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Crew Resource Management & The Command Officer

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1 Crew Resource Management & The Command Officer
Proven Tool for a Safer Scene Control Crew Resource Management & The Command Officer Bob Bartosz Photo Partnering for Safe Leadership Ruidoso, NM May 7, 2008 Battalion Chief John Tippett Montgomery County Fire & Rescue Service (MD)

2 What do we hope to accomplish today?
Interactive discussion. Preserve “good” traditions. Acquaint you with “new” approach to command & control. Provide tool you can use beginning today. Safety Based Culture Non-Punitive Approach to Error

3 Is there a problem with the way we do business?

4 Acceptable Losses? 105 fatalities to date* 2006 Statistics
106 firefighters died while on duty in volunteer, 29 career. 6 multiple fatality incidents, 17 killed. 22 killed during brush, grass, or wildland firefighting. 36 died at the scene of a fire. 15 died responding to or returning from emergency incidents. 9 died engaged in training activities. 20 died after the conclusion of their on-duty activity. 50 died from heart attacks. 19 killed as a result of vehicle crashes.

5 Reasons & Costs Better protection, aggressive tactics, lighter weight construction and improved handling capabilities of heavy apparatus are putting firefighters at greater risk. Non-fatal firefighter injuries and prevention efforts cost anywhere from $2.8 billion to $7.8 billion per year. (NIST Report on Consequences of Fire Fighter Injuries )

6 Why isn’t technology enough?

7 “Normalization of Deviance”…

8 …becomes our nemesis

9 …To err is human… Error Management Marcus Tullius Cicero 106-43 B.C.
1 Fatality 10 Lost Time Injuries 100 Minor Injuries 1000 No Loss Accidents 10,000 UNSAFE ACTS!

10 Human Factor Error Causes Gordon Dupont’s “Dirty Dozen”
Lack of Communication Complacency Lack of Knowledge Distraction Lack of Teamwork Fatigue Lack of Resources Pressure Lack of Assertiveness Stress Lack of Awareness Norms

11 Who Carries the Load?

12 When Things Go Wrong . . . How It Is Now . . . How It Should Be . . .
You are highly trained You are human and and Humans make mistakes If you did as trained, you would not make mistakes so so Let’s also explore why the system allowed, or failed to accommodate your mistake You weren’t careful enough so and You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

13 Layers of Defense Trap Crew Errors
Use All Resources Maintain Situational Awareness Follow SOPs High Level of Proficiency

14 You may not know where the holes are
Use All Resources Follow SOP’s Maintain Situational Awareness High Level of Proficiency James Reason’s “Swiss Cheese”

15 When the holes line up… DISASTER! Use All Resources Follow SOP’s
Maintain Situational Awareness DISASTER! High Level of Proficiency James Reason’s “Swiss Cheese”

16 Crew Resource Management
What it is Where it came from How it works Why we should use it How we know it works

17 What Is Crew Resource Management?
Force multiplier Uses all resources Enhances supervision Improves safety Raises level of awareness for those engaged

18 Crew Resource Management (CRM) is a tool created to optimize human performance by reducing the effect of human error through the use of all resources.

19 Where Did It Come From? Aviation Community
Air Crashes Dominated Industry Attention Technology Only Went So Far 1970’s –Dr. Robert Helmreich and CVRs

20 Helmreich’s Error Management Model

21 How Does It Work? Six Principles Communication Decision-Making
Task Allocation Teamwork Situational Awareness Debrief*


23 Communication Barriers and bias block effective communication
Standard language benefits all Practice “active” listening Divide duties to prevent overload Minimize distractions Establish Inquiry/Advocacy patterns Clear, Concise, Complete Respectful Bishop’s Assertive Statement

24 Communication Active Listening Face individual(s) Maintain eye contact
Only one person speaks at a time Formulate reply after other person speaking finishes talking Distractions Turn down radio(s) Phones on vibrate No multi-tasking during periods of high stress Ambient noise Adjourn to quiet location

25 “Sterile” Command Post
Everyone needs to be “all business” when it’s time for business. IC sets the tone for the CP. Photo by Carlos Alfaro

26 Todd Bishop’s Assertive Statement
How to talk “up” the chain of command If you are a subordinate: – use the technique If you are a supervisor: – LISTEN FOR THE PROCESS!

