SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND

COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS

by

Ronald P. Timmons

APPROVED BY SUPERVISORY COMMITTEE: ___________________________________________ Douglas J. Watson, Ph.D., Chair ___________________________________________ Kimberly A. Aaron, Ph.D. ___________________________________________ Donald R. Arbuckle, Ph.D. ___________________________________________ James W. Marquart, Ph.D.

Copyright 2009

Ronald P. Timmons

All Rights Reserved

“…our effectiveness is only as good as our ability to communicate.”

(Donald J. Burns in U.S. Fire Administration 1993, 54)

This dissertation is dedicated to the memory of Assistant Fire Chief Donald J. Burns,

New York City Fire Department.

At two of the most difficult fire department operations imaginable, there was one man

in the unique position to understand the interconnectedness of communications and

command. After facing the first World Trade Center attack in 1993, Chief Burns testified

that, “One of our biggest problems was communications” (U.S. Fire Administration

1993, 54). He returned on September 11, 2001 to command a portion of the FDNY

response to the terrorist attacks at the same skyscraper complex. Although radio

recordings prove police helicopter warnings of impending collapse of the second tower,

there is no indication that the message on the police radios made it to Chief Burns’ fire

command position at the base of the North Tower (Dwyer 2002; National Commission on

Terrorist Attacks 2004, 309). He died along with 403 other brave first responders in the

collapse of the buildings.

Befitting the man who served the citizens of New York for 39 years, many years past

retirement age, his funeral mass occurred at Saint Patrick’s Cathedral on October 9, 2001.

His wife and three children joined hundreds of uniformed firefighters lining Fifth Avenue

to salute the man, despite the unimaginable reality that his unrecovered remains were just

four miles away. The dignitaries used words such as “hero,” “patriot,” and “unparalleled

experience” to salute him at the funeral (Virasami 2001).

My experience with Chief Burns was happenstance, but indelibly memorable. I was

in need of a ride out the Long Island Expressway on a hot Friday afternoon in June 1987

and he was going in my direction. I was a rookie lieutenant from one of the smallest fire

iv

departments in the state and he was the chief in charge of the officers’ training program

for the largest fire department in the country. He was the boss and I was the student at his

training academy. Hierarchically removed from me by several ranks, it would have been

easy for him to say no to my request for a ride, but he did not. He was older and much

more experienced, but he was interested in what I had to say and impressed by my

educational and career aspirations. As much as I tried to turn the 90-minute conversation

back to him and his experiences, he was more interested in what I could tell him that he

did not know. He inspired me with his gentle, confident humility and encouraged me with

his vision of advancing our profession through formal education.

It is my fervent hope that this dissertation will inspire future generations of first

responders to address the perennially vexing problem of emergency communications, in

all its forms: technological, relational, and physiological. Chief Burns sparked that

interest in me, and now it is time for you to take it further…

Ronald P. Timmons

SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND

COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS

by

RONALD P. TIMMONS, B.S., M.P.A., M.A.

DISSERTATION

Presented to the Faculty of

The University of Texas at Dallas

in Partial Fulfillment

of the Requirements

for the Degree of

DOCTOR OF PHILOSOPHY IN

PUBLIC AFFAIRS

THE UNIVERSITY OF TEXAS AT DALLAS

May, 2009

ACKNOWLEDGEMENTS

I gratefully acknowledge the…

…loving support from my wife and daughter

…grounding and example from my beloved parents

…interest and encouragement from my brother and sister

…patience and insightful wisdom from Dr. Douglas Watson

…suggestions and generous service of the dissertation committee

…the dedicated firefighters of the Allen, Plano and McKinney Fire Departments

…assistance and inspiration from my devoted coworkers at the city of Plano, Texas March, 2009

vi

SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND

COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS

Publication No. ___________________

Ronald P. Timmons, Ph.D. The University of Texas at Dallas, 2009

Supervising Professor: Douglas J. Watson The decision-making and communications processes of community first responders are

frequent concerns at intense crisis responses. Effective command is dependent on sound

decision-making; adequate communications processes are critical elements in successful

crisis decision-making. Homeland security initiatives have reemphasized this issue. Although

the assumption may be immediate and complete improvement of communications is solely

awaiting radio hardware upgrade, this study identifies nontechnical factors impeding

successful communications. Of particular interest were those situations whereby radio

messages were clear; however, the intended recipient was unable to receive the message or

make best use of it, despite evidence of cogent message delivery on recordings.

One hypothesis tested is whether sensory overload contributes to ineffective

communications. Also tested is a prediction that commanders at emergency scenes mishandle

radio messages even when the equipment is functioning properly. Case studies of actual

incidents and observation of realistic training exercises allowed isolation and analysis of

vii

common features of communications dysfunction. A series of phenomenological studies

observed first responders in the act of communicating as they typically would at emergency

scenes. This fieldwork at fire department training exercises allowed the researcher to collect

data associated with distractions and communications dysfunctions.

Validation of both hypotheses occurred. Messages requiring repeating, as well as those going

unanswered or otherwise missed were common. Most of the dysfunctional radio

communications occurred because of inattention to the radio due to distraction from talking

in person to others nearby, confusion over proper radio channel selection, garbled, excited, or

unintelligible messages from the sender, and background noise associated with chaotic

emergency scenes. In 38 percent of the cases, there was no apparent reason for the missed

message; physiological and psychological factors from analogous studies provide potential

explanation.

The significance of this research is in studying the specific moment of radio dysfunction and

correlation with underlying causes. In those instances where no apparent reason existed for

the communications dysfunction, physiological stress reactions are theorized as underlying

factors, along with a number of equipment and human factors. Readers receive practical

solutions for improvement of emergency communications, acknowledging that some

occurrences of missed messages are inevitable in the demanding emergency environment.

viii

TABLE OF CONTENTS

Acknowledgements............................................................................................................ vi

List of Figures ................................................................................................................... xii

CHAPTER 1 INTRODUCTION .......................................................................................1

First Responder Communications Issues .................................................................4

CHAPTER 2 LITERATURE REVIEW ............................................................................7

Decision-making in the First Responder Environment............................................7

Military ....................................................................................................................9

Personal Influences ................................................................................................10

The Role of Communications in Crisis Decision-Making.....................................13

Sensory Overload and Task Interruption ...............................................................16

Inattentional Blindness...........................................................................................24

Literature Review Summary ..................................................................................27

Hypotheses.............................................................................................................28

CHAPTER 3 METHODOLOGY ....................................................................................29

Research Design.....................................................................................................29

Data Collection ......................................................................................................33

Coding of Observable Behaviors ...............................................................34

Data Organization and Analysis ................................................................34

CHAPTER 4 CASE STUDIES OF ACTUAL INCIDENTS ..........................................36

Syracuse, New York 1978 .....................................................................................37

Hackensack, New Jersey 1988...............................................................................38

North Hollywood, California 1997........................................................................39

Seattle, Washington 1998 ......................................................................................43

Prince William County, Virginia 2007 ..................................................................44

Charleston, South Carolina 2007 ...........................................................................46

ix

New York City, New York 2009 ...........................................................................52

Common Themes Among All Cases Studied ........................................................57

CHAPTER 5 CASE STUDIES OF TRAINING EXERCISES .......................................61

McKinney Fire Department Case Studies Venue Description ..............................61

Exercise Data .........................................................................................................66

McKinney Case Studies Day One..............................................................69

McKinney Case Studies Day Two.............................................................78

McKinney Exercises Analysis ...............................................................................81

Plano Fire Department Case Studies Venue Description ......................................83

Plano Case Studies Day One......................................................................86

Reevaluation of the Simulation Environment – Testing Sub-Theories .................92

Plano Case Studies Day Two.....................................................................92

Plano Case Studies Day Three...................................................................99

Plano Exercises Analysis .........................................................................106

McKinney and Plano Exercises Compared..........................................................108

Influence of Talking While Wearing A Mask .........................................109

Simulation Environments.....................................................................................109

CHAPTER 6 IMPLICATIONS AND RECOMMENDATIONS..................................112

Research Summary ..............................................................................................112

Hypotheses Results ..............................................................................................113

Why Messages Are Missed..................................................................................115

Sensory Overload.....................................................................................116

Physiological Hearing Deficit..................................................................117

Inattentional Deafness..............................................................................119

Solutions ..............................................................................................................120

Human Factors Engineering ....................................................................122

Training....................................................................................................124

Final Thought.......................................................................................................126

APPENDIX A..................................................................................................................127

APPENDIX B ..................................................................................................................128

x

APPENDIX C ..................................................................................................................129

BIBLIOGRAPHY............................................................................................................130

VITA

xi

LIST OF FIGURES

Number Page

1. Summary of Positive Scores From McKinney Day One ...............................................77

2. Summary of Positive Scores From McKinney Day Two ..............................................81

3. Ranked McKinney Scores..............................................................................................81

4. Scores Compared To Pace .............................................................................................82

5. Summary of Positive Scores For Plano Day One ..........................................................91

6. Summary of Positive Scores For Plano Day Two .........................................................98

7. Summary of Positive Scores For Plano Day Three .....................................................105

8. Collaboration Influence In Scoring..............................................................................106

9. Correlation of Collaboration With Scores ...................................................................107

10. Comparing Influence of Mask Usage on Communications Efficacy ........................109

11. Communications Deficits...........................................................................................116

xii

1

CHAPTER 1

INTRODUCTION

First responders are the police, fire, and emergency medical personnel who respond to

emergencies throughout our communities. Daily routine allows for management of incidents

in a habitual manner. Occasional intensive disasters, ranging up to the scope of the 9/11

terrorist attacks, Hurricane Katrina, the Columbine High School shooting, and the Oklahoma

City Federal Building bombing, are examples of calamitous incidents requiring the most

urgent of communications and decision-making capabilities by first responder incident

commanders.

Failure in this decision-making environment can result in dire consequences for crews

and citizens awaiting rescue. Commanders at emergencies do not have the luxury of

deliberation and debate. They often need to take instant action to achieve objectives within

very tight timelines. One study showed that fire department commanders face dynamic

conditions at emergency scenes, requiring new decisions to answer an average of five

situational changes within the typical incident (Klein 1999, 6). An interesting aspect of

emergency scene decision-making is the instant feedback provided to the decision-makers.

This allows a honing of decision-making skills and rapid development of experience in

critical situations, along with a tendency to apply heuristic decision-making as reflexive

coping mechanisms (Simon 1981, 66). People functioning as incident commanders at

2

community emergencies face a number of unique challenges. The rapidly changing

environment makes actions appropriate for one moment, yet inappropriate in new

circumstances just a short time later.

The command staff somehow has to reverse hierarchical practices used during daily para-

militaristic practices, as they seek to find creative, flexible decision solutions in infrequent

crises. Decision-making in hierarchical organizations can be problematic. Conflicting

interests of serving political or internal command structures make it difficult to provide

commanders in high-pressure situations the flexibility necessary to react to changing

circumstances (Roberts et al. 1994, 623). Mendonça (2007, 964) argued for the need to build

robust systems allowing flexibility and creativity for the proper handling of extreme events.

Analogies of jazz musicians using improvisation techniques built within the constraints of a

musical chord structure show the possibility of making procedures and rules constructed to

allow some degree of customization depending on the circumstances (Mendonça 2007, 964).

Comfort (1985, 158-159) highlighted the importance of concurrent information gathering

as the interaction of people and events generate geometric complexity in the decision-making

process at emergencies. All responders present at the incident need to make a scan of the

operational environment with relevant information fed to a centralized decision-making

authority. In one study, firefighters interviewed about their decision-making process denied

that it was a formal process of weighing several alternatives, but rather a reflexive reaction to

circumstances as they occur (Klein 1999, 16). Therefore, something significant is occurring

in the milliseconds between input of conditions stimuli and the resultant selection of an

appropriate response (Gladwell 2005, 11-15).

3

First responders rely heavily upon two-way radio equipment to communicate with one

another and to gather the information necessary to start the decision-making process before

arrival at the scene. “Inadequate fireground communication is repeatedly cited as a

contributing factor in many of the incidents reported through the United States,” according to

the U.S. Fire Administration (1999, 1-3). Chaotic communications at emergency scenes are a

frequent frustration with the assumption that only a technological improvement is necessary,

ignoring human factors (National Commission on Terrorist Attacks 2004, 280-285). The

weakest link in communications networks can be the human element. “There is a dearth of

available literature pertaining to the impact of human factors on effective fireground

communication” (U.S. Fire Administration 1999, 2). Even the most robust of radio systems

can be overwhelmed during routine incidents. Intense crisis situations can lead to almost

certain network collapse unless the users prioritize their messages. Radio traffic

management, within a fine line between too much information and not enough, needs

attention to assure that critical situational and safety information reaches incident

commanders (U.S. Fire Administration 1999, 10). The events and rapid flow of information

at emergency scenes can quickly overwhelm fireground commanders. The reduction in the

number of support personnel available in the form of chiefs’ drivers and aides may make this

concern more acute (U.S. Fire Administration 1998, 10).

This topic is ripe for further research to establish cause and effect relationships between

physiological and environmental influences in the emergency environment and the quality of

communications used by first responders. The commanders of emergency incidents measure

their successes by lives and property saved. Therein resides the difference between the

classic treatment of decision-making in the literature and the need for more research and

4

understanding of the unique challenges present in fast-paced emergency operations.

Demands for rapid decisions in compressed timeframes with limited information and

significant consequences for poor choices challenge emergency responders (Klein 1999, 9-

12; Garnett and Kouzmin 2007, 174.) Emergency commanders work in a critical decision-

making environment where the common doctrine of decision-making theory does not always

apply or it may need modification to meet the unique challenges. Decision theory literature

tends to focus on boardroom-style decision-making; slow, deliberate decision process is of

marginal value to emergency responders working in fast-paced, high stress, high stakes

environments (Klein 1999, 9, 18-19; Weick 2002, S12). Quality decisions by those

responsible for commanding emergencies are critical for the successful outcome of the

incident. Responders perform a number of critical tasks; the safety of those operating at the

scene, and the wellbeing of those affected by the incident, add to the pressure to find correct

decision solutions. One of the ironies and realities of all improvised decisions, such as those

made at emergency scenes, is the realization that a chosen tactic is not working only occurs

after it has already failed (Weick 2002, S12). Failure in the emergency services domain can

sometimes result in unnecessary death, destruction of property, and significant interruption of

commerce, which intensifies the need for sound decision-making practices.

