­Risk management and firearms safety – there is obviously more to it than the four rules of firearm safety. We have a number of instructors in our Tribe, which is why so many of our own people found this article compelling.

Featured image courtesy of Dark Angel Medical LLC

RISK MANAGEMENT PRINCIPLES AND FIREARMS SAFETY

Let’s talk about safety.

I know, I know, everyone already knows the­­­ four cardinal rules of gun safety, and I have no intention of explaining what they are here.  I want to go beyond the basics and talk, not about what procedures we should follow to be safe, but rather about how to think about safety and risk management in general.

I am a firearms enthusiast who regularly trains, carries a gun daily, and occasionally even teaches others how to shoot.  But that’s my hobby.  In my day job, I am a risk management and reliability consultant.  My colleagues and I help leaders in many different industries figure out how to identify and mitigate risk within their own systems.   The concepts we use are universal—we’ve applied them in fields as varied as healthcare patient safety, gas and electric utility employee safety, and manufacturing production reliability.  Essentially, we help clients identify what kinds of negative outcomes they might experience, how likely they are to experience them with their current systems, and how to redesign their systems to reduce any unacceptably high risks.  I firmly believe that the concepts we use to do this would help to reframe gun safety discussions in a way that gets shooters and instructors to think about risk and safety and what we can do about them, rather than to mindlessly parrot rules.

And I’d like to start by stating, up front, a few general principles of risk management.

Note the tourniquet tucked into the pocket of his jeans where he can access it quickly. He’s probably wearing a pocket IFAK of some sort in there too.

GENERAL PRINCIPLES

First, there is no such thing as “safe,” at least in the sense commonly meant by “not risky.”  Life is risk.  Every time you stand up you risk falling down.  Every time you read a book you risk a paper cut.  Risk management is not about eliminating risk; it is about reducing the risk as much as reasonably practicable while maintaining the utility of the activity in question.  Handling a firearm is an inherently high-risk endeavor.  Firearms safety isn’t about eliminating all accidents ever for everyone; it’s about managing the risk to an acceptable level, so that as few people have safety mishaps as possible, and when they do inevitably occur those mishaps result in the least harm possible.

Second, different people have different acceptable levels of risk in their activities: some people drive Volvos at the speed limit, while others ride motorcycles through dense traffic at 100 miles per hour without a helmet.  And sometimes someone else’s actions might put us at risk.  It doesn’t have to be your mistake that gets you into a car accident or gets you shot at the range. Think about the untrained novice shooter at the range who constantly muzzles everyone around him or her.  This means that we need to design our personal risk management systems to account not just for our own mistakes, but those of others.

Third, human beings are fallible.  We make mistakes.  We cut corners.  We don’t follow rules; we follow the path of least resistance towards our own goals.  That means that no procedure can be counted on 100% of the time: whether through complacency, distraction, or tripping over our own feet, we WILL screw up at some point.  This means our systems must be designed to take this fallibility into account.

Fourth: The most effective method of planning for fallibility is layering our risk management systems.  We CAN improve human reliability through good human factors design, but only so far.  It’s usually far more effective to assume people will sometimes screw up and work to ensure multiple things must go wrong before we reach a negative outcome than to strive for perfection with the one or two we currently have.  That way, even when we screw up or for whatever reason cut corners and skip safety steps, there are other management systems in place to stop it from becoming a problem.

How, then, do we design our personal systems in such a way as to manage the risk to an acceptable level, taking into account human fallibility and the risks caused by others around us?

NEGATIVE OUTCOMES

The first thing to think about is “What is/are the negative outcome(s) I’m trying to avoid?”  If you’re driving your car, do you want to avoid crashes entirely, or do you want to avoid injurious crashes?  This is important because we use different tools to avoid different outcomes.  Your car has a fender, crumple zones, safety glass, seatbelts, airbags, etc.  These all help avoid injury but do absolutely nothing to prevent the crash in the first place.  For that, we have to look at a broader system: barriers between lanes of traffic moving in different directions to prevent head-on collisions, lane assist technology to avoid drifting into cars around you, rumble strips to help drivers stay on the road and out of a ditch, adaptive cruise control and automated breaking technology to keep you from rear-ending the driver in front of you, etc.

