Cultures, countermeasures & the introduction of CRM

Transcription

1 e-newsletter: May 30, 2008 Counter Culture Cultures, countermeasures & the introduction of CRM By Billy Schmidt Firefighting operations occur within the context of many cultures: the culture of the fire service; the culture of specific fire departments, including the battalions, shifts and crews; and the culture of the individual firefighters themselves. In general, most aspects of fire service culture increase the probability of safe and effective operations but some may actually increase risk. In this article, I ll discuss the positive and negative potential for each culture, as well as what we can do to counteract behaviors and errors that, if left unchecked, may ultimately lead to tragedy. Fire Service Culture Figure 1 below shows some of the positive and negative aspects of the fire service that influence the safety and effectiveness of fire operations. Old traditions, such as autocratic leadership (domineering or micro-managing), individualism (freelancing firefighters) and a heavy reliance on new technology and protective clothing can lead to error. Conversely, flexible and democratic leadership, teamwork and a healthy amount of skepticism regarding the use of technology and the capabilities of protective clothing can reduce risk and errors.

2 Figure 1. Influences of the fire service culture on error (based on Robert Helmreich s National Culture Model). Note: Robert L. Helmreich is a professor of Psychology at the University of Texas, where he is the principal investigator of the Human Factors Research Project, which studies aviation safety. He has developed strategies for error management, where crew resource management is the foundation and the vehicle for teaching these strategies. Fire Department Culture Fire departments and firefighters talk a lot about the value and importance of safety, but many departmental cultures don t support the safety standards in actual practice. It takes the entire fire department (firefighters and leaders) working together to complete the puzzle that results in a safe operation. Specifically, fire departments must accept and follow operational policies, recognize the importance of sustained training, have access to needed resources, and facilitate communication between officers and firefighters. Only after these things are accomplished can any department increase the probability of safer and more effective operations. Fire department leaders are role models; therefore, they must demonstrate and reinforce the safe practices listed above if they want their department s culture to change for the better. If leaders only talk about safety without acting safely themselves, the probability of errors and accidents will increase.

3 Figure 2 below shows how fire department culture can affect those who actually perform the tasks every day the firefighters. Figure 2. How fire department culture can affect individual firefighters (based on Helmreich s Organizational Culture Model). Firefighter Culture There are a number of negative behaviors (unsafe acts) possible in an individual firefighter s culture, as shown in Figure 3, that can lead to error. Some may include personal limitations, such as poor physical fitness, weak communication skills or inadequate job performance skills and abilities. When combined with other conditions, these behaviors, which are a firefighter s personal responsibility, can break down a safe and effective operating system (culture).

4 Figure 3. Firefighter behaviors that can lead to error (Based on Helmreich s Crew Culture Model). An Error Management Model: Strategies & Countermeasures Human error is inevitable. But when error meets expected or unexpected threats (big red flags), and combines with latent (organizational and individual) and active conditions (unsafe acts), the potential for accidents or injury increases. As part of their operational duties, firefighters can employ strategies, or countermeasures, to create safer, more effective fireground operations. This set of error countermeasures can be described as the three layers of defense, which are shown in Figure 4 below. Naturally, the first layer is avoiding errors, followed by trapping developing errors before they occur and lastly, mitigating the consequences of any errors that weren t trapped. These countermeasures can apply to any situation. For example, consider a fire crew operating inside a residential structure fire when they re overcome by smoke and high heat because shutters weren t removed from the windows. Gathering information from a good size-up and receiving a quick briefing from the company officer (CO) would ve helped the crew avoid this error altogether. The crew practicing situational awareness and communicating with their CO could ve enabled them to trap the error before it occurs. Since the crew failed to use these two layers of defense, they should employ the last layer, which would involve using the appropriate tactics and teamwork to mitigate the consequences of an inadequate size-up and poor communication.

