The Deadly Errors

[Matthew Temkin]

Back in 1975 a LAPD detective named Pierce R Brooks wrote a book titled ..OFFICER DOWN---CODE THREE.
Brooks was one of the detectives in the 1963 Onion Field incident which, IMHO, was the real beginning of the officer survival movement.
According to the author, the following are responsible for the majoriy of police officer deaths throughout the world.

1) Failure to maintain proficiency and care of weapons, vehicle and equipment
If you have learned to shoot, will your gun fire when you pull the trigger? Will your car respond when you need it?

2) Improper search and use of handcuffs.
Many police fatalities here.

3) Sleepy or asleep.
How well can you react when you are?

4) Relaxing too soon.
Usually at those "phony" silent alarms.

5) Missing the danger signs.
Miss or don't recognize them; they can be fatal either way.

6) Taking a bad position.
Writing a citation or an FI card with your back turned to the subject. or, while confronting the barricaded gunman, be casual or curious from your place of concealment rather than careful and cautious from place of cover.

7) Failure to watch their hands.
What else can the subject hold a gun, or a knife, or a club?

8) Tombstone Courage.
Why wait for backup?

9) Preoccupation.
Worrying about personal problems while on duty may be the hard way to solve the problem.

10) Apathy.
A deadly disease for the cynical, veteran officer.

[Geezer]

I thank Matty for introducing this topic.

MISTAKE
1. An error or fault resulting from defective judgment, deficient knowledge, or carelessness.
2. A misconception or misunderstanding.
Deficient knowledge is something that can only be corrected after the fact, so that part of the definition is not germane to this discussion. (You cannot determine that you made a decision based on deficient knowledge until after you have made the decision and your knowledge level has been tested by the results of the decision.)

In almost every human endeavor, we install procedures and standard practices to guard against mistakes. If mistakes were the result of choices in every case, there would be no need for procedures, simply a need to weed out people who made poor choices.

Research into the how and why of mistakes has been shut off from funding for some 50 years more or less, because the results are politically and socially incorrect. (For those of you who have an inordinate respect for science, all research funding is driven by whatever is politically and socially correct at that moment. If there is any possibility of your findings upsetting the trend-setters, it ain’t gonna happen. Over fifty years ago scientists stated unequivocally that any research which might make any group feel bad was not to be funded nor published.)

Included in such forbidden research is the very important discovery that the brain goes to sleep every 90 seconds or so for a moment, and during that moment everything, including memory is shut off. All of you have looked both ways at an intersection, and then pulled out only to have another vehicle appear from nowhere. That is the result of a “brain nap”. The proper procedure to avoid this is to look both ways twice. The probability of your brain taking a nap both times at that precise moment is insignificant.

The purpose of procedures is to protect you against brain naps, and various lapses of memory. Fatigue, stress, fear, anger, advancing age, hierarchal imperatives, (hunger, thirst, sexual urges), all conspire to create the lapses in thinking and general brain functioning that result in mistakes.

It doesn’t matter if you are on top of the bell curve, among the very best 5%, or at the very bottom of the curve among the worst 5%, it happens to everyone. No one is exempt. The only “mistake” a person has conscious control over is to either install poor and inefficient procedures, or to make the decision not to follow the appropriate, efficacious ones. An example is to install the procedure of always finding hard focus on the front sight before pulling the trigger. This procedure is inefficient. To choose to install it is choosing an inefficient procedure, and one thusly incurs the responsibility for the less than pleasant results. Zeroing a rifle is an efficient procedure, yet every year hundreds, if not thousands of hunters ignore that procedure, with the result that many of their freezers are still empty after the hunting season is over. That is not the fault of the rifle, the scope, the game department, George Bush or God, it is the fault of the careless hunter.

Summing up, making a mistake is not a personal “bad”. Making a conscious decision not to follow an effective procedure is. No one can function perfectly, but everyone can follow sound procedures to protect us against our own brain naps. Based upon the extant research, it is inappropriate to condemn someone for a mistake.
It is appropriate to censure a person for not following common sense procedures.

This is very relevant in the various debates concerning interactions of police officers with civilians. There is a tendency to hold LEOs to absurd and extremely unscientific, ergo impossible standards simply because the media, the politicians and police administrators have the power to do that.

If a police officer is following procedure, then there is not any valid reason for blaming him/her for the results. It is always possible that the procedure is at fault, but that is the responsibility of the suits, not the officer on the spot.

If the procedure is sound, and the officer followed it reasonably well, then the results are not anyone's fault, no matter how unfortunate or even tragic they might be. When all is said and done, sometimes s**t just happens.

This carries over to the grey world of CCW holders as well. While an event is unfolding is no time to be contemplating various courses of action. Those decisions and the action triggers need to be made well ahead of time. This is where “campfire” bull sessions come into their own. In the exchange of war stories F2F, each individual can get a sense for situations which others have experienced, and through the group conscience, arrive at pre-combat decisions and action releasers that are based on actual experiences and real-time events. Thus the CCW holder can face the future with a set of procedures that, albeit informal, are based on successful encounters with death. They can be visualized, and practiced until they are an integral part of one’s responses.

