As a foreign commercial airliner was climbing out to its assigned cruising altitude, the following translated discussion was captured on the cockpit voice recorder. The first officer points out to the captain that the flaps on the plane are still extended at a 15-degree angle. The pilot does not give an understandable response to this statement. Then, a second warning is issued by the co-pilot that the plane's airspeed is too slow, and again the pilot makes an unintelligible, grunt-type sound.
The co-pilot issues a desperate third warning. He indicates that the plane's flaps are extended, the airspeed is too slow and that the plane's altitude is too low. The pilot breaks his frustrating silence by telling the first officer to "Shut up and look out the window. If I want your opinion on how to fly this plane, I will ask for it."
Within two minutes, the plane flew into the side of a mountain, killing everyone aboard. The captain's lack of leadership and teamwork (human factors) is listed as the principal cause of the crash.
CRM Competencies
The commercial aviation industry's crew resource management (CRM) process identifies four specific competencies that crewmembers must abide (live) by to simply avoid crashes. Communications, leadership/ teamwork, task allocation and critical decision making are the "big four" elements that make up the airline industry's CRM system. Interestingly, I propose that there are amazing parallels between commanding an incident and commanding a jetliner. This is the fourth article in a multi-part series that looks at how the fire-rescue service can adopt the airline industries crew resource management system to improve firefighter safety and overall street-level operations ("helping Mrs. Smith"). CRM leadership and teamwork skills will be the topic of discussion in this article as they relate to human factors performance at emergency alarms.
The Risks
One only needs to consider what is at risk when a commercial plane takes off from the runway to begin appreciating the similarities between our professions. For starters, there are usually many souls on board an aircraft making the life risk element very significant. Among the lives placed in harm's way are those of the entire flight crew (this prospect adds an interesting and personal dimension to preventing a crash).
If the plane were to go down in a populated area, the lives of still more people would likely be lost. Property loss can be outrageously high, considering the expense of an airplane and collateral property damage that generally occurs. Negative environmental impact does happen when a plane crashes, especially if leaking fluids make it into waterways or smoke liberated from ensuing fire pollutes the air. Finally, the good name and business reputation of an air carrier are at stake when a crash takes place.
These risks are exactly the same in our business; so therefore, we need to take advantage of the human factors performance improvement research developed by the airline industry to be able to "prevent harm in our communities."
As was painfully pointed out in the opening vignette, the pilot was too stubborn or perhaps too egotistical to simply take advice from his own co-pilot (team member). Does this dilemma sound familiar to anyone out there in the fire-rescue service? Perhaps you've heard statements like, "Need I remind you that there are five trumpets on this collar?" or maybe "What part of 'I'm in charge' don't you understand?" I can remember working for a colorful old captain who would boldly state at lineup that, "All working fires must be knocked down before the chief arrives." He was serious about his stance, even though battalion headquarters was just about two miles away from our company.
Another personal example of the "fighter pilot/I'm the only one who can handle it" mentality was the repeated behavior of a battalion chief that I would occasionally have the opportunity to drive. Great guy, but he never called or allowed me to call for a second alarm. He was supportive with the requests for assistance, as long as it was a special call or task force alarm, never a second.
One day, I was brave enough to suggest (actually, to urge him) that we desperately needed a second alarm at a large apartment fire that had several "jumpers" coming out of the rear windows. He responded, "Call for a task force, wait a few minutes and repeat the message for another task force," to get the appropriate level of help.
Boy, was I confused at his directions, but I followed them to the letter. Back in quarters that same day, I asked why not call for a second? Without thinking about the response, he stated that a second alarm gets the deputy fire chief to respond and why would I want to screw up his fireground?
The Commander Is In Charge
CRM does not ask the captain of an airplane to give up command. In fact, it reinforces the concept that the captain has the legal and complete authority to fly the aircraft as he or she sees fit. The process does not turn the cockpit into a "majority rules" or "vote your conscience" type of system to make a decision. CRM simply states that good leaders must always be able to effectively use various types of input from the crew that support them on the flight line. In other words, the captain becomes the team leader and uses all available information to avoid problems.
The same rule needs to be applied to commanding a fire or rescue incident. A good incident commander (IC) must take appropriate input and use such information to make the best decisions for the circumstances. An excellent IC develops a system to seek out critically needed information to make the best call.
The leadership and team-building elements of CRM simply ask incident commanders to set aside their egos and use the human capabilities that are readily available. The final decision is the commander's, no argument, but enlightened bosses know how to effectively use all types of input to manage the system. Leading-edge fire departments teach their members how to approach the bosses with information without being offensive or viewed as troublemakers (this is a two-part process).
