Crew Resource Management – Part 7: Your Call To Action

I came by my fascination with this decision-making process honestly. In 1994, after attending an incredible keynote presentation delivered by Captain Al Haynes of United Flight 232 , I was hooked on the concept. Haynes referenced a textbook entitled Cockpit Resource Management that was edited by Dr. Robert Helmreich, a world-renowned human performance scientist.

Being an avid reader, I ventured out and made the purchase of the book that Haynes cited in his program. The more I read the text, the more that I became an advocate for the concept of reducing human error. Several years later (in 1999), the International Association of Fire Chiefs (IAFC) called a meeting to formally explore the feasibility of applying the CRM concepts of human error prevention to incident management. I am not sure why I was invited to these meetings, but what an honor it has been to continue to work on this most critical enhancement to the incident command system. A tip of the helmet goes to the ICHIEFS for picking up the "CRM ball" and running with it toward the goal of reducing firefighter death and injuries.

"FRONTIER FOR CHANGE"

I cannot overstate my belief that CRM is the next "frontier for change" in the command system process. Keep in mind it is not replacing the incident command system (ICS) in any form or fashion, but greatly improving the single most important part of the command system - the human factor.

Documented in six previous editions of Firehouse® Magazine is the "nuts-and-bolts" information about the CRM program:

• Part 1 - The Nuts & Bolts of CRM (May 2001).
• Part 2 - Human Factors of Fireground Injuries & Fatalities: Breaking the "Error Chain" (June 2001).
• Part 3 - Communications Under Stress (July 2001).
• Part 4 - Leadership (August 2001).
• Part 5 - Task Allocation (November 2001).
• Part 6 - Critical Decision Making (July 2002).

The purpose of this article will be to quickly review the highlights of this series and to challenge you, the fire service's best and brightest, into action. Considering that we seem to be stuck on losing 100 firefighters per year, there needs to be some way to break through to lower this deplorable recurring statistic.

The commercial aviation community realized a long time ago that plane crashes would most likely involve human error as the root cause. Therefore, they have worked diligently to eliminate human error from the cockpit of commercial jetliners.

Consider that there are four primary causes of aircraft accidents (actually all types of accidents can be lumped into one of these four broad categories): environmental conditions, engineering controls, administrative process/procedures and human error. Research shows that the most difficult factor to control has been the human input (error). Accident investigation research and near-miss reporting indicates that the most likely cause of an airplane accident will be human error. In fact, the human error factor is the causative agent in 80% of all commercial aviation accidents.

Although, we do not have the same research data capabilities available, I would submit that our profession matches aviation's 80% human error mark or, quite possibly, we might hit a higher percentage for human factor miscues. It makes sense that the other two areas (that we have control over - specifically administrative and engineering) of potential accidents have been improved tremendously, so why not focus on that "last frontier"?

Driving out human error has proven difficult to do, but worth the effort. With so much weighing in the balance, the fire-rescue service must take this same difficult, but highly profitable journey of removing human error as a cause of accidents.

CRM Review

The CRM concept is rooted in a very tragic plane crash that occurred in December 1978. Without going into the technical details, the pilot did not take advantage of the crew's capabilities during an inflight emergency. After a series of very poor decisions and contrary to the requests of the first and second officers, the DC-8 crashed six miles from the Portland, OR, airport. The end result was that 10 people were killed (including the second officer) and 23 injured.

The Federal Aviation Administration (FAA) listed the cause of this accident as human error. Based on this very avoidable crash, the FAA ordered all U.S. commercial carriers to adopt, develop and implement CRM as a human error avoidance model. At that time, the first program was entitled Cockpit Resource Management. Over the years, the revised concept has taken advantage of the brainpower of all of the on-board crewmembers and not just the captain of the craft. Over the last 23-plus years, CRM has grown into a comprehensive program that does takes advantage of all of the "crew" members, hence the name change to Crew Resource Management. The CRM program has been on the road of constant, continuous improvement to make sure that human error has the best chance of being eliminated from cockpit operations.

The CRM basic philosophy is that there should be redundancy on the flight deck at all times when the plane is in flight. The value system was changed from the captain being the undisputed boss, without questioning, to a checks-and-balance process that requires more input. (In the fire-rescue service we describe the undisputed boss using the Golden Rule, "he or she who has the gold rules").

