Crew Resource Management Notes PDF.pdf

Crew Resource Management for the Fire Service by R. Okray, T. Lubnau II (2004) Robert Diggs Crew Resource Management for the Fire Service Chapter 1 Crew Resource Management (CRM): Purpose of this book - Our purpose for writing this book is to transfer concepts that we learned from other industrie...

Crew Resource Management for the Fire Service by R. Okray, T. Lubnau II (2004) Robert Diggs Crew Resource Management for the Fire Service Chapter 1 Crew Resource Management (CRM): Purpose of this book - Our purpose for writing this book is to transfer concepts that we learned from other industries to the fire service. - CRM was first implemented officially at United Airlines, in the late 70s. Called CLR (command, leadership, resource management). - Improvements in protective clothing, SCBA, fire knowledge, additional equipment, improved techniques, etc. do not seem to affect 100 firefighters lost each year. Most of what kills our firefighters are human issues not technical issues. - Normal safety programs deal too much with technical-based solutions. They teach us how to do our jobs safer. They established officer positions to monitor how we do our jobs. The shoot safety slogans at us like BBs out of a shot gun. - Effective safety programs not only need to address the technical and organizational sides of our jobs, but also the behavioral/human side. - Safety is often subjective and not objective. - Many "safety infractions" are based on a FFs perceptions and as such are sometimes very personal, a gut feeling even. - It is often a perception of risk more than an actual violation of SOPs or appropriate work practices that turns out to be the contentious item on the fire ground. - Gut feelings can often be a FFs savior when all other tools fail him. - An action is easily seen and measured while the effects of a safety item are often difficult to measure, and the prophecy of doom may or may not be realized whether we change our operations or not. - Theory of Risk Homeostasis - no matter how good you train your FFs or how good their equipment is, they will still get injured or killed. All humans have their level of acceptable risk. We always, subconsciously, accept the level of risk we are comfortable with. - The problem with telling FFs, "be safe" is that they have a pretty high level of risk acceptance, and they like it that way. 1 - Only way to affect FF deaths and injuries is by modifying how we work together, especially under stressful conditons. - It is normal for people to summarily dismiss new info that they do not understand fully, that they disagree with, or that they think will never work in their particular area. - Each FF is only one person. If all FFs are taught, expected, and do work together, the sum of their individual parts become much greater than just them together. - CRM optimized a crew's interactions in times of high stress and little information, where the lives of many people were at stake. - The aviation industry discovered accidents were associated with various failures in command, communications, and crew coordination. - A focus on the human factors affecting firefighting will prevent injuries and death. - The third phase of the federally mandated Tri-Data study, Wildland Firefighter Safety Awareness Study, adopted 86 goals and more than 200 specific recommendations for improving the organizational culture, leadership, human factors, and external infuences that affect wildland FF safety. - Campbell County FD in northern Wyoming was probably the first in the nation to adopt a comprehensive CRM program for its department. - The Tripod of Success 1. Fire - what is the fire doing, where is it, etc. 2. Plan - what are we doing, is it affecting the fire or is the fire affecting the plan? 3. People - CRM skills, interactions, and teamwork, how are they implementing the plan? - CRM concentrates on improving the people side of the tripod. By strengthening this leg the plan leg is also improved and stregthened. - If the operation is normal (standard) the outcome is usually positive; but, if something unexpected (non-standard) occurs that requires high levels of interaction and teamwork, the outcome could be negative, or unsuccessful, even deadly. - James Reason developed a model on how CRM can be used as an error trapping system. - Swiss Cheese Error Model 2 - For a novice FF, the holes in the cheese are larger than someone who has lots of experience. As we gain experience, some of the holes get smaller while others like, preconceived notions and hazardous attitudes, may get larger. Chapter 2 Organizational Safety Culture - A safety program is another in an endless series of initiatives designed to make the individual FF aware of the risks inherent in firefighting. On the other hand, a safety culture grows from the very roots of the organization. - Phase III of the Tri-Data study noted the needs for a safety culture in the wildland firefighting environment. Authors of the study found a pervasive cultural disregard for safety concerns. - Goal 2. A code of conduct should be established in which employees should have both the right and the obligation to report safety problems, and to contribute ideas on their safety to their supervisors. - A military operation may be of such strategic value that a 10-15% soldier mortality rate is acceptable. - Organizations in America have found that there is a definite chain of events that leads to incidents (small, no injury, little cost problems), accidents (some injuries, more cost), and fatalities. - The current safety program mentality attempts to convince employees to be safe, but many may not give them the tools they need to report unsafe activities and behaviors. - Safety program mentality usually does not address the needs of an emergency service department that immerses itself in risk every time the department performs. - Commercial aviation industry saw a 70-80% drop in accidents and incidents in a very short time after implementing human factors training. - CRM only works effectively in functional organizations with technically proficient personnel. Functional organizations must have continuously supported technical proficiency, individual responsibility, accountability, and discipline. - In the fire service, we can never become independent of human behavior. We'll never become error-free, injury-free, or fatality-free. 3 - By using CRM principles, we are providing barriers to the proliferation of errors. The more people we have watching for errors (barriers), the fewer unbroken error chains exist and the fewer and less severe are the problems that occur. - Power structures, organizational inertia, budgetary constraints, and fear of change all act as barriers to successful implementation of a safety culture. - The biggest barrier to implementation of a culture of safety is the power structure in the organization. - The dissipation of pure authority from the leader of an organization tends to be the biggest impediment to the adoption of a safety culture in departments without such a culture. - Operational Inertia - People do certain things, certain ways, time after time. The reason for doing things is lost but tradition is still there. - Only a dedicated management that has taken the time to market the culture to the organization will succeed in changing the attitudes of the culture. - Safety culture is the predominant culture in the aviation industry. Those who disregard safety for the bottom line are termed rogue operators and are the subject of much disdain. - Fives important steps in creating a culture of safety: 1. 