BY TOM LUBNAU III
On October 25, 1854, at the battle of Balaclava, 673 English soldiers of the Light Brigade charged headlong into the valley of death. The Russian army held three sides of the valley; the charge meant certain death to many brave men of the Light Brigade. Of the original 673, 247 were killed or wounded in the charge. Alfred Lord Tennyson’s poem, “The Charge of the Light Brigade,” commemorated the tragedy.1 After their deaths, these men were celebrated as brave heroes. But what caused their deaths? What breakdown in situational awareness led to the sacrifice of so many brave soldiers? Can we look at history to make our current firefighting operations safer?
This article will look at the study of human behavior during fireground operations; analyze the database of information related to situational awareness near-miss incidents; and, based on that information, make recommendations on how to avoid “The Charge of the Light Brigade” during fireground operations. To adequately examine the topic, it is necessary to understand basic crew resource management (CRM), situational awareness, and firefighter near-miss reporting.
CREW RESOURCE MANAGEMENT
CRM is the firefighter’s owner’s manual. It examines how a firefighter will react under certain conditions, given certain information.2 CRM involves the use of all resources, human and mechanical, to improve performance and to avoid, trap, or mitigate error. It focuses on improvements in communication, decision making, situational awareness, task allocation, and teamwork.3
CRM science was developed in the aviation industry in the late 1970s and early 1980s. At that time, the aviation industry realized that, although aircraft were mechanically reliable, planes were still crashing. The industry studied human error and how to avoid and trap it. After nearly 30 years of study, the CRM scientists have concluded that human beings behave predictably and that if certain behaviors are learned and practiced, operations can be made significantly safer. CRM science is currently used in the fields of aviation; nuclear power; medicine; space exploration; and, most recently, the fire service.
Essentially, CRM teaches that every person on a team is a resource. By appropriately using the combined resources of each individual member of the team, not just relying solely on the leader, operations can be made safer. In his poem, Tennyson describes the situation of the unquestioning follower:
Not tho’ the soldier knew
Some one had blunder’d:
Their’s not to make reply,
Their’s not to reason why,
Their’s but to do and die:
In CRM, each team member has an obligation to be aware of the situation, to communicate with the team, and to avoid the “Their’s not to reason why, Their’s but to do and die” scenario. Obtaining and maintaining situational awareness is the first step in becoming an effective team member.4
SITUATIONAL AWARENESS
Situational awareness is “the perception of the elements in the environment within a volume of time and space, comprehension of their meaning, and the projection of their status in the near future.”5 It’s knowing and understanding what’s going on and knowing how to react to a situation.
In fireground operations, maintaining situational awareness is at best a challenge. Multiple hazards, intense time pressures, the “fog of war,” life-or-death decisions, and the need to use multiple resources to effectively accomplish a difficult and varied task provide barriers to knowing what is exactly going on at any one time.
Often, in a post-incident review, the question is asked, “Why did that happen?” Invariably, the answer is, “The crew lost situational awareness.” That analysis is meaningless unless the inquiry is carried further. A firefighter does not lose situational awareness except by becoming physically unconscious. The firefighter always has some idea of where he is, what he is doing, and how the system or process is working.6 When an investigation reveals a loss of situational awareness as a cause, what is really revealed is the disconnect between reality and the firefighters’ perception of reality. The firefighters were aware of something; hindsight just revealed that the firefighters were aware of the wrong thing. The inquiry’s focus then shifts to why the crew’s attention or awareness was focused on one particular bit of information to the exclusion of the relevant information. (6) In the battle between perception and reality, unfortunately, reality always wins.
NEAR-MISS DATABASE
In 2001, some visionary firefighting pioneers determined that if firefighters were consistently making the same types of mistake over and over again, a database of those mistakes might provide the fire service with a valuable learning tool to aid in preventing future injuries and accidents. Examined within the context of CRM principles, such a database might provide some evidence of how to prevent firefighting injuries and deaths. In 2004, the International Association of Fire Chiefs (IAFC) received a grant from the Department of Homeland Security’s Assistance to Firefighters Grant Program to create a national near-miss reporting system for the fire and emergency service, with a supporting grant from the Fireman’s Fund Insurance Company. Deputy Chief Billy Goldfeder and Gordon Graham, founders of FirefighterCloseCalls.com, provided additional support. The IAFC administers The National Fire Fighter Near-Miss Reporting System in consultation with the National Fire Fighter Near-Miss Reporting System Task Force.7
The database, available at www. firefighternearmiss. com, provides a confidential reporting system in which firefighters can submit information regarding near-misses. By collecting and compiling that information, nationwide trending information that may provide clues on how to conduct safer fireground operations can be developed.