First Responder Communications Issues

This research challenge is an outgrowth of the dissertation author’s interests and

experiences surrounding emergency scene decision making and communications processes.

Research shows human impediments to communications beyond the predominant technical

interoperability issues being address by homeland security professionals (Hutchins and

5

Timmons 2007). First responders face a work environment replete with stressful situations

and difficult choices in compressed timeframes. Since Gaines and Jermier (1983, 571-572)

claimed the literature conflicts in establishing the influences of stress and fear in decision-

making, this dissertation works to “de-conflict” the connection between environmental

influences and humans communicating and making decisions in crisis mode.

Upon arrival at an emergency scene, personnel quickly have to decide their initial tactics

from a range of choices. Years of adhering to customs and experience yield heuristic “rules

of thumb,” such as “lives first, property second.” However, within those two major

categories are dozens, or hundreds, of sub-options. Are there people in immediate danger

needing rapid rescue by the personnel already on the scene? Can the subjective assessment be

made that some victims are beyond hope of surviving their injuries, and the limited resources

available be redirected to the “savable?” The minimally injured “walking wounded” may also

be the most vociferous demanders of attention by the first responders, as they may

aggressively demand treatment, or want help to locate lost companions and family. Will the

decision-making first responders be able to transcend their daily orientation of helping people

in minor situations and go past those pleading for help, to seek those within minutes of losing

their lives from critical injury and immediate peril? The presence of multiple distraction factors

in the emergency operation environment can lead first responders not to hear critical information

on their radios due to noise at the scene and the sheer volume of radio traffic (Spahn 1989, 18;

U.S. Fire Administration 1999, 6). These are the realities of the first responder decision-

making and communications environment targeted by this research effort. There is a need to

study attention span and sensory overload as significant factors in communications efficacy.

6

This research is particularly timely since homeland security has received increased

interest and funding in this decade. Command and communications issues predate the terror

attacks of 9/11 and have been a factor for many years (Hawkins 2007, 1, 5-6; National

Commission on Terrorist Attacks 2004, 280-285; U.S. Fire Administration 1993, 14, 32, 38-

39, 51; U.S. Fire Administration 1999, 2-3, 9). Many of the same communications challenges

facing the responders to the World Trade Center in 2001 existed when they responded to the

same complex for the first terrorist attack in 1993 (U.S. Fire Administration 1993, 14, 32, 38-

39, 51). Some of the communications issues in high-rise buildings are technological, but

some part of the burden falls to the radio operators. There is a relatively low level of

consensus among emergency responders that they have a share of the responsibility in

communications failures. The tendency has been to blame the radio equipment, instead of

considering the human elements involved (Timmons 2007, 2).

This dissertation first examined the unique challenges present in the community

emergency environment and then outlined several underlying influences and biases in the

decision-making process used by command personnel at intense incidents. Communications

efficiency and the influence of distracting factors are the specific focus of this dissertation

since communications are such a critical component of the decision-making process. The

researcher presents new approaches in providing communications and decision support to

incident commanders and suggests implications and recommendations in the final section of

this dissertation. These suggested decision-support and communications improvement

opportunities customize the existing literature on generic decision-making, along with

information learned from analogous disciplines and perspectives.

7

CHAPTER 2

LITERATURE REVIEW

Decision-making in the First Responder Environment

Paradoxically, those involved in the dynamic environment of emergency services

traditionally have a systemic resistance to change (Comfort 1985, 163). Rapid, adaptive

learning, in “real-time” has to occur, yet those involved have classic attributes of traditional,

rules-bound bureaucrats. The same hierarchical orientation from daily para-militaristic

practices requires reversal by the command staff, as they seek creative, flexible decision

solutions in occasional crisis situations. A scan of the operational environment by all

responders present at the incident is valuable, with relevant information fed to a centralized

decision-making authority. Roberts and Rousseau (1989, 135) found it important for

researchers to consider the multiple levels of activity and the impact of expected and

unexpected events on people operating in high-reliability situations. Subsequent behaviors

redirected by unexpected events, make study and analysis of crisis decision-making very

complex.

Personnel in public safety agencies tend to function in rigid, linear organizations in which

inflexible rules convey organizational expectations and standardize the approach to situations

encountered. As much as the words “good discipline” may seem an oxymoron to some, they

may be desirable, if for instance they appeared on the performance appraisal of a police

sergeant, as in “maintains good discipline among subordinate personnel.” Bigley and Roberts

8

(2001, 1293) noted the conundrum generated when it becomes necessary to commingle the

tenets of hierarchical management, emphasizing rules, routine, and procedures, yet needing

to encourage procedural flexibility during occasional and intense decision environments.

The decision-making process starts before arrival, as responders build their knowledge of

what is occurring, in bits and pieces, while they monitor radio transmissions from dispatchers

and those already at the scene (Bigley and Roberts 2001, 1291). Emergency response

personnel use several terms to describe the notion of attaining pertinent information in the

operational environment. The need to establish “situational awareness,” “size-up,” and “big

picture” are terms used to acknowledge the tendency of those at the task-level to take a

myopic view of circumstances immediately affecting them, to the exclusion of considering

the overall scene.

An anecdote in decision-making literature sheds light on the conflicted association

between classical decision-making theory and the realm we are just starting to understand-

crisis decision-making. Howard Raiffa, noted scholar and author on decision-making,

received an offer in 1957 to leave his post on the faculty of Columbia University for a

position at Harvard. His relationship with his prevailing dean was such that he went to him

for advice. The dean’s alleged response was sarcastically that Raiffa should apply his own

principles of decision theory scoring, and to go where the result of the arithmetic formula

said he should. Raiffa’s response was purportedly, "No, this is a serious decision" (Bazerman

et al. 1998, 236).

Emergency responders are likely to think the same thing—that their decisions are too

serious for reduction to weighted scoring and sterile calculations. According to Bazerman et

9

al. (1998), Raiffa insisted the story was not accurate, but it amused him nonetheless. He saw

the story as proof that there is an inevitable tension between formal and informal decision-

making processes, and there is an acknowledged role for both in the arrival at the optimal

decision.

Military

Parallels in military culture exist, as similar situations have led the armed forces to pursue

adaptive behaviors. Development of situational awareness is a necessary ingredient in sound

crisis decision-making and effective communications are an important part of gaining the

necessary information to form situational awareness.

In the U.S. Navy, “having the bubble” is the phrase for maintaining a big picture view of

operations (Roberts and Rousseau 1989, 135; Bigley and Roberts 2001, 1292). Much like

counterparts in the military, our community first responders face overwhelming variables,

chaotic situations, critical decisions, and death of citizens and coworkers a potential

consequence of poor decisions.

Radios proved to be useful in the Vietnam War allowing commanders in the rear to

monitor battleground communications and attempt to piece together what was occurring at a

location they could not see. The communications at times included excited voices in which

net controllers had to exhort the senders to slow down and clearly articulate what it was they

were requesting. In one sequence of communications from the battle at la Drang Valley in

1965, a lieutenant colonel was pinned down and calling for support (Moore 1992, 246 – 248).

When he started yelling over the radio, “They're running! They're running!” his colonel

thought for a moment that he meant his own battalion was on the run, but the sender of the

10

message meant it was the enemy who were running as a result of the air strike (Moore 1992,

247). Such inappropriate assumptions of intent in phrases with double meanings occur in

both military and first responder settings. Message clarity is an important element in effective

emergency scene communications. Excited, emotionally aroused people can exhibit loud and

uncontrolled voices, making it very difficult to understand what they are saying (National

Institute for Occupational Safety 2003, 17).

Personal Influences

Want/Should

External command of the people working at emergency scenes is one aspect of the

overall decision-making arena for first responders, but there are also introspective

intrapersonal conflict considerations. Bazerman et al. (1998, 225-230) described our inner

conflict as we wrestle between what we know we should do for our own good, and that

which is more pleasing, easy, or desirable for a variety of reasons. Diet and exercise are good

examples of what we know to be good for us, yet the translation into action is missing for

many. While it seems likely that incident commanders can put aside concerns of personal

comfort or be truly altruistic in the necessity of the moment, it is important to consider that

decision-making in daily life does little to prepare incident commanders for a predominately

“should” environment. Increased focus on the safety of responders has presented additional

internal conflict between the “want” of personal safety and the “should” of rescuing people in

dangerous situations.

11

Groupthink, Stress, and Fear

Janus (1972, 9-10) established that people functioning in groups tend to form a collective

mindset and cultivate an atmosphere in which there is a strong bias for the status quo. Subtle

squelching of dissenters is common. Janus (1972, 143) juxtaposed the relative success of the

Cuban missile crisis in which President John Kennedy encouraged opposing viewpoints with

the Bay of Pigs incident where groupthink predominated. Janus cited the latter as an example

of the deleterious effect of groupthink. Schafer and Crichlow (1996, 429) noted that group

influences are presumed to be at their highest point in crises, yet the data show a lack of

documented influence under such circumstances. Since crises are the category of interest for

this research effort, and the influences delineated in their study are pertinent to first

responder operations, the findings in the Schafer and Crichlow study are applicable since

they suggest negligible groupthink influence at emergency operations. There is a need for

further study before connecting significant inferences to the emergency environment.

Occasionally, in military and community emergencies, a cascade of poor decisions makes

it difficult to bring the chaotic situation under control, as was the case in the example of the

Bay of Pigs cited by Janus. Major failures in emergency circumstances can be a product of

multiple, successive failures. Schafer and Crichlow (1996, 418-420) examined 19 different

wars throughout history to measure the influence of the following ten attributes of

groupthink: group insulation, impartial leadership, methodical procedures, group

homogeneity, time constraint, recent failure, personal stress, invulnerability illusion, closed-

mindedness, and uniformity pressures. Schafer and Crichlow were not able to validate a

significant influence to wartime decision-making from these factors, despite assumptions

they are contributing factors in crisis decision-making dysfunction. The authors admit to a

need for further study and a greater sample size beyond their cold-war era study. Bravado

12

and peer pressure play some role in influencing the decision-making process of first

responders, as customs and traditions meld with presumed deleterious elements of

groupthink. There is a need for further study to establish connectedness to the emergency

environment before making significant inferences.

A tendency to scramble and hastily recover from an initial poor decision may negatively

influence subsequent decisions. Caldwell and O’Reilly (1982, 124, 134) referred to a level of

“self-justification,” in which decision-makers may get filtered information portraying

conditions being better than they really are, in an effort to mask failing courses of action and

to highlight positive cues. Another term generated from Caldwell and O’Reilly’s research is

“impression management,” which identifies the phenomenon of justifying increasingly

failing approaches in an attempt to prove the soundness of the initial premise. Watergate and

the Vietnam War are prime examples of self-justification and impression management

(Gouran 1976, 183-185; Caldwell and O’Reilly 1982, 124-125; McDermott et al. 2002, 145).

Another influence imposed upon first responders is a state of “expressive suppression,”

which involves the conscious inhibition of emotional expressions while emotionally aroused.

First responders force themselves to “stay calm” and to control their emotions as they try to

work through the formidable challenges present in the emergency theater of operations. One

study showed that people who suppress natural emotional responses experienced elevated

blood pressure, increased stress levels, disrupted communications, a reduction in rapport

building, and inhibited relationship formation (Butler et al. 2003, 48-67). Emotions play a

significant role in the operations at emergency scenes. It is not possible for the responders to

isolate themselves entirely from the effects of emotion, despite expectations of peak

efficiency. Kahneman (2003, 706) observed that it is not possible to separate emotions from

13

the decision-making process and that emotion is triggered by the dynamic conditions at the

scene. Kahneman (2003, 706) noted that the long-term environment is not where life is lived

and he cautioned decision theorists that broad, long-term views may be prescriptively sterile.

As Bazerman outlined in his subchapter on harm, omission bias, and status quo (2006,

54-55), there is a tendency to select options having even a slight possibility of doing no harm,

even when probability suggests that it may be wise to sacrifice the few in order to save a

larger group at risk. A false sense of heroics and false optimism for a miraculous outcome

can lead to overly conservative tactical strategies, even when the odds are stacked against

successfully saving everyone. The “do no harm” alternative (Bazerman et al. 2001, 1-10)

carries a strong bias, since it presumably requires the least amount of explanation, has a long

history of use in everyday situations, and is consistent with change-averse organizations,

which is a typical feature of public safety agencies.

The Role of Communications in Crisis Decision-Making

In studying common features of disaster management behaviors, Karl Weick noted the

importance of communications (Weick 1990, 589). Effective communications allow complex

systems to become more understandable. Discovery of new pieces of information allow one

to make sense of one’s experience thus allowing the situation to become linear, predictable,

and controllable. Weick argued that the situation is more complex than simply telling people

to talk more, noting the disorganization and chaos that can evolve when too many people are

talking at once. In recalling the atmosphere inside the control room at the Three Mile Island

nuclear power plant during tense moments surrounding the release of radioactive steam

during a serious accident in 1979, Weick noted there were too many people in the control

14

room talking at the same time. Each was attempting to contribute their hunches to what was

occurring and what tactics should be employed (Weick 1990, 589).

The literature reveals a contrast between classical decision-making theory, such as the

rational-comprehensive model in which exhaustive examination of all factors is made before

decision selection (Morçöl 2006, 5), and the “Thin Slicing” theory introduced by Gladwell

(2005, 23). Gladwell (2005, 23) defined thin slicing as “the ability of our unconscious to find

patterns in situations and behavior based on very narrow slices of experience.” Klein (1999,

4) noted that fire department commanders make about 80 percent of their decisions in less

than one minute. In the course of normal operations, emergency responders use recognition-

primed decisions (RPD), employing the first workable solution in the interest of time and

expediency (Klein 1999, 30).