2. 3. 4. Organization must build trust among its members. Organization must adopt a non-punitive policy toward error. Organization must demonstrate a willingness to reduce error in the system. Organization must provide training in error avoidance, detection, and management strategies for crews. 5. Organization should provide training in evaluation and reinforcing error avoidance, detection, and management. Clear, honest debriefing of incidents serves as a perfect tool for meeting this goal. Chapter 3 Mission Analysis and Planning - The formula for successful fireground operations contains many elements. Each element will determine the results of the operations. The formula is the operation. The result is the answer. - We begin mission analysis and planning by gathering our previously known information. - Other elements in the formula include experience, judgement, training, team trust and strength, resources, and size-up quality. 4 - An important change in the formula rules as they relate to the inputs is that any individual can be a resource with the correct information to input into the formula. - For the team as a whole to be effective, the team must be knowledgeable in what their duties are for their own task, to the strategy, to the operation, and to the other teams. - NASA tested 7500 flight crews and determined that the two most significant factors in the promotion of good CRM principles were: - the captain giving a thorough briefing the first officer (subordinates) making inquiries and advocating his/her position - Fire service can do the same: - always give a crew briefing and make sure instructions are understood always monitor, inquire, and advocate your position no matter what your level in the organization. - Briefs should include: - desired results of the operation expectations of individuals, teams, etc. responsibilities of individuals, team, etc. available resources micro-training opportunities encourage input from team members positive, proactive attitude accountability - Wildland community is very good at defining desired results. These goals are written down and every attempt is made to support them. - Desired results allow everyone to see what the results of all their hard work should be. Without addressing the desired results, the operational plan sometimes gets off course, and we achieve something we did not set out to achieve. - There will be times when the exact responsibilities of teams and individuals will not be apparent to everyone involved. Better to address those outright before running into problems later on when emergency conditions exist that make planning and communications more difficult. - If you want someone to take the responsibility for a certain operation, make sure you tell them that up front and also tell them what kind of feedback you need. 5 - Make sure the teams know what is available and how long it will take to get there; it will definitely change their tactical plans and it will help to lighten the stress on FFs. - Many injuries, fatalities, and unsafe acts are due to standard strategies and tactics being applied to non-standard incidents or ones without the proper resource support. - Everything we do on an incident adds to our knowledge and experience base. - We must strive to create an atmosphere where people will learn the right procedures, and keep the wrong ones in perspective. - Using the stress of the job provides real life training, if we take the opportunity to use it. - The climate of micro-training opportunities is set prior to the incident, during the incident, and even after the incident. - Just like the flu, a negative attitude has the ability to cripple your station’s ability to do its job. Conversely, a positive attitude can be the energy source that propels you and your team to the top of its game. - Your positive attitude, coupled with a proactive personality, will make your team successful and excited to be doing their job. - People also like to follow proactive leaders who are grounded in reality at least a little and people who take personal initiative to make things better for themselves, their team, and the situation. - FFs are usually most at risk for emotional problems when they feel helpless and are not doing something. - Never employ busy-work tactics in an attempt to "keep the crew busy." Using the dig-a-holeand-fill-it-up mentality leaders can destroy morale, a team, and an individual. - Lazy leadership should be held accountable by the team and by the leadership of the department. - Safety is not a part of the operation, it is the operation. - FFs are often caught up in the adrenaline of the scene and their can-do attitudes and perform unsafe operations under the pretext of being on-scene, and therefore they must do something. - We must look at our operations with regard to FF safety by reviewing three points: 1. We are always dealing with the unknown. 6 2. The likelihood that a problem will arise, or the potential that a problem will arise. 3. Seriousness of the hazard or problem. - We can make efforts to reduce the weight of the unknown by implementing stronger building codes, inspection programs, and preplanning duties. - Mission analysis and planning tools are directed toward safety and not operational effectiveness. - While we can agree that the unknowns we deal with are a factor in the number of FF injuries and deaths, we must also agree that FF risk analysis and risk acceptance are direct and contributing factors. - Cultural biases, gender, education, life experience, mental attitude, personality, and many other items figure into our thoughts of what level of risk we could or would accept. - "...if we wish to make an attempt at reducing [accidents/injuries] ... an attempt should be aimed at reducing the level of risk accepted..." Therefore, as FFs and leaders, we must help FFs adjust their levels of risk acceptance to a level that is both effective and safe. - We need to accept the level of risk that: - we can accept without injury we can correlate with the expected gains we can support - Lessons learned in regards to the level of gains: - we should not trade lives for gains, we're not the military we must continually adjust our gain expectations to the reality of the situation. - Many times, our risk-versus-gain analysis takes on a silver lining view that looks on at the good things and not the bad. - In our risk-versus-gain analysis of our incidents and operations, remember: 1. Everyone's perceptions of the risks and gains are personal; and therefore, unpredictable, hard to explain, and unknown to others. 2. Some risks are too great no matter the expected gain. 3. Continually adjust the risk-versus-gain analysis to match the situation. 