"In so many areas of life, you need to be a long-term optimist but a short-term realist. That is especially true given the inherent dangers in aviation. You cannot be a wishful thinker. You have to know what you know and don't know, and what your airplane can and can't do in every situation." That quote is from Captain Chesley “Sully” Sullenberger. Substitute “firefighting” for “aviation” and “available resources” for “airplane,” and you have a quote that would serve any incident commander (IC) at a fire scene well.
Aviation has transitioned from a daredevil pastime to the safest mode of transportation. Yes, there are still terrible air crashes, but overall, commercial aviation is the safest way to travel. According to Flight Global, an industry newsletter, in 2014, aviation was twice as safe as it was in 2004. It is 5 times safer than it was in 1984, 10 times as safe as in 1974 and 300 times safer than in 1950. I think you would agree that this is an amazing aggressive record of risk reduction.
Aviation changed its culture to make this safety improvement. So are there risk management lessons that the fire service can learn from aviation?
Comparing flying and firefighting
The fire service has already adopted some concepts from aviation. Many of you are no doubt are familiar with crew resource management (CRM) and situational awareness as they apply to the fire service. (Check the Suggested Reading section at the end of this article for more information on these topics.)
The fire service needs clear rules of engagement for high-risk operations. Aeronautical engineering informs flying; fire science needs to inform fireground operations. Pilots get frequent check rides to monitor their proficiency. Why not the same for ICs? The purpose of proficiency checks is to identify needed training, not to discipline.
Aviation is a highly regulated industry with procedures that need to be followed carefully before an aircraft moves. Freelancing is definitely not allowed. Imagine a pilot taxiing an airliner to the runway without clearance. The fire service needs to have a zero tolerance for freelancing.
The top three priorities of flying are aviate, navigate and communicate. Three priorities of fireground command are manage, plan and communicate. Management of the incident includes span of control, accountability and scene safety. Planning includes gathering information, making forecasts of future events, and planning actions using strategic tools. Communicate includes making sure that everyone is aware of the plan and safety zones.
When things start going wrong in the air, remember to fly the aircraft. When things start to go wrong on the fireground, remember to manage the incident.
Captain Sullenberger had a fortune from a fortune cookie taped neatly in his Jeppesen Airway manual for years. It read, “Better a delay than a disaster.” In trying to meet the response guidelines of NFPA 1710 and 1720, some firefighters do not wear seatbelts or complete PPE and figure they don’t have time to do a 360. Would it make you feel secure if the captain of your flight skipped checklists in order to maintain an on-time schedule?
Crew resource management
The road to a safer aviation industry began in earnest after the worst air disaster in history. On March 27, 1977, two 747s crashed in Tenerife, Canary Islands. A KLM 747 was cleared to hold on the only runway while a Pan Am 747 taxied on that runway. The KLM captain thought he was cleared for takeoff. The co-pilot apparently did not want to contradict a senior captain. As a result, 583 people died. Out of the tragedy came crew resource management, which gave flight crews the ability to question the actions of a captain without fear of retribution. Previously, the captain was beyond question in the hierarchy. Substitute fire chief for captain and you have the structure of some fire departments. CRM is a team approach to danger recognition and workload allocation. Initially, some pilots derided it as “charm school,” but it has proven itself a very effective tool for accident reduction. What would things look like if the IC and another senior officer were trained to manage the scene together within the hierarchy like a captain and first officer?
In the cockpit, there is a clear division of functions. The Pilot Flying (PF) is responsible for flying the aircraft, even if the autopilot is on. Any functions other than flying the aircraft are handled by the Pilot Monitoring (PM). The transfer of roles is done verbally with confirmation. The PF looks at the PM and says “your aircraft.” The PM responds “my aircraft.”
What might this look like on the fireground? The IC Managing would turn over control to the IC Supporting any time he or she needed to do something other than actively managing the scene. This may be as simple as taking a bathroom or food break. “Your fireground” and “my fireground” would positively transfer control. At smaller incidents, the incident safety officer (ISO) could fill this role. Of course, the functions of the ISO still need to be done. At a larger incident, someone who has no other responsibilities would fill this position. In the cockpit, the flight plan is the agreed upon course and on the fireground it’s the incident action plan.
Human factors analysis
After every aviation accident, there is an investigation that goes beyond what happened and looks at why it happened. What was the crew’s state of mind prior to the accident? Did fatigue, distraction, or any other human factors play a role. Saying that the aircraft was too low and struck the mountain is not sufficient any more then saying that firefighters were in the fire building when it collapsed without looking at why they were there at that time.
Five dangerous attitudes
The FAA commissioned a study by Embry Riddle Aeronautical University. They discovered that five attitudes keep showing up in incidents involving poor pilot decision-making. I have added examples of similar attitudes that some in the fire service have and the antidote to those attitudes.
1. Anti-authority: “You can’t tell me what to do!”
Fire service: “Forget what they told you at the academy, kid, we’ll teach you how we do things here!”
Antidote: “We are disciplined professionals.”
2. Impulsivity: “Do something quickly!”
Five service: Quick attack mode without doing 360 first.
Antidote: Gather information quickly and make an informed decision.
3. Invulnerability: “It can’t happen to me (us).”
Fire service: “We have been doing it this way for years without any problems.”