Since rational-comprehensive models are impractical in the emergency environment

(Klein 1999, 9-12; Soelberg 1967, 26), another view is necessary to bring clarity to

emergency command situations. Lindblom (1959, 80-83) challenged those facing complex

problems to acknowledge the limits of intellectual capacities and to narrow analysis to the

most critical, non-exhaustive components. Lindblom (1959, 80-83) contended that any

attempt to take every possible factor into consideration leads to the likely outcome of narrow

definitions and a resultant limited scope. Former Secretary of State and retired U.S. Army

General Collin Powell waited for 40 percent certainty on data before considering an intuitive

solution to a problem. To overcome what some may call analysis paralysis, Powell viewed

any more than 70 percent certainty to be more information than necessary to make a sound

decision, wasting valuable resources on data acquisition (Klein 2003, 171).

15

Herbert Simon’s bounded rationality theory holds that actors in intensive decision-

making situations use a form of “rational choice that takes into account the cognitive

limitations of the decision-maker—limitations of both knowledge and computational

capacity” (Simon 1997, 291). Simon contended that people use heuristics to make decisions

instead of attempting to optimize the decision with extensive data acquisition and analysis.

Heuristics are a reflex reaction when deliberation costs are high and the actor has a base of

experience to draw upon to arrive at a rapid and usually sound decision (Simon 1981, 66).

Render et al. (2006, 68) outlined the several steps in decision-making; they essentially are

to gather information, process it, and apply the best choice. Render et al. (2006, 68)

articulated an idealistic notion of decision-making in stating that any decision based on logic,

after scrutiny of available data and alternatives, applied in a careful, systematic manner is a

good one, regardless of the outcome. Emergency responders attempt to apply all of these

steps, in milliseconds, when corporate managers can take weeks to reach decisions with far

lower consequences. Emergency responders would likely take little comfort from Render’s

sound decision disclaimer, regardless of how perfect the logic was, especially if the result of

decisions involved loss of life. Testing of counterfactual alternate endings is not possible in

the emergency environment.

For a variety of reasons, some academics and practitioners may make incorrect

assumptions about how emergency first responders make decisions (Klein 1999, 7-13). Some

portion of the body of literature tends to address boardroom style decision-making, in which

students are encouraged to gather facts, extrapolate decision formula, and choose the best

option derived from multiple options, although contemporary approaches have begun to

recognize the impracticality of doing so (Morçöl 2006, 5). Even the most ardent quantitative

16

decision-making academic may ponder the applicability of this process for the incident

command personnel if personally impacted by a disaster.

Sensory Overload and Task Interruption

Framing and Heuristics

The term decision framing refers to the situation whereby acts, outcomes, and

contingencies attributed to each choice in a decision sequence shape the decision-maker’s

perceptions. Framing is influenced by both the circumstances prevailing within the decision,

and the habits, customs, and norms possessed by that particular decision-maker (Tversky and

Kahneman 1981, 453). Therefore, there are two variables present in any major decision: the

person and the circumstances.

Bazerman (2006, 43) argued that people make decisions from their own neutral reference

point, making the location of the reference point, i.e. positively or negatively framed, an

influence on the amount of risk assumed. The decision-maker may select a different course

of action, if he had greater awareness of a slightly different decision frame or ease in which

to access and consider other alternatives. The communications process is a key factor in

alternatives awareness. Decision frame also gives the decision-maker a comfort zone of

operation, in which the single option chosen early in the process becomes more and more

fortified, shaping the point of reference, and increasing risk propensity (McDermott et al.

2002, 145).

Subtle perceptions of risk and reward, as well as the tendency of the individual to take

risk, can produce widely differing outcomes when two or more people view the same

circumstances. Tversky and Kahneman (1981, 454-458) established that seemingly

17

inconsequential shifts in circumstances, or perceptions thereof, could produce wide variation

in choices made to address a dilemma and give those frame elements weighted values within

prospect theory. Prospect theory assumes decisions have two major phases: 1) editing and

framing, and 2) evaluation, during which choice selection occurs (McDermott et al. 2002,

135). Prospect theory requires time to gather and evaluate data before reaching the decision.

The communications process is integral in gathering data for first responder consideration.

First responders must compress the timeframe of the decision process and yet arrive at sound

judgments.

The presence of uncertainly leads to psychological shortcuts in daily life to get through

the number of overwhelming choices one faces navigating through a typical day. Heuristics

are short cuts or “rules of thumb” used to transfer familiar experiences into new situations

with presumed similarities. First responders bring heuristic orientations with them to the

workplace and rely heavily upon them to seek positive outcomes. Use of heuristics occurs

especially in situations of uncertainty, where available options are imprecisely specified

(Kahneman et al. 1982, 710-712; McDermott et al. 2002, 136). People prefer heuristics under

unfamiliar or critical circumstances because they are cerebrally economical, demanding

fewer cognitive resources to reconcile the dilemma presenting itself. Bazerman et al. (1998,

236-238) acknowledged the presence and significance of “gut feelings” but also advocated

for an umpire to assure that the logical mind has an opportunity to seek any disproving

evidence through the objective examination of fact. A gut feeling can serve as a re-opener

when something does not seem quite right about a pending decision; gut feelings are an

unproven, and admittedly unscientific phenomena, but their anecdotal occurrence rate

suggests the need for greater study and quantification.

18

Tversky and Kahneman (1974, 1124) recognized the usefulness of heuristic principles in

helping people maneuver through complex tasks and in predicting the outcome of decisions

based on similar experiences, but they articulated a number of instances in which heuristics

can lead to severe systemic failures. Over-reliance on heuristics can lead to cognitive biases,

which degrade decision quality and preclude the consideration of better alternatives. Tversky

and Kahneman (1974, 1124-1131) called attention to three areas of heuristic and cognitive

bias concerns:

1. Representativeness, in which one facet of the decision is influenced by the other. In

this filtering situation, preceding actions taint the final decision. Another way of looking at

representativeness heuristic is gambler’s dilemma, in which the gambler expects a certain

outcome to be “due” despite equal odds of any of the possible outcomes occurring next.

2. Instance and scenario availability, during which people recall personal experience with

a circumstance and disproportionately assume recurrence of factors despite nuanced

differences and often-disparate time and conditions from the base experience triggering the

recollection.

3. Adjustment from an anchor refers to situations in which bias influences people in

picking a starting point presuming an outcome and/or tends to stay close to an expected

outcome and rearrange the circumstances to fulfill preconceived expectations.

Rensink et al. (1997, 372) suggested that perception of a change occurs most effectively

when the object is given focused attention. When there is a lot of changing stimuli observed,

it is unreasonable to expect all unusual events to receive equal attention. Distraction conflict

theory investigates the influence of distractions on decision performance. Speier et al. (2003,

19

773-774) used distraction conflict theory as the basis for building their interruption/decision-

making model. Their findings included:

1. Capacity interference results when the amount of incoming cues is greater than the

processing ability of the decision-maker.

2. Interference occurs when the decision-maker must attend to two or more inputs

requiring the same physiological mechanisms.

3. As people attend to multiple demands for attention, they may be unable to access the

necessary amount of additional cognitive processing capabilities needed for successful

problem resolution.

4. Memory loss and confusion are likely byproducts of such circumstances.

While processing critical information, decision-makers tend to minimize their

expenditure of scarce cognitive resources, which results in a lack of scrutiny of both relevant

and irrelevant new information (Speier et al. 2003, 775). For example, cell phone use while

driving has opened a debate about the influence a seemingly minor task (talking on the

phone) has with a relatively critical task (operating a vehicle). Bazerman (2006, 171-172)

attributed the association of traffic accidents and cell phone usage to be a result of

inattentional blindness, a phenomenon in which the majority of those viewing extreme

features of an event do not perceive critical elements. Bazerman (2006, 172) also gave the

example of spouses frequently accusing the other of not retaining something just told to them

by their partner. One study (O’Conaill and Frolich 1995, 262-263) showed that managers

spend 10 minutes out of every hour at work responding to interruptions. In 41 percent of the

cases studied, managers do not return to the original task after interruption (O’Conaill and

20

Frolich 1995, 262-263; Speier et al. 2003, 772). It is not just the actual time of the

interruption to consider. The decision-maker must cognitively re-immerse in the train of

thought prevailing before the interruption during a recovery period (Speier et al. 1999, 339).

Incident commanders experience a constant stream of interruptions and redirection of their

attention through contacts with people over two-way radios and in person. Physiological

influences detrimental to cogent information processing and articulation of optimal

communications may be a major factor in the quality of decisions made by first responder

commanders.

People in all fields of endeavors find value in taking a break when faced with a situation

in which they are stuck in finding the solution to an issue at hand. After relaxing or attending

to other matters and then returning to the work, the solution often spontaneously emerges

into consciousness (Speier et al. 2003, 790; Lyubomirsky and Nolen-Hoeksema 1995, 187).

Such “time-outs” are valuable to our decision-making abilities, yet time is a luxury not

usually available to first responders. Speier et al. (2003, 790-791) recommended taking a

break and “quiet time” as antidotes to debilitating information overload and constant

interruption. Those recommendations work in some venues, but the incident commander of

an emergency response, dealing with time-critical matters, has minimal time for fact-finding

and debate.

Like many aspects of decision theory, the absolutes elude us when it comes to

interruptions, however. Speier et al. (1999, 340-348) tested a theory whereby the assumption

is that some level of interruption is welcome and valued in the decision-making process.

After observing subjects as they perform in a problem-solving environment, Speier et al.

(1999, 344-353) found that interruptions used to gather more information input and time for

21

collaboration helped to improve the quality of decisions made on “simple tasks.” Task

complexity is increased by making later decisions dependent on imbedded decisions made

earlier in the sequence. As Speier et al. (1999, 346-350) predicted, the quality of the decision

degrades upon interruption during complex tasks, yet the quality improves after interruption

when working on simplistic, monothematic issues. Improvements in the human-machine

interface hold potential for improved decision-making in critical situations, since incident

commanders use an increasing array of technologically complex communications and

information management equipment while operating at emergencies (Speier et al. 1999, 351-

353).

The presence of stress has some positive outcomes in-group performance when low-to-

moderate levels of stress were present (Selye 1936, 32; Kerr and Tindale 2004, 630-640). So

it is likely that some level of managed stress at incidents can sharpen the decision-makers’

attention toward better processes, and therefore better decisions. Statistics show some

increased danger in public safety occupations; in addition, the perceptions of danger by first

responders is as significant as the actual risk (Jermier et al. 1989, 28). While it may be an

overstatement to label safety concerns as preoccupations or obsessions, there is a potential

connection to distraction and risk-aversion due to the state of mind of those needing

maximum faculties to make difficult decisions. First responders work in stressful situations

and make difficult decisions in rapid timeframes. An assumption may be that such stress

influences and degrades the quality of decisions made. Gaines and Jermier (1983, 571-572)

called the literature “conflicting” on the influences of stress, burnout, exhaustion, danger, and

fear. Counterintuitive subtleties, such as organizational structure and promotional

opportunity based on perceptions of fitness for command, appear to be at least as significant

22

in generation of stress, as is impending physical danger. However, Gaines and Jermier (1983,

571-572) admitted that the relationships are intricate and in need of additional study.

Entropy

In A Mathematical Theory of Communication (2001), Claude E. Shannon’s seminal piece

established entropy theory, and shaped the computer and communications systems in wide

use today. Shannon (1951, 50) defined entropy as “a statistical parameter which measures, in

a certain sense, how much information is produced on the average for each letter of a text in

the language.”

The study of patterns of letters in the English language, with pages of mathematical

proofs, establishes the probability of conveying the essence of a message without

transmission of the entire message (Shannon 2001, 1-19; Posner and Rodemich 1971, 2079-

2125). In further documentation, Shannon (1949, 700-701) reported a 50 percent redundancy

in the English language with accurate communications resulting in one study in which

removal of the vowels from passages, without essential loss of the message, occurs. The

missing letter concept advanced further another step, when Shannon calculated the

probability of predicting the next letter of a text when spelling of a word is initiated (Shannon

1951, 50). The average person can relate to those occurrences whereby someone is able to

finish the sentence of another, based on the context up to that point. Certain letters have a

greater propensity to follow others when forming words and the filling-in of missing words is

relative to familiarity with clichés, idioms, lingo, and the context in which something is

stated. Computer users have begun to discover the power of computer portholes, such as

Google, which has an automatic suggestion feature to fill in the missing word consistent with

Shannon’s theory.

23

The concept of entropy helps to explain some of the dysfunction experienced at

emergency scenes as incomplete communications are conducted and statements among first

responders jump around from topic to topic. The phenomenon of entropy also holds promise

for compression and prioritization of critical information at incident scenes. New

technologies could be aimed at abbreviated delivery of critical information among first

responders, based on the likely content of frequent messages, i.e. “send more help,” “mass

care for casualties needed,” “evacuate the area,” “building structure unsafe,” and “hazardous

substance present.”

In situations whereby a high degree of noise prevents a satisfactory message

accomplishment rate, Shannon (2001, 22) made the case for message redundancy as the

answer for greater accuracy. Message redundancy has several meanings in this context; from

a technical systems approach, it may mean multiple communications via parallel, redundant

paths, to assure a critical message makes it to the destination. Redundancy can also mean

several persons passing similar observations or key messages to a single collection point for

additional validation and the resultant improvement in the quality of information upon which

to base critical decisions (Surowiecki 2004, 4-6). Information overload, in the emergency

environment, makes it impractical to bombard incident commanders with more and

redundant information. The challenge posed to the human factors community is to devise

technological improvement in the human-machine interface, to allow critical information to

flow, without overwhelming the incident commander with sensory overload.

24

Inattentional Blindness

In a well-known study written by Simons and Chabris (1999, 1066-1073), test subjects

were instructed to focus their attention on people playing a basketball bouncing game. The

video features the introduction of a gorilla into the video frame, or more exactly a person in a

gorilla suit, who walked across the screen in front of basketball players. The person in the

gorilla suit did not just flash across the screen but rather stopped in the middle of the players,

as the action continued around the gorilla-suited person. The person in the gorilla suit

actually turned and faced the camera, thumped his chest, and resumed walking at a leisurely

pace across the field of vision. Half of the people who observed this demonstration did not

see the person in the gorilla suit at all because they focused intently on counting the number

of the passes between members of the different basketball teams.