4. There is a fine line between too much risk and not enough risk. Always err on the side of less risk if you are unsure of yourself, partner, or team. 7 - Good teams always have a plan, a backup plan, and are working on the backup-backup plan. Chapter 4 Situational Awareness - Situational awareness is the skill of becoming aware of the situation as it actually exists. - Situational awareness training teaches the signs and symptoms of loss of situational awareness. - To fight a fire, you need to be aware of three things: the fire, the plan, and the people. - The skills necessary to maintain situational awareness include monitoring, evaluating, anticipating, and considering. - Thinking ahead of the fire is the key to maintaining present situational awareness. - To maintain situational awareness, the most important thing to focus on is what is right, not who is right. Crews need to strip themselves of rank, bias, prejudice, cultural, and communication issues, and focus on the situation at hand. - Clues to the loss of situational awareness: - fixation overconfidence distraction information overload communication low stress level high stress level lack of experience fatigue/illness reliance on machines unresolved discrepancies professional attitude looking for ghosts gut feeling - Fixation or tunnel vision is one of the most common incidents on the fire scene. The responder is faced with a dire situation and the focus naturally narrows down to the most serious situation facing the team. 8 - One of the first incidents that led to the development of CRM, was the crash of an Eastern Airlines jet into the Florida Everglades. - The first step we take to avoid tunnel vision is to make sure that the command officer remains at the command unit. - When command is no longer at the command unit, that fact is a clue to all FFs on scene that overall situational awareness is being lost, and every FF should take extra precautions to understand the situation. - Second step to avoid fixation is to appoint a safety officer, whose sole purpose is to ensure all operations are conducted safely. - Third step is to provide time prompts from dispatch or an on-scene timer. - Situational awareness is the correct perception of the situation as it actually exists. The "theory of the situation" is what a person assumes to be true for a specific period of time. - The belief that one knows exactly what is happening and is in absolute control of the situation is a type of fixation that lulls the FF into a sense of false security. - Information overload was recognized as one of the problems facing FFs by the Tri-Data study. - First step in avoiding loss of situational awareness caused by distraction is to minimize the level of distractions. - Aviation industry enacted the "sterile cockpit" concept to limit communications to only those related to the task at hand during certain phases of a flight. - Second step is to train to recognize the distractions. - Last step is to develop a series of standardized protocols and checklists. - Doing the same thing the same way every time results in matched expectations and fewer distractions. - Timely information is needed to keep current on the situation, but information overload can be as devastating as not having enough info. - The human animal reacts to stress in a predictable fashion. As info overload increases, shortterm memory decreases. The human animal begins to rely on those memories stored in longterm memory. 9 - Over-learning is the deliberate process of over-training a task beyond the level of initial proficiency. Helps to avoid info overload. - study found a group that over-learned committed 65% fewer errors. - Strategy for decreasing stress in the less experienced FF is to pre-brief the situation. - The object of communication skills is to develop a shared mental model of the situation as it actually exists. A shared mental model is simply for all members to have the same mental picture of what is happening. - Those crews that have developed the shared mental model consistently outperform those crews that do not develop such a model. - Complacency is one of the major keys to loss of situational awareness on the fireline. - FFs heart rate: - 70-90 bpm appropriate stress level and is concentrating on what is happening. 90-110 bpm FF needs to take a few deep breaths and think about what is going on. >110 bpm with no exertion, take a few steps back, calm down, and get back into it - Overstressed FF is not aware of the situation around him. - Lack of experience comes in two varieties, personal and situational. - The inability to know what indicators are important and what indicators are not contributes to a lack of overall awareness. - Situational inexperience can affect anyone. - When two pieces of info do not match, something is happening that needs to be investigated. - One of the most important indicators of situational awareness is to look for what is not there that should be. (Looking for ghosts) - Your gut level perceptions do not suffer from mental filters, prejudices, or processing. -FFs are summoned to every type of emergency that can be created by man. Man has demonstrated an extraordinary ability to create infinitely variable emergency situations. - FFs are trained that the mere utterance of "ah shit" indicates a need for the extreme application of situational awareness skills. 10 -Next they are trained that they did not create the situation and the worst thing they can do is charge in and make the situation worse. - Next step is to break the situation into manageable tasks rather than being overwhelmed by the scope of the entire task. - Experience creates a mental file that FFs draw upon every call and use it to assess conditions and make decisions. - Under pressure people tend to revert to previous patterns of behaviors. - Training adds to a FFs experience by creating events that rarely happen in real life. - Training must stress repetition of tactics to be used in an emergency situation, since humans resort to long term memory to guide decision making in a stressful situation. - An individual's emotional and physical condition affects perception of the environment. - First step in maintaining situational awareness is to maintain control. - Key to maintaining control is to force yourself to take a step back from the situation, take a deep breath, and think to yourself, "what is really going on here? Am I seeing the big picture?" - Very often we will make a snap decision, on limited info, when we can make an informed decision on good info, if we take the time to figure out where we are and what we need to do. - Shedding tasks can be accomplished by delegating the tasks to another person, or simply putting the tasks on hold, and working on the most critical problem. - Another way of dealing with time-critical decisions is to preplan the response before the time critical event happens. (Two in two out example) - NASA Space Division has taken preplanning to an extreme. Every contingency is planned and anticipated. - If an action is taken, monitor the results of that action. - If a FF thinks a loss of situational awareness has occurred, the FF should revert immediately to the basics: - maintain control - fight the fire assess the problem in the time available gather info from all sources monitor the results - alter the plan as required 11 - fire-plan-people 1. what is the fire doing? 2. how is the plan working? 