Using Crew Resource Management to Reduce Accidents

By Craig Nelson

I used to be an airline pilot with big dreams of a six-figure salary and world travel. I spent my days screaming across the sky at 40,000 feet until September 11, 2001, happened. My life changed overnight, along with many others’ whose change cost much more than mine did; I lost only a career. Before I left that career, though, I became familiar with Crew Resource Management (CRM), a method of operating that improves safety and performance for people who work as crews in high-performance and high-consequence environments.

The airlines began discussing CRM back in the early 1980s because air crash investigations found that more than 70 percent of crashes involved one common cause: human factors. Imagine putting a number on how many lives you can save in a high-consequence environment by finding out that there is one common cause of the majority of your incidents and accidents.

Armed with that kind of information, the airlines focused the proportionate amount of resources toward finding solutions for their biggest threat to safety. It is a good thing they did. If they hadn’t, they either would have lost a lot more lives or wouldn’t be in business anymore. In the airline story, some of the smartest people on the planet got together (NASA folks—real rocket scientists) at a workshop to examine the role human factors were playing in air crashes. When smart people get together, it is generally a good idea to take notes, learn, and implement. So that is what the airlines did. They turned to a couple of psychologists (John Lauber and Robert Helmreich) to help them develop psychological-based training.¹

The psychologists developed a Line Operations Safety Audit (LOSA) to address safety threats and inevitable/predictable human error that accompany complex flight operations. They found that airplanes weren’t falling out of the skies for mechanical reasons or because they had bad pilots; they were falling out of the skies because of the human factors that are always involved when people work as crews in high-consequence environments. Some of the specific human factors they identified were crew leadership, situational awareness, communication, and decision making.

Armed with this information, they focused on a solution that led them to CRM. It is less of a silver bullet solution and more of an ongoing process solution. It represents a cultural and an operational change that has required much research, study, and training to get it where it is today. But the rewards of their labor are results that show a roughly 70-percent drop in airline crashes. This number reflects the great success the airlines have had, but we need to take a deeper look at the threats to reveal even more startling numbers.

Unlike firefighting operations, airline flights are well-planned events where every last detail is prepared in advance. They still found that 98 percent of all flights face one or more threats and that errors are made on 82 percent of all flights, with the majority being well managed. (1)

HUMAN FACTORS IN THE FIRE SERVICE

Now imagine how many threats and errors the fire service faces on an average fire run. My guess is that because of the dangerous nature of our job and the lack of information we have going into emergency responses, we encounter a significantly higher number of threats and errors on every fire run. Let’s take the same investigative approach for the fire service. What is probably the root cause of the large majority of our accidents and incidents in the fire service? Human factors play a very large role in the majority of our operations every day in the fire service. So, would we benefit from looking deeper into our incidents and accidents? Should we provide the majority of our training in the area of human factors? We’ve known about CRM since 2002, when the International Association of Fire Chiefs (IAFC) published “Crew Resource Management: A Positive Change for the Fire Service.”²

So, where are we with human factors in the fire service? I believe that we are not as far as we should be. Too many of us are still getting hurt and killed. Besides a natural human resistance to change, I believe it is primarily because CRM and human factors do not lend themselves well to a silver bullet quick-and-easy fix. It takes study, practice, training, and eventually acceptance. Is the fire service now ready and up for the challenge? I believe that we are. We have seen some positive movement with resources such as The National Firefighter Near-Miss Reporting System, which seeks out information about near-misses so that we can track and trend our accident causes with the ultimate goal of then training on the issues that are causing us the most problems (the airlines have been doing this for years).

You may be thinking that the results the airlines have seen are great for them, but we still have very different jobs so it probably wouldn’t work for the fire service. Well, you may be partially right. There are differences that would require some adjustments in the specifics, but we both work in crews; deal with highly complex life-or-death situations; must communicate quickly and effectively; and must make timely decisions, often with only a fraction of the information we would like to have. Of course, we can simplify this by saying that the pilot sits and gets served coffee and breakfast while blasting across the sky at more than 500 miles per hour, while the firefighter starts his day helping lift a disabled person off the bathroom floor and then puts out a fire. They are very different, but let’s take a look at the similarities that go beyond the specific tasks to the general operations.

