crew resource management & the command officer partnering for safe leadership ruidoso, nm may 7,...

Crew Resource ManagementCrew Resource Management&&

The Command OfficerThe Command Officer

Partnering for Safe LeadershipPartnering for Safe Leadership

Ruidoso, NMRuidoso, NM

May 7, 2008May 7, 2008

Battalion Chief John TippettBattalion Chief John Tippett

Montgomery County Fire & Rescue Service (MD)Montgomery County Fire & Rescue Service (MD)

Proven Tool for a Safer Scene ControlProven Tool for a Safer Scene Control

Bob Bartosz Photo

What do we hope to accomplish today?What do we hope to accomplish today?

Interactive discussion.Interactive discussion. Preserve “good” traditions.Preserve “good” traditions. Acquaint you with “new”Acquaint you with “new”

approach to command &approach to command &

control.control. Provide tool you can Provide tool you can

use beginning today.use beginning today.

Safety Based Culture

Non-Punitive Approach to Error

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

Acceptable Losses?Acceptable Losses?

105 fatalities to date*105 fatalities to date*

2006 Statistics

106 firefighters died while on duty in 2006. 77 volunteer, 29 106 firefighters died while on duty in 2006. 77 volunteer, 29 career. career.

6 multiple fatality incidents, 17 killed. 6 multiple fatality incidents, 17 killed. 22 killed during brush, grass, or wildland firefighting. 22 killed during brush, grass, or wildland firefighting. 36 died at the scene of a fire. 36 died at the scene of a fire. 15 died responding to or returning from emergency incidents. 15 died responding to or returning from emergency incidents. 9 died engaged in training activities. 9 died engaged in training activities. 20 died after the conclusion of their on-duty activity. 20 died after the conclusion of their on-duty activity. 50 died from heart attacks. 50 died from heart attacks. 19 killed as a result of vehicle crashes.19 killed as a result of vehicle crashes.

Better protection, aggressive tactics, lighter weight Better protection, aggressive tactics, lighter weight construction and improved handling capabilities of construction and improved handling capabilities of heavy apparatus are putting firefighters at greater heavy apparatus are putting firefighters at greater risk.risk.

Non-fatal firefighter injuries and prevention efforts Non-fatal firefighter injuries and prevention efforts cost anywhere from $2.8 billion to $7.8 billion per cost anywhere from $2.8 billion to $7.8 billion per year. (NIST Report on Consequences of Fire Fighter year. (NIST Report on Consequences of Fire Fighter Injuries - 2005)Injuries - 2005)

Reasons & CostsReasons & Costs

Why isn’t technology enough?Why isn’t technology enough?

““Normalization of Deviance”…Normalization of Deviance”…

……becomes our nemesisbecomes our nemesis

Error ManagementError Management

……To err is To err is human…human…

Marcus Tullius CiceroMarcus Tullius Cicero

106-43 B.C.106-43 B.C.

1 Fatality

10

Lost Time Injuries

100

Minor Injuries

1000 No Loss Accidents

10,000 UNSAFE ACTS!

Human Factor Error CausesHuman Factor Error CausesGordon Dupont’s “Dirty Dozen”Gordon Dupont’s “Dirty Dozen”

Lack of Lack of CommunicationCommunication

ComplacencyComplacency Lack of KnowledgeLack of Knowledge DistractionDistraction Lack of TeamworkLack of Teamwork FatigueFatigue

Lack of ResourcesLack of Resources PressurePressure Lack of Lack of

AssertivenessAssertiveness StressStress Lack of AwarenessLack of Awareness NormsNorms

Who Carries the Load?Who Carries the Load?

When Things Go Wrong . . .When Things Go Wrong . . .