3. how are the people doing? - Short-term memory or working memory retains small amounts of info while we are using other thought processes. - Working memory is limited. We can store up to seven plus minus two pieces of information in a working memory. - Long-term memory is the storage center for info that may need to be retrieved at a later date but is not to be acted upon immediately. - The accuracy of long-term memory access depends on the frequency, recency, and relevance. - As an individual becomes more stressed, that individual's focus shifts from a group focus to an individual focus. And when a person is placed under stress, that persons working memory diminishes. - A person normally reverts to prior over-learned behaviors. This happens as a direct result of a person's working memory and reasoning processes breaking down when trying to think a way out of the stressful situation. - Chunking means putting the info in a relational group. The info constitutes one piece of info rather than several. - Training-in-context theory, you train as closely as possible to the way you play. Chapter 5 Communications - In a study of FAA data concerning aircraft incidents, more than 70% of the reports contained evidence of error in the transfer of information. - One of the most common communications problems was failure to initiate the information transfer process, 37%. - Another 37% was inaccurate, incomplete, ambiguous, or garbled messages. 12 - Other problems included failure to transmit the message at the appropriate time, message was either not received or was not understood, and a small portion, 3%, was classified as equipment failure. - Human factors issues related to interpersonal communication have been implicated in approximately 70-80% of all commercial airline accidents during the past 20 years. - CRM has a workable system of communications that includes inquiry, advocacy, listening, feedback, and conflict resolution. - The primary conclusion drawn from the study of aircraft accidents, was that most problems and errors were induced by breakdowns in crew coordination rather than by deficits in technical knowledge and skills. - Verbal information is passed face-to-face, on the phone, and over the radio. This is usually what people think of as communicating. - We tend to listen to the tone of the communicator's voice, the volume, the speed, and word selection. - Unusual incidents and situations tend to lock up our mental processes. - We become so casual or uninvolved in our defined speech patterns that we speak without thinking. - Verbal communication has become standard, stock phrase, and does not have the intended cognitive processes that should accompany it. - In the absence of other forms of communication, we use our perceptions to interpret what was meant. - You must apply non-verbal cue to the verbal cues to come out the complete meaning of a message. - Symbolic communication consists of our appearance and what we keep near us in the way of items. Can be easily staged and often misinterpreted by others. - Symbolic communication runs deep in the fire service. Department shirts, hats, etc. - Like a computer, people are somewhat predictable in the way they will communicate. - Main reason we communicate is that we want others to share the exact meaning for a thought, feeling, or idea. 13 - In emergency situations we are dealing with time pressures, important info, and varying levels of experience and backgrounds. And we have some almost insurmountable obstacles like talking through an SCBA, high noise levels, unknowns, and other problematic issues. - "communication is always coherent under normal low and normal high workload conditions. in contrast, danger situations contain instances in which the communicational dynamics are disrupted: questions are not answered; the crew members work on different communicative tasks and interrupt each other. - Eight realities to communications in humans: 1. We tend to protect, maintain, and enhance ourselves when we communicate. 2. We defend against looking ignorant or foolish for fear of ridicule. 3. We wish to maintain consistency; we tend to support our opinion even when we suspect that we may not be totally correct. 4. We wish to feel valued, worthwhile, belonging and meaningful. Meaning we must be acknowledged with respect and trust. 5. The reality of the situation is second to our perception of the situation and our mindset may be very difficult to change. 6. We behave according to our perceptions; we may not be aware of the level of risk. 7. Emotions take first place - feelings are the facts. 8. Commitment comes from self-determination; people have their own motivations. - Studies show that constant one-way communication, usually orders, does not improve team performance, especially during times of stress. - We tend to use the emergency scene as an excuse for all types of irrational or inappropriate behaviors. - We must use 95% of the calls to build a strong, functional, knowledgeable, and trustworthy team for that 5% of the calls where we must rely on each other for immediate decisions and actions without the luxury of time. - Effective communications between crew members ought to be maximally explicit and direct. - call a duck a duck - A team should be comfortable enough with its members to accept direct and explicit communications during times of stress. - The emergency incident sometimes only gives you one shot at getting your message across correctly. 14 - With verbal communications we don’t have the luxury of re-reading what someone has said, and if we do not question (inquiry) what they said, their exact meaning, etc. we are left confused and ineffective. - You communicate continuously through non-verbal and symbolic cues. - Silence is still a form of communication, sometimes even more powerful than words. - On an emergency scene some of the most powerful communication is the kind that you do not hear. - Double meanings, slang, and complexities in language make misunderstandings commonplace; address these immediately to prevent bad things from happening. - Most communication problems involve livewire (humans) and not hardware (radios). - No differences were found between the severity of the errors made by the effective and ineffective crews, rather it was the ability of the effective crews to communicate that kept their errors from snowballing into undesirable outcomes. - Researchers have found that human factors training produces measurable improvements in communication skills. - The steps of advocacy, listening, feedback, and conflict resolution are vital to the team's safety and the efficiency of the operation. - Inquiry Skills: 1. 2. 3. 4. Be respectful in your communications. Ask for clarification. Use questions. Actively seek answers for the things you don’t know, even if they seem unimportant right now. 5. Verify your information and information transferred to you. 6. Be explicit and direct in your communications. 7. Admit any confusion or misunderstanding. - Lack of communication is what leads to FFs getting injured or killed and makes operations less than professional and efficient. - Common sense is not an excuse to be disrespectful, or a reason to stop following a strong inquiry/advocacy model of communicating information. 