The theory is based on Heinrich’s error pyramid theory, which states unsafe acts lead to minor injuries and, over time, to major injuries. The accident pyramid proposes that for every 300 unsafe acts there are 29 minor injuries and one major injury.8 To prevent the major injury, compiling a database of minor injuries allows us to predict when another accident may occur. The ability to predict the accident allows us to put in place strategies to prevent future accidents. Gordon Graham sums it up best, “Predictable is preventable!”
ANALYSIS
For purposes of this article, I analyzed the category “Fire emergency event: structure fire, vehicle fire, wildland fire” in which situational awareness was implicated as a contributing factor. I examined 89 reports to determine the types of hazards, the attitudes involved, and whether lessons could be learned from the data.
In conducting such an analysis, the interpretation of the events affected the outcome. The best practice would have been to interview each of the reporting parties to determine whether there was a problem with working memory: What was in the person’s perceptual store? Was there trouble in retrieving a piece of knowledge from long-term memory? (6, 70) Unfortunately, within the parameters of the near-miss-reporting database, such an inquiry with the appropriate follow-up questions is impossible. However, I took the liberty of basing the analysis on the wording in the reports.
Four types of breakdowns occur in situational awareness scenarios: user-task (the user does not understand or know how to complete the task); user-tool (the tool fails, the user does not understand how to operate the tool, or the tool is inadequate for the job); user-environment (the user suddenly becomes aware of the environment); and user-user (insufficient information, message is unclear, or the message was not received).9
In analyzing the 89 situations, very few user-user and user-task events were reported. The inference that can be drawn from the lack of these reports is that the firefighters who were assigned specific tasks were very clear on what the objectives were and those objectives were communicated to them well.
The bulk of the hazards came in the user-environment situation, where the user suddenly, and often catastrophically, became aware of hazards in the environment of which he should have been aware but for some reason was not.
Several inferences can be drawn from these data. In situational awareness situations in which the firefighter is not aware of a dangerous life-threatening condition, 38. 2 percent of the time, that dangerous condition is a collapse hazard (Figure 1). There was a commonality in many of the incident descriptions. The team went in. Without warning, the floor collapsed and a firefighter went through or, by some divine intervention, the team was distracted from making entry, or it made a hasty exit, and then the entire structure of the building failed.
The lesson that can be learned from this statistic is that firefighters may routinely underestimate the structural instability of a building before entering and, as a result, place themselves in a zone of danger. In other words, firefighters lose their situational awareness of structural stability.
The error is overestimating the structural stability of a building, and that error becomes a starting point for further inquiry. The human error is the effect, or a symptom of a deeper trouble. The error is not random and is systemically connected to the firefighters’ operating environment. (6, 61) The next step in the inquiry is why overestimating the structural stability of a building made sense to obviously well-trained firefighters at the time of the entry.
Prior to conducting an analysis of why firefighters potentially overestimate building stability as well as other hazards, other hazards deserve comment.
The next most common error is an equipment error, which occurs 18 percent of the time. These errors are varied but fall into a couple of categories-air supply, water supply, and communications. The air supply errors arise when a firefighter enters a building and does not manage air correctly or the SCBA does not operate correctly. The next type of error arises when the firefighter enters the building without water or runs out of water while deep inside the interior. The final general type of error in this category is incorrectly operating a radio, so communications become garbled. The error is incorrectly operating equipment. What are the departmental cultural factors that would allow these types of actions to make sense at the time of entry into the structure?
The organization’s values determine the culture of an organization. Is being macho more important than being cautious? Are speed and efficiency more important than contemplated actions? Is tradition stressed over new concepts? Is physical fitness an important component, or is it not stressed? By answering these questions and many others like it, the organization’s culture can be determined and we can better understand the context in which situational awareness is lost.
The next most common hazard that arises in the situational awareness context is electricity. The stories, again, are very similar. One of two scenarios is common. First, a firefighter enters a building assuming the electricity is off. Once inside the building, while carrying a long, wet, grounded hose, the electricity sparks, informing the firefighter that the electricity is still on. The second scenario is the firefighter’s arrival at a fire. While outside, the firefighter gets ready to enter the building. On the way in, a power line burns through and nearly hits the firefighter. The error is failing to notice electricity. The question for your department is, What are the cultural factors that cause well-trained firefighters not to notice charged or burning electrical devices?
The next most common hazard is underestimating fire behavior. Again, the stories are remarkably similar. A firefighter enters a structure, usually to conduct a search. Generally, the firefighter is above the fire; the fire then grows rapidly, trapping the firefighter, usually at the top of the stairs. The error is underestimating fire behavior. Why do highly trained firefighters underestimate the growth of the one thing they are highly trained to fight-fire? What is the culture that allows firefighters to go in too deep too fast?