How It Is Now . . . How It Should Be . . .You are humanYou are highly trained

and

If you did as trained, you would not make mistakes

Humans make mistakes

so

You weren’t careful enough

Let’s also explore why the system allowed, or failed to accommodate your mistake

so

You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

and

so

and

Layers of Defense Trap Crew ErrorsLayers of Defense Trap Crew Errors

Use All ResourcesMaintain Situational

Awareness

Follow SOPs

High Level of Proficiency

You may not know where the holes areYou may not know where the holes are

High Level of Proficiency

Maintain SituationalAwareness

Follow SOP’s

Use All Resources

James Reason’s “Swiss Cheese”

When the holes line up…When the holes line up…

High Level of Proficiency

Maintain SituationalAwareness

Follow SOP’s

Use All Resources

James Reason’s “Swiss Cheese”

DISASTER!

What it isWhat it is Where it came fromWhere it came from How it worksHow it works Why we should use itWhy we should use it How we know it worksHow we know it works

Crew Resource ManagementCrew Resource Management

What Is Crew Resource What Is Crew Resource Management?Management?

Force multiplierForce multiplier Uses all Uses all

resourcesresources Enhances Enhances

supervisionsupervision Improves safetyImproves safety Raises level ofRaises level of

awareness forawareness for

those engagedthose engaged

Crew Resource Management Crew Resource Management (CRM) is a tool created to (CRM) is a tool created to

optimize human optimize human performance by reducing the performance by reducing the

effect of human error effect of human error through the use of all through the use of all

resources.resources.

Where Did It Come From?Where Did It Come From?

Aviation CommunityAviation Community Air Crashes Dominated Industry AttentionAir Crashes Dominated Industry Attention Technology Only Went So FarTechnology Only Went So Far 1970’s –Dr. Robert Helmreich and CVRs1970’s –Dr. Robert Helmreich and CVRs

Error ManagementError Management

Helmreich’s Error Management ModelHelmreich’s Error Management Model

AVOID

TRAP

MITIGATE

How Does It Work?How Does It Work?

Six PrinciplesSix Principles

CommunicationCommunication Decision-MakingDecision-Making Task AllocationTask Allocation TeamworkTeamwork SituationalSituational AwarenessAwareness Debrief*Debrief*

CommunicationCommunication

Barriers and bias block effective communicationBarriers and bias block effective communication Standard language benefits allStandard language benefits all Practice “active” listeningPractice “active” listening Divide duties to prevent overloadDivide duties to prevent overload Minimize distractionsMinimize distractions Establish Inquiry/Advocacy patternsEstablish Inquiry/Advocacy patterns

Clear, Concise, CompleteClear, Concise, Complete RespectfulRespectful Bishop’s Assertive StatementBishop’s Assertive Statement

CommunicationCommunication

Active ListeningActive Listening Face individual(s)Face individual(s) Maintain eye contactMaintain eye contact Only one person Only one person

speaks at a timespeaks at a time Formulate reply after Formulate reply after

other person other person speaking finishes speaking finishes talkingtalking

DistractionsDistractions Turn down radio(s)Turn down radio(s) Phones on vibratePhones on vibrate No multi-tasking No multi-tasking

during periods of high during periods of high stressstress

Ambient noiseAmbient noise Adjourn to quiet Adjourn to quiet

locationlocation

““Sterile” Command PostSterile” Command Post

Everyone needs to Everyone needs to be “all business” be “all business” when it’s time for when it’s time for business.business.

IC sets the tone for IC sets the tone for the CP.the CP.

Photo by Carlos Alfaro

Todd Bishop’s Assertive StatementTodd Bishop’s Assertive Statement

How to talk “up” How to talk “up”

the chain of commandthe chain of command If you are a If you are a

subordinate:subordinate:

– – use the techniqueuse the technique If you are a If you are a

supervisor:supervisor:

– – LISTEN FOR THE LISTEN FOR THE PROCESS!PROCESS!

