when he found himself careening down the street with inadequate brakes, the situation would have reminded him to apply steady pressure on the brakes and engage the secondary braking system.

What makes this situation even sadder is that firefighters typically have lots of time between emergencies to engage in training. Even if a high-fidelity simulation was too expensive, a simple e-learning program that simulated driving emergencies might have worked to create cognitive links sufficient to create spontaneous remembering.

 

Research

Bjork, R. A. (1988). Retrieval practice and the maintenance of knowledge. In M. M. Gruneberg, P. E. Morris, R. N. Sykes (Eds.), Practical Aspects of Memory: Current Research and Issues, Vol. 1., Memory in Everyday Life (pp. 396-401). NY: Wiley.

Bjork, R. A., & Richardson-Klavehn, A. (1989). On the puzzling relationship between environmental context and human memory. In C. Izawa (Ed.) Current Issues in Cognitive Processes: The Tulane Floweree Symposium on Cognition (pp. 313-344). Hillsdale, NJ: Erlbaum.

Crooks, T. J. (1988). The impact of classroom evaluation practices on students. Review of Educational Research, 58, 438-481.

Davies, G. (1986). Context effects in episodic memory: A review. Cahiers de Psychologie Cognitive, 6, 157-174.

Eich, J. E. (1980). The cue dependent nature of state dependent retrieval. Memory and Cognition, 8, 157-173.

Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69-119.

Pashler, H., Rohrer, D., Cepeda, N. J., & Carpenter, S. K. (2007). Enhancing learning and retarding forgetting: Choices and consequences. Psychonomic Bulletin & Review, 14, 187-193.

Roediger, H. L., III, & Guynn, M. J. (1996). Retrieval processes. In E. L. Bjork & R. A. Bjork (eds.), Memory (pp. 197-236). San Diego, CA: Academic Press.

Roediger, H.L. & Karpicke, J.D. (2006a). The power of testing memory: Basic research and implications for educational practice. Perspectives on Psychological Science, 1, 181-210.

Smith, S. M. (1988). Environmental context-dependent memory. In G. M. Davies & D. M. Thomson (eds.) Memory in Context: Context in Memory (pp. 13-34), Chichester, UK: Wiley.

Smith, S. M., & Vela, E. (2001). Environmental context-dependent memory: A review and meta-analysis. Psychonomic Bulletin & Review, 8, 203-220.

Story of the accident: http://www.boston.com/news/local/breaking_news/2009/01/fire_engine_cra.html

Story of the accident investigation:

http://www.boston.com/news/local/massachusetts/articles/2009/12/11/poor_training_cited_in_crash/

Photo from Massachusetts AFL-CIO website

Lieutenant Kevin M. Kelley
(Killed in Fire Truck Accident)

Comments

[Donald Clark]

Something does not sound right with the Globe's article. Air brakes work the opposite way -- it takes air pressure to release the brakes -- if there is an air pressure failure then the brakes apply.

Maybe they build air brake systems backwards these days but I was in the heavy equipment field for 22 years (Army) and know of two accidents involving air brake failures. In both cases the root cause was tracked to poor maintenance of the braking systems.

Of course the driver was still wrong because if he was pumping the brakes then, 1) he would rapidly loose air pressure, 2) the brakes should automatically clamp shut and 3) the truck should stop.

[Matt Leavitt]

Did you happen to see this NYT article last week? The author cites at least two red flags facing China's expanding nuclear energy industry: corruption and lack of a well-trained workforce. Sounds like a big human performance scenario brewing, with worldwide ramifications. I hope the training for China's nuclear inspectors, engineers and technicians is as context-rich as it could possibly be.

[screw press]

Impressive Tour! Awesome photos ctxguide! Keep up the great work!

[wood pellets]

The author has a great job in sharing this great piece of news with us through this blog. Thanks. Keep up the good work.

[Marc by Marc Jacobs Handbag]

for his many years in leading the workplace learning