15 - Feelings plus the facts usually have a place in the second advocacy statement. - People operate from a base of what they know. The perceptions and levels of risk they are willing to accept guide their actions. - Monitoring is the process of keeping track of the effects of your actions. It's especially important to do after an inquiry or advocacy statement or discussion. - Filters in communication affect how we receive the messages and info available to us. - Conflict is a normal part of a group interaction. All personnel in the team must expect that conflict will occur, even in highly organized and effective teams. - Respectful interaction and rational thinking, void of any inappropriate influences, will lead to a successful resolution to any conflict. - Teams that experience conflict early in their formation and work through it, will bond earlier and stronger than teams who conflict later in the formation process or not at all. - Proper communications depend on continuous feedback. Simple, concise read backs will clear up a lot of misunderstandings and potentially dangerous situations. - What is effective communication? - Includes more than just one form of communication into a message and makes those styles match as closely as possible. Takes place when both the sender and receiver recognize that perceptions, influences, situations, and filters affect the message. Must have active listeners for comprehension. Uses the communication loop of sending, receiving, and feedback with all parties. - By communicating info constantly in a valid, workable system, you move part of your formal training program to an informal, on-the-job program. Chapter 6 It's CRM Leadership - It is within the last 50 years that the perceptions of leadership have changed dramatically. Within the last 20 years leadership has changed even more. - The Art of War, book by Chinese war lord Sun Tzu gained notoriety in the fire service and was applied to fireground planning and operations. 16 - Today, because of the situations we put our leaders in, we must rely more and more on a team of leaders rather than a single leader. - The one problem in identifying and training leaders is that not everyone agrees on the definition of a good leader and the definitions change with the situation. - Good fire service leaders should be: - technically competent honest open experienced trained knowledgeable fair mission and vision minded good communicators organized - We believe that good leadership qualities come from a proper base of leadership understanding and management understanding. - As with CRM as a whole, you must first gain technical proficiency in your area before you can hope to succeed as a CRM FF or leader. - Three basic reasons FFs follow their leaders: 1. Followers do not know any better and they feel compelled either through cultural, personal, peer, or organizational pressures to obey commands given by leaders and/or more senior personnel. 2. Followers know better, through training and experience, but still feel compelled to obey commands either because of cultural, personal, peer, or organizational pressures. 3. Followers truly have proof to trust their leader's abilities and skills. - A big part of the baby boomer generation's background was shaped by this information blitz and the effects of a military climate. - Belief that an order is an order and leaders should not be questioned. Communication pathways were not bi-directional. - Members of the newer generations do not have a problem (as a whole) in questioning a superior. 17 - New generations have a head start on the concepts of CRM through the background information that surrounds them growing up. - Most rookies have little to no knowledge of actual operations, strategies, and tactics. They follow their leaders because: 1. that is what they think should be done 2. that is what their peers do or say to do 3. that is what the organization says to do. - This mindless following is the first step in their assimilation into the organization. - People with a general knowledge of the operations and policies understand why we are and why we are not performing certain operations. They don't openly question the effectiveness of a command. - Interrogation stage is the destination for many FFs. These individuals feel that the organization or leader does not want feedback and that they have it "all under control." - In the wildland fire community there are 10 Standard Fire Orders that are supposed to be "unbendable and unbreakable." - The father of the CRM movement in the fire service developed the "Real Ten Standard Fire Orders": 1. Fight fire aggressively but provide for safety first. 2. Initiate all action based on current and expected fire behavior. 3. Recognize current weather conditions and obtain forecasts. 4. Ensure instructions are given and understood. 5. Obtain current info on fire status. 6. Remain in communication with crew, your supervisor, and adjoining forces. 7. Determine safety zones and escape routes. 8. Establish lookouts in potentially hazardous situations. 9. Retain control at all times. 10. Stay alert, keep calm, think clearly, act decisively. - The last stage of truly trusting the leaders you follow is the summit of the mountain in organizations. Individuals "trust their leaders with their lives." They do this not because someone told them to but because: 1. the FFs have the appropriate level of knowledge regarding their operation. 2. leaders share both info and lack of info with their team. 18 3. the team is allowed to share both info and their lack of info with their leaders. 4. experience has proven this to be true. - Two-way communications (bi-directional) consist of the transfer of pertinent info and the transfer of the lack of info up and down the chain of command. - Simply stating you don’t have all the info you think you need for a sound decision, puts the team into the mode of watching out for everybody more carefully and gathering more info. - CRM leadership will make those successful leaders more successful, and those marginal leaders much, much better. - Traditionally, most leadership lines of authority and channels of power travel up, not down. - Individuals who perform leadership activities without formal status on a continuing basis, could be classified as informal leaders. - As a leader you should be identifying what people are best at. - People who accept informal leadership positions, for the most part, know it's temporary. - As the formal leader of the group, you have important steps before, during, and after an informal leader takes control of a situation. 1. 2. 3. 4. Know the individuals on your team and their capabilities. Create mini-opportunities for informal leadership whenever possible. Support those informal leaders. After the fact, make sure everyone knows how you feel about informal leaders. - Situational leaders are leaders without a formal position but have specific expertise that is useful under the right circumstances. - With the fire service's repeated incursions into unfamiliar territory, the situational leader will become more and more important to the safety of the FFs and the citizens, and to the effective resolution of the incident. - In the fire service we have drawn many of our own concepts of leadership from the military ideals of command and control. - You may have authority to command FFs at a scene, but it is far from having your FFs trust to lead them on scene. - South Canyon Fire in Colorado Leadership was arguably strong within each crew but very weak between the crews. 