When I think about the future of our business, there is not a lot that makes me nervous or pessimistic. Having been around for several decades, I am well aware that change can seem to take forever, but still usually happens. Not trying to sound trite or aged, I can remember riding on the backstep, wearing "day boots" and using a 15-minute airpack. Each of these practices has faded away in time, and looking back, I think about the tremendous safety improvements that the replacement of each of those items brought to our industry.
Some of those changes have been so complete that there are only a few of us in the active duty service that will remember them at all. To demonstrate, try this little experiment. Next shift at the coffee table, conduct a survey of "who remembers." Perhaps get the folks to do a show of hands if: they ever drove an open-cab truck; used a filter- or demand-style mask; or engaged an aerial ladder stabilizer device on a tractor-drawn aerial turntable. Odds are that not many will be able to have experienced those "good old days."
CRM Background
This brief series of columns will not be about the past. In fact, it is about arguably one of the most profound changes that should be taking place in the American fire-rescue service today, but as yet does not seem to be gaining any traction. So little progress is being made in this area that I feel compelled to use this article to shout for help — your help, to be exact. I know that change (and, in particular, meaningful change) takes a lot of time — I first wrote about this concept in Firehouse® Magazine in the 1990s.
A little over 10 years ago, I had the wonderful career opportunity to attend a "world-class" lecture presented by an airline pilot, Captain Al Haines. As you may recall, in 1987, Haines was the pilot of United Airlines Flight 232, which crash-landed in Sioux City, IA. Although it was a "high-impact crash" (one in which it is unlikely that anyone would survive), Haines and crew — to include the air traffic controller — managed to save 182 of the 296 souls on board that afternoon. This was a feat that had been previously unheard of in the aviation industry.
Toward the middle of Haines' incredible presentation, he spoke about the commercial aviation industry's human-error-avoidance and checks-and-balances system known as Crew Resource Management (CRM). As Haines recounted that fateful flight for the audience, it hit me: we must adopt, modify and fully implement CRM to improve firefighter safety and survival. To add to the importance of implementing CRM, it will greatly enhance operational outcome, thereby, reaching our top two strategic goals of saving lives and property.
Quick System Review
CRM uses the basic philosophy, penned by the great poet Alexander Pope, "To err is human." In other words, people are always going to be proven to make errors. (Remember the axiom, "Pencils have erasers because people make mistakes"?) Knowing that, the aviation community has built in a great set of "checks and balances" to ensure that human inputs (decisions) during flights are flawless and error free.
The investigation of a 1978 plane crash determined the cause to be totally due to human inputs (decisions). While enroute to Portland, OR, the fuel supply of United Airlines Flight 173 was completely used up. Both the co-pilot and the second officer warned the pilot several times of the fuel situation, but based on the flight line operations of the day, the captain in charge of the DC-8 jetliner disregarded their warnings, which resulted in a fatal crash. Ten people on the plane were killed (including the second officer) and 23 were critically injured.
The only redeeming factor that surfaced on crash day was that there was no fire associated with the crash of Flight 173 (the impact took place in a Portland suburb) because the fuel was completely used up. If an ignition had occurred, it is widely believed that all aboard would have likely perished.
In the aftermath of Flight 173's crash, the error-avoidance program known as Crew Resource Management was born. By 1980, all commercial airlines were required to place great emphasis on the avoidance of human errors by implementing CRM. As a result, the aviation industry has seen remarkable results in eliminating, avoiding or trapping human-error issues before there are any consequences (unplanned events, i.e., crashes). Even though the captain has the final say for all flight operational decisions (same as the incident commander), they are trained to listen and use a multitude of inputs before taking any critical action, including travel-route and/or emergency decisions.
In addition, the other flight crewmembers such as the first officer, flight attendants, maintenance folks and air traffic controllers, to name a few, are thoroughly trained to be bold and assertive to make sure that the captain gets the critical input necessary to safely operate the aircraft.
The results of full implementation of CRM have been phenomenal. Human-error accidents are now almost non-existent in commercial aviation. Further, other organizations have picked up the CRM process and, after only a few years, have seen a great reduction of accidents and personal injuries.
As an example, one of the military branches reported a 71% reduction in accidents and injuries after CRM was integrated into its air and field operations. I have heard only "glowing" reports about results relating to the utilization of the CRM process.
The Concern
After about 10 years of discussion, only a few fire-rescue agencies have developed, adopted and integrated Crew Resource Management into how they do business on the streets. My personal notation is that a comprehensive CRM program for our industry would greatly reduce firefighter injuries and fatalities, as well as greatly improve the service that we deliver to our customers every day.
Researching just about any firefighter fatality report from the National Institute for Occupational Safety and Health (NIOSH) will support this argument. While referencing the material, pay special attention to the incident causes and recommendations, as well as the root causes of the accidents that led to members' deaths. The typical findings will be that most firefighter fatality scenes are riddled with human errors.
The operational error that seems to occur most often is the failure to implement (or only partially implement) the incident command system, as well as the failure to identify and activate an incident safety officer. Without question, the complete application of CRM will eliminate this and all other human input errors, if used properly. A recent seminar I attended theorized an 80% or greater reduction in performance errors would be realized as a result of the application of CRM.
As I mentioned earlier, our armed forces are using CRM with great results. Beginning with the various aviation operations and then blending into all other functional operations, the transition of application of CRM for the military was relatively easy. The result of CRM speaks volumes and cannot be denied. The next logical step is to drive it further into each organization.
The medical field is now embracing CRM in an effort to eliminate human errors and omissions that occur each year at a rate of 1% to 1.5%. An excellent performance rate of 98.5% sounds like a great track record, unless you or a family member is part of the unfortunate group in the remaining percentage. Stories of being the wrong person under the knife are real and CRM will become a major tool for the medical field to reduce or eliminate these types of needless tragedies. Interestingly, Dr. Robert L. Helmreich, a professor of psychology at the University of Texas who is considered to be one of the CRM "giants," has co-authored a book (Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences) as well as consults to medical care practitioners.
The Challenge
The American fire-rescue service must develop a comprehensive plan to fully implement Crew Resource Management. Further, if we are going to reduce firefighter fatalities and injuries anytime soon, we must take action on this issue quickly.
It is my hope that all of the major fire-rescue service organizations will accept this challenge and "run with the ball." Ideally, it is my desire that the National Fire Academy (NFA) will develop a comprehensive resident program as well as an abbreviated off-campus offering of CRM. Further, a substantial training component on CRM needs to be integrated into every NFA operational training course.
Next, it would be wonderful if the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) would adopt and urge the support of its members to use the national model developed by the NFA. Although the IAFC is doing an extraordinary job with the near-miss reporting program, it would make more sense to me to develop the strategy to prevent the "near misses" in the first place.
I will close with an excellent example that everyone should attempt to model. The Phoenix, AZ, Fire Department has developed an 80-hour "Command Officer Training" course. The content is loaded with CRM components. Having spent a few days attending the program at Phoenix's Command Training Center, I can truly say that the process is leading edge. Maybe Phoenix could help the NFA to develop a national CRM training curriculum.
DENNIS L. RUBIN, a Firehouse® contributing editor, is chief of the Atlanta Fire Department. Previously, he was city manager and public safety director for the City of Dothan, AL. Rubin is a 33-year fire-rescue veteran, serving in many capacities and with several departments. He holds an associate's degree in fire science from Northern Virginia Community College and a bachelor's 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 Chiefs (IAFC). He serves on several IAFC committees, including a two-year term as the Health and Safety Committee chair. Rubin can be reached at [email protected].