So what negative outcomes do we, as gun owners want to avoid?  Unintentional discharges, for sure.  But also, in the event of an unintentional discharge, how about avoiding injuring someone or damaging something we care about?  Are there negative outcomes to be avoided with intentional discharges?  Absolutely: Claude “The Tactical Professor” Werner collects examples of such cases, where people shot the wrong person—they intended to fire the gun, but got the wrong target through confusion or poor target identification or tunnel vision or whatnot.  And even if you intentionally shoot the right target, there are negative outcomes to avoid: ricochets and hearing loss at the range, being convicted of a crime because you didn’t know the laws of self-defense in your area, and more.  There are MANY potential negative outcomes associated with operating a firearm, and different aspects of risk management will come into play for different outcomes.  “Do not point a gun at anything you aren’t willing to kill or destroy” is an important rule precisely because we recognize that we may be unsuccessful in preventing an unintentional discharge for some reason, so we want to avoid the further negative outcome of injuring or damaging someone or something.

INITIATING EVENTS

Once you’ve identified a negative outcome, think up the ways that it might come to pass.  This is what we call the initiating event.  If the negative outcome is accidentally rear-ending the car in front of us, the initiating event might be “lost sight of the car ahead of us while actively driving,” whether through distraction or something else.  Still moving forward, lose track of the hazard to the front, now we can potentially crash unless something (such as an adaptive cruise control system) prevents it.

Taking this concept back to the firearms world, what are the initiating events that may lead to an unintentional discharge?  There are, of course, many: a firearm malfunction (such as a slam fire), pressing the trigger when we don’t mean to (such as through a startle response or general carelessness), an external object pressing the trigger (such as a cover garment getting caught in the trigger guard during holstering), a dropped weapon without a functional drop safety, etc.  What are the initiating events that may lead to shooting the wrong target?  How about those that may lead to other negative outcomes?

It’s important to match up the initiating events with the associated negative outcome because that lets us define what we can call the path of the error: the initiating event to the potential outcome.  And doing so lets us identify the risk associated with various actions and mistakes and mechanical failures.

There are three tools we can use in designing our safety and reliability systems to manage risk.  We call these precursors, defenses, and mitigations.  Let’s look at each in turn.

PRECURSORS

Precursors are strategies to reduce the likelihood of a given initiating event.  One precursor strategy might only affect one or two potential initiating events, or it might affect many.  Training and education often act as general precursors for a variety of initiating events in a given task.  In trying to prevent the initiating event of “losing track of vehicle in front of me while moving forward,” and thus its associated potential negative outcome of “rear-ending vehicle in front of me,” I have several precursors.  One might be defensive driving training, which helps me avoid a variety of potential initiating events.  Another might be ensuring my front window is clean, which specifically helps me avoid losing sight of hazards in front of me through glare or grime or an otherwise impeded view.  I can improve this precursor strategy by ensuring I have washer fluid and functional wipers to clear the windshield if it becomes obstructed.  And so forth.

So if my initiating event of concern is “pressing the trigger when I do not intend to press the trigger,” a precursor would be “Keep the finger off the trigger until ready to fire.”  Another would be specifically to keep the finger in register, which helps prevent unintentional trigger presses through startle responses or sympathetic reactions and so forth.  Training and experience and education would be a general precursor that helps prevent a variety of errors and risky choices; specific procedures like trigger finger discipline tend to focus on a relatively small number of potential problems.

DEFENSES

Defenses, on the other hand, are strategies that prevent negative outcomes from occurring even when an initiating event of concern happens.  Continuing with our rear-ending example, if I’m driving a vehicle equipped with adaptive cruise control, even if I lose sight of the car in front of me and they suddenly brake, my car automatically slows down to prevent the collision.  That’s a defense—something else beyond the initiating event that has to fail for the negative outcome to come to fruition.  If I lose sight of the vehicle to my front, for whatever reason, I am much less likely to have an accident if my adaptive cruise control system has to fail as well.

Taking this back to our firearms example of an unintentional discharge, an external safety on a firearm helps prevent a shooter from discharging the firearm even if they accidentally press the trigger.  A drop safety helps prevent the firearm from discharging even if the gun strikes the ground with force.  Personal protective equipment like eye protection and gloves are a defense against other types of initiating events, like ricochets and firearms malfunctions that might otherwise cause injury.

No such thing as safe: beyond the four rules

MITIGATIONS

Finally, we have mitigations.  Mitigation strategies seek to reduce the level of harm associated with a negative outcome if we can’t prevent its occurrence.  Airbags, seatbelts, crumple zones, and safety glass reduce the harm associated with a car crash, thus potentially preventing further negative outcomes like severe injury and death.

Similarly, “do not point a gun at anything you aren’t willing to kill or destroy” helps ensure that even if we do have an unintentional discharge, the harm will be minimal.  Carrying medical trauma gear like a tourniquet is another mitigation strategy to stack on top of muzzle awareness, which applies when we reach the negative outcome of “unintentionally shot someone” (or, for that matter, “got shot by someone”).

PUTTING IT ALL TOGETHER

 Now that we have the pieces, let’s look at a couple contexts to see what it looks like in practice.