5 Other countermeasures that can help prevent accidents from occurring include employing early command and control, practicing accountability, briefing the crew and following standard operating guidelines or even personal strategies and tactics, such as carrying a flashlight or personal tool. Figure 4. Helmreich s Error Management Model CRM: When It Started & Why It s Important For many years, even as technology became more reliable, the aviation community continued to experience a high rate of accidents. The environment, including new technology, aircraft design, training and consumer expectations, became more demanding. Consider the following incident: On Dec. 28, 1978, United Airlines Flight 173, a DC-8 aircraft with 8 flight crew members and 181 passengers, was traveling to Portland, Ore. The commercial flight took off on time with a textbook departure. The flight crew consisted of a captain, a first officer and a flight engineer. The journey to Portland was uneventful, until the plane was prepared for landing. Instead of the usual three down and green, which indicates the landing is gear down and locked into place, the nose gear light did not illuminate. In the cockpit, the captain radioed Air Traffic Control to report the problem and request a holding pattern to buy time to resolve the issue. The captain then completed his checklists and procedures to ensure he had taken all the proper steps to prepare for landing, but the light still indicated that the nose gear wasn t locked. The captain continued in his holding pattern around the Portland Airport until the situation worsened. The plane had only 58 minutes of fuel remaining when the pattern began, and his time had run out; the fuel tanks showed empty with the airport 6 miles out. One by one, the aircraft s four engines sputtered and flamed out from being fuel starved. Ironically, the flight engineer and first officer had warned the captain several times during the flight that the fuel supply was running low, but the captain took no action. An airplane with a mechanical malfunction, but probably still capable of landing safely, became fuel starved and fell from the sky, killing 10 people and injuring 23 others. It was later discovered that the nose gear operated correctly, but the $ 0.59 indicator light bulb was burned out. Two flight crew members and 10 passengers were killed. The National Transportation Safety Board s (NTSB) investigation of this incident, as well as many others, identified a culture and work environment in aircraft cockpits that, rather than facilitating safe flight operations, may have contributed to accidents. The NTSB believed that the UA Flight 173 accident illustrated a recurring problem in aviation: a breakdown in cockpit management and teamwork during an unexpected event in flight operations. The flight crew focused on a gear malfunction and failed to fully comprehend the significance of the situation, communicate with each

6 other or make critical decisions in a timely manner. After this incident, the NTSB and aviation community as a whole concluded that flight crews the humans in the cockpit flying the airplane represented the weak link in aviation safety. To combat this problem, the aviation community developed the concept of crew resource management (CRM). Drawing on research by the National Aeronautics and Space Administration (NASA), the NTSB recommended that the Federal Aviation Administration (FAA) and the airline industry adopt methods that encourage increased training in flight crew teamwork, focusing on communication, decision making and task allocation in a stressful environment. Today, CRM is practiced in other high-risk professions, including the military, the nuclear power industry, offshore oil drilling, the railroad industry and the field of medicine. Firefighters share common ground with these professions as successful fireground operations also require clear communication, team cohesiveness and critical decision making in a rapidly changing environment. So why shouldn t the fire service use CRM to reduce errors and operate safer and more effectively? We should! In my next Firefighting-360 column, I ll discuss the components of CRM and how they can help the fire service manage errors through improved training and skills in communication, teamwork, situational awareness, task allocation, critical decision making and debriefing. Until then, get prepared, be ready and stay safe! References Helmreich, R.L. (1998). Error management as organisational strategy. In Proceedings of the IATA Human Factors Seminar (pp. 1-7). Bangkok, Thailand, April 20-22, Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), Heinrich, D. (2007). Threat and Error Management for Business Aviation. In Proceedings of the Flight Safety Foundation Workshop. Atlanta, Georgia, October 17, Billy Schmidt is a district chief assigned to the 3rd battalion with Palm Beach (Fla.) County Fire Rescue. An adjunct instructor for the department s Training and Safety Division, he has a bachelor s degree in Human Resource Management and an associate s degree in Fire Science. Copyright Elsevier Public Safety and Fire Rescue Magazine Terms & Conditions Privacy Policy