19 - Lack of leadership as a while for the fire was not addressed formally. Lack of trust in leadership, fellow FFs, and bad decisions led to fatalities. - Leadership and not just formal leadership begins when you first meet someone. - The NTSB studied 37 air carrier mishaps and found that 73% occurred on the first day the captain and first officer were together and 44% occurred on their first flight together. - A study of naval inflight refueling crews suggests, "taken as a whole, crew familiarity research suggests that familiarity impacts coordination and performance positively on early sorties and negatively later on." - roommate effect - trying hard to make it work early on then deteriorates as time goes on. - Teams must be built for the majority on a professional level and personal level. - Teams built on a social level tend to exclude individuals who are perfectly capable professionally but lack the necessary social stuff to be one of the guys. - Warning signs of a dysfunctioning team: - the team breaks down into smaller groups as a norm rather than the exception frequent disagreements and arguments personal matters brought into professional discussions open disrespect for team members, their values, and/or possessions observed lack of teamwork and support organizational inaction towards necessary SOPs, meeting standards, etc. tardiness/absences lack of motivation destructive, behind-the-back gossip - Part of the problem with teamwork in the fire service is that it is often not a requirement established by the department. - During non-stressful times, FFs will tell you that they would disregard their own safety for the safety of their partners or for the rescue of a civilian. But research shows that when bad things happen and it's life or death humans tend to react in predictable ways. - resort to over-learned behaviors, lose mental capacity for creativeness and cognitive processing, and tend to separate from the group and save themselves. 20 - Our current safety programs concentrate on safety within the structure of an incident. CRM takes the safety out of the operational mode and allows FFs to truly be safe. - When planning an operation, you should make sure safety allows the operation to take place, and not how to safely perform the operation. - While we as FFs strive for perfection, our focus should not be solely on the quality of our product or the lack of errors, but on our people and their safety and effectiveness. - By applying team-oriented, consensus based processes constantly, our leaders lose the ability to read the situation and act accordingly. - Building a team either through long-term assignments or short-term duties is the single most important job you have. - Training, planning, briefings, and communications help FFs realize how they support the operation as a whole and what their goals are in the operation itself. - Without a shared mental model of the overall goal and the individual strategies, the team cannot hope to succeed in difficult emergency situations. - Teams must be given a clear course of action. Ambiguous orders, lack of info, and other problems deny FFs the right to safe assignment and denies the public the right to a good service. - One of the most common and desirable traits in an organization and its leadership is consistency. Inconsistency in leadership, organizational values, and other areas of uncertainty develops into a fragmented, unsuccessful, unsafe team. - Rewarding marginal behavior is almost as bad as rewarding bad behavior. - Your department's administrative structure has a major role in the success of your teams, especially newly formed or extemporaneous teams. - Within your organization there must be a conscious acknowledgment made of the available, pertinent standards, regulations, rules, and accepted operating practices. - Departments must perform only within their levels and abilities, regardless of pressures inside or outside their organization. - The most important service we can provide is not to our public but to make sure "everyone goes home safe." 21 - Sociologist Jon Driessen studied seasonal workers in the forest service and determined that it takes about 6-8 weeks for them to click into cohesive teams. - Structured and unstructured activities will help develop your group into a team. - Structured activities give everyone a chance to learn the acceptable norms and values of the organization, the leader, and the team. - classroom training scenario tabletops - one of the best ways to speed team formation physical training skills training reality (real incidents) - Used wisely unstructured time will help form bonds that may or may not carry over onto the emergency scene. - The attributes of falling performance in long-term teams: 1. leadership issues - lack of a present, formal, effective, central leader seems to be a factor in failing teams. 2. Personal issues - will affect the team and should not be systematically ignored. 3. Organizational support - crucial to team effectiveness. 4. Self-factors - how FFs operate from a position of inner strength will affect how successful they and the team are. - One of the more dangerous times during a wildland incident is called transition and happens when the incident has become too large for "local" resources or has lasted too long for those resources. - If the systems of communication are not established prior to the team being thrown together, the team will likely fail when presented with non-standard or unpredictable situations. - Non-standard incidents fall outside our normal training, preparation, and thought processes. - When faced with unconventional situations, sometimes unconventional tactics must be employed. - What-ifs are an excellent tool for combatting complacency, providing micro-training opportunities, warding off boredom, and mentoring potential leaders. - People must be technically competent to contribute as team members. 22 - CRM enables you to use micro-training opportunities to increase the knowledge and readiness of your team. - The scene is a perfect place to transfer little jewels of info that will increase current understanding and effectiveness and will transfer to other situations and further increase the effectiveness, safety, and understanding of your team. - Preparing your team is a function of technical proficiency. CRM proficiency includes proactive planning for expected responses, unusual responses, and the leader setting the team climate. - In effective long-term teams, questions do not always appear. When situations get stressful and nonstandard events are taking place, the lack of questions is a pertinent negative. - Every critique of every emergency incident has at least one communications problem that is identified. - A critique after the incident is imperative to clear up confusion, address problems, reinforce successes, and transfer information about strategy, tactics, and decision-making to those involved. Chapter 7 Followership - Perhaps the most under-trained topic in the fire service arena is followership. It is also the most difficult to describe in concrete terms. - Good followers support their leader through technical expertise by compensating for other, less capable team members, and as "translators" of the leader's intentions into practical actions by the team. - Followership is the skill of being the best contributor to the team a person can be. - Followership is three things: 1. ability to contribute to task and goal accomplishment 2. possession by the FF of the skill set necessary to be technically capable, understand environmental cues, and communicate those cues in a respectful and time-appropriate manner. 3. it is not a challenge to command authority, but neither is it unthinking compliance with directives. 