Say I’m an individual armed citizen, and I want to do some dry fire practice at home in my one-bedroom urban apartment.  What’s the biggest negative outcome I’m concerned about?  Well, probably accidentally shooting a live round and injuring myself or someone else in or around my apartment building.  So if I’m trying to prevent this from occurring to the best of my ability, I need to figure out what initiating events might lead to it.  One might be the classic example of “Don’t worry, it’s not loaded:” picking up a gun, with the intention of dry firing it, when I think it’s unloaded but there’s still a round in the chamber.  How, then, do I manage this risk?

Well, I have a precursor: the First Rule tells me to always assume a gun is loaded, so if I’m following it, I will clear the gun every time I handle it.

But if I pick it up without clearing it, I also might have a defense: dry fire practice is often done with brightly colored snap caps and specifically labeled magazines, to help visually alert us to the status of the weapon.  A procedure in which I verify the label or color of the magazine and press check to verify the color of the dummy round could catch my error before I press the trigger and reduce the chance of firing the live round.

But if I only have one or two defenses and precursors, like in dryfire, it’s almost statistically certain that sooner or later they’re going to fail—if not for me, then definitely for someone, somewhere, at some point.  So now I need to do one of two things: figure out how to add more defenses or precursors, or make sure I have mitigation strategies in place.  I may ensure I always conduct dry fire aimed at a solid backstop that I trust to catch an unintentional discharge, like an exterior cement wall or a telephone-book-filled box.  I may have a trauma kit on hand and emergency medical training to deal with the consequences of an unintentional shooting.  I know I’m assuming a risk with my current system design, so I need to improve my system design or try to mitigate the harm of a negative outcome.

Let’s look at another context: I’m running a class for brand new shooters on a public range, and I’m concerned about the negative outcome of someone getting shot.  For this example I’ll focus on the initiating event of “a brand new shooter accidentally presses the trigger when the muzzle is pointed in an unsafe direction.”

Think about that for a second.  What defenses do I have between the shooter putting his or her finger on the trigger and a round firing in an unsafe direction?  Not much.  MAYBE an external safety.  But that’s probably it, right?  And if they’ve taken the safety off, it’s no longer a defense at all.  So we’ve identified this as an extremely high risk initiating event.  And I need to focus on first trying to prevent it from occurring, and second, trying to mitigate the harm when it inevitably does (again, if not to me, then to someone).

Precursors might include limiting the class size to a manageable level, so I (and my assistant instructors, if I have them) can keep a close watch for anyone doing anything unsafe.  They also might include in-depth safety training, stressing the importance of trigger and muzzle discipline, before anyone ever touches a real gun.  Some instructors manage this risk by having only one novice student operating a weapon at a time—this allows them to act as a defense by physically preventing the student from aiming in an unsafe direction.  There are many strategies to reduce the chance of the initiating event in question.  They might include teaching—and hoping students follow—the Four Rules, but the rules themselves are not enough, because we can’t trust a novice shooter to follow them at all times.  I need to design my system with layers to account for student error.

I also want to recognize that this initiating error is likely to occur at some point, and when it does it will almost certainly lead to a potential negative outcome—once the student pulls the trigger with the muzzle in a random unsafe direction, the difference between someone getting shot or not is pure luck.  So I need mitigating strategies.  Maybe I keep my students corralled in a relatively safe location away from the firing line.  Hopefully, I have medical equipment and training at hand to respond to an accidental shooting.  I should probably also have a medevac plan in place, right?

Note that in both of these scenarios, I’m recognizing the limitations of the Four Safety Rules.  I literally cannot keep my finger off the trigger until I’m ready to send bullets downrange if I want to conduct dry fire practice, so I need to ensure my other risk management processes are in place and effective—such as the OTHER three safety rules, maybe some specific dry-fire safety procedures to ensure the gun is ready for dry fire, plus having medical equipment ready to go.  Similarly, I cannot trust novice shooters to adhere to the Four Rules at all times, so I have to design my risk management systems in such a way that I expect them to violate the rules sometimes and have a plan to prevent it as much as possible and deal with it when it happens.  But I can’t do that if I simply parrot the Four Safety Rules as a mindless mantra that will protect me against all harm with a gun.  I need to understand what my risk management system actually looks like, and where the risks really are, so I can devote resources to fixing potential problems before they occur.

WHY THIS MATTERS

Dividing risk management strategies into precursors, defenses, and mitigations are useful for two reasons.  First, it helps us identify where given risk management strategies like each of the four safety rules actually help reduce risk—some strategies apply to many risks, some are focused on relatively few risks.  Second, from there, we can figure out where our risk management is strong, and where it’s weak.  This allows us to develop a plan to strengthen our weak areas without weakening our strong areas.  So now that we’ve established this model of risk management, let’s go back to the four rules of gun safety, and see if we’ve learned anything useful.