5 Easy Steps5 Easy Steps

Opening/attention Opening/attention (Call the supervisor by (Call the supervisor by name or rank)name or rank)

State concern/owned emotion State concern/owned emotion (I’m concerned (I’m concerned about…)about…)

State the problem as you see it State the problem as you see it (Someone is (Someone is going to get hurt if we…)going to get hurt if we…)

State a solution State a solution (I think we can do it another (I think we can do it another way…)way…)

Obtain agreement (aka buy-in) Obtain agreement (aka buy-in) (Does this (Does this make sense to you?)make sense to you?)

Recognize problemsRecognize problems Continue to “fight Continue to “fight

the fire”the fire” Maintain SAMaintain SA Assess hazardsAssess hazards Assess resourcesAssess resources Solicit solutionsSolicit solutions Make a decision!Make a decision!

Critical Decision MakingCritical Decision Making

KleinKlein

MethodMethod

Recognition Primed Recognition Primed NaturalisticNaturalistic Cue BasedCue Based

Decision MakingDecision Making

Cue BasedCue Based Compare existing Compare existing

knowledge base knowledge base against situationagainst situation

Improve base throughImprove base through TrainingTraining ExperienceExperience KnowledgeKnowledge Case studiesCase studies

““blink”blink”

Rapid CognitionRapid CognitionThin-slicingThin-slicing

Ability of the unconscious to find patterns in Ability of the unconscious to find patterns in situations and behaviors based on very narrow situations and behaviors based on very narrow slices of experience. slices of experience.

Automated, accelerated recognition of identifiable Automated, accelerated recognition of identifiable patterns.patterns.

““Coup d’oeil” - the power of the glanceCoup d’oeil” - the power of the glance

- - Malcolm GladwellMalcolm Gladwell

Klein, Gladwell & Today’s Fire OfficerKlein, Gladwell & Today’s Fire Officer

Task AllocationTask Allocation

Know your limitsKnow your limits Know your crew’s Know your crew’s

limitslimits Capitalize on Capitalize on

strengthsstrengths Seek out “experts”Seek out “experts” ““Eat the elephant Eat the elephant

one bite at a time”one bite at a time”

Task Allocation ExerciseTask Allocation Exercise

What You HaveWhat You Have

3 Story MFD3 Story MFD Fire on 2 Fire on 2

floors and floors and through roofthrough roof

Type V Type V Construction Construction

Wood Truss Wood Truss RoofRoof

Who’s On the Way…Who’s On the Way…

BC1

• 28 years, 6 as Ops BC

• 14 years in busiest areas

• EFO Grad

• Bachelor’s in Fire Protection

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

EMS BC

• 16 years, 2 as EMS BC

• 12 years in Suppression ranks

• 2 years as Training Captain

• Associates’ Degree, EMS

Who Gets the Job?Who Gets the Job?

• Fire Attack

• Safety Officer

• Senior Advisor

• Roof Sector

TeamworkTeamwork

LeadershipLeadership

FollowershipFollowership

Photo by Bob Bartosz, Camden Fire Department

TeamworkTeamwork

LeadershipLeadership AuthorityAuthority

Mandated by rankMandated by rank Derived through respectDerived through respect

MentoringMentoring Lead by exampleLead by example Admit mistakesAdmit mistakes Be technically competentBe technically competent Share knowledgeShare knowledge

TeamworkTeamwork

Conflict ResolutionConflict Resolution Focus on issueFocus on issue Keep ego in checkKeep ego in check Listen Listen

Mission AnalysisMission Analysis

#1 Priority:#1 Priority:

Continuous Continuous

Risk vs RewardRisk vs Reward

EvaluationEvaluation

TeamworkTeamwork

FOLLOWERSHIPFOLLOWERSHIP

Self AssessmentSelf Assessment

Physical ConditionPhysical Condition Mental ConditionMental Condition

AttitudeAttitude Understands human Understands human

behaviorsbehaviors

TeamworkTeamwork

Respect authorityRespect authority Personal SafetyPersonal Safety Crew SafetyCrew Safety Accepts authorityAccepts authority Knows authority Knows authority

limitslimits Leader successLeader success Good communication Good communication

skillsskills

Learning attitudeLearning attitude Ego in checkEgo in check Balance Balance

assertiveness/authorityassertiveness/authority Accept ordersAccept orders Demand clear tasksDemand clear tasks Admit errorsAdmit errors Provide feedbackProvide feedback AdaptAdapt

Followership

How Well Do You Team?How Well Do You Team?