A looming CRM principle is that "to err is human." I would suggest that the entire Firehouse® readership agrees with this premise. Understanding the power of this statement leads me to point out that most likely the incident commander will be the last one to realize that he or she has made a mistake or omission. This statement is logical, because if the IC knew that a miscue was committed, he or she would have avoided it in the first place. Therefore, it is very likely that someone other than the IC will recognize that an error has been made at the command level, such as the problems pointed out on the ill-fated flight by the co-pilot in the opening case study.
If the pilot had listened to his "teammate," a major disaster would have been averted. Redundancy at the incident command post (just like the concept of always having two pilots on the flight deck) makes sense. The notion that "two heads are better than one" helps the IC avoid or trap mistakes long before they have a chance to produce negative consequences.
CRM Applied
As I was flying across our country recently, I had an interesting experience while waiting for the plane to taxi out to the runway. The main cabin door had been shut for take-off and the final check-off had started in the cockpit. Without warning a very loud bang occurred and the plane rocked back and forth (even more noise and movement then an Atlanta ground crew can make). The next action that I observed, was the pilot leaving the cockpit (real trouble I thought?) and helping the flight attendant open the once secured doorway. He quickly exited the plane. After about six or seven minutes the pilot returned and the first officer left without much delay.
Once the cockpit crew returned to their places and the doorway was secured, the public address system clicked open. The captain announced that the auxiliary air conditioning system high pressure hose had broken and was wiping about the body of the aircraft. He went on to say that he and then the co-pilot had visually inspected the entire exterior of the plane. He then indicated that the results of the two separate inspections indicated that no damage had been caused by the failed hose. The total result of the air conditioning hose failure was the noise and the abrupt rocking of the aircraft. The two-team members made a separate and independent evaluation of an abnormal situation and agreed on the proper course of action. The good news was that we were ready to taxi out to be number 20-something for take-off on runway 27.
In Summary
It seems like the culture of the fire-rescue service often is the greatest barrier to improve operational conditions. We must identify and use the "best practices" for our industry or at least give an honest chance for success. The crew resource management process is one that we must take seriously if we are to improve firefighter safety statistics.
I submit that this concept is not a "flash in the pan" or a fad. The airlines took on this mission in December 1978 and have not looked back. In fact, they describe the CRM system in its sixth revision phase.
In most incidents involving firefighter injuries and/or fatalities, the most frequently reoccurring contributing factor is human error. It just makes good, common sense to use tools that are available to improve human performance and lower these alarming, tragic statistics. The CRM concept is such a powerful tool, and fire-rescue officers should consider using it in administrative settings as well as at incidents. Just think about it, maybe your secretary is able to head off your next big administrative mistake, saving time, money and your job.
Providing redundancy at the command post with a second command-level (trained and experienced) officer/member may seem difficult for smaller organizations to obtain. Some departments have approached me from time to time about the fact that they do not have enough personnel to handle "two-in/two-out" requirements, much less build a command team.
My suggestion is to develop a plan that provides for enough personnel to perform the task at hand. Those departments need to consider mutual aid, automatic aid or expanding internal resources (new positions, recruiting volunteers and perhaps even police assistance). Hiding from this powerful process or other firefighter safety tools because of barriers that can be resolved should not be tolerated.
Finally, the American fire-rescue service needs to agree upon and document the minimum set of skills, knowledge, behaviors and experience that an incident commander should possess. This information should find its way into various national standards for implementation and training into our business. The standards to be a fire-rescue IC should have specific re-certification requirements, much like the annual simulated flight checks that the pilots go through to prove their ability to be able to fly commercial airplanes.
The next time you fly the friendly skies, think about the type of pilots that you want at the controls to deliver you safely to your destination. I bet you want certified and up-to-date individuals at the controls. Until next time, be safe out there.
Dennis L. Rubin, a Firehouse® contributing editor, is chief of the City of Norfolk, VA, Department of Fire & Paramedical Services. He previously was chief of the Dothan, AL, Fire Department. Rubin holds an associate in applied science degree in fire science from Northern Virginia Community College and bachelor of science degree in fire science from the University of Maryland, and is enrolled in the Oklahoma State University Graduate School Fire Administration Program. Rubin is a 1993 graduate of the National Fire Academy's Executive Fire Officer Program and holds the national Certified Emergency Manager (CEM) certification and the Chief Fire Officer Designation (CFOD) from the International Association of Fire Chief (IAFC). He serves on several IAFC committees, including a two-year term as the Health and Safety Committee chair.
