Richard B. Gasaway begins a two-part series discussing how situation awareness affects your decision making.Part 1 - Understanding Situation Awareness & How It Affects Your Decision Making
In 2007, the National Firefighter Near-Miss Reporting System annual report identified situation awareness (SA) as the leading factor in firefighter near-miss events. In studying National Institute for Occupational Safety and Health (NIOSH) line-of-duty death reports, it becomes apparent that issues with situation awareness are contributing to firefighter casualties as well.
For the years 2001 through 2005, I found 26 residential dwelling fire fatality incidents where human error related to situation awareness was a contributing factor to the firefighter casualty. The situation awareness-related issues cited in these reports included inadequate initial and ongoing size-ups, failure to continuously evaluate the risk versus benefits during the entire operation, ineffective communication of fireground conditions and failure to recognize hazards. Much has been written about issues with situation awareness on the fireground. Yet, when asked, many fireground commanders struggle to explain what it means to have situation awareness. Even worse, commanders struggle to explain how situation awareness is lost and what things can be done to keep it intact. In general, there is a lack of awareness...about awareness. How ironic.
Let's start by getting a good handle on what situation awareness means. After that, you'll be in a better position to understand how situation awareness can be established, maintained, impacted, lost and regained. I have heard several people offer simplistic definitions of situation awareness that, in some ways, capture the essence of the concept, yet do not do it justice. For example, I have heard it described as "paying attention" or "where perception and reality meet." Can't argue with that, but what does that really mean?
To help you understand situation awareness in a meaningful way, I turn to the work of Dr. Mica Endsley, founder and President of SA Technologies. Endsley has written over 200 scientific articles and several books on issues related to situation awareness in dynamic high stress environments. In a 1988 paper titled Design and Evaluation for Situation Awareness Enhancement, Endsley defined situation awareness as a perception of elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.
Stated another way, situation awareness is your ability to capture cues and clues from what is happening around you...then being able to put those together to mean something...then being able to predict future events as a result of what you have captured and the meaning you gave to it. Endsley's research discovered there are three levels of situation awareness:
- Level 1 is the perception phase (this is where you capture the cues and clues).
- Level 2 is the comprehension phase (this is where you put those cues and clues together to mean something).
- Level 3 is the projection phase (this where you predict future events based on Levels 1 and 2).
This is important to understand because if, for some reason, you are not able to capture the right cues and clues, it will impact your ability to understand what is happening. This, in turn, will impact your ability to predict what is going to happen next. Chances are pretty good that you have read an after-action report or watched a fire scene video where something went wrong and said to yourself "How could they not see this coming?" or "That could never happen to me."
First of all, it is easy to read these reports or watch these videos and become angry because what you see coming is SO obvious. Well, it wasn't obvious to the incident commander. They didn't respond to that call thinking to themselves, "I'm going to lose my situation awareness on this call...make some bad decisions...and jeopardize the safety of my firefighters." Yet it happens.
The sad part of this is, most of the time the fireground commander never saw it coming. Maybe they had done the same thing the same way for years and never had even as much as a near-miss event. Maybe they thought they had good situation awareness. Then, it happened... a significant near-miss or catastrophic event. The first misnomer you need to come to grips with is, the loss of situation awareness can afflict any fireground commander and impact decision making with no warning signs.
Issues with situation awareness and its impact on decision making has been studied in a number of professions where decisions are made in dynamic, fast-paced, ever-changing, high-risk environments. Extensive research has been done to understand how military battleground commanders, airline pilots (especially when something has gone wrong and the flight is in jeopardy) and surgical teams make decisions. From this research have come some very important lessons the fire service can learn from. These include:
- A commander with poor situation awareness can still make a good decision, if only by luck.
- A decision made with good situation awareness can still have a bad outcome.
- Maintaining situation awareness requires a physical, mental and emotional commitment to paying attention.
- What to pay attention to is not always obvious.
- Your attention is drawn to things that are loud, bright, moving or in close proximity to you.
- Commanders rarely realize they are losing their situation awareness until it is too late.
- Humans can only remember seven (plus or minus two) unrelated pieces of information. It may be less when conditions are stressful.
Unfortunately, very little research has been done to understand how fireground commander situation awareness is impacted. Through an exhaustive search of the existing literature, coupled with interviews conducted with expert-level fireground commanders, I have been able to amass a list of 116 potential barriers that can impact a fireground commander's situation awareness. As I assembled this list, similar barriers were grouped together, resulting in 12 categories of situation awareness barriers, including: staffing, communications, data/information management, physical and mental stress, workload management, attention management, mission/goals, mental models, human factors, command location, command support and team/crew performance.
Each of these categories contains barriers that make up the list of 116. For example, in the staffing category, there are potential barriers to commander situation awareness that can arise from understaffing, overstaffing, unpredictable staffing, quality of staffing, response time delays, lack of experience and inadequately trained personnel. As another example, in the communications category, there were potential barriers to commander situation awareness from issues with verbal and non-verbal communications, progress/update reports, misinterpreted words or phrases, incomplete communications loop, missed radio communications, radio equipment problems, non-compatible radio equipment, using multiple radio channels, too much radio traffic, and crews not willing or unable to communicate by radio. As you can see through these examples, in each category, the potential barriers are rather extensive.
In part two, I will share important lessons I learned from interviews with commanders about how their situation awareness is impacted.
DR. RICHARD B. GASAWAY joined the fire service in 1979 and has worked for six emergency services agencies in West Virginia, Ohio and Minnesota. He has been a career fire chief for 20 years and currently is chief of the Roseville, MN, Fire Department. Gasaway's doctoral research focused on fireground command decision making under stress, and more specifically, the barriers that impact commander situation awareness. He applied the findings of his research to develop 50 Ways to Kill Your BrotherÂ©, a program designed to help fireground commanders understand and improve situation awareness. Gasaway is also the host of "The Leader's Toolbox," a podcast program hosted on Firehouse.com. He can be reached via his website at www.RichGasaway.com.