No matter how well prepared, however, it is still possible to make a mistake, and even more possible to simply be unlucky, but that is between oneself, and one’s Higher Power. No forum can address that dialogue.

God bless and y’all be mindful out there.

[MarkC]

I thank Matty for introducing this topic.

MISTAKE
1. An error or fault resulting from defective judgment, deficient knowledge, or carelessness.
2. A misconception or misunderstanding.
Deficient knowledge is something that can only be corrected after the fact, so that part of the definition is not germane to this discussion. (You cannot determine that you made a decision based on deficient knowledge until after you have made the decision and your knowledge level has been tested by the results of the decision.)

In almost every human endeavor, we install procedures and standard practices to guard against mistakes. If mistakes were the result of choices in every case, there would be no need for procedures, simply a need to weed out people who made poor choices.

Research into the how and why of mistakes has been shut off from funding for some 50 years more or less, because the results are politically and socially incorrect. (For those of you who have an inordinate respect for science, all research funding is driven by whatever is politically and socially correct at that moment. If there is any possibility of your findings upsetting the trend-setters, it ain’t gonna happen. Over fifty years ago scientists stated unequivocally that any research which might make any group feel bad was not to be funded nor published.)

Included in such forbidden research is the very important discovery that the brain goes to sleep every 90 seconds or so for a moment, and during that moment everything, including memory is shut off. All of you have looked both ways at an intersection, and then pulled out only to have another vehicle appear from nowhere. That is the result of a “brain nap”. The proper procedure to avoid this is to look both ways twice. The probability of your brain taking a nap both times at that precise moment is insignificant.

The purpose of procedures is to protect you against brain naps, and various lapses of memory. Fatigue, stress, fear, anger, advancing age, hierarchal imperatives, (hunger, thirst, sexual urges), all conspire to create the lapses in thinking and general brain functioning that result in mistakes.

It doesn’t matter if you are on top of the bell curve, among the very best 5%, or at the very bottom of the curve among the worst 5%, it happens to everyone. No one is exempt. The only “mistake” a person has conscious control over is to either install poor and inefficient procedures, or to make the decision not to follow the appropriate, efficacious ones. An example is to install the procedure of always finding hard focus on the front sight before pulling the trigger. This procedure is inefficient. To choose to install it is choosing an inefficient procedure, and one thusly incurs the responsibility for the less than pleasant results. Zeroing a rifle is an efficient procedure, yet every year hundreds, if not thousands of hunters ignore that procedure, with the result that many of their freezers are still empty after the hunting season is over. That is not the fault of the rifle, the scope, the game department, George Bush or God, it is the fault of the careless hunter.

Summing up, making a mistake is not a personal “bad”. Making a conscious decision not to follow an effective procedure is. No one can function perfectly, but everyone can follow sound procedures to protect us against our own brain naps. Based upon the extant research, it is inappropriate to condemn someone for a mistake.
It is appropriate to censure a person for not following common sense procedures.

This is very relevant in the various debates concerning interactions of police officers with civilians. There is a tendency to hold LEOs to absurd and extremely unscientific, ergo impossible standards simply because the media, the politicians and police administrators have the power to do that.

If a police officer is following procedure, then there is not any valid reason for blaming him/her for the results. It is always possible that the procedure is at fault, but that is the responsibility of the suits, not the officer on the spot.

If the procedure is sound, and the officer followed it reasonably well, then the results are not anyone's fault, no matter how unfortunate or even tragic they might be. When all is said and done, sometimes s**t just happens.

This carries over to the grey world of CCW holders as well. While an event is unfolding is no time to be contemplating various courses of action. Those decisions and the action triggers need to be made well ahead of time. This is where “campfire” bull sessions come into their own. In the exchange of war stories F2F, each individual can get a sense for situations which others have experienced, and through the group conscience, arrive at pre-combat decisions and action releasers that are based on actual experiences and real-time events. Thus the CCW holder can face the future with a set of procedures that, albeit informal, are based on successful encounters with death. They can be visualized, and practiced until they are an integral part of one’s responses.

No matter how well prepared, however, it is still possible to make a mistake, and even more possible to simply be unlucky, but that is between oneself, and one’s Higher Power. No forum can address that dialogue.

God bless and y’all be mindful out there.

Hi Geezer

I was very interested in the information about the brain momentarily shutting down every 90 seconds or so for an instant. Is there somewhere you can point me to that has more information on this as I'd like to incorporate the information into our training but I'd need to reference it.

When I did a course with the FBI in New Zealand a couple of years ago they were talking about studies that showed if you turned your head 45 degrees the blink reflex automatically took place. It was theorised that the momentary vision shutdown was one of the causes of accidents at intersections as the brain was processing an after image rather than real-time information about approaching traffic. It's interesting stuff.:)

[Nscale]

No matter how well prepared, however, it is still possible to make a mistake, and even more possible to simply be unlucky, but that is between oneself, and one’s Higher Power. No forum can address that dialogue.

I totally agree with this statement, however, I offer the following for consideration.