"To err is human"

A challenge-and-confirm mentality does not overthrow the captain or in any way usurp his or her authority. The captain is still the captain and completely in charge of the operation of the aircraft. However, the belief is that by requiring the other flight crew members to speak up about concerns and observations, the best (hopefully correct) decision is made the first time and every time. "To err is human" seems to be one of those time tested truths having originated in 43 B.C. Therefore, the crew concept of more than one person providing input into making a critical decision just seems to make good sense.

One last CRM "duh" relating to committing human error and that is someone else is more likely to catch your error before it becomes a consequence (in our business firefighter injury or fatality) than your are. The acid test for this notion is, "If you knew that your actions were going to lead up to a mistake, would you still take the same action?" Enough said about the value of challenge and confirm. Redundancy at the command post (utilization of the command team process) is a critical necessity when we have members in hazardous atmospheres or dangerous situations.

Principles Of CRM

Four supporting principles guide the CRM program: communications, teamwork/leadership, task allocation, and critical decision making. Each of these elements are designed to enhance the overall command team performance when properly applied to the emergency situation.

None of these concepts are new to our business; however, the notion that "teams" of people, instead of just the single incident commander (IC), should manage incidents is groundbreaking news. We tend to want to be the "Lone Ranger" or perhaps "Robinson Crusoe" when we are in the IC hot seat. CRM makes you rethink the antiquated idea that input from others is unnecessary and/or a sign of weakness. Command team incident management will require a change in our collective "corporate culture" before it is accepted and results can be seen, specifically, lowered fire fighter line of duty deaths and injuries.

Command Team Development

It is my strong belief that a minimum command team of four members should be utilized any time our personnel enter an immediately dangerous to life or health (IDLH) environment or other types of danger. The roles that must be filled are: incident commander, deputy incident commander, accountability/documentation officer and safety officer.

Each person needs to be trained, skilled and experienced (just like airline industry requirements for flight operations) to be able to properly fill the required duties of the command team positions. Each job function has specific demands and responsibilities that must be performed at incidents. As well, all team members (for that matter all operating members) must challenge and work toward resolution of any poor/incorrect decision(s).

The member who challenges the IC (or any higher boss) needs to be correct, tactful, professional and firm. Many accident investigations have reveled that various members knew that the actions being taken would lead to the negative consequence of an accident, but they failed to speak up in time. When asked why members kept quiet and did not correct a developing mistake,"I thought that the situation was obvious to command" or perhaps "I did not want to embarrass the IC" are commonplace responses. This lack of action is not tolerated by the basic CRM philosophy and requires the member(s) with the better plan or knowledge of the circumstances to speak up.

Along with the need for training the command team members to speak up when things are not going well is the need to train the incident commander to be receptive to the critical input. In other words, the IC should never kill the messenger, but perhaps reward him or her in some way to reinforce the notion of "teamwork."

Some military folks that have participated in CRM programs have used the term "obedient disobedience" to describe what I am trying to say. Both the superior and the subordinate need to be schooled in how to convey (send and receive) mission critical information that avoids or traps a potential accident before it can occur. I know that this concept sounds simple, but the human nature of egos and pecking order always seems to get in the way. CRM training helps any organization realize that one guy or gal does not have to have all of the answers all of the time.

A little case study that I like to share about the "command team" concept in practical application dates back to my glory days as a field battalion chief. I was assigned to a station that had a water rescue unit attached and would respond to a fair amount of water related emergencies in the warmer months. When the operations got complicated (point of reference - I can lap a standard pool about twice), which was often, I used the best team member on duty that day as the "dive master." That person provided all of the strategic and tactical input that would carry the day and insure that our members would not get hurt in the rescue/recovery process.

I made no bones about it - I was the highest-ranking member on location, but the least qualified for the water rescue task at hand. Using (actually insisting because the best divers always wanted to be the lead swimmer) the collective skills, knowledge and abilities of the "team" allowed the best decisions to be made without unreasonable risks to our people. I took the "dive master's" advice and input to develop a sound incident action plan and learned a lot of new information along the way. Just in case you are wondering, I did reward the entire crew for the great effort regularly.

The Phoenix Fire Department has implemented the entire list of tenant's of crew resource management into their day-to-day operations. Chief Alan Brunacini has long been developing a comprehensive command team approach to avoid or at least lessen human error at alarms. Whenever Phoenix firefighters are placed into an IDLH/dangerous position, a command team is quickly and consistently established. About the only small variation of their program is that they use the term senior advisor rather than deputy incident commander to describe the second-in-command position. Phoenix quickly identifies safety officers as well as other command team members to strengthen incident management very early into the operation.

