Crew Resource Management – Part VII

I have spent a great deal of time researching, writing about and teaching the concepts of Crew Resource Management (CRM). CRM is a very interesting process that commercial airline pilots use to avoid, trap or mitigate human error that can occur during flight, thereby preventing negative consequences. 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 Captain 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 (1999) the 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 towards the goal of reducing firefighter death and injuries. 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 ICS in any form or fashion, but greatly improving the single most important part of the command system - the human factor.

Documented in the six previous editions of Firehouse Magazine is the "nuts and bolts" information about the CRM program. 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 (Firehouse readers), into action. Considering that we seem to be stuck on losing 100 fire fighters per year, there needs to be some way to break through to lower this deplorable reoccurring 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) and they are: 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 does not take advantage of the crew's capabilities during an in-flight emergency. After a series of very poor decisions and contrary to the requests of the 1st & 2nd officers, the DC - 8 crashes six miles from the Portland, Oregon Airport. The end results are that 10 people are killed (including the 2nd officer) and 23 are injured. The Federal Aviation Administration (FAA) lists the cause of this accident as human error. Based on this very avoidable crash, the FAA orders all US 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 last 23 plus years, CRM has grown into a comprehensive program that takes advantage of all of the "crew" members and not just the two pilots, 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 balances process that requires more inputs. (In the fire - rescue service we describe the undisputed boss using the Golden Rule, "he/she that has the gold rules"). A challenge and confirm mentality does not overthrow the captain or in any way usurp his/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 43B.C. Therefore, the crew concept of more than one person providing input into making a critical decision just seems to make good sense. And finally, 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 fire fighter injury or fatality), than your are. The acid test for this notion is,