This may seem to be off topic, but bear with me and I will try to explain why I believe it fits. At the very least it will provide food for thought about mistakes or errors and our abilities to avoid them in general.

Many may have heard the term “Zero Defects”. This is a term that was used some time back in the corporate world, usually connected with the organizations quality program/policies. This is my area of expertise and the “Zero Defects” Philosophy has always been intriguing to me and challenged me personally.

The definition is obvious “Zero Defects” = the ability to perform a task or complete an objective without error.

It has been argued this is not a viable philosophy and can not be expected because “we are only human and we all make mistakes”. I do not totally disagree, but still I ask the following questions to challenge the way we think regarding mistakes or errors.

Any philosophy that admits we will make mistakes says;

If it is acceptable to make a mistake what percentage of mistakes are acceptable?
This sounds like a reasonable question. It is so reasonable corporate America applies a dollar value to it. They calculate losses based on scrap, rework, etc. due to mistakes.

Now apply it to these scenarios.
What percentage of babies may the nurse drop when he or she carries them from the delivery room to pediatrics? Of course the answer is Zero.

How many times do you accidentally make the mistake of depositing your paycheck into someone else’s bank account? Again the answer is Never, Zero.

When coming home from work in the evening, how many times do you turn into your neighbors’ driveway instead of your own? Never, Zero.

I know these scenarios may sound silly, but we are capable of performing certain tasks without making mistakes.
As “only humans” we excuse mistakes when obviously we are able to perform tasks in our personal life with out ever making a mistake “Zero Defects”.

We also apply different rules to different activities. Activities that are important to us or society have a smaller margin for mistakes. Less critical activities we tend to overlook mistakes. Certainly carrying and using a weapon falls into the first.

Just food for thought. If we can accomplish “Zero Defects” in one area of our lives activities why can’t we expect (or strive toward) zero defects in all areas of our lives?

It is not my goal to disagree or argue with the information posted here. I certainly would not suggest we stop exploring and discussing potential mistakes and how they may be avoided.
I do believe if we apply the “Zero Defect” philosophy we will greatly improve everything we do.
Like Brownie says “The Mind is the Limiting Factor”

[Roundeyesamurai]

Many may have heard the term “Zero Defects”. This is a term that was used some time back in the corporate world, usually connected with the organizations quality program/policies. This is my area of expertise and the “Zero Defects” Philosophy has always been intriguing to me and challenged me personally.

The definition is obvious “Zero Defects” = the ability to perform a task or complete an objective without error.

I was of the impression that the corporate world had determined "zero defects" to be impossible and had adopted the "Sigma" measurement of defect rate, where "Six Sigma" represents a process executed with less than one defect per 5 million operations (99.9999998% defect-free)?

Quite obviously, there really is no such thing as "perfect", especially not when regarding interactions between persons (including violent interactions), and no matter how hard you work, "anyone can get got".

[Nscale]

Absolutly correct my roundeyed friend :)

And Geezers post regarding procedures is right on.

[Brownie]

Forethought and observation coupled with proper training and to a lesser degree equipment lets the cat keep his lives more often than not.

Deadly errors? Not having the above to begin with IMO

[JMusic]

NO. 8, Tombstone courage. I planted the man that replaced me within 9 months of him taking that position. I could see where he had kicked his heels in the ground as he passed. We all can give examples of why each are important. That one was the most profound for me.

We practice 6 sigma. It is not a search for perfection but a certain rate of failures counted in parts per million. I think the number is more like 3.43 per million for a six sigma score. I'll check and see. Motorola was the leader at the time.
Jim

[Guantes]

I think everyone makes mistakes so sometimes it comes down to luck in relationship to the mistake. If you make a potentially deadly mistake and your foe was either too dense to pick up on it or for some reason he decided not to take advantage of it, luck bailed your butt out.

[Brownie]

"Luck favors the prepared", or something like that:)

As to the luck comment, I have to admit that with all the training and experience I've had over the years, lady luck has played a major part all too frequently to be ignored.

In the investigative work particularly, luck played a role to successful outcomes 90% of the time. Intuition and skill really played a small part to the successes that were enjoyed.

I've been told far too often by associates that my 9 lives had been used up long ago. Not sure what to make of that really, but to trust that lady luck stays with me for another couple of decades till I put the Marine bat down.;)

[Guantes]

I've heard it several ways. Actually, I think they are a deriviation of the original by Louis Pasteur, "In all matters of observation, chance favors the prepared mind.".

[Brownie]

Yes,

Thats the one I was looking for "Chance favors the prepared mind". Didn't know it was Louis', very nice.

Thanks

[Dave James]

If all else fails remember the " LAW OF SEVEN P'S"

[Guantes]

One advantage I think that an armed citizen has over an LEO, cop, Peace Officer, whatever the term du jour is, is lack of routine. Most of these errors, in my opinion stem from routine, such as the "routine traffic stop". Things are done so many times without incident that they become routine and that's when one jumps up and bites you in the butt. For the armed citizen, unless he lives in Tombstone, he does not encounter a sufficient number of incidents for things to become routine.