Another Phoenix-specific CRM role is support officer, a position that is included at all major calls with an eye toward eliminating human error. A while ago, I had the chance to be inside Phoenix's command van at a second-alarm fire being commanded by Deputy Chief Bruce Varner (now the Carrollton, TX, fire chief). The command team functioned seamlessly, managing a major fire and multiple sources of information, as well as keeping track of about 15 companies and 60 firefighters. It was an awesome sight from a command and control standpoint. It also reinforced the strength of the team approach to incident command.

Many classroom exchanges have caused an eyebrow or two to be raised in describing a "command team" consisting of a minimum of four people. The feedback is generally that the department does not have the level of staffing available to be able to accomplish this requirement. I do understand; however, the staffing situation does not change the need to have the four-member team in place at IDLH situations.

Modern departments need to "think outside of the box" (to use a well-worn cliche) to focus on the possibilities rather than obstacles. We need to build coalitions that involve the use of automatic and/or mutual aid. Consider adding more staff. I painfully know the difficulties with this statement. By embracing the command team concept, the justification keeps weighting the scales towards adding more mission critical personnel in the eyes of the decision makers.

Your Call To Action

As promised in the title, I want you to develop a personal agenda, along with me, relating to the implementation of the CRM concept into the incident management operations. This is your chance to greatly improve command functions in your own department and hopefully throughout the American fire-rescue service. If CRM is able to lessen the human error problem within our business as effectively as it has within the commercial airline industry, the impact will be a staggering success.

Your first step is to make it a point to learn more about the CRM program. Several courses are being presented around the nation. For example, there are several CRM presentations at the upcoming Fire-Rescue International in Kansas City, MO. Also, the Command School program always seems to have more information about this and leading-edge training information available. After all, being informed is the best approach to be a change agent within your department. Next, review the previous Firehouse® articles to get a better insight into the entire program. Firehouse® has always been strongly in favor of making our jobs safer and this series goes a long way towards improving command functions.

Make sure that you let the International Association of Fire Chiefs (IAFC) and the International Association of Fire Fighters (IAFF) know that you would like them to continue to pursue this joint venture in order to bring this program to completion to their respective memberships. Without question, the joint programs that these two "heavyweight" organizations have previously developed are popular and well received throughout North America. Both associations have a genuine commitment to the notion of firefighter health and safety; therefore, moving CRM forward is well within their mission, vision and goals.

Advise the U.S. Fire Administration (USFA) that it may want to consider developing a course that embraces the CRM process to eliminate human error from critical decisions. Not only would it be a great addition to anyone's command process, but it could also be expanded by USFA/National Fire Academy to avoid all types of human error, whether operational or administrative.

Finally, make sure that National Fire Protection Association (NFPA) knows that the first revisions to the NFPA Standard 1710 (Deployment for Public Career Departments) and 1720 (Deployment for Combination and Volunteer Departments) should have the requirement of a four-person command team added to both of them. Of course, the team would be a requirement only when our members are placed in an IDLH/dangerous situation.

This may sound like a radical idea to some readers who fought against the 1710 Standard, but adding this paragraph to the only recognized fire industry standard makes it harder for elected officials and bean counters to ignore this need for firefighter safety. It cannot be denied that when we keep our people safe and out of harm's way, we are delivering a much better product to our customers. Presented properly, increased firefighter safety and improved service delivery is a combination that is difficult to beat, giving fire-rescue administrators the tools necessary to justify the added resources.

In Summary

The first step in this journey (avoiding/lessening human errors at incidents) is for fire-rescue service leaders to buy into the CRM concept. We must be the catalyst and advocates demanding change to improve firefighter safety at alarms. It has been my goal in writing this series of articles to make the reader think about commanding incidents in a way that perhaps has never been considered by our industry, but has shown tremendous results.

CRM does not change the incident command system process, but it gives commanders new tools to improve the most critical input, the human input. If we are ever to change the tragic annual firefighter fatality and injury statistics, a different way of managing alarms needs to be identified and embraced. I am convinced that CRM "raises the standards" of performance to the next level.

I hope that you have found this CRM series interesting and provocative. If you keep an open mind and explore the possibilities and opportunities that CRM has to offer, our members and customers will be better served. If CRM is injected into the future of the incident command/incident management process, human errors will be greatly reduced.