The Simons and Chabris (1999, 1063-1064) experiment was an update of an earlier study

in which a woman with an umbrella walked across the test subjects’ screen. The study,

conducted by Becklen and Cervone (1983, 601-608), showed a similar inattention bias to

those who observed the incident because they focused their attention so sharply on the area

of interest. In the Simons and Chabris study, one team of the three basketball players wore all

white; the other team of three wore all black. Since the gorilla suit was all black, they were

able to test and control for the influences the colors and inattention had on whether subjects

noticed the gorilla walking across the frame. In a counter-intuitive result, the study

demonstrated that those who were studying the black-suited players were more likely to

notice the similarly colored black-suited gorilla walk across the screen, instead of those who

were concentrating on the players dressed in all white. This differed from the expected

outcome since we may anticipate they would notice something contrasting from the white-

25

suited players. However, the researchers concluded the observers focused so intently on those

similar to the object of their attention that they were not able to see the opposite effect.

The “Gorilla” study, “required observers to attend to one event while ignoring another

that was happening in the same region of space” (Simons and Chabris 1999, 1072). Simons

and Chabris called this a phenomenon of “directed ignoring” which could inhibit perception

of not just the event the individual is attempting to ignore, but of all unintended events that

may occur in the space studied. The subjects involved in this experiment were more likely to

notice an unexpected event that shares the same basic visual features, which in this case was

color. This would be the opposite of the phenomenon expected in which an item that differs

in basic features from the rest of the display might be easier to notice and identify. With

approximately half of the observers overall failing to notice the highly contrasting but

unexpected event that moved across the screen, Simons and Chabris were able to

demonstrate “a robust phenomenon of sustained inattentional blindness for dynamic events”

(Simons and Chabris 1999, 1069).

The next question pondered by the dissertation author is whether the previous studies

involving visual perceptions and sensory input also apply to strictly auditory worlds. This is

pertinent since so much of the emergency communications process is strictly auditory.

Neumann et al. (1986, 186-187) addressed whether there is a direct correlation between

visual and auditory sensory input. Neumann et al. cautioned that there are certain

fundamental differences between the information processing used in vision as opposed to

audition. They suggested that there should be models developed to recognize the selective

processes within the different senses individually and not treat them all as the same, because

there are fundamental differences in the critical process of deselecting information in the

26

studied space. It is important for the subject to reject, block, or at least manage in some

manner the amount of received sensory input. In the visual world, this is somewhat different

from strictly auditory input. In filtering out input received through auditory channels, it is

necessary to make some distinction between the “signal,” that is, the desirable input from the

unwanted “noise” that the individual is attempting to sort out. This notion of signal-to-noise

separation is an important feature of auditory sensory input. Neumann et al. (1986, 185-188)

left it to future researchers to make fine distinctions, inferring it is more difficult in the

auditory world to make such isolations. There are fewer layers and less depth present in the

sense of hearing to assess situations and to make the appropriate distinctions among the

images seen by participants.

The Neumann et al. (1986, 186) challenge to the research world to do more

individualized studies in auditory perception was followed up in the 1998 book Inattentional

Blindness by Mack and Rock (1998, 215-223), in which they indicated that there is a

connection between the inattention phenomenon in the visual world as well as in the auditory

world. They indicated that inattention phenomenon cuts across all sensory input settings.

Mack and Rock (1998, 215-223, 246) established that auditory deafness is analogous to

inattentional blindness. Nearly everything that could apply to inattentional blindness

translates directly into auditory deafness. They conducted a series of studies in which

individuals had input given to them over headphones while there were multiple things

occurring. Replication of the very same version of the shadowing task used in the gorilla suit

and umbrella exercises proved to apply in the strictly audible world, too. Mack and Rock

found inattention and an inability to respond to those incidents that were above an auditory

threshold. The inattention phenomenon is not unique to vision, therefore, and migrates across

27

all sensory input. Mack and Rock (1998, 223-225) did tactical studies using puffs of air

blown onto subjects’ arms at certain times to determine if they would recognize a distraction

while they focused intently on a task. Regardless of whether the input was tactical, visual, or

auditory, Mack and Rock (1998, 74-103) found similar inattention when individuals focused

intensely and exclusively on a single task.

Literature Review Summary

In summary, this review of decision-making literature reveals:

1. Communications are a critical element in successful decision-making

2. People in stressful situations experience communications deficits

3. There are a variety of circumstances and stimuli attributable to a state of

debilitating sensory overload

4. There is a relationship between stress reactions and communications difficulties

The literature suggests that humans in stressful situations are likely to exhibit verbal

communications deficits due to the nature of and influences present in such circumstances.

Communications deficits are measurable in terms of inadequate and ineffective

communications turns, especially in situations whereby radio calls go unanswered by the

intended recipient, or need repeating. There is an unmet need to study the micro factors

present in the emergency command environment causing communications inefficiencies.

28

Hypotheses

An informed review of the literature forms the basis for the issues addressed in the

empirical work contained in this dissertation.

Hypothesis #1: Sensory overload leads to ineffective communication, as measured by

missed messages, by first responder commanders under emergency conditions.

Hypothesis #2: Commanders at emergency scenes mishandle communications even when

utilizing functioning, state-of-the-art equipment and the messages prove to be clear and

concise.

CHAPTER 3

METHODOLOGY

This chapter explains the data collection methodology, analysis process, and the approach

used to test the hypotheses. Chapter Four presents a series of case studies from actual

incidents to establish common features of communications lapses. The final product of this

dissertation is a test of the hypotheses and a presentation of the findings and the implications

they have for training and formatting of first responder incident command communications.

Research Design

The study presented in this dissertation’s Chapter Five employed a phenomenological

case study technique to determine the non-technological influences affecting efficient first

responder radio communications at emergency scenes. The subjects for the field study were

fire department response personnel functioning as incident commanders at the scene of

simulated emergencies. Observation of personnel at training exercises and emergency

simulations served as the basis for this study. Of particular interest were simulations of

emergency scenes where large complements of personnel were operating, and the potential

for simulated injury or death was present. Participants included personnel from fire

departments in McKinney and Plano, Texas with assistance from the Allen, Texas Fire

Department. The University of Texas at Dallas Institutional Review Board granted approval

29

30

to observe first responders at the scene of training exercises and to document the occurrence

of interruptions and distractions when dysfunctional radio communications occurred.

The researcher used a degree of sensitivity and discretion to put the subjects at ease and

to assure cooperative access to their operational environments. A statement of research

purpose was included in the pre-exercise briefings along with a request for written

permission to videotape the participants. The researcher realized that it might have been

necessary to discontinue the documentation of any single incident that was particularly

emotional or sensitive out of courtesy and respect for those involved.

Video and audio recording of the command post environment, synchronized with radio

traffic recordings, formed the raw data for the study. This allowed for the documentation of

the multiple influences causing the sensory overload and the resultant degradation of fluid

verbal communication. A combination of live observation, subject interviews, and review of

the audio/visual recordings provided the documented observations germane to the study. The

first observation step was to listen and document missed radio messages and to note the

distractions and influences at that specific instant. The researcher scored an unacknowledged

or repeated message as an ineffective, or negative, communications turn. The use of a coding

scheme (Appendix A) allowed for the conversion of qualitative data into quantitative data.

The second step in the series of outdoor exercises was a post-incident interview with the

subjects, where data gathered provided balance and explanation for any factors not

observable by the researcher. Joint review of the videotape provided an opportunity to refresh

memories and present factors not perceived as they occurred. The interview style was a semi-

structured format using an outline of interview questions (Appendix B), allowing for a free-

31

flowing explanation of circumstances experienced by the subject. Standardization was less

critical at this step, since the purpose of the interview was to add richness to the observation

data. Each interview lasted between 30-45 minutes at the subject’s normal place of work.

Follow-up interviews with the commanders from the indoor simulation exercises were not

necessary due to the immediate access the researcher had with them in the laboratory

environment provided by the simulator.

This research builds upon data derived from an earlier study, whereby 428 radio

communication turns at a multi-jurisdictional fire training exercise were assessed using a

coding scheme (Timmons, 2006). The previous study established that the incident

commanders missed or did not respond to a significant number of radio calls from

operational personnel; 11.9 percent of all the radio calls at the exercise were

unacknowledged, which compared closely to actual incident recordings reviewed. Thirty-

three out of the overall fifty-one unacknowledged radio messages in that earlier study were

people trying to call the incident commanders. Incident recordings show the messages in the

earlier study were cogent, yet at incident debriefings, it was common to hear assumptions

that the radio was not working, rather than cognitive inability to receive and process multi-

sensory stimuli. The first study only examined radio recordings, which demonstrated the

presence of inattention; actual field observation in this study determines what the distracting

influences are. The precise moment of inattention is the focus of this new research, so that

the researcher can establish the type of distraction and its impact on the ability to process the

information from documented radio transmissions.

Documentation of deficiencies provides insight into specific causes of communications

failures commonly identified after disasters. The specific area of concern is radio

32

communications used by first responders in the course of their operations at emergency

scenes. Discovery of sets of negative influences in sufficient quantities and from common

sources draws cause and effect relationships, suggesting better training and compensating

strategies.

The case selection strategy used for this multi-case phenomenological study involves

simulated emergency situations routinely assigned to first responder personnel. The

interaction between the responders at an incident and the distraction factor it introduces is the

focus of these observation exercises. The researcher made a conscious effort to avoid

distraction during the observation data collection to avoid being handicapped in objective

data collection. The researcher stayed focused on the sensory influences occurring in the

communications interface between responders and commanders. In doing so, this reduced the

possibility that the same influences negatively affecting the subjects would also similarly

affect the researcher.

The subjects of the study were the response personnel, especially the command officers

from fire departments in Plano and McKinney, Texas. This study allowed for the observation

of multiple parties from two different fire departments for stronger scientific validation.

Training exercises attempted to create realistic emergency circumstances, testing and honing

skills used at actual emergencies. The study’s venues were the fire training facilities in Allen

and McKinney, Texas. Training exercises provided an environment conducive to observe

pertinent influences without an undue Hawthorne effect (Bracht and Glass 1968; Cook 1962;

Jones 1992). The participants were present primarily to solve a tactical scenario, allowing the

researcher an opportunity for separate and discreet observation of the decision-making and

communications processes.

33

Actual emergency scenes offer the opportunity to test the truest of circumstances and

influences. One drawback of this method is that access and opportunity are limited since the

case cannot be staged or scheduled, and because intense incidents are sporadic and

unpredictable (Klein 1999, 10). Because of these limitations, this project focused exclusively

on training exercises. Improvements in miniature camera technology may allow future

researchers to keep subjects “wired-up” with video and audio observation capability until the

occasional incident of interest occurs. Miniaturized biomonitoring may allow measurement

and analysis of pertinent biological factors.

Data Collection

The data collected in this study are the communications behavioral choices made by

incident commanders in emergency command situations. The research observer chronicled

the sensory influences present in the emergency environment and their impact upon the

incident commander. Comparison of observation data with any radio communications

underway at the same instant helped to determine the influence the distracting stimuli had on

the quality of the prevailing radio communications.

Data derived from the interviews provided the opportunity to compare and contrast what

the objective observer saw with what the subjects perceived was happening. This method

helped to triangulate the data (Creswell 2007, 208; Berg 2007, 5-8; Patton 2002, 248) and

give it greater quantification strength. This study observed and analyzed multiple sequences

of command decision-making and communications to establish the frequency of errors and

the trends and causes therein; the simultaneous recounting by the actors involved provided

additional perspective. The study also gave the opportunity to examine the benefit of two-

34

person command crews, as a contrast to the typical solo command operations, with the hope

of yielding valuable insights.

Coding of Observable Behaviors

Coding of the observations (Appendix A) allowed for documentation of the type of

apparent distraction leading to the missed turns of communications. The observer first noted

the existence of one of the following markers of a dysfunctional radio communications turn:

• Unacknowledged message

• Clearly delivered message needing to be repeated

• Inappropriate translation of message intent (i.e., “What color is the

sky? Answer: “three”)

At the instant when the researcher noted one of the above-named radio communications

dysfunctions, he documented the presence of influences in the incident commanders’

operational environment. The researcher observed the incident commanders as they

conducted their duties with the distractions codes list acting as a menu of specific distracters.

This allowed for the association of influences indiscernible from the incident recording

review or by either party of the communication since they are typically isolated spatially,

thus their use of the radio.

Data Organization and Analysis

As advocated by Weiss (1995, 21), the quantity of cases observed was driven by analysis

of the early results. Once returns became redundant or peripheral, there was a discontinuance

35

of additional data collection. Yin (2002, 21-22) suggested that cases can be events or entities;

in this instance, the cases are both, since the event, i.e. the emergency, is a necessary

ingredient, yet it is the actions of the actors at the emergency that are the subject of this

study. The post-incident interviews followed Creswell’s (2007, 159) suggestion to develop

generalized “meaning units” or theme categories derived from significant statements

collected from the subjects. Use of this technique promoted uniformity of the data and

assured high accuracy and validity. Collection of the raw data was through a process of

coding the behaviors and responses observed in the test environment derived from the

observations. Analysis of the coded results disclosed any discernable patterns and cause-and-

effect relationships (Creswell 2007, 152).

CHAPTER 4

CASE STUDIES OF ACTUAL INCIDENTS

This section reviews several significant emergency incidents in which use of radios

played a key role in the outcomes. Two incidents of major concern to the fire service

community occurred during the spring of 2007. In one instance, a firefighter died while

fighting a structure fire in April 2007 in Prince William County, Virginia. The second

incident was a major furniture store fire in June 2007 in Charleston, South Carolina. Both of

these incidents raised significant concerns because the mayday distress calls placed over the

radios during the incidents were associated with the firefighters’ deaths. These two fire

incidents had common factors with an incident predating them by nineteen years, in which a

building collapsed during a fatal fire at a car dealership in Hackensack, New Jersey in 1988.

Case studies of precursory fires in Syracuse and Seattle are included here to provide

additional insights into recurring communications dysfunctions. Next, the researcher presents

the case of a dramatic 1997 bank robbery and shootout in North Hollywood, California

showing the challenge of communicating during an intense police incident. The final case

study in this chapter is from a highly publicized successful emergency plane landing in the

Hudson River in New York City in February 2009. Radio transmissions during the

emergency landing hold important lessons in crisis communications.