Antidote: “It CAN happen to us! We need to always be looking for ways to manage risk better.”
4. Macho: “I can do this!”
Fire service: “We can do anything!”
Antidote: “Let’s see how we can do this safely.”
5. Resignation: “What’s the use?”
Fire Service: “This is a dangerous job. We just have to accept 100 LODDs a year, and we can’t do anything about it.”
Antidote: “We can protect our own better. There is always room for improvement.”
Confirmation bias is the human characteristic of searching for and interpreting information in a way that confirms one's preconceptions. On Sept. 3, 1989, Varig flight 254 to Belem ran out of fuel and crashed in the Amazon jungle. The crew had entered the wrong heading into the flight computer and ignored any evidence that they were not where they thought they were, including common sense observations, such as the location of the setting sun. They were convinced that they were close of Belem when in fact they were 600 miles away. The parallel in the fire service is being convinced that the fire is on the ground floor when in fact it is in the basement.
Before the crew of an aircraft moves from the gate, takes off or lands, a checklist is completed. They are also used in any emergency. Would the fireground be a safer place if the IC and co-IC completed a quick checklist before committing firefighters to an interior attack? A little known fact is that even before he became famous for the "Miracle on the Hudson," Captain Sullenberger was consulting with hospitals on CRM and checklists to make surgical procedures safer.
One of the characteristics of a high-reliability organization (HRO) is the preoccupation with failure. Pilots are constantly checking instruments and looking for a place to land if the engine(s) suddenly quit. Would the fireground be safer if the command team was always thinking about what could go wrong and what they would do about it?
The fire service is historically not an HRO. Reading NIOSH fatality reports reveals a small cluster of issues that are repeated over and over. Following a tragic airline disaster, imagine the airline industry saying, “Catastrophic airline crashes are the unfortunate cost of doing business in a high-risk environment.” Raise your hand if you would be comfortable flying your family across the country.
Every time there is a crash, it is thoroughly investigated, even going so far as to rebuilding the aircraft in a warehouse. The FAA, the manufacturer and the airline unite with a single mission: To make sure what caused the crash never happens again. It is this attitude, that passenger fatalities are unacceptable, that has made air travel as safe as it is. The other component is that after the cause is determined, action is taken. The aircraft manufacturer may change the design of a part or system, change a maintenance procedure, or make some other modification that will make their aircraft safer. Airlines will change crew training and supervision because of an accident. The FAA will send out Safety Alert for Operators (SAFO) as needed. The purpose of all of these measures is to make sure that everyone affected knows what to do in order to make sure that the accident isn’t repeated. The fire service has a way to go in this regard. Battalion Chief Mark Emery looked at NIOSH reports and found that the same causes were present over and over again (“13 Fireground Indiscretions,” Firehouse, March 2006). There are no new ways to crash an airplane. There are no new ways to kill a firefighter. Additionally, Chief Eric Tomlinson wrote an excellent article in the April 2016 issue of Firehouse about using aviation-like accountability on the fireground. There are clearly more things that can crossover.
Call to action
Quote from Highest Duty by Captain Sully Sullenberger: “I am trained to be intolerant of anything less than the highest standards of my profession. I believe air travel is as safe as it is because tens of thousands of my fellow airline and aviation workers feel a shared sense of duty to make safety a reality every day. I call it a daily devotion to duty. It’s serving a cause greater than ourselves.”
The old days of cowboys in the cockpit were certainly more exciting and fun than today with compliance being the criteria upon which pilots are judged. That being said, I don’t think anyone would seriously advocate for a return to “the good-old days.” Across the fire service, we need to make sure that we are, at all times, disciplined professionals. No more freelancing cowboys or non-compliance with safety rules. Adopt CRM whole-heartedly. Make training and recertification mandatory. Just because someone has been doing something for 30 years does not automatically make it a best practice.
How can you be an agent for change? Gandhi said, “Be the change you want to see in the world.”
Firefighters: Wear your PPE and fasten your seatbelt. Know and follow your departments SOPs. Do not speed or race other companies to the call. Be prepared to respectfully point out safety concerns to company officers and chiefs. Seek out training opportunities.
Company officers: Use CRM principles. Make sure your crew follows SOPs. Lead by example. Bring up safety concerns immediately.
Chief officers: Make sure that cultural practice is in accordance with your SOPs; if not change one or the other. You are responsible for your department’s culture—own it!
One of the maxims of aircraft accident investigation is, “There is always more than one cause.” Generally, there is a chain of events that lead to an accident. If any one of them had not occurred, the accident would not have happened. Redundancy, checklists, warning systems and constant monitoring are employed to break the chain that could lead to an accident. An example of this we already use is cross-checking your partner’s PPE before entering the hazard area. Review your department’s procedures to see if you can insert other chain breakers into your operations.
Everyone should review Close Calls and NIOSH reports to see what you can do to prevent a repeat. Initiative and creative problem solving should be encouraged. The question you should be asking yourself before making a decision is, "Will this action increase or decrease firefighter safety?"
Is the fire service ready to make the same evolutionary change? The job is exciting and fun without rounding safety corners. We owe it to those who are counting on us at home, at the fire station, and on the streets to make sure that every call is a roundtrip for everyone. Stay safe!