What Nearly Happened

September 22, 2017

I recently asked a very knowledgeable university-level researcher who studies police and, specifically, the effects of fatigue on officer performance a simple question: “Can you name a case in which officer fatigue was identified as contributing to a bad outcome?”

He never got back to me.

So I asked around and everyone basically said the same thing: Identifying fatigue as a contributor in a less-than-optimal outcome would open the agency and/or officer up to liability. The result: We have no idea how widespread a problem fatigue is in contributing to police errors on the job. We instead pretend that it isn’t an issue. Or we pretend like it’s a vague and somewhat academic ‘issue,’ rather than a specific and predictable contributor to awful outcomes that we could prevent if we chose to.

Fatigue is just one example. What other factors are law enforcement personnel willfully ignoring for fear of liability? What is the price of not knowing, to our officers and communities?

The good news: There is a better way, one in which officers and agencies can be honest about mistakes, so that the profession can benefit, without exposing themselves to liabilities. It’s called non-punitive close-calls reporting, and, thanks to the Police Foundation, it now exists for law enforcement.

Learning from Mistakes

“The site was launched in early 2015,” says Brett Cowell, who helps to manage LEONearMiss.org on behalf of the Police Foundation. “From there we’ve been building a national effort to grow, partnering up with organizations and agencies who share a similar goal of improving officer safety.”

Firefighters have been doing non-punitive close-calls reporting for decades, and in fact LEONearMiss.org was modeled off of and shares the technology platform with FireFighterNearMiss.com.

A major reason firefighters led the way are the steadfast work of California Highway Patrolman and risk manager Gordon Graham, who supported the effort and its sister iteration, FirefighterCloseCalls.com. Graham is passionate about non-punitive close-calls reporting—he wrote his graduate thesis on it at USC—and he is convinced that law enforcement must embrace it if it’s serious about officer safety.

“I’m a student of the work of H.W. Heinrich, who studied work accidents for Traveler’s Insurance in the 1930s,” says Graham. “Heinrich’s theory was that if there are 300 mishaps at work, one will be tragic, and we will derive lessons from it—which is of no benefit to the person hurt or killed by the mishap. The better idea is to learn from your close call—the other 300 mishaps that could have been tragic—and then share the pertinent lessons throughout the industry.”

A wide array of industries employ non-punitive close-calls reporting, but medicine and aviation are the standard-bearers. Embracing this concept engenders a culture of safety, continuous learning, and honesty—virtues we should be encouraging in police ranks, according to Graham. “We need to be training and learning every day,” he says, “and non-punitive close-calls reporting builds that institutional knowledge, which is so important.”

The challenge for the Police Foundation and for law enforcement as a whole is to embrace this concept fully. “We have about 60 reports so far. They run the gamut,” says David Waltemeyer, the system’s other manager. “We’ve been promoting this for a few years now. We haven’t really seen significant traction yet. That’s what we’re working toward now.”

This was a challenge for firefighters too when they first got going with close-calls reporting, according to John Russ, who manages FirefighterNearMiss.com for the International Association of Fire Chiefs.

“Firefighters were skeptical at first too,” says Russ. “We would take our SMEs (subject matter experts) to a fire department and have them write down a near-miss in front of us, enter it into the website, and show them how it works and how they are de-identified. We showed them the backend too so that they could see what we would see. If someone said they responded to a specific city or address, we would anonymize that. We had to earn that trust, so that they could submit that story and trust that it wouldn’t come back to get them.”

So what qualifies as a “close call” or “near miss”? That depends on who you ask. According the Police Foundation’s standard it is an event that could have resulted in death or serious injury. Russ is looking to a more inclusive definition for the firefighters, based on the chemicals industry: “An opportunity to improve environmental, health, and safety practice based on a condition, or incident with potential for more serious consequence.”

Here’s how it works. If you’ve experienced an event that might qualify as a close call (in other words, if you think other cops could benefit from hearing of your experience), you can visit www.LEONearMiss.org and submit a report. (This could be anything from slipping on a soapy floor to taking an intersection too fast at night.) All identifying information will be redacted from the report and it will then go before a minimum of one SME, who will then make recommendations for the industry. Ideally these reports would then be widely distributed via industry media. Use it for roll-call training or peruse while waiting for your next call—the idea is to inspire you to be more aware of the risks you undertake everyday as a cop.

Another great advantage of collecting this data is that it will show law enforcement areas in which it must improve. Fatigue, my initial example, is a case in point. Go to www.LEONearMiss.org and keyword search “fatigue” (or whatever factor you’re interested in learning more about). You can also search by locale. Eventually this data can be analyzed and released as a sort of state of the industry report. But again, to get there we’re going to need your support, and your honesty.

If you’re worried about plaintiff’s attorneys and hackers getting your information, keep this in mind. Everything that identifies you or your agency in the report is scrubbed, meaning it no longer exists once it is processed. Graham, for his part, thinks that reporting should be entirely anonymous. “Asking for ID before someone enters a report is an immediate roadblock to honesty,” he says. “It should be anonymous, not simply confidential.”


I worked with Chief John Tippett and the IAFC back in 2007 when FirefighterNearMiss.com got up and rolling, and we would publish its monthly reports. I saw how firefighters would use the reports in training and I knew it was making a difference. It’s past time law enforcement started learning its lessons and, thanks to the Police Foundation, you now can. On behalf of Calibre Press, I offer our support.

1 Comment

  1. LegalBeagle

    Shift rotation is so clearly dangerous that a good argument can be made that it is incompetence/dereliction to allow it, and that discipline for command officers should be imposed (and brutal – multi-month suspensions and demotion to entry level if not termination). The information on this stuff has been out there for a long time, but universally ignored. Shifts over 10 hours are also demon spawn. (If the 10 hour shift are set up correctly, officer will have the last 2-3 hours to finish paper and get done, and not be shagging calls to the end and then doing paper – that’s just dumb because the shifts become 12s, which are clownshoes.)


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