Crew Resource Management - Part I

For more than a thirty-year span ICS ? FGC has seen a tremendously wide acceptance with some improvements and updating. However, the greatest opportunity to improve has just been placed in our hands with a new collection of human factor tools called...


In the early 70's, California was on fire. It was during this time frame that many wildland fires raged to tremendous proportions and required dozens (if not hundreds) of fire departments to work together to bring these campaign fires under control. Many problems erupted in the management structure, organization and common understanding at these exceptionally large natural cover fuel fires. It was nearly impossible to get everyone on the same page without a well-used and understood game plan. As a logical lesson learned from all these major disasters, the Incident Command System (ICS) was born. The FIRESCOPE group developed a system that facilitated common terminology, effective utilization of available resources, comprehensive communications, incident action planning and fire fighter safety concerns as the standard way of performing emergency response duties.

FGC is Developed

Just about at the same time, Chief Alan Brunacini (Phoenix Fire Department) was developing the structural fire response equivalent. History would reflect that this program was (of course), the Fire Ground Commander (FGC) system. FGC was adopted by the National Fire Protection Association and converted into textbooks, videotapes and procedural guidance to help the American Municipal Fire Service improve the management element of our emergency response capability. As both systems (ICS - FGC) matured and improved over the years, Chief Brunacini once again took the leadership role, along with others, to merge the ICS - FGC into model procedures and guidance for our industry. What a tremendous difference and benefit that ICS - FGC has been for the safety, efficiency and effectiveness of how emergency incidents get resolved.

For more than a thirty-year span ICS - FGC has seen a tremendously wide acceptance with some improvements and updating. However, the greatest opportunity to improve has just been placed in our hands with a new collection of human factor tools called "Crew Resource Management" (CRM). This is the first article in a multi-part series that will take a very interesting and promising look at the process that can be applied to the field of incident command.

CRM is Born From Crisis

On December 28, 1978 United Airlines Flight #173 was traveling to a destination of Portland, Oregon. The commercial flight took-off on time with a textbook departure. The crew that day consisted of a pilot, first officer and flight engineer to handle the operations of the DC-8 aircraft. The journey along the way was equally uneventful (just like the crew and passengers hoped for) until the plane was made ready for landing. Instead of the usual "3 down and green" (landing gear down and locked into place) indication, the nose gear green light did not illuminate. The following series of events that occurred in the cockpit were unbelievable.

The Captain radios the landing gear problem to the air traffic controller and requests the authority to stay aloft (holding pattern) to buy more time to resolve the issue with the landing gear light problem. The Captain goes through the checklists and procedures to ensure that all steps were properly taken to prepare for landing. This action is to no avail, the indicator light still shows red (nose gear not locked). The Captain continues in a holding pattern around the Portland (OR) Airport until more trouble visits the cockpit. The plane had only 58 minutes of fuel remaining when he started circling and (you guessed it) the tanks are showing empty with the airport 6 miles out. One by one the four mighty aircraft engines sputtered and flamed out from being fuel starved. Ironically, the flight engineer and the first officer had warned the pilot on several occasions that the fuel supply was running low without the proper action being taken by the captain. Because of miscommunications; lack of teamwork / leadership; improper task allocations; and poor critical decision making, the (perfectly capable, but fuel starved) United jet fell from the air, killing 10 people and injuring 23 other souls. It was later discovered that the nose landing gear operated correctly, but the $ .59 indicator green light bulb was burned out. In the wake of the needless death and destruction, the Crew Resource Management program was developed and implemented by the commercial airline industry.

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