36

37

Syracuse, New York 1978

The earliest documented case of radio communications contributing to a firefighter

fatality occurred in Syracuse, New York in 1978. Four firefighters died at a fire in an

apartment building (Varone 2003, 142; Demers 1978, 24-25). According to official radio

recordings, there was a weak radio transmission made around the sixteen-minute mark

stating, “Help me.” An investigative report indicated the radio signal was very weak on the

tape recording and there was no indication that anyone on the fireground heard it. A district

chief and deputy chief were present at the incident prior to the call for help; they had been

issuing orders for several minutes prior to the distress message.

About one minute after the original distress call, a second transmission was recorded, this

time someone stating, “Help, help, help,” followed by static. None of the fire personnel at the

scene or at the dispatch office heard any of these radio transmissions. An observer at the

incident heard a radio message on a scanner stating, “Help, help, help, third floor attic.” The

bystander immediately reported the information to a fire department command officer at the

scene. It was later determined that the four firefighters died on the third floor (Varone 2003,

142; Demers 1978, 24-25).

Recovery of the first firefighter’s body occurred 20 minutes after the original unnoticed

distress call. The remaining comrades were not located for another 54 minutes following a

search of the gutted interior and calls to local hospitals to see if they were among several

firefighters sent for treatment (Demers 1978, 15, 24-25). There was only one portable radio

issued among the four victims; it was later recovered in the debris and found to be in working

condition after drying out and being outfitted with a new battery (Demers 1978, 24-25).

38

Hackensack, New Jersey 1988

One of the most prominent early instances of miscommunications at fire scenes involved

the fire at a Ford dealership in Hackensack, New Jersey on July 1, 1988. Five firefighters

died while engaged in interior fire suppression efforts following the collapse of the building

(Klem 1988, 1). Investigators studying the fire command operations found a number of

issues with the radio communications at the incident. “Apparently due to the initial confusion

that existed on the fire ground after the collapse and the sounding of tones for the recall over

the only emergency fire ground radio frequency, the initial calls for help from the firefighters

were not acknowledged” (Klem 1988, 14).

A detailed investigative report based on radio recordings from the incident concluded

there were numerous radio messages that were unanswered, messages delivered but not

acknowledged, and there were several requests for messages to be repeated (Demers 1988,

8). Tape recordings of radio messages clearly showed the trapped firefighters articulated their

specific location several times. There was no acknowledgement for the messages over the

radio, nor were those working at the incident aware of the distress calls, as revealed during

post-incident interviews (Demers 1988, 10-15). The incident commanders did not

acknowledge one-half of the radio messages transmitted at the Hackensack fire.

Unacknowledged messages created an obvious safety hazard for the personnel at the scene,

and contributed to further overload of the radio system since the message needed to be

repeated (Varone 1996, 98). One investigator concluded, “There was a great deal of talking

on the radio but a severe lack of communication” (Demers 1988, 14). As was the case in the

Syracuse incident that preceded it, people remote from the fire scene monitored the desperate

39

messages on scanners and they called to report them, yet the incident command personnel at

the scene were unaware of such messages (Varone 2003, 141).

On the twentieth anniversary of the Hackensack fire last year, the retired fire chief, now

age 84, in command of the incident that day reflected upon the criticism involving the tactics

and communications used at the fire. The retired fire chief stated that he had asked for budget

dollars to improve the department’s radio system at least a year before the fire, but the city’s

administration denied the funding request. The Hackensack Fire Department was using hand-

me-down radios from the police department on the day of the fire; the chief’s radio was

inoperative and he had to borrow one at the scene before he could do anything (Bonamo

2008). The rationalization involving equipment failure being the major contributing factor

belies the significant command and control issues outlined in the Demers report (1988, 14).

The incident commander blamed the equipment, but people detached from the scene were

able to monitor the messages.

North Hollywood, California 1997

On February 28, 1997, a bank robbery turned into an armed standoff with the Los

Angeles police officers seriously mismatched by robbers with automatic weapons, extensive

body armor, and armor piercing ballistics. At the conclusion of the 44 minute incident, over

1000 rounds had been fired, ten police officers and six bystanders were wounded, and the

two perpetrators were dead (CNN 1997).

The incident began as a radio report from a unit in the area of a robbery in progress with

shots fired. Bystanders reported to the patrol unit that heavily armed men, wearing all black

outfits and ski masks and carrying assault rifles, had entered the bank. Immediately after

40

arrival, the excited radio communications began with the officer broadcasting, “Shots fired,

shots fired, officers need help!” As numerous units acknowledged the call for help and

radioed that they were responding, there were multiple overlapping layers of radio

transmissions, making it difficult for the dispatcher to track the messages. The conflicting

radio broadcasts of the physical descriptions of the suspects ranged from white, black, and

Hispanic, with numbers ranging from two to eight. At the conclusion of the incident, it was

determined that there were two white males involved. The dispatcher remained controlled

and helpful in reaction to a constant barrage of requests and situational updates. There were

isolated instances of the dispatchers raising their voices in anxiety level in reaction to

particularly emotionally charged messages from the field units. There were several

occurrences of officers screaming on the radio that they were injured, pinned down, and

requested assistance. At one point, the dispatcher asked if any units knew how many officers

were down. The response from an excited voice was, “more than one, more than one!”

In reviewing the incident recordings, it was obvious in several instances that units were

overlapping each other’s radio transmissions, not awaiting acknowledgement for messages,

and covering the more critical messages with less critical ones. In one interval, the suspects

had exited the bank and were shooting at officers in the area; other officers were attempting

to broadcast a warning of their movement. At that instant, an unintelligible voice started

screaming something over the radio, with a siren running in the background, similar to radio

transmissions expected during a vehicle chase. It was just barely discernible that the officer

was saying something about an injured civilian, perhaps while transporting someone to

medical treatment. The dispatcher asked the officer to roll up the car windows so the radio

message could be heard over the siren; the message was not repeated and the radio channel

41

resumed other critical information on the movement of the active shooters. There were some

instances of messages requiring repeating, but given the intensity of the event and the

number of people attempting to transmit at the same time there were surprisingly few

repeated messages, owing to the communications skill of the dispatchers and first responders

(Rigg 1997).

Review of the recordings reveals that there were three broad categories of use for the

single incident radio channel: 1) tactical consideration of where the suspects were and

strategies to engage them, 2) maintaining radio contact with the injured officers awaiting

rescue, and 3) requests for additional personnel, specialty units, and supplies such as

ammunition and radio batteries. Each of these differing yet simultaneous uses of the radio

channel created contention and inefficiencies, especially when wounded officers needed

reassurance help was on the way.

Following the incident, there was some criticism of the incident command structure used

at the scene. The dispatcher asked multiple times where the command post location would be

and where to send the additional inbound resources. The original locations attempted for

placement of the command post proved to be too close to the incident, considering the

weapons in use. Tactical commanders eventually did identify who was in command, assert

control on the radio channel, and issued orders on the rules of engagement. Even one hour

after the shooting stopped, police command officers struggled to track the number of

personnel at the scene and to determine if all elements of the incident were secure (Edwards

2002). Before a specific incident commander was established over the radio, the police

helicopter served as temporary incident commanders issued commands based on what they

were able to observe from above the incident. Interestingly, they passed along officer safety

42

updates to the units on the ground, while the ground units warned the helicopter crew as the

suspects fired their automatic weapons skyward towards them. The pilot’s voice was slightly

more controlled and less emotional than the field units due to the helicopter’s remote position

and they were able to lend valuable insights and perspective, reminiscent of the helpful,

accurate updates provided by the helicopters and fireboat during 9/11 in New York City

(Firehouse Magazine 2005).

Of the 300 officers who eventually responded to the incident, all of them survived,

including the ten officers who suffered a variety of ballistics wounds. Many involved still

carry emotional scars from the incident even those whose connection to the action was only

over the radio. Several of the officers who worked at the North Hollywood shootout

subsequently received therapeutic counseling for depression and substance abuse, and three

of the officers involved later committed suicide. One of the officers with lingering impact

from that day attributed some portion of his trauma to hearing his wounded comrades

screaming for help over the radios (Edwards 2002).

A reporter covering the story noted that one of the detectives who responded to the

incident and worked to assist an injured partner “was still gripping her police radio so tightly

that her knuckles were white,” even one-half hour after the shooting had stopped. The

detective praised her wounded partner’s presence of mind to broadcast his location so his

rescue could be arranged, showing the value of having a radio at such intense incidents

(Shuster and Rainey 1997). It was because of her monitoring the radio while working another

assignment that she became aware of the shootout and she responded to the citywide request

for officers to assist.

43

The radio also became pertinent in another one of the many subplots to this story. Two

injured officers made their way into a dentist’s office and received first aid treatment for their

wounds. Maintaining radio contact and assuring one another that more help was on the way

allowed them to stay in their protected position and overcome their instinct to go help a

wounded partner in the street below (Shuster and Rainey 1997).

Seattle, Washington 1998

A fire at a lumber company in Seattle in September 1998 resulted in the death of one fire

lieutenant and injury to two other firefighters. The Seattle fire department arrived two

minutes after a telephone report of a fire at a lumber facility at 9:23 p.m. Firefighters made

entry in the building and began extinguishing efforts. One of the fire crews became lost and

disoriented in the heat and smoke with the command officer trying several times to call for

help on his portable radio. As the lieutenant ran low on air, he handed the portable radio to a

firefighter; that same firefighter attempted radio contact with incident commanders with

negative results. The firefighter was able to hear the dispatcher sending additional fire units

so he was sure the radio was working. The National Fire Protection Association (NFPA)

investigation of the incident indicated one of the factors contributing to the death of the fire

lieutenant was an inadvertent use of the wrong radio channel by the two disoriented

firefighters. They may have selected a setting on their portable radio intended for scene use

only; the message would not have gone through a repeater system allowing monitoring and

recording at the dispatch office. Citizens in the area monitoring on their scanning radios

heard the distress calls, but the incident commander and the dispatch office did not (Isner

1990b, 20-21). The NFPA report suggested the possibility that the firefighters were not using

their radios appropriately, or that their message was lost in the flow of loosely monitored

44

incident command radio traffic by the incident commanders. The report was also critical of

the system of accountability used to track and control the operation of firefighters in the

hazardous environment (Isner 1990b, 18-19).

The firefighter with the radio somehow made it out of the building and to medical

treatment with only a vague recollection of what had occurred. It eventually became apparent

that the lieutenant he had been with was still missing. Following an extensive search, his

body was located under about two feet of debris inside the building (Isner 1990a, 31–34).

Prince William County, Virginia 2007

A fire occurred in Prince William County, Virginia on April 16, 2007 in a single-family

residence on a very windy day. The wind was a major contributing factor in the rapid spread

of the fire, just as firefighters began entry into the structure. As it turned out, the occupants

had escaped prior to the fire department’s arrival and no one was awaiting rescue within the

building. The only fatality was a firefighter conducting suppression and rescue operations

inside the house (Prince William County 2008, 4-5).

Reports from this incident indicate that the fire department did a number of things

correctly. A command structure was in place. The incident commander was operating from a

stationary position of tactical advantage across the street and from within a vehicle where the

ambient noise could be controlled. The incident commander was apparently operating alone

during the early critical stages of this incident. The command officer of the firefighter who

eventually perished, as well as the firefighter in peril, transmitted separate mayday radio calls

per the department’s policy. However, no one at the scene recalled hearing a mayday

message.

45

Review of recordings after the incident show the mayday radio message transmitted

clearly, as well as urgent follow-up messages. However, the incident commander did not hear

the mayday call; but he heard something he did not understand and requested the repeat of

the last message. When there was no reply to his request for a repeat of the last message, the

incident commander moved to other tactical messages with other units operating at the scene,

unaware of a mayday message. The fire-dispatch center operator was aware of the mayday

message; the dispatcher initially attempted to assist the incident commander in hearing and

reacting to the message, but the dispatcher did not persist in making sure the incident

commander was aware that a mayday message existed. There are other procedures in place

requiring the broadcast of an emergency announcement over the radio channels from the

dispatch center when a mayday is declared, but the dispatcher did not interrupt the steady

flow of tactical messages on the radio channel (Prince William County 2008, 64-66).

Prudent practice dictates establishment of radio contact with a firefighter declaring a

mayday emergency. In this instance, the firefighter was in peril several minutes until he made

his final anguished request for water, which proved to be his final transmission. Review of

the recording showed two ways to interpret his request for water. It is clear now that it was

the extreme heat he was experiencing and he was referring to the life-threatening situation he

was experiencing when pleading for water. It is also common for firefighters to radio

requests for more water, for tactical application to extinguish the fire, while still in tenable

conditions within their turnout gear. The typically muffled voice of the firefighter trying to

speak while wearing a self-contained breathing apparatus mask may have contributed to the

misinterpretation of message intent. The distressed firefighter was indicating a life-

46

threatening situation. The twenty-four year old firefighter was later found deceased within

the structure (Prince William County 2008, 16-18).

The investigator’s report of the incident is critical of the radio discipline used at the

incident (Prince William County 2008, 68, 121). After declaration of the mayday, radio units

at the scene continued to make radio transmissions unrelated to the mayday event, as well as

items of non-emergent nature. The report recommended the way to overcome this in the

future is to designate individual radio channels for specific tasks. However, a person must be

dedicated at the command post to monitor each of these radio channels, assuring continuity

of critical communications on all channels (Prince William County 121, 2008).

Charleston, South Carolina 2007

Nine firefighters died while fighting a fire at the Sofa Super Store in Charleston, South

Carolina on June 18, 2007. The city of Charleston commissioned a panel of nationwide

experts to examine the handling of the fire. The investigation reports indicated a number of

radio communication failures. In most instances, it was not equipment failure, but rather the

practices that were in use by the individuals operating at the scene. The committee generated

a number of recommendations and observations about the operations during the incident

(City of Charleston 2007).

