Do you want to know why these columns are viewed as “Miscellaneous Ramblings”? Because they truly are that. I had every intent this issue of continuing on from last issue’s message on Organizational Risk Management. But over the last month or so, some interesting developments have occurred leading me to write about something else. So, our topic for this column is Nonpunitive Close-Call Reporting (NPCCR) and what your role is as a chief officer, manager, supervisor or bottom-line road-dog worker bee. How can I best do this in 1,500 words? Here is a strange…

For those of you who have read this column before or whom I have been fortunate enough to meet, you know I spent 20 or so years working the street as a cop. “Mr. Peabody, let’s set the Wayback Machine for August, 1974, Northbound Hollywood Freeway at Lankersham Boulevard.” And that is where our tale starts, with me stopping some guy for speeding in a 1970 or so vintage Dodge Charger. Following my safe right-side approach (even managing risk then — not today’s topic, but any cop walking up on the traffic side of a car needs some adjustment) and out gets this guy with a sweater on … in July in L.A. So this little bell goes off in my head saying, “Why would this guy be wearing a sweater in 100-degree weather?” Hmmm . . . and without further ado (making a very long story much shorter), I grab this guy, spin him around and hook him up. During the subsequent pat down, I feel a real hard lump where there shouldn’t be a lump at all, pull up the sweater and “Holy Moley” this guy has got a .45 automatic tucked in his waistband.

Now 27 years ago, this was a big deal, ’cause everyone in L.A. did not have a gun then. Needless to say, I was one extremely proud probationary employee. A quick check of his ID disclosed an active parole card. WOW … me, Gordon Graham ripping a gun off a parolee all by myself. It was with great pride that I announced on the radio what I had, advising I did NOT, repeat, DID NOT, need anyone else on scene; and I promptly ran a computer check on the gun and requested a tow truck for the in-custody’s car. Now computers back then were not as sophisticated as they are now, so what takes 5 seconds to return today was a 20-minute process a quarter of a century ago. As I waited there, I decided I should unload this gun. NOW THE ONLY HANDGUN I HAVE EVER HELD IN MY LIFE IS A .38 REVOLVER, AND NOW GENIUS BOY-WONDER IS ATTEMPTING TO UNLOAD A MILITARY .45 SEMI-AUTO WHICH HAS A SUBSTANTIALLY DIFFERENT WORKING MECHANISM THAN MY REVOLVER. But when you are 22 years old, these thoughts do not enter the area of the brain that actually thinks. I vaguely remember seeing someone once push a button on the left side of a semi-auto, and with that push out came a magazine of ammo. So now I have (OR SO I THOUGHT) an unloaded weapon. As I awaited the return on the gun and the tow truck, my boredom led to toying with the gun, doing a couple of John Wayne/Harry Callahan type swirls with it, looking down the barrel and all the other things that bored kids would do. Suddenly, I hear another cop coming up on a Harley (unmistakable patented sound: “potato, potato, potato, potato” or for those of you from Indiana, “potatoe”) and off this oil-leaking vehicle, whose natural position of rest is on its side, steps the guy who broke me in on the job a mere four months or so earlier. He immediately grabs the .45 out of my hand, and starts screaming at me (same stuff I heard four months prior) about how stupid I was and how he was glad he got there before I killed myself and that I don’t belong on the job because I am inept and stupid and that he should have shot me when he had the chance (we are actually good friends now) and that the gun was loaded and I was playing with it and I was stupid…. To all of which I responded, “Hey stupid, I took the bullets out”; and I proudly presented the loaded magazine. I really thought I was something hot until my break-in officer, who was fresh out of Vietnam where he served as a sergeant, USMC, pulled back the slide on this bad boy and out popped a live round. “I knew you would forget the one in the chamber, stupid. When I heard you run that gun, I knew that you never had this experience before, and that you would end up getting hurt.”  My tail was sufficiently between my legs, and my greatest worry would be that he would tell someone, which while on probation would have serious consequences. I negotiated with him, and we both agreed that this would be as far as it would go. I LEARNED A VALUABLE LESSON THAT DAY BUT NEVER SHARED IT WITH ANYONE FOR FEAR OF DISCIPLINE.

Six months later, a classmate of mine had the exact same scenario, with a different ending. He had an accidental discharge with the semi-auto, killing the side of a freeway embankment. I recall his incident also, and because of the AD he had to stand up in briefing the next day and explain to all the rest of us on that shift in that office what happened, presumably so it would never happen to any of us. But that was as far as it went, one shift in one office with maybe 30 or so other young cops learning from his AD. How about if the bullet would have gone into someone’s head: how many people would learn from that?

Fast forward a couple of years to 1976, USC graduate school, where I met perhaps the smartest person in the world, Chaytor Mason; and, in a discussion on accident prevention, he said something that stuck with me and rekindled some dormant brain cells. “THE ONLY TIME YOU LEARN FROM THE MISTAKE OF ANOTHER IS WHEN IT ENDS UP IN DISASTER.” He used this as an introduction to the work of H.W. Heinrich, a risk-management guy from several decades earlier (run his name through your search engine — interesting yet controversial guy) who had a theory that major injuries and deaths were not isolated incidents. Similar fact patterns and behaviors had happened many times before with less serious consequences, and hundreds of times before with no consequences at all. He developed a ratio (which I will round off for purposes of simplicity) of 1:30:300. In a nutshell, give me a group of people doing the same or similar tasks (F-18 pilots, motorcycle cops, municipal FF’s, meds, etc.), and the group will occasionally make mistakes. Out of 300 mistakes for the group, one in ten, or 30 in 300, will end up in a mishap (event with some consequences) and one in 300 will end up in the big one, death or GBI. When a firefighter dies or is seriously injured in an incident involving a mistake, we all learn from the events that led up to this tragedy. However, in some (many??) cases, the mistake made had happened before many times (30) with less severe consequences, and many times before (300) with no consequences at all. Learning from the death of a co-worker is a good idea. The better idea would be to learn when the consequences were not as tragic. THE BEST IDEA WOULD BE TO LEARN WHEN IT WAS JUST A MISTAKE, WITH NO CONSEQUENCES AT ALL.

Which brings us to our topic today: NONPUNITIVE CLOSE-CALL REPORTING. I strongly encourage you to share your close-calls with others. It is tough, because there is always the fear of embarrassment or discipline, so I continue to look for the “best” way to do this. Here is a website for you to check out: www.firefighterclosecall.com. A firefighter buddy of mine, Chief Glenn Usdin out of PA, has taken the time to formalize my thoughts in this regard. Take a look at what he has done, and if you have ever had a close call where you missed death by the hair on your chinny chin chin, take the time to anonymously share it on this site so that others can learn, BEFORE IT HAPPENS TO THEM!!! Anyhow, the website is self-explanatory, and, it is hoped, it will grow with tons of things from which we can all learn.

Well, there is a “CHiPs” rerun coming on TNT at the top of the hour, so that will be all for today. Looking forward to chatting with you again next time. Until then, Good Luck, Good Health, Goodbye, God Bless You, and God Bless America. Gordon Graham signing off. Until next time, Be Safe.

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