Pilot

• Safety checks equipment for all flights
• Works in a crew setting with an officer in charge
• Operates within a chain of command
• Situational awareness is critical to operations
• Deals with emergency situations
• Trains for emergencies
• Deals with high-liability situations (life safety)
• Makes frequent critical communications
• Makes important, timely decisions
• Mistakes cost lives

Firefighter

• Safety checks equipment every day
• Works in a crew setting with an officer in charge
• Operates within a chain of command
• Situational awareness is critical to operations
• Deals with emergency situations
• Trains for emergencies
• Deals with high-liability situations (life safety)
• Makes frequent critical communications
• Makes important, timely decisions
• Mistakes cost lives

I list the operational similarities but realize there are subtle nuances between the two jobs. Simply, CRM for the fire service will need some alteration to maximize its effectiveness specifically for the fire service, but how do we begin to transform? First, maximize use of the best resource we have at our disposal, our people! Encouraging our people to read, study, and learn from fire publications, Web sites, educational institutions, and fire schools will get the ball rolling in the right direction. This primes our people for learning and helps to foster an organizational culture where learning is highly valued (imagine the ideas and operations of a department where everyone is constantly encouraged to read daily, study department operations, learn about their profession, and then share their ideas). This is where CRM starts, with an organization that is ready and motivated to learn.

From there, we move into more complex topics such as situational awareness, leadership, communication, and human factors. There is currently a disconnect between what research shows us and how we are operating. Research shows that around 70 to 80 percent of our incidents and accidents in the fire service are caused by human factors,³ yet most of our “fixes” seem to focus on technological advances or new safety rules, neither of which solves the root problem. Our current fixes simply mask the real problems. This delays the inevitable from happening again by letting it build until the next time it occurs with much more severe consequences. This is what we do because it is quicker and easier than fixing the complex operations of human factors.⁴

Truly learning from incidents, accidents, and line-of-duty deaths will require us to learn about and understand the human factors that research shows are truly causing fire service accidents. Don’t get me wrong: Technological equipment advances are great, and we need to ensure they continue, but if the vast majority of our incidents are from human-related causes, then shouldn’t we be focusing a larger part of our efforts on human solutions?

CRM could make a dramatic impact on the safety and effectiveness of operations in the fire service. Transformation will not be easy, especially when it is this large. It can help us develop as a profession of learning, and in the end it will be more than well worth the effort to ensure we provide a better and safer service to our communities.

ENDNOTES

1. “Making air travel safer through crew resource management (CRM).” American Psychological Association. (February 6, 2004). Retrieved from http://www.apa.org/research/action/crew.aspx.

2. “Crew Resource Management: A Positive Change for the Fire Service.” International Association of Fire Chiefs. (2002). Retrieved from http://www.iafc.org/files/pubs_CRMmanual.pdf.

3. “National Firefighter Near-Miss Reporting Resources.” Elsevier Public Safety. (2008). Retrieved January 25, 2011, from National Firefighter Near-Miss Reporting System: http://www.firefighternearmiss.com/Resources/Annual_Reports/Active_Resources/2008_Annual_Report.pdf.

4. Leadership on the Line: Staying Alive Through the Dangers of Leading. Heifetz, R. A., & Linsky, A. (Boston, MA: Harvard Business School Publishing, 2002, p. 123.)

CRAIG NELSON has been in the fire service for more than 10 years, working as a volunteer, paid-on-call, and full-time firefighter/EMT. He works for the Fargo (ND) Fire Department and part-time at Minnesota State Community and Technical College-Moorhead as a fire instructor. He is a columnist for fireengineering.com. Previously, he worked seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Prior to his fire career, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.

Craig Nelson will present “Crew Resource Management” on Thursday, April 19, 2012, 10:30 a.m.-12:15 p.m., at FDIC in Indianapolis.