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 9th 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)