Situational AwarenessSituational Awareness

Point where perception Point where perception and reality collideand reality collide

Reality Reality alwaysalways winswins Beware of loss factorsBeware of loss factors

AmbiguityAmbiguity DistractionDistraction FixationFixation OverloadOverload ComplacencyComplacency Unresolved discrepancyUnresolved discrepancy

Hazardous AttitudesHazardous Attitudes

InvulnerabilityInvulnerability Anti-authorityAnti-authority ImpulsivityImpulsivity MachoMacho ResignationResignation

““Air Show Syndrome”Air Show Syndrome” ““Pressing”Pressing”

Good Situational AwarenessGood Situational Awareness

Good crew Good crew coordinationcoordination

Proper task Proper task completioncompletion

UnderstandingUnderstanding Smooth rideSmooth ride Crisp and appropriate Crisp and appropriate

radio callsradio calls Use of checklistsUse of checklists

Preventing Loss of Situational Preventing Loss of Situational AwarenessAwareness

Crew mental joggersCrew mental joggers ““What do we have What do we have

here?”here?” ““What’s going on What’s going on

here?”here?” ““How are we doing?”How are we doing?” ““Does this look right?”Does this look right?”

Preventing loss of Situational Preventing loss of Situational AwarenessAwareness

Personal mental joggersPersonal mental joggers ““What do I know that they need What do I know that they need

to know?”to know?” ““What do they know that I need What do they know that I need

to know?”to know?” ““What do we all need to What do we all need to

know?”know?”

DebriefDebrief

Pre-BriefPre-Brief TopicTopic DecorumDecorum

FacilitateFacilitate AnalyzeAnalyze

OperationsOperations Human BehaviorsHuman Behaviors

Why Should We Use CRM?Why Should We Use CRM?

Error is a fact of all Error is a fact of all performanceperformance

Command becoming Command becoming more complicatedmore complicated

Command successes Command successes are a function of are a function of teamwork teamwork

Proven success in Proven success in multiple industries with multiple industries with similar structuresimilar structure

How Do We Know It Works?How Do We Know It Works?

55thth Generation in Aviation Industry Generation in Aviation Industry U. S. Marine Corps Adopting as Basic U. S. Marine Corps Adopting as Basic

PhilosophyPhilosophy Significant Reductions in Injuries and ErrorSignificant Reductions in Injuries and Error

Commercial Aviation IndustryCommercial Aviation Industry U.S. Coast GuardU.S. Coast Guard U.S. NavyU.S. Navy U.S. Air ForceU.S. Air Force Veterans’ Administration Hospital SystemVeterans’ Administration Hospital System

ReviewReview

What CRM isWhat CRM is Where it came fromWhere it came from How it worksHow it works Why we should use itWhy we should use it How we know it worksHow we know it works

For More InformationFor More Information

http://www.iafc.org/http://www.iafc.org/associations/4685/files/CRMassociations/4685/files/CRM%20Manual.pdf %20Manual.pdf (downloadable manual)(downloadable manual)

Okray and Lubnau, Okray and Lubnau, Crew Crew Resource Management for Resource Management for the Fire Servicethe Fire Service. Penwell . Penwell PublishingPublishing

Contact InformationContact Information

john.tippett@montgomerycountymd.govjohn.tippett@montgomerycountymd.gov

jtippett@iafc.orgjtippett@iafc.org

240-832-6563240-832-6563

QUESTIONS?QUESTIONS?