As in several other incidents, radio communications were ineffective at the Charleston

furniture store fire. Recordings show a typical tangle of incomplete, indiscernible, and

disconnected communications segments. A number of firefighters were calling for help

within the building, yet the incident commanders at the scene did not hear the distress

messages. In fact, no one at the scene recalled hearing the radio messages that contained calls

47

for help (City of Charleston 2007, 22). During the fire, firefighters transmitted 16 different

distress messages from inside the building. They were emotionally charged radio messages,

including firefighters praying and asking comrades to send sentiments to their loved ones

with the assumption that they would not survive the incident. No one involved at the incident

scene heard any of these distress messages (City of Charleston 2007, 70).

An off-duty fire department employee gave the first indication of firefighters awaiting

rescue inside the raging fire. He was able to monitor the radio communications on his car

radio as he was responding. Upon arrival at the scene, he made the incident commanders

aware that there were firefighters calling for help within the building. His notification was

the first indication anyone in charge at the incident had that there were firefighters in peril.

Confusion followed as to how many were missing, where they were, and whether they had

already been rescued (City of Charleston 2007, 74).

There were a number of complicating matters at this incident combining to form a

paralyzed and ineffective communications situation.

• Many fire departments use standardized alarm levels, i.e. second alarm, third

alarm, to streamline the calling for additional resources and to minimize

contention for airtime. The practice at Charleston involved requesting and station

radio dispatching of each unit individually, one by one, over the same radio

channel used for tactical level conversations at the fire scene (City of Charleston

2007, 111).

48

• During the incident, a civilian inside the building called 911 indicating he could

not escape and was awaiting rescue. This created additional urgent radio traffic on

top of that typically expected at a routine incident.

• This was a rapidly developing fire with plenty of fuel load in a very large non-

standard building, which placed additional responsibilities on the fire department.

The experience base of the typical fire department is in much smaller structures,

such as single-family residences.

• Inaccurate assumptions of radio message content and intent occurred between the

commanders. In one particularly poignant radio exchange, the fire chief called his

assistant chief at another side of the building and a message was transmitted;

however, each thought the message meant something else, so ineffective

communication was occurring. The fire chief said that he wanted to know how

things were looking inside of the store. The assistant chief replied, “I am trying to

get back to it now.” The fire chief heard the message but inaccurately interpreted

it as, “we’re getting to it now,” which he assumed to mean that they were starting

to make progress on the fire and that no extension of the fire into the remainder of

the showroom was anticipated. It was in that area where a majority of firefighters

eventually died (City of Charleston 2007, 105).

• The report is highly critical of the incident command principles used by the

Charleston fire department at the incident. The National Fire Protection

Association 1500 firefighter safety standard indicated the incident commander has

49

a responsibility to “initiate, maintain, and control incident communications” (City

of Charleston 2007, 115).

• The fire chief and command staff did not establish a fixed command post at a

single location. Video recordings from the scene show chiefs moving across a

wide area of the building’s exterior and doorways. The fire chief operated at the

tactical level directly supervising tasks at one side of the building as the assistant

chief was similarly directing tactical level tasks at another side of the building,

each giving conflicting orders to the other’s and neither attaining an overview of

the incident scene itself. Stationary command allows for better, more effective

overall scene management from a calm, controlled position (City of Charleston

2007, 97). The fire chief was not in a position to manage the overall incident. The

type of posturing and pacing during radio communications at the Charleston

incident was very similar to that seen during the training exercises of this

observation study (see Chapter Five). These practices were reflective of how fire

departments operated 20 to 25 years ago, where the fire chief typically was much

closer to the operation and was in a position to command directly the forces at the

incident. This worked well for incidents of relatively minor significance, which

comprise the large majority of situations to which fire departments respond. It is

at incidents such as the Sofa Super Store fire where commanders need to

transition to a different style of command in contrast to daily practices.

• The culture of the Charleston fire department dictated minimal use of portable

radios; they were ostensibly reserved only for dire emergencies. Firefighters and

officers had portable radios issued to them, but they typically kept them within

50

their turnout gear pockets and did not use speaker microphones or receive tactical

updates and commands over those radios. The radios were for personal distress,

yet there was very little practice with the radios for firefighters ahead of such need

(City of Charleston 2007, 113).

• Use of the term “mayday” only occurred once on the incident recordings of the

Sofa Super fire. This is inconsistent with the policies that were in place by the

Charleston Fire Department. However, the lack of training and practice with the

use of that phrase can contribute to the lack of inclination on the part of those

needing immediate assistance to use the phrase “mayday” (City of Charleston

2007, 113).

In summarizing the influences pertinent in the inability to communicate effectively at the

scene, the report cited a number of factors. Heavy radio traffic was a significant aspect

inhibiting the ability of those at the scene to communicate effectively. Ambient noise at the

fire scene impeded firefighting personnel from hearing the radios adequately. The report also

listed the absence of a fixed command post as one of the contributing factors and the report

flagged the importance of designating someone at the incident scene specifically to monitor

the tactical radio channels in use at the incident (City of Charleston 2007).

51

Charleston firefighters did not have adequate training in effective radio communications

techniques. The report advocated the use of the “order model”1 to indicate who is calling,

exchange clear information, and confirm message receipt (City of Charleston 2007, 140;

Brunacini 2003, 532-533). Use of standardized phrases helps to make clarity the first priority

for each radio communication. The report recommended training for firefighters to monitor

the tactical radio channel, so that they may receive instructions and advisories from the

incident commanders and fellow firefighters, as well as relaying periodic updates to the

incident commander.

An interesting observation was noted within the Charleston report whereby not only did

firefighters and command officers report not hearing radio calls but they also testified that

they heard certain things over the radio system that cannot be verified after the fact in

reviewing the recordings (City of Charleston 2007, E-5). This indicated another interesting

phenomenon whereby people under stress may imagine they are hearing things, or interpret

information in very different ways than radio recordings show after the fact.

1 The Fire Chief's Handbook (Brunacini 2003, 532-533), provides this sample communications sequence using the order model:

Command to Engine 1. This is Engine 1-go ahead Command. I want you to lay a 2 ½" line to the north side of and advance a 2 ½" attack line into the east exposure for search, rescue and to keep the fire from extending. You will be East Sector. Engine 1 copy-lay a 2 ½" line to the north and a 2 ½" attack line to the east exposure for search, rescue and to keep the fire from extending. We will be East Sector.

Having the receiver “parrot” the order back ensures that they completely understood the order and eliminates confusion.

52

In addition to the significant disruption to operations that the tragedy of losing nine

firefighters triggers, as well as all of the personal lives that were impacted by that incident,

the Charleston fire department underwent a considerable period of disruption and

introspection in the months following the incident. The recommendations from the report

received national attention while the fire chief resigned. The new chief implemented major

organizational changes, while other elements of the critical report remain unfulfilled.

In the most recent news from December 2008, the Charleston Fire Department has

experienced a drop in its fire insurance rating score. It was a Class One fire department, the

coveted highest ranking on the scale issued by the Insurance Services Office (ISO), a de facto

national ratings system for fire departments from which a community’s fire insurance rates

are established. Charleston dropped to a Class Three following re-examination of the fire

department’s capabilities last year. The ISO system grades fire departments on their

resources to stop major fires, but does not address the safety of operational personnel or the

quality of incident communications and command. The fatal fire at the Sofa Super

Showroom did not directly trigger this drop in fire insurance ratings. However, ISO

conducted a considerable re-examination of all the fire department’s capabilities at the time

of the 10-year cycle for re-inspection (Insurance Services Office 2008; Gentile 2008, 12, 16;

Menchaca 2008; Jennings 2008).

New York City, New York 2009

On January 15, 2009, U.S. Airways Flight 1549 with 155 people aboard landed safely in

the Hudson River in New York after a flock of birds entered the jet engines resulting in loss

of all engine thrust. “The pilot radioed air traffic controllers on Long Island that his plane had

sustained a ‘double bird strike.’ Without power, returning to the airport was out of the

53

question, aviation experts said. He (the pilot) saw a small airport in the distance, apparently

at Teterboro, New Jersey, but (he) decided to head down the Hudson and make a water

landing, a rare event …” (McFadden 2009).

All of the passengers and crew survived the landing in icy waters. On February 5, 2009,

the Federal Aviation Administration released the recording of radio traffic between the New

York Terminal Radar Approach Control in Long Island, New York and the pilot of the

disabled plane (Otterman and Wald 2009). Pilots and air traffic controllers are experienced in

using radios to communicate with one another in clipped and fast-paced phrases (Levin

2009a). The flight of 1549 started in a routine manner, but soon after the pilot with many

years of experience was at the controls of a fully loaded plane with no power over the densest

population center in the country. What followed was a calm yet urgent set of radio messages

with the air traffic controller, a ten-year veteran. In just three minutes, the flight went from

uneventful takeoff to a risky emergency landing in a river. The transcript of the radio

communications showed an incident analogous to what often occurs in critical first-responder

situations.

Flight Communications Transcript

Below are selected passages between the doomed plane and the controller. “Cactus” is a

call sign used on flight radios denoting U.S. Airways, a remnant from its Phoenix, Arizona

partner company’s heritage. The same controller was also juggling other high-pressure

telephone demands between these transmissions, such as stopping the departures from

LaGuardia airport, since the original plan called for 1549 to return there. The controller also

spoke with Teterboro airport, the back-up landing site requested by the pilot. Late in the

sequence, an America Eagle flight in the area helped to repeat what he heard the disabled

plane’s pilot say. All times shown are local, Eastern Standard Time.

54

Selected passages from “Full Transcript, Aircraft Accident, New York City, NY,

January 15, 2009” (Federal Aviation Administration 2009):

(The plane’s passages have been underlined to aid the reader).

3:27:36 Flight 1549: "Ah, this, uh, Cactus 1539. Hit birds, we lost thrust in both engines. We're turning back towards LaGuardia."

3:27:42 Air Traffic Control: "Okay, yea, you need to return to Laguardia. Turn left heading of uh, 2-2-0."

3:27:46 Flight 1549: 2-2-0.

3:28:05 Air Traffic Control: "Cactus 1529, if we can get it to you, do you want to try to land runway 1-3?"

3:28:11 Flight 1549: "We're unable. We may end up in the Hudson."

3:28:31 Air Traffic Control: "Alright cactus 1549. It's going to be a left. Traffic to runway 3-1."

3:28:34 Flight 1549: "Unable."

3:28:36 Air Traffic Control: "Okay, what do you need to land?"

3:28:46 New York Tower: "Cactus 1549, runway four is available if you want to make left traffic to runway four."

3:28:50 Flight 1549: "I am not sure if we can make any runway. Oh, what's that over to our right? Anything in New Jersey, maybe Teterboro?"

3:28:55 Air Traffic Control: "Okay yea, off to your right is Teterboro airport."

3:29:02 Air Traffic Control: "Do you want to try and go to Teterboro?"

3:29:03 Flight 1549: "Yes."

3:29:21 Air Traffic Control: "Cactus 1529, turn right 2-8-0, you can land runway one at Teterboro."

3:29:25 Flight 1549: "We can't do it."

3:29:26 Air Traffic Control: "Okay, which runway would you like at Teterboro?"

3:29:28 Flight 1549: "We're gonna be in the Hudson."

3:29:33 Air Traffic Control: "I'm sorry, say again, Cactus."

3:29:51 Air Traffic Control: "Cactus, ah, cactus 1549, radar contact is lost. You also got Newark airport off your two o'clock and about seven miles."

55

3:30:09 Eagle Flight 4718: "… I don't know, I think he said he was going in the Hudson."

3:30:14 Air Traffic Control: "Cactus 1529, uh, you still on?"

3:30:22 Air Traffic Control: "Cactus 1529, if you can, ah, you got, ah, runway 2-9 available at Newark off your two o'clock and seven miles."

Flight Communications Analysis

Both voices on the recording do not reflect the amount of stressful decision-making

occurring in a compressed timeframe, especially considering the immediate risk to

passengers, crew, and people on the ground. The only hint of a stress reaction is the

misstating of the correct flight number—the pilot used “1539” instead of the correct 1549

when reporting the initial problem, then the controller later used “1529” in the middle and

end of the sequence. Both knew what the other meant since they were concentrated on

helping each other to a safe conclusion.

The pilot and controller had a lot to do other than talking on the radio, thereby placing

extensive cognitive demands upon them. The pilot was atypically both flying and talking on

the radio, while the copilot worked the emergency checklist and tried to restart the engines.

The controller, who usually acknowledges the departure of multiple flights and assigns

navigational levels and headings, had to contact other airports while focusing on just one

flight (Otterman and Wald 2009). The pilot started to interpose hints that he was not going to

make it to any airport, yet the controller couched his response assuming that first it would be

LaGuardia, then Teterboro, and finally Newark airports. Thirty-five seconds after hitting the

birds, the pilot said, “…We may end up in the Hudson.” The controller does not

acknowledge that statement, but rather he responded by giving a runway assignment. In the

subsequent one minute of conversations, they discussed landing at Teterboro in New Jersey,

56

but the pilot quickly stated, “We can't do it." The controller stayed focused on runway

selection, but the pilot meant that he was not going to attempt a runway landing.

Finally, after using the word “unable’ twice, and including phrases such as "I am not sure

if we can make any runway,” and "We can't do it," the pilot stated, “"We're gonna be in the

Hudson." The controller, who had been trading communication turn-for-turn up until that

point, did not understand the message and asked the pilot of the ditching plane to repeat. The

controller continued to send messages about alternate airport options and noted that radar

contact was lost. Another plane on the frequency received departure information and told the

controller that he thought the pilot said they were going to land in the Hudson River. The

inability of the controller to accept an eventuality different from the expected one is

reminiscent of Simons and Chabris’ (1999, 1072) inattentional blindness study with the

gorilla. In his testimony before a House Aviation Subcommittee, the air traffic controller

later commented on his reaction to the pilot's radio call saying he planned to splashdown in

the river. “I asked him to repeat himself, even though I heard him just fine. I simply could

not wrap my mind around those words. People don’t survive landings on the Hudson River; I

thought it was his own death sentence. I believed at that moment, I was going to be the last

person to talk to anyone on that plane alive” (Harten 2009; Levin 2009b). The controller

reported extreme emotional disturbance since the event, although asserting that, “During the

emergency itself, I was hyper-focused. I had no choice but to think and act quickly, and

remain calm. But when it was over, it hit me hard” (Harten 2009). Due to the trauma he

experienced over the radio, the air traffic controller remained off the job for at least a month

and a half (Harten 2009).