23 - Aviation research found that junior officers usually tend to delay actions, rather than begin action too decisively or too early. - Inexperienced officers tended to jump to a drastic conclusion early in the decision-making, but then delayed acting upon the observed situation, and observed that the situation did not justify the drastic action. - Inexperienced officers will not use the time available to attempt a small corrective action that might have helped keep the situation under control. - The recent adoption of a fitness standard, "the pack test," reinforces a cultural norm of physical fitness that exists in the wildland theater. - 60% of FF deaths fall into the clearly preventable, non-emergency related category. - Fatigue is a part of the job, but excessive fatigue and inadequate periods of rest are more dangerous than responding to calls under the influence of alcohol. - Studies have shown that losing as little as 2% of body mass due to dehydration can lead to decreased capacity and damage to bodily functions. - Good rule of thumb is 2 bottles of water for every bottle of air and 1 bottle of gatorade for every 2-3 bottles of water. - To be a good follower, a FF should become familiar with individual tendencies of each weakness of a crew member. - The FAA completed a study and found that the most pilot induced accidents were caused by crews who had been together for less than a month. - Crew cohesion and accident rates work on an inverse correlative relationship, meaning crews are predisposed to accidents and problems until crew cohesion occurs. - Crew cohesion takes effect after approximately 6 weeks. - 5 hazardous attitudes outlined by the FAA: - Anti-authority: "Don't tell me!" Impulsivity: "Do something quickly!" Invulnerability: "It won't happen to me." Macho: "I can do it." Resignation: "What's the use?" 24 - We all have the right to question authority, but a person who resents authority for the sake of resenting authority is dangerous to himself and others. (anti-authority) - Charging ahead without a plan (freelancing), destroys the team approach to the operation, and frequently places the freelancer and the team at greater risk than necessary. (impulsivity) - US Forest Service suggest two more hazardous attitudes: - Pressing ("get-home-itis") Airshow syndrome - Critical judgement errors are made in the name of getting the job done. - One way to keep from thinking a hazardous thought is to think another thought. By telling yourself something different from the hazardous thought you're "taking an antidote" to counteract the hazardous thought. - "Hurry-Up Syndrome" - the more serious the incident, the greater the rush, and the more likely it is that a firefighter will make a hurry-up mistake. - On the fireground, our subjective view of time available until some event occurs and our perception of time progression directly affect our decisions and operations. - As FFs we tend to operate on a perceived time deficit pressure. Most "snap decisions" are unnecessarily rushed. - Errors of commission are those in which people carried out some element of their required task incorrectly, or executed a task that was not required, which produced an unexpected or undesirable result. - Errors of omission are those in which the person neglected to carry out some element of a required task. - Study showed 60% of mistakes are made when in a hurry are errors of commission. 40% of mistakes were omission errors. Errors caused by time pressures or high workload. - A powerful leader creates success and personal fulfillment in the followers, and the capable and intelligent followers allow the leader to succeed. - In a successful teamwork climate, a good leader will solicit the input of the followers. - Warren Bennis, the great student and teacher of leadership, reports that 70% of followers will not question a leaders point-of-view, even when they believe the leader is about to make a serious mistake. 25 - A good follower has the following responsibilities: - responsible for their own training responsible for their own safety and general safety of the organization must know the goals and purpose of the organization must challenge a leader when actions are contrary to goals of organization - It is incumbent upon the follower to let leaders know what type of training is necessary to insure that good service is delivered to the customer in a safe and efficient manner. - Everyone is responsible for the safety of others on scene. - It is a failure of responsibility not to act when the risks are acceptable, and the purposes and values of the group would have us act. - It is a failure of responsibility to act when the risks are unacceptable and acting endangers the organization's purposes or violates its purposes. - The follower is responsible for the culture of an organization. - The follower recognizes that chronic complaining and criticism is toxic to an organization. Constructive criticism and a willingness to solve the problem is an asset. - Clear knowledge of the organization's goals and values, as well as an understanding of the organization's SOPs, will assist the follower in helping the leader lead. - The tendency for a human being who is in the process of being overwhelmed at a scene is to revert to prior over-learned behaviors. - When a leader gets overwhelmed by the situation, the good follower will suggest that the leader take a step back and regain situational awareness. - An arrogant leader is toxic to an organization. On the surface it appears to be a strength, but really communication is stifled, creativity is hampered, and initiative is dampened. Arrogance should be challenged. - Unconstructive criticism, public berating, and ridicule are contrary to the spirit of a constructive organization. The follower should meet with the leader in a non-public forum and challenge the leader on such behavior. - Allowing bad behavior to continue is an endorsement of the behavior, and silence in the face of abuse is tantamount to committing the abuse yourself. 26 - When confronting a leader, they should be told: 1. What behavior is causing the problem? 2. What effects is the behavior having? 3. What are the consequences of the behavior in as specific terms as possible? - Challenging a leader on specific items from time to time is a healthy practice, but a pattern of constantly challenging a leader all the time is insubordination. - Skills to be a good follower: 1. 2. 3. 4. 5. 6. FF needs to develop a healthy respect for authority Responsibility for personal safety and an eye toward the safety of others Technical competence Good communications Develop a learning attitude Recognizing the effect one's behavior has on others - Whether leader or follower, the egotistical person gains a distorted perspective on the world. They only hear positive comments. - If there was a controversial topic CRM creates, it's the authority/advocacy balance. - Leaders should respect the amount of courage it takes for a follower to display the assertive behavior, and the follower should be assertive when it is important. - The good follower doesn't know everything, demands clear assignments, and admits to errors or omissions from assigned tasks. - By distorting the truth, the team dynamic is destroyed, and the credibility of the FF who did not admit the mistake is forever damaged. Chapter 8 Decision-Making - Some federal agencies have a hard, fast rule that people actively fighting fire do not ride on the backs or tops of the units. Developed out of safety consideration to federal FFs. - in the prairies of northeastern Wyoming, this rule puts FFs at greater risk than if they were riding on the engines because of fast moving fires. 27 - FF'ing tactics for a particular locality evolve as a result of local experience, knowledge levels, and conditions. The decisions that are made for a particular locality evolve as a result of the collective experience of the FFs involved. - Each officer and FF must assess his/her capabilities, experience, and equipment before making a decision on how to act. - Most models of decision making have a 4-step process: 1. 