The final hazard to be discussed is that of explosion. Again, the stories are very similar. The firefighter enters the house to do suppression activities. Once inside, the firefighter notices a huge cache of explosives (usually propane, gasoline, or oxygen). The firefighter exits, and the building blows up. What context allows firefighters to enter a building not knowing it contains a large quantity of explosives?
SECOND-STAGE ANALYSIS
The next stage in the loss of situational awareness analysis is determining what important cultural and operational factors were competing for the firefighter’s attention. Safety is usually cited as an organization’s most important goal, but it is never the only goal (and in practice not even a measurable overriding goal), or the organization would have no reason to exist. People who work in these systems have to pursue multiple goals at the same time, which often results in goal conflicts. Goal trade-offs can be generated by the nature of the work itself and by the nature of safety and different threats to it at the organizational level.(6, 89) The next stage in the analysis, then, is to determine what the competing goals of the organization are and how they run contrary to the pursuit of safety.
The mission of the fire department is to save lives and protect property. What, then, are the factors that cause highly trained firefighters to lose situational awareness?
One possible cause for loss of situational awareness is pattern mismatch. Gary Klein, in his book, Sources of Power, examined the way that firefighters make decisions at emergency scenes.10 He determined experienced firefighters scan through their memory until they come upon a scenario that closely matches the present situation. The experienced firefighter takes the methods and skills used in the similar pattern and then plots a course of action. Most of the time that process is successful. Sometimes, though, the present situation and the pattern the experienced firefighter is relying on is not the same. The term for that situation is pattern mismatch. The experienced firefighter assumes the situation to be one way, when in actuality it is another way. For example, a firefighter arrives at the scene of a single-family residence. There appears to be a fire in the bedroom. The firefighter searches his memory for strategy and tactics for attacking a room-and-contents fire. He opts for a quick knockdown and begins an attack with tank water. On the way in the door, the firefighter notices a walker for an elderly person. The firefighter charges into the bedroom, where he suddenly discovers the bedroom is full of oxygen tanks. The pattern mismatch occurred when the firefighter decided the fire was a routine room-and-contents fire; from that point on, situational awareness was lost because the firefighter was relying on the prior patterns instead of seeking additional clues before entering.
Another possible cause for loss of situational awareness is error creep, in which deviations from the norm become the norm. (6, 116) Getting away with one carelessly handled tactic can make that type of behavior a common occurrence. Soon, the proper way to execute the tactic fades into distant memory and the improper method becomes the norm.
As an example, prior to entry, the entry team may fail to confirm that the structure’s utilities have been turned off. Usually, the utilities are turned off, so there is no reason for the entry team to confirm that they had been turned off. The assumption is that that function had been delegated to another party and, therefore, there is no reason to confirm that the task was completed. The entry team simply enters the structure and accomplishes knockdown. This will be the case until one day when the entry team enters the structure, begins suppression operations, and suddenly finds a ball of sparks shooting out of the wall when an outlet is hit by water from its hoseline. At this incident, the utilities had not been turned off.
Another possible cause for loss of situational awareness is complacency. After knockdown, a firefighter enters a building to assist with salvage and overhaul. Since the initial knockdown crew must have sounded the floor, there is no reason to sound the floor. Since there is no real active burning, the firefighter assumes there is nothing to worry about. The firefighter walks into a closet and falls through the floor. The complacency lulled the firefighter into a state of situational numbness.
Another cause of loss of situational awareness is memory and attention overload. Firefighters, as humans, are limited in memory and attention.11 When faced with many choices of hazards to assess, the firefighter prioritizes the information based on how important he perceives that information to be. (11) For example, an entry team is conducting a search in a structure for possible victims. When accomplishing this task, the firefighter has a multitude of different factors to assess and judge, tasks to accomplish, and strategies and tactics to determine. The firefighter, prior to entry, has to assess building layout and potential location of any possible victims. The firefighter has to consider search tactics, fire location and behavior, and any possible hazards that may pose a risk to the victims. All of these assessments must be done very quickly because the life of a victim may be at stake. Is it any wonder, then, with this limited channel capacity of the human mind, that the firefighter fails to confirm that the air bottle on the SCBA is not full?
Many other potential causes for a loss of situational awareness exist. To say what the specific cause of loss of situational awareness was in each of the reported incidents in the firefighter near-miss database would be speculation. A second-stage analysis that ascertains the organizational goals, the workload, mission analysis, and departmental culture is required for an explanation of the loss of situational awareness in each case. For this article, when a loss of situational awareness is implicated as a cause for an incident or a near-miss, that implication is a beginning point, not an end point.
RECOMMENDATIONS
Several recommendations can be gleaned from the analysis of the firefighter near-miss database to preserve situational awareness. First, conduct refresher training with your firefighters on the primary hazards that occur most often in firefighter near-miss incidents. In other words, your department should conduct refresher training on collapse hazards, electricity hazards, fire behavior, and indicators of explosions. These are the hazards that consistently provide life threats to firefighters and are often missed. The organization should not only train in the identity of these hazards but also when the members should look for them.