57

The presence of slightly mismatched communications with answers not precisely

matching the questions, and the condition of not acknowledging subtle nuances of message

intent is reminiscent of first responder communications recordings. The occurrence of a third

party on the same frequency hearing the critical message, while the primary recipient had to

ask for message repeat, has similar precedence in first responder communications.

Common Themes Among All Cases Studied

Based on the cases presented above, the researcher was able to identify common

themes. They fall into six separate categories, as follows:

Missed Messages

• No one at the scene hears urgent radio messages, despite recordings and others

hearing it

• People remote from the scene hear and understand messages better

• Inaccurate recollections not verifiable on recordings

• Tendency to blame the equipment and ignore human factors

Command and Control Issues

• Confusion and chaos over the radio

• Incident command structure lacking

• Command post designated late or not at all

58

• Too few people initially to support command post functions

• Inability to rapidly transition from frequent routine incidents habits to practices

and reactions appropriate for low frequency intense crisis events

• Lack of standardized phrases limiting optimal message clarity and efficient use of

air time

• Agency culture: either too much or too little radio use at the tactical level

• Not enough practice using the portable radios and reacting to distress calls

Message Construct

• Request to repeat the message

• Message delivered but not acknowledged

• Not waiting for acknowledgement

• Double meanings, misinterpreted messages

• Barrage of reports and requests without spacing, reply or acknowledgement

• Multiple layers of overlapping communications

• Emergency messages formatted in incomplete, clipped syntax, open to multiple

meanings and interpretation

• Prioritization of messages lacking

• Calls for additional resource not abbreviated or optimized

59

• Failure to use the order model (standardize message format, including

acknowledging party repeating back message received for verification)

Stress Reactions and Perspective

• Remote command positioning gives better perspective and voice control,

especially from a helicopter

• Emotionally charged, loud, and strained voices are common

• Stressful events are magnified by listening on the radio, emotional impact lasts for

years

• Physiological changes in voice pitch

• Unknowingly misstating or transposing numbers and phrases

• Answers not matching questions

• Failure to accept the oddity of the situation, i.e. Hudson River Landing Controller:

“…could not wrap my mind around (the) words” (Levin 2009b)

User Ergonomics

• Manipulating the settings on the radio is cumbersome and not intuitive

• Confusion when switching radio channels in the midst of the operation

• Operating in direct or conventional mode, causing no monitoring or recording

capability beyond the scene

60

• Self-contained breathing apparatus obscures vocal clarity

• Background noise causes voices to strain

Conflicting Purposes of Radio Traffic

Multiple, overlapping uses for the same radio channel:

1. Tactical- direction of the operations

2. Direct contact with responder in distress- gaining information, providing

reassurance

3. Call for additional resources- Overly wordy requests for help and logistical

support

CHAPTER 5

CASE STUDIES OF TRAINING EXERCISES

McKinney Fire Department Case Studies Venue Description

The first venue for the command communications and distraction studies was an

abandoned house in the city of McKinney Texas. The McKinney Fire Department used the

house for training purposes before final demolition. The site allowed for realistic apparatus

staging and crew deployment since there are roadway access points isolated from nearby

busy roads. Fire crews assembled at the site with the same groups participating in two sets of

evolutions before lunch. When those crews returned to their stations, a new set of firefighters

rotated to the site for the afternoon sessions. Crews mustered for a briefing on an adjacent

street where the exercise controller gave a general overview of the purposes and goals of the

drill. Following introduction of the researcher to the group by the training facilitator, the

researcher gave the participants a brief overview of this study’s purpose.

In this sequence of drills, firefighters practiced their reaction to a firefighter in distress

within the building, known as a "mayday" condition. Use of non-lethal theatrical fog

machines created realistic visibility obscuration within the building. The phrase “mayday”

has come into common practice over the last few years as the distinctive indication that there

is a firefighter in immediate peril, needing rescue (U.S. Fire Administration 1999, 15). The

origins of the use of the word “mayday” transmitted over radios to indicate a perilous

61

62

situation is traced to mariner operations and is said to be an Anglicization of the French

words for “help me” (“Mayday,” in The American Heritage Dictionary of the English

Language, 4th ed.).

High profile incidents nationwide (including those outlined in this dissertation’s Chapter

Four), at which firefighters lost their lives while awaiting rescue, have emphasized the need

for improved policies and practices concerning coordinated command and communications

during these intense events. Members of the McKinney Fire Department training staff were

the controllers for the exercises along with staff from the Collin College Fire Academy.

Members of the college staff were dressed in full firefighter turnout gear and were talking on

the radios as if they were the first arriving engine company crew at the incident. Per the

policy of the McKinney Fire Department, the first arriving engine company in such

circumstances worked as a team to start suppression and rescue activities (“fast attack”),

while the command officer on the second-arriving apparatus sought to establish command of

the incident. Deployment of the personnel in this manner for these exercises helped to target

the specific skills needing practice, creating the most realistic circumstances possible. The

controllers allowed the crews to attend to their usual tactical objectives, and then upon cue, a

confederate facilitator inside the structure, fully equipped in turnout gear and self-contained

breathing apparatus, made a realistic mayday call over the radio system. The commander and

crews needed to continue the firefighting operations with some of their personnel, while a

Rapid Intervention Team (RIT) deployed to aid the downed firefighter in the building. Once

crews reached the area where the mayday originated, they found a life-size and weight

mannequin in turnout gear needing removal to a treatment area outside. After the firefighter

replica was outside, the incident commander went through the process of a roll call on the

63

radio (referred to as PAR—Personnel Accountability Report). Upon completion of the PAR

process, the drill sequence concluded, the firefighters were debriefed, and reloading of the

hose and equipment occurred in preparation for the next sequence.

Videotaping of the exercises was a critical component for the researcher to be able to

recall the observations, to glean factors not apparent “in real time,” and to provide a platform

for the post-incident interviews with the subjects. The exercise controllers were reluctant to

script the sessions too tightly in the interests of maintaining realism. As a result, the exact

position of the incident commanders could not be determined for the researcher to establish a

fixed camera position. These exercises featured actual firefighters and their fire trucks,

rolling onto the scene from a staging area at the end of a short roadway on the property. Fire

personnel took positions on the exterior of the house, just as they would for an actual

incident. As such, there was a degree of discretion on the part of the subjects, as well as

randomness created by the mix of people for each session and the various options of where

the vehicles could park and where the commander could stand. These factors led to the need

for flexibility and some degree of anticipation on the part of the researcher, finding camera

angles to document the command environment with full-facial view of the incident

commander and the interactions with those around him. There was also the imperative to

maintain some distance so the researcher did not influence the observation environment

(Berg 2007, 179, 186-189). In some instances, abrupt changes of the camera position were

necessary as the scenario unfolded, especially when arriving vehicles blocked the camera

angle, or when the incident commander wandered out of view. The incident radio traffic on a

radio near the camera provided a continuous soundtrack and allowed for documentation

64

continuity in the rare case when the camera was on the move and the incident commander

was temporarily out of view.

At the choice of the hosting department, engine and truck company captains remained in

command throughout the duration of the exercise. It would be common for the captain to

transition to operations positions after transferring command following the eventual arrival of

a battalion chief. Allowing the captains to continue in command throughout the exercise

served several objectives:

1. There is an everyday possibility of delayed or no response of the battalion

chief due to other incidents working, distance, or response accident.

2. A mayday can be called at any point in an incident and the most critical

challenge of logistics and low resources is at the early stages of the operation, when

the captain is still typically in charge before elaborate support and command

contingencies can be established.

3. Captains fill in for whole shifts when battalion chiefs are absent.

4. Even with experience levels ranging from eight to 27 years, the captains have

a relatively low experience base with multi-company command situations. Their

department has experienced few working structure fires in recent years, despite rapid

growth of the community; conversely, earlier in their careers, the department was

much smaller with simpler tactics and smaller contingents to command.

Some fire departments have adopted a policy of stationing the incident commander

within a vehicle, i.e. cab of the fire engine, or a sports-utility command vehicle. The observed

65

department generally adhered to the more traditional posture of the commander being on foot

within a general area around the first arriving apparatus, usually in front of the structure.

Although the focus of this study was to determine the type and quantity of environmental

influences and distractions leading to communications dysfunctions, it was interesting to note

the body English displayed by the commanders as they moved around a predictable

footprint—often within 20 feet of where they started. Perhaps this was because the subjects

were all suppression captains and recognizing that they are closer to the day-to-day, hands-on

tactical environment than chief officers are. There was a noted tendency for them to pace

around a lot, especially as the tempo and severity of the simulation increased. When the

practice mayday calls occurred, some of the captains/incident commanders took a few steps

toward the structure, as opposed to their previous back-and-forth pacing, in symbolic or

perhaps even subconscious reflexive desire to help a comrade. There was a lot of movement

observed whenever they transmitted on the radio and even some while in the act of listening

to a specific radio message.

The weather conditions came into play to a certain extent; the first day was mild and very

windy with the wind carrying the fog from the house toward the incident commander. While

the volume of fog did lend an air of realism, it also caused some obscuration of the people in

the camera view. Day two was much cooler with a wind shift allowing better viewing

contrast on the video. Day three turned very cold, causing postponement of the exercises for

that day. Another factor needing sensitive treatment was the death of a co-worker during the

series of drills. A McKinney firefighter died from injuries sustained off-duty after a hospital

stay wrought with emotions for his family and fellow firefighters. Fire departments are tight-

knit communities with death of active members invoking elaborate funeral traditions and

66

redirection of the usual daily routine. The researcher was able to gain sufficient data before

the postponed sequence occurred. The researcher acknowledged their loss during the

personal follow-up interviews. It was an interesting coincidence that the death occurred

within the month of the training exercises aimed at rescuing a firefighter in perilous

situations. While no one articulated as much, it is intriguing to ponder whether the sudden

death had any impact on the intensity and eagerness in preparing for firefighter rescue

missions.

Exercise Data

The researcher based his determination of subjective rating of communications as either

inadequate or ineffective on messages remaining unanswered or needing repeating. Seventy-

four instances of radio inattention occurred during the two-day series of exercises comprised

of seven distinct exercise sequences. No apparent reason could be determined in a majority

of the situations (n=28). The next most common reason for inattention was distraction by

talking in person to someone nearby (n=14). The emergency command environment demands

a high level of collaboration and information transfer with those in the immediate area.

Although the number of influences was few due to the absence of common real-scene

distractions, such as redirection of attention while conducting conversations with others, the

exercise controller adequately mimicked some of the distraction factors inhibiting full

attention to the radio by the incident commanders. In real-life situations, there likely would

be victims, neighbors, onlookers, media, representatives of other agencies, and other

firefighters awaiting deployment trying to access the incident commander. The noise around

the simulated incident scene also contributed to the inability to hear the messages clearly.

67

Interviewees cited engine noise, power tools, road noise, and people yelling as factors

influencing the typical listening environment.

Several of the participants moved in a variety of ways when performing radio calls. Some

immediately started walking away from the huddle of others at the command post upon

receiving a message. Some even turned their backs to the incident entirely in an attempt to

gain some control of the listening environment. When questioned later, most indicated that

their experiences in using portable radios taught them that a feedback squeal would result if

they stay close to others who typically keep their radios at a loud volume. This causes a lot of

movement around the command environment with some portion of cognition reassigned to

ensuring the movers go to appropriate alternate positions, do not step on something, do not

move into a lane of traffic, or in any other way endanger themselves. The researcher

observed a great deal of body movement and contortion with subjects often craning their

necks in some fashion to get their mouths or ears closer to a fixed speaker/microphone

position. Some bent at the waist in an attempt to create a slightly better listening vantage

point. Several interview participants indicated a degree of frustration over the

speaker/microphone situation. They stated that the operation of the external microphone

assembly is especially ineffective after recent exposure to water at fire scenes. Although

there are headphones available within the cab of the trucks, the respondents were not

enthusiastic about using headsets within the fire command environment. They contended that

headphones make it too difficult to hear other important things, like people yelling, subtle

changes in sounds coming from the structure (which could signal sudden failure of the

building systems), or other timely safety factors. When prompted on whether they could

envision any circumstance in which they would simply stay in the cab of the truck to

68

command an intense incident, most said they would consider it only in dire circumstances.

They admitted that their culture and practice have patterned them to assume the exterior

command position, consistent with the common practice of captains being relieved of

command soon after assuming it.

The researcher was able to draw upon more than thirty years of public safety experience

in determining whether replication of realistic command and radio conditions were present at

the exercise. Although the pace and volume of radio traffic were below that which can

typically be expected under the circumstances being simulated, the conditions were enough

of an accurate reflection of pertinent factors to derive data and gain insights. The slower pace

did allow for better examination of the interactions of relationships, distractions, and

influences, both while observing in person, as well as during later replay of the video tapes

for data collection. The slower pace and volume allowed for something akin to slow motion

video, whereby nuances and subtleties are more apparent than when they occur at usual

speed.

In conversations with the exercise controllers on the days of observation and at most of

the post-exercise interviews with the incident commanders, the researcher learned that the

participants’ department does not typically generate a lot of radio traffic at incidents. They

have made a conscious effort toward scripted tactical objectives, conveyed in shortened,

“bullet-point” radio transmissions in lieu of verbose, lengthy radio turns. There was some

evidence of this, especially during Case Number Four, where short tactical commands proved

to be very effective in rapid and efficient relay of commands. Most of the interviewees

conceded that an actual situation of a firefighter calling for help would have triggered a

higher degree of anxiety and emotions with one subject indicating that adrenaline production

69

would be a physiological factor influencing radio traffic management. One of the captains

interviewed indicated that studying recordings of “fires gone wrong” often disclose too much

radio use occurring to the detriment of overall command and control.

McKinney Case Studies Day One

Case Number One

In Case Number One, a captain with eight years of experience assumed the role of

incident commander. One of the observations made during the exercise was that he

frequently took notes on a small notepad in an attempt to keep track of company assignments

as they were occurring. He assumed a standing position of command near one of the fire

engines during most of the exercise. Between the establishment of command and the calling

for the simulated mayday, he took notes trying to track the location and assignment of units

at the scene.