2. 3. 4. define the problem generate a course of action evaluate the course of action carry out the course of action - Given the luxury of time and a consideration of all the contingencies, the executive decision making model can avoid the tragic consequences of a poor decision. - Gary Klein, in Sources of Power, How People Make Decisions, studied FFs, healthcare workers, and the military in determining how decisions are made under stress. - He found that fire command officers arrived on scene, they assessed the problem, and visualized the way the problem could be solved based upon experience and resources available. No models, no assessment, no specific steps. - The key to success in decision making is to give the decision maker the most experience and training possible. -Successful decision making ensures that the patterns stored in our memories are the ones that are relevant to the situations we will be facing. - By storing more patterns in our mind, we also develop informational filters, which gives us the ability to prioritize pertinent info and ignore spurious info. - We can increase the patterns and filters stored in our minds through experience, training, briefing, and debriefing. - If we use storytelling correctly, we can gain experience even if we are not personally at a particular incident. - By creating "artificial experience," we place more tools in our decision making toolbox. - aka training 28 - Tactical Decision Making Under Stress (TADMUS) research, the development team found those teams that perform the best under stressful situation are those teams that adapt their decision making strategies, coordination strategies, and even their structure when faced with escalating workload and stress. - Elements for successful team adaptability: - team must have a common mental model of the situation level of communication of relevant info increases team exhibits anticipatory behavior - If done properly, debriefing can be one of the single greatest teaching devices available to a fire command officer. - Properly debriefing an incident immediately after the incident while memories are fresh, allows all of the participants to get the entire picture of how an incident came together and how actions by one division interrelate with actions performed by other divisions. - Human beings learn by hearing stories. Stories provide content, relevance, and the emotional ties necessary to remember and relate to the info and learning experience. - For those with limited experience, the preplanning exercise gives the novice FF the opportunity to ask questions outside of a time stressed environment. - Preplanning can be either formal or informal. - Formal - visits to buildings, inspections of the premises, listing of assets and hazards, formalization of an attack plan before anything bad happens. Informal - can be on the way to the incident, theoretical. - By putting our people in imaginary "real-life" situations and allowing them to think their way out of the situation, we develop more able, creative, and efficient FFs. - The preplanning process is a micro-training opportunity, which allows the senior FF and the novice to test each other and exchange knowledge of tactics and operations in a safe situation. - One of the most effective training programs that exists in every fire department in the storyteller. - As stress increases, the ability to receive and process information decreases. - Fire service can benefit from checklists. 29 - Examples of a checklist: SAMPLE - S - Signs and symptoms A - Allergies M - Medications P - Past pertinent medical history L - Last oral intake E - Events leading up to the onset of problems - Another example of a checklist used by the wildland community: LCES - L - Lookout C - Communication E - Escape routes S - Safety Zones - Checklist used by the HAZMAT community: SIN - S - Safety First I - Isolate entry and deny entry N - Notify the proper authorities - SAFE STOP mnemonic device can aid the interior FF on what information command needs to make strategic decisions. - S - Structural stability A - Access in F - Fire stage/behavior E - Exit out S - Smoke T - Temperature O - Occupancy P - Potential fuel/fire load - Structural degradation, crew endurance, and fuel supplies are all time dependent. - Good decisions cannot be made in an atmosphere of chaos. Disciplined communications with relevant information are the key to a good decision making environment. - Keys to good decision making: 1. Maintain good situational awareness 2. Maintain technical proficiency 30 3. Know your resources 4. Evaluate, evaluate, evaluate - Tips to better facilitate better decision making: 1. Pre-load your people with patterns and filters. 2. Use notes, operational checklists, status boards or other tracking tools to reduce the mental load you are carrying. 3. Learn to recognize when you are overloaded mentally and physically. 4. Don't resist help. Chapter 9 Debriefing and Critiques - What we should be doing as a fire service, is to use scheduled training for teaching new skills, and incident debriefs to refresh our knowledge. Also, we must employ refresher training, not just annually, but whenever sub-standard skills exists as a whole. - Fire service should be lobbying against mandatory refresher training based upon subjective time frames. A more valuable type of refresher training should be taking place after every call. - Reviews should be performed after every incident, large or small. - Critiques tend to have a negative connotation, and are many times instructor led. Debriefs are generally group oriented. - Debriefs are valuable tools but are not based on one instructor teaching the group. They are discussions of the incident and what we can learn from them. - To conduct a proper debriefing of an incident it must be: 1. Within a few hours of the incident. Exceptions: excessively fatigued personnel cannot be debriefed effectively. Extraordinary events preclude immediate operational debriefing. 2. With everyone involved. Exceptions: if personnel cannot attend, an officer must make the effort to meet with the absentees to address issues and to transfer knowledge gained from the official debrief. 3. Of sufficient length to include available feedback and discussion. Exceptions: Time constraints prevent this occasionally. 31 - Debriefing Template: - Step 1 - Just the facts. Step 2 - What did you do? Step 3 - What went wrong? Step 4 - What went right? Step 5 - So what are you going to do about it? - Many arguments during operational debriefings are based on the tactics versus strategy of the incident. - Adults learn best by comparing and applying their previous experiences and their existing knowledge to the current problem. - The goal of an instructor during a debriefing session is to be a facilitator, a listener, a guide who has the map of where he wants the students to go, but does not show it to them. - Do's of Facilitation: - Do set the expectations for participation and the blue line. Do facilitate the debriefing to achieve the objectives. Do use the level and method of facilitation the group requires. Do specifically draw out quiet or reluctant FFs. Do complete all five steps of the debriefing process. Do expand on important instructional points Do make the positives known and draw those out of people at the proper time. - Don'ts of Facilitati