An advanced technique would be for the engine officer, while en route to the fire, to conduct more intensive operational prebriefings of the hazards, so the memory of the hazards has primacy and is fresh in the firefighters’ minds. Another not so intensive approach would be simply to say as the unit is arriving on-scene, “Be careful out there-the hazard you expect is not the hazard that is going to hurt you. ”
Second, look more deeply into the cultural factors that cause a loss of situational awareness. When a near-miss incident occurs, the investigation should focus not only on what the hazard was and that the firefighter lost situational awareness but also on the systemic error that allowed the loss of situational awareness. Gordon Graham has pointed out often that a properly designed system that is kept up to date and is fully implemented will never let you down.12
Third, solicit structured feedback in the post-incident review on what was happening that caused the loss of situational awareness. Ask questions such as the following: What was going on in your mind when that happened? What were you trying to do? What did you anticipate was going to happen? Looking back on things now, why did what you do make sense at the time? By asking these questions, the organization will get an indication of the cultural factors that may be causing a systemic breakdown in departmental situational awareness.
When a near-miss does occur, it should be reported to the firefighter near-miss database. By looking at the information available, the fire service can determine trends and recommend changes in operations. The analysis conducted in this article is basic. With more data, we will be able to determine trends that will help us conduct safer and more efficient fireground operations.
Finally, if an incident should occur, it is recommended that, in addition to the traditional human error inquiry, the department use the Dekker model as an investigative tool to get at the roots of organizational error. (6)
• • •
Human factors science has advanced exponentially since 1854, when The Light Brigade made its valiant charge. Communications and command structure has advanced. The time is past when it is appropriate to be celebrated in verse for a suicidal charge that had no effect on the outcome of the battle.
While horse and hero fell,
They that had fought so well
Came thro’ the jaws of Death,
Back from the mouth of Hell,
We should never again unnecessarily sacrifice a firefighter to injury or death because of human error. The tools are in our hands-all we need to do is use them. Be careful out there; the hazard you expect is not the hazard that is going to hurt you! ■
References
1. http://www.nationalcenter.org/ChargeoftheLightBrigade.html.
2. Okray, R., and Tom Lubnau, Crew Resource Management for the Fire Service, Fire Engineering, 2004, 10.
3. Tippett, J., “Learn from others about saving ourselves,” International Association of Fire Chiefs (IAFC), http://www.iafc.org/displayindustryarticle.cfm?articlenbr=27206, June 15, 2005.
4. For more information on Crew Resource Management, a free introductory download can be obtained at the following Web address: www.iafc.org. For more detailed information, visit http://store.yahoo.com/pennwell/crewresmanfo.html, and see “Crew Resource Management for the Fire Service.”
5. Endsley, M.R. “Design and evaluation for situation awareness enhancement.” In Proceeding of the Human Factors Society 32nd Annual Meeting (97-101) Santa Monica, CA: Human Factors Society (1988), as cited in Endsley,M.R. and Garland, D.J. (Eds.) Situation Awareness and Measurement. Mahwah, N.J: Lawrence Erlbaum Associates, 2000.
6. Dekker, S., The Field Guide to Human Error Investigations, Burlington, VT: Ashgate Publishing Company, 2002, 113.
7. National Fire Fighter Near-Miss Reporting System, Program Kit, International Association of Fire Chiefs, Fairfax, Virginia, 2005
8. Heinrich, H.W., Industrial Accident Prevention: A Scientific Approach, third edition, McGraw-Hill, 1950.
9. Childs, J., Ross, K., Ross, W., “Identifying Breakdowns in Team Situational Awareness in a Complex Synthetic Environment to Support Multi-Focused Research and Development,” http://www.link.com/pdfs/sa.pdf.
10. Klein, G., Sources of Power: How People Make Decisions. Cambridge, Mass-achusetts, MIT Press.
11. Endsley, M.R., “Theoretical Underpinnings of Situational Awareness, a Critical Review” in Endsley, M.R. and Garland, D.J. (Eds.) Situation Awareness and Measurement. Mahwah, N.J: Lawrence Erlbaum Associates, 2000.
12. Graham, G., “Non-Punitive Close-Call Reporting: Learning from the Mistakes of Others Prior to Disaster,” Graham Research Consultants, www.gordongraham.com, Long Beach, CA, 2002.
■ TOM LUBNAU II is a member of the Campbell County Fire Department in Gillette, Wyoming, and is co-author with Randy Okray of Crew Resource Management in the Fire Service (Fire Engineering, 2004). Lubnau and Okray will present “Preventing Human Error on the Fireground” at FDIC 2006.