The four rules aren’t indivisible, though they’re often treated that way.  The truth is, as many writers before me have pointed out, we often violate one or more of the rules on purpose for a variety of reasons: disassembling a Glock requires a trigger press when we don’t want to shoot the gun, as does dry fire practice; sitting down with a gun in AIWB almost always results in muzzling one’s own leg or crotch.  But these aren’t generally problematic, specifically because the rules aren’t indivisible—they’re a layered system design that incorporates precursors, defenses, and mitigations.  It’s only when we thoughtlessly discard multiple Rules at the same time that we start to risk serious trouble.

“Always treat every gun as if it’s loaded” is a precursor or a defense, depending on the initiating event in question: it’s a precursor to picking up a loaded gun and thinking it’s unloaded, but a defense against picking up a loaded gun and failing to clear it (because even without clearing it, if we treat it as if it’s loaded we won’t shoot it unintentionally).  “Never point a gun at anything you aren’t willing to kill or destroy” is a precursor against accidentally shooting someone or something you care about, and a mitigation against unintentional discharges in general.  “Always be sure of your target, what is around it, in front of it, and beyond it” is a precursor against shooting someone or something you didn’t mean to shoot.  “Keep your finger off the trigger (and/or in register) until you are ready to fire” is a precursor against accidentally pressing the trigger when you don’t want to and a defense against startle responses and sympathetic reactions.

The Four Safety Rules are a remarkably effective system of layered risk management strategies.  But they aren’t the only strategies we have available, and in many activities, they simply aren’t enough.  Which of the Four Safety Rules prevents a piece of t-shirt or old worn-out leather (or hybrid) holster getting caught in a trigger guard and pressing the trigger during reholstering?  Which of the Four Safety Rules prevents a piece of shrapnel from bouncing off a target back into a shooter’s eyes at the range?  The Four Safety Rules are great for reducing the risk associated with unintentionally pressing the trigger with your finger, and the Second Rule is a great mitigation for almost any type of unintentional discharge.  But there are many other risks associated with operating a firearm, and we need to manage those risks, too.

Fortunately, we’ve developed a lot of other procedures and strategies to prevent problems not covered by the Four Rules.  Physical safety mechanisms on firearms themselves.  Grip designs to reduce the chance of dropping a gun.  Well-designed holsters with retention and trigger coverage to prevent guns from falling out or objects getting into the trigger guard.  Ballistic eye protection.  Shooting gloves.  Various forms of hearing protection.  Specific procedures designed to minimize the chances of a problem, like the four count draw stroke and “looking the gun into the holster.”  The list goes on and on and on—the Four Rules are the basis of gun risk management, but they focus on only one type of problem (the gun unintentionally discharging), and they certainly aren’t the only tools we have to reduce risk when operating firearms.

So when you’re operating a gun—an inherently risky activity—rather than hand-waving the Four Safety Rules, stop and think through what your actual risk management system looks like.  What negative outcomes are you trying to avoid?  What initiating events can get you to those negative outcomes?  What precursors do you have in place to reduce the chance of each initiating event?  What defenses do you have, if any, to ensure an initiating event doesn’t become a negative outcome?  What mitigations do you have to reduce the harm of a negative outcome in the event one occurs?  And if any of those precursors, defenses, and mitigations are procedures where you or someone else has to actually DO something (as opposed to physical defenses like internal safety mechanisms), are you or they actually doing it on a regular basis to the best of your ability?  If not, is that procedure actually effective at managing your risk, or is it just giving you a false sense of security?

Or are you just relying on yourself and others never to make a mistake?

Which sounds like a more effective plan: relying on luck and human perfection, or assuming something will go wrong and working to manage that risk to an acceptable level of safety?

This sounds complicated, but it’s really not.  With a bit of practice, it becomes almost second nature, much like muzzle awareness and trigger discipline.  These concepts are universal.  From driving a car to cooking a meal, to babyproofing your house, to running a 500-bed hospital, these exact same concepts can help you identify where the risk really is in your systems and processes, where you need to be concerned, and how to manage it with the resources you have.  Whether you’re an instructor figuring out how to manage risk when teaching twenty people how to shoot, or an individual armed citizen figuring out how to avoid accidentally injuring yourself or others in your daily firearms-related activities, understanding these basic concepts of risk management and system design will take your safety to the next level.

We’ll never get rid of risk: guns are dangerous tools and are meant to be dangerous.  The risk in operating a gun isn’t a flaw, it’s a feature.  But with just a little bit of thought, we can manage that risk to an acceptable level.