Firefighters are not robots – at least not yet! – which makes the recent discussions about the concept of human factors in firefighting particularly relevant. But what does human factors mean in the context of our day-to-day operations? In short, it’s the impact of human behavior and performance, including our decision-making on the scene.
Human behavior patterns suggest that even the most well intentioned, best-trained, consistently performing individuals and work groups can, and do, commit errors. Some of these errors are miniscule in scope and have little or no impact on events. Others are calamitous.
Of course, no one intentionally sets out to commit an error, but it happens, nonetheless. Why does this matter, beyond the obvious work to eliminate such errors in our work? The National Institute for Occupational Safety and Health (NIOSH) recently put out a call for public comment asking if human factors should be added to the process for investigating firefighter fatalities on the fireground. Let’s consider what this means for the fire service, starting with an important history lesson.
Human factors and the aviation industry
On March 27, 1977, two Boeing 747 planes collided on the runway at Los Rodeos Airport (now Tenerife North Airport) in the Canary Islands, resulting in the loss of 583 lives. The investigation revealed that human factors, namely miscommunications and poor decision-making within the cockpit, played a significant role in the accident.
The following year, on Dec. 28, United Airlines Flight 173 was on its final approach to Portland (Oregon) International Airport after an uneventful flight. The pilot noticed that he had not received the usual “three down and green” indicator light telling him that all landing gear was properly deployed. As the captain circled the plane, moving through the troubleshooting processes, crewmembers told the captain that they were running low on fuel. Eight passengers and two crewmembers were killed, and 23 people were seriously injured when the plane ran out of gas and crashed six miles short of the runway.
The Tenerife and Flight 173 disasters were among the catalysts for the commercial aviation industry’s recognition that technology alone was not the primary cause of air mishaps or crashes. As a result, a new training program was implemented that looked to capture and minimize human failures: cockpit resource management (CRM).
Introducing CRM: The roots of CRM training in the United States trace back to a 1979 workshop titled “Resource Management on the Flightdeck,” sponsored by NASA. During this workshop, NASA researchers found interpersonal communication failures, decision-making issues, and leadership challenges as key contributors to air transport accidents. CRM described the process of training flight crews to reduce errors from human factors through optimization of human resources on the flight deck. The aviation industry started using CRM as a set of training procedures using aircraft simulators designed to reduce human errors in the cockpit of commercial planes where such errors can have devastating effects.
A CRM success story: Fast-forward to United Airlines Flight 232 bound for Los Angeles from Chicago in July 1989. The plane experienced a catastrophic failure of one of its engines in flight that subsequently severed all three hydraulic lines necessary for controlling flaps, rudders and other flight controls. With both the primary and redundant features of the aircraft disabled, the captain and crew used engine controls alone and managed to bring the crippled plane into the Sioux City, Iowa, airport. While 111 people died in the crash, another 184 survived. The captain used behaviors learned in CRM training focused on how to overcome the key factors that contribute to human error: communication, situational awareness, decision-making, teamwork and barriers to the other four factors.
The evolution of CRM: Over the years, CRM training programs have proliferated globally, and the focus shifted from the cockpit alone to a broader concept we know as crew resource management. The goal was to enhance teamwork, communication and decision-making skills among all crewmembers. CRM became a global standard, emphasizing error-management strategies to prevent and mitigate errors during flight operations.
From aviation to fire service success
In 2003, the IAFC published “Crew Resource Management: A Positive Change for the Fire Service. A comparison of the interaction and behaviors of firefighting crews and flight crews revealed several similarities:
- Both crews are structured with a leader and one or more crewmembers.
- The group functions best when it works as a cohesive team.
- The team can spend hours of time conducting mundane activities and then be called upon to act swiftly under stressful conditions.
- Some crews work together frequently, and others are assembled on short notice.
Taking this concept a step further, we can work from the five factors that contribute to human error in order to minimize firefighter risk in the following areas, considered the key principles of CRM in the fire service:
1. Communication skills are key to success in any endeavor. We have all experienced misunderstandings that led to errors and mistakes. CRM teaches people to focus on the communication model (sender-message-medium-receiver-feedback), speaking directly and respectfully, and taking responsibility for one’s communication.
2. Situational awareness covers the need to maintain attentiveness to an event, plus the effects of perception, observation and stress on personnel. There is emphasis on the need to recognize that situations in the emergency services are particularly dynamic, stressful and require one’s full attention.
3. Critical decision-making relies heavily on risk/benefit analysis. Too little information results in poor risk assessment by the decision-maker and results in errors, injury and death. Too much information overloads the decision-maker and makes it difficult to make effective decisions. A tactical decision-making model used by many fire departments is the OODA Loop, developed by Col. John Boyd:
- Observe: Observing and collecting information about an event.
- Orient: In what environment is the event occurring (e.g., building and occupancy type, weather, fire, hazmat)?
- Decide: Decide on a course of action based upon what’s been learned during Observe and Orient.
- Act: Commit the necessary resources to implement the decided upon plan.
4. Task allocation involves a fire department having a command system that guides incident commanders in dividing a given task into equal parts to ensure no one worker is overloaded, including the IC. Overloaded workers make mistakes.
5. Teamwork in CRM training focuses on “leadership-followership,” so all members understand their place on the team and the need for mutual respect.
Final thoughts
Firefighters and officers are typically well-prepared when it comes to operational proficiency (they know how to do their job) and being physically fit for their duties. It’s only recently that their mental readiness to engage in emergency operations has become a significant part of the conversation.
Life Safety Initiative #9 asks us to learn from our mistakes. The only way to do this is to thoroughly investigate every near-miss, significant injury or fatality. Furthermore, as stated in the IAFC’s Crew Resource Management resource:
Congress recognized the need to address the national problem of work-related firefighter deaths, and provided the funding and direction to NIOSH to standup the Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) and conduct independent investigations of firefighter line-of-duty deaths and recommends ways to prevent deaths and injuries [4].
It’s long past the time for NIOSH to begin evaluating human factors as part of FFFIPP to thoroughly investigate every firefighter fatality.