27 5 Easy Steps Opening/attention (Call the supervisor by name or rank)
State concern/owned emotion (I’m concerned about…) State the problem as you see it (Someone is going to get hurt if we…) State a solution (I think we can do it another way…) Obtain agreement (aka buy-in) (Does this make sense to you?)

28 Critical Decision Making
Recognize problems Continue to “fight the fire” Maintain SA Assess hazards Assess resources Solicit solutions Make a decision!

29 Klein Method Recognition Primed Naturalistic Cue Based

30 Decision Making Cue Based
Compare existing knowledge base against situation Improve base through Training Experience Knowledge Case studies

31 “blink” Rapid Cognition Thin-slicing
Ability of the unconscious to find patterns in situations and behaviors based on very narrow slices of experience. Automated, accelerated recognition of identifiable patterns. “Coup d’oeil” - the power of the glance - Malcolm Gladwell

32 Klein, Gladwell & Today’s Fire Officer

33 Task Allocation Know your limits Know your crew’s limits
Capitalize on strengths Seek out “experts” “Eat the elephant one bite at a time”

34 Task Allocation Exercise
What You Have 3 Story MFD Fire on 2 floors and through roof Type V Construction Wood Truss Roof

35 Who’s On the Way… BC1 28 years, 6 as Ops BC 14 years in busiest areas
EFO Grad Bachelor’s in Fire Protection EMS BC 16 years, 2 as EMS BC 12 years in Suppression ranks 2 years as Training Captain Associates’ Degree, EMS Fire Prevention AC 20 years 6 in Ops as FF, Remainder of time in Fire Prevention EFO Grad Bachelor’s in Fire Protection NIMS Instructor Operations AC 34 years, 2 as Ops Chief 12 as Training DC 4 as Arson BC 8 as Safety Captain Bachelor’s in Fire Service Management

36 Who Gets the Job? Fire Attack Safety Officer Senior Advisor
Roof Sector

37 Teamwork Leadership Followership
Photo by Bob Bartosz, Camden Fire Department

38 Teamwork Leadership Authority Mentoring Mandated by rank
Derived through respect Mentoring Lead by example Admit mistakes Be technically competent Share knowledge

39 Teamwork #1 Priority: Continuous Risk vs Reward Evaluation
Conflict Resolution Focus on issue Keep ego in check Listen Mission Analysis #1 Priority: Continuous Risk vs Reward Evaluation

40 Understands human behaviors
Teamwork FOLLOWERSHIP Self Assessment Physical Condition Mental Condition Attitude Understands human behaviors

41 Teamwork Followership Respect authority Personal Safety Crew Safety
Accepts authority Knows authority limits Leader success Good communication skills Learning attitude Ego in check Balance assertiveness/authority Accept orders Demand clear tasks Admit errors Provide feedback Adapt

42 How Well Do You Team?

43 Situational Awareness
Point where perception and reality collide Reality always wins Beware of loss factors Ambiguity Distraction Fixation Overload Complacency Unresolved discrepancy

44 Hazardous Attitudes Invulnerability Anti-authority Impulsivity Macho
Resignation “Air Show Syndrome” “Pressing” Refers to an individual’s frame of mind. First 5 are FAA.

45 Good Situational Awareness
Good crew coordination Proper task completion Understanding Smooth ride Crisp and appropriate radio calls Use of checklists

46 Preventing Loss of Situational Awareness
Crew mental joggers “What do we have here?” “What’s going on here?” “How are we doing?” “Does this look right?”

47 Preventing loss of Situational Awareness
Personal mental joggers “What do I know that they need to know?” “What do they know that I need to know?” “What do we all need to know?”

48 Debrief Pre-Brief Facilitate Analyze Topic Decorum Operations
Human Behaviors

49 Why Should We Use CRM? Error is a fact of all performance
Command becoming more complicated Command successes are a function of teamwork Proven success in multiple industries with similar structure

50 How Do We Know It Works? 5th Generation in Aviation Industry
U. S. Marine Corps Adopting as Basic Philosophy Significant Reductions in Injuries and Error Commercial Aviation Industry U.S. Coast Guard U.S. Navy U.S. Air Force Veterans’ Administration Hospital System

51 Review What CRM is Where it came from How it works
Why we should use it How we know it works

52 For More Information (downloadable manual) Okray and Lubnau, Crew Resource Management for the Fire Service. Penwell Publishing

53 Contact Information


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