Six minutes into the exercise, the incident commander did ask for a progress report. This

was notable since this fire department does not use automatic time checks for updates. Some

departments have a procedure whereby the dispatcher signals the incident commander at

specific timed intervals, triggering a reevaluation of circumstances and the issuance of an

update report. The number of radio transmissions occurring at this exercise was 22; twelve of

them or 55 percent were effective communications turns with 10 sequences or 45 percent

judged ineffective. Some of the reasons for the ineffective communications during Case One

were distractions from talking to other individuals in person while people were calling on the

radio, as well as background noise and scene-generated noise. In other instances, there was

no apparent reason for the inattention to the radio calls.

70

In a post-exercise interview with the captain from Case Number One, he recalled there

was some switching of channels to segment units at the scene, which he believed confused

people more often than aiding effective scene communication. When asked whether he was

aware that he had missed any calls, he said, “No,” he was not aware that he had missed any

radio transmissions. When asked if he was aware of any distraction that may have caused a

missed radio transmission, he indicated that there were instances where he was meeting face-

to-face with other individuals at the command post, which could have led to missed radio

transmissions. He also emphasized empathically that he was against changing channels in the

midst of an operation, essentially splitting up those at the scene on the two different radio

channels, in an attempt to allow the mayday operation to be separate from the suppression

efforts.

In response to a question about whether the exercise was realistic, the captain from this

case indicated that he thought it was realistic. His fire department normally has a relatively

quiet pace on the radio channel. He believed that many of the operationally flawed fires that

he had studied in other parts of the country had a feature of too much radio use occurring as a

contributing factor. In making recommendations for future improvement, he indicated the use

of a scribe or aide would be very helpful, but it is best if that occurred right from the very

beginning. He felt that the exercise facilitation process interrupted his normal command flow,

creating a distraction factor that was somewhat unrealistic; he suggested improvement in the

facilitation process in future training exercises.

When questioned about the use of headphones, he responded that he could not envision

their practical use for routine incidents, but perhaps under unusual circumstances they would

be appropriate. His biggest concern for headphones was that they cause an audible separation

71

from all the people he commands, inhibiting cognitive awareness of what is occurring around

him. He did see room for technological improvement in the headphones and microphone

arrangements used inside self-contained breathing apparatus since they frequently led to

muffled transmissions requiring message repeating.

The overall time of Case Number One was 25 minutes with the mayday called 13

minutes into the operation; the time from the mayday to the conclusion of the drill was an

additional 12 minutes.

Case Number Two

In Case Number Two, the captain with over 20 years experience was observed during an

exercise lasting 17 minutes. The time from dispatch to the first mayday call was eight

minutes, followed by a sequence from mayday until the simulated firefighter victim removal

and drill conclusion of nine minutes. There were 16 radio communications during this

incident at a pace of nearly one per minute. The number of communications effectively

occurring were 44 percent (n=7) and the ineffective communications totaled nine for a 56

percent overall negative rating.

The captain said in the interview that he was not aware of missing any radio messages as

they occurred, but he noted that the tone of voice and inflection used by some of the parties

as they called gave him an indication that it was not the first time they attempted contact.

Several of the radio transmissions needed repeating, although they were clear on the

recording. In some instances, there was no acknowledgement or answer given to radio

messages, once again being clear on the recording but apparently going unheard by those at

the scene.

72

In the post-exercise interview, the captain recalled the communication situation as

somewhat frustrating, especially recalling the confusion upon splitting the radio channels.

The split occurred at the time of mayday, keeping the operation for firefighting on one

channel and the rescue for the downed firefighter diverted to a secondary channel. When

asked if he missed any communications, he estimated that there was at least one missed.

The captain in Case Number Two indicated that face-to-face discussions with bystanders

was a likely distraction leading to missed communications, and he projected that it will be

even worse at real incidences since they often need to interview victims, or neighbors, or

other individuals in the area while simultaneously listening to the radio.

Observations during this case, as well as in other evolutions in the series, showed that the

incident commander was also responsible for maintenance of an accountability tag system.

Tags helped command personnel track the specific personnel operating at the scene. This

proved unwieldy since it interrupted the manual dexterity needed to use his portable radio,

and did redirect some cognitive attention away from radio communications and incident

command concerns. Engine noise and general scene background noise also contributed to

missed radio transmissions and those requiring repeating. There was some feeling of

frustrations on the part of the incident commander since the changing of radio channels did

not work exactly as hoped. Improvement in changing of radio channels when splitting

incident communications into two or more radio channels is an unmet need. When

questioned about how realistic the exercise was, the captain indicated that it was somewhat

realistic, but, certainly, emotions would have been running much higher during an actual

incident, especially if a mayday is declared.

73

The captain for Case Number Two recommended further improvement by assignment of

a scribe or aide from whatever source possible, especially in the early stages of an incident.

However, he admitted that it is very difficult to have the available staff to accomplish that.

The irony is the longer the incident goes, the more support there is for the incident

commander. However, it is during the critical early stages of the incident where the most

acute communication needs are present. In this instance with an overall 17-minute evolution,

it was obvious that the units on the scene would have to work with a limited number of

personnel before establishment of formalized support.

Case Number Three

Case Number Three involved a captain with eight years of experience. He moved around

continually while transmitting messages on his radio. He would often take a few steps away

from anyone he was nearby when transmitting and that same habit was consistent when there

was no one near him. When questioned, he indicated that feedback squeal and additional

noise is often an issue at the company officer level. Company officers become accustomed to

having to move away from other people as they are keying up their portable radios. This

distracts and redirects some of the officer’s attention span to figure out where to move just to

transmit routine radio messages.

Case Number Three lasted for 16 minutes with the mayday declaration seven minutes

into the operation with an additional nine minutes to rescue the firefighter and conclude the

drill. There was a considerable amount of fumbling with the radio channel controls to

accomplish the radio channel change. The channel change occurred as a part of the mayday

operation and the incident commander was uncomfortable with the radio change. This

incident commander did not huddle very often with others around him, except for a battalion

74

chief and the exercise controller in the area. Of the 17 radio transmissions, again at a pace of

about one per minute, the number of effective communications was seven at a 41 percent

rating and this series had the highest rate of error for communications at 59 percent with 10

radio turns judged as ineffective.

Some of the researcher’s observations made during the missed radio messages were they

happened while conducting a face-to-face conversation with an observing battalion chief and

there were other missed radio calls for unknown reasons. Some cross-channel dysfunction

occurred with people talking on one channel receiving their answers on the other channel not

monitored by the unit calling. When asked in the post-incident follow-up what he recalled

about this incident, the captain indicated that the pace was slower than the real thing but he

felt it was somewhat unrealistically controlled and contrived, but still helpful and useful as

practice. When asked if he missed any radio communications, he did indicate “a few” and

guessed maybe five. He had the highest guess rate of any of the post interviewees, which

mirrored the data, but was still under-estimated. His guess was only accurate by one-half

since the number of negative communications was actually ten. When asked about what

some of the distractions were that caused the missed radio traffic, he stated there was radio

traffic on other channels drawing his attention. In other words, hearing other radio channels

nearby split his peripheral attention. Background noise was a contributing factor; this captain

also indicated that there was a gap in getting his battery changed on his radio as he started to

get a low battery signal.

This incident commander also readily admitted that the emotion present in this exercise

was not to the full intensity expected at an actual incident, especially where a mayday was

involved. He hoped that in future exercises there could include randomized sequencing of

75

variables, so it did not feel as rehearsed and predictable. Apparently, there had been

information sharing occurring from previous participants, causing some lack of spontaneity

and challenge. Despite this, this incident commander missed 59 percent of the radio turns.

This captain stated that he would like to see more training on mayday operations and

integration of an aide to assist in the sensory attention needed by a solo incident commander.

He advocated the use of a single operations channel making urgent radio traffic more

difficult to ignore. When asked about the use of headphones, he saw some value but he was

not sure how to integrate its use into the McKinney Fire Department’s emergency command

environment.

Case Number Four

Case Number Four, involving a captain with over 20 years experience, had the longest

duration of the series observed with the exercise lasting 26 minutes. There was an 18-minute

period from dispatch until declaration of the mayday with the personnel accountability report

(PAR) called between the dispatch and the first mayday, which prolonged some of the

overall timeframe. This gave the observer the opportunity to study the additional radio turns.

The time from the mayday until the drill’s conclusion was an additional eight minutes for an

overall 26-minute evolution. The number of radio transmissions in this exercise was the

largest studied in the series with 40 radio sequences; 26 were completely effective for a rate

of 65 percent, and only 14 assessed as ineffective for the lowest rate of 35 percent.

This incident commander started out by giving a series of short tactical commands in the

pre-mayday environment, which proved to be very effective. He assigned specific tasks and

they generally were able to understand them and respond appropriately. One interesting

feature in this case was that the incident commander seemed best able to understand short

76

messages. The longer the message got, the less likely he seemed to retain all of the content

and to understand the message clearly. Some degree of such truncation deficit existed in

other sequences, but this case was particularly notable. He successfully repeated the last parts

of longer messages to verify what it was he was hearing. Such instances counted as a

miscommunication for the purposes of scoring, because it amounted to repeated information

by the sending party.

There was a well-balanced mix of causes identified for the missed radio transmissions. In

some instances, the garbled message was attributable to background noise or muffled words

while the sender tried to talk with a self-contained breathing apparatus mask over his mouth.

Repeating of the whole message was necessary in some instances for longer messages and

yet, in some instances, there was no known reason why a repeat or no answer occurred.

The presence of feedback squeal over the radio system was also a considerable concern in

this sequence. That was puzzling because the incident commander was not obviously near an

open speaker, yet feedback squeal occurred during some portions of the exercise, perhaps

because of high radio volume on trucks nearby. During the interview, he was not able to state

which open speaker was causing the squeal. In the post-incident interview, the captain from

this case recalled that the splitting of the radio channels did not go very smoothly. He was

emphatic that he could not do multiple, simultaneous tasks with equal efficiency.

When asked whether he missed any radio traffic, he thought maybe there was one missed

radio transmission during a face-to-face conversation. The face-to-face conversations and the

noise of the command environment were commonly cited reasons in all exercises for missed

radio traffic. The use of the radio itself is felt to be sometimes cumbersome and not a smooth

77

interface for the user. He asserted that the key is to split the radio channels for some

appropriate division of duty, taking the radio off the scan position when segmenting duties,

and assigning separate command officers on each channel. This captain was able to delegate

radio monitoring to a second individual and appeared the most comfortable of all those

studied to ignore completely the other radio channel and focus exclusively on the radio

channel command that he retained. The assistant assigned to monitor the other channel was

more animated than the others observed. He was pacing, posturing, and bending at the waist

as he strained to hear the radio held up to his ear. This created even more movement around

the command post footprint, adding to what looked like something of a clunky ballet from

the observation position.

McKinney Day 1 Scores Comparison

30%35%40%45%50%55%60%65%70%75%

Case 1 Case 2 Case 3 Case 4 Average

Figure 1. Summary of Positive Scores From McKinney Day One

78

McKinney Case Studies Day Two

Case Number Five

Case Number Five involved a captain with about 10 years of experience. There were 21

radio communications during this exercise with 12 found to be effective for a 57 percent

positive rating and nine were ineffective for 43 percent occurrence rate. The drill lasted for

36 minutes. This captain turned his back to the scene and walked around quite a bit while

transmitting. He shifted from a stationary position and started pacing or turning directly away

from the incident while making radio calls.

There were several instances during Case Number Five where the recording is clear but

the incident commander did not understand the message. There was some confusion created

when the split of the radio channels occurred. The attention of the incident commander was

distracted whenever the designation of “rescue command” occurred on the other radio

channel with an open speaker nearby. The phrase “command” on the other channel seemed to

get his attention since it was the same designator for him on the channel he was working. He

would then look at the radio that he was holding and questioned if it was still functioning

appropriately, not immediately cognizant that it was someone on another channel calling

someone else.

Of the nine communications found to be ineffective, there were some whereby repeating

was necessary, although the recording was clear. In other instances, calling units received no

answers without apparent reasons. In one interesting situation where the incident commander

looked puzzled by the transmission, it was possible to read his lips, as he shrugged his

shoulder and looked at those around him, mouthing the words, “What did he say?” The

79

captain for Case Number Five declined the post-exercise interview, deferring comments to

his command officers.

Case Number Six

The captain for Case Number Six has approximately 15 years of experience. The exercise

lasted 27 minutes with a 13-minute timeframe from dispatch to declaration of the mayday

and an additional 14 minutes then from mayday to a conclusion. This captain was observed

to step away from the grouping or huddle of individuals whenever transmitting on the radio.

There was also some confusion noted during the channel change with some missed

transmissions along with some individuals missing the mayday message as a result.

The captain in Case Number Six did have an aide or scribe assigned. The aide seemed

diligent in tracking information on a clipboard. However, the captain maintained an interval

of distance between them during almost all of the exercise only approaching the aide in a

couple of instances when he needed specific information. There was not a high level of

teamwork or collaboration observable between them.

The communications were very efficient at the start of the exercise but they tended to get

scattered as the exercise played out, especially following the split of the radio channels.

Some messages triggered a request for a repeat for no apparent cause. There was some

feedback squeal contributing to the inefficiency of messages. There were also several

instances where the requests and the answers were on two different channels when the

channel split occurred. There were 30 communications during Case Number Six and,

interestingly, the efficiency rating was the same as the one (Case Number Five) preceding it

on the same day, with a 57 percent efficiency rating for positive communications, while 43

percent were ineffective. Due to scheduling conflicts, there was no interview conducted.

80

Case Number Seven

Case Number Seven involved a captain with 20 years experience as an incident

commander. There was a 14-minute timeframe from dispatch until declaration of the mayday

with the mayday-to-rescue time only five minutes in this exercise, overall time was 19

minutes. There were 24 radio communications during this exercise with 15 deemed as

positive for 62 percent efficiency rating and nine found to be ineffective for a 38 percent

score.

When asked in the post-exercise interview whether he missed any radio communications,

the captain indicated “maybe a couple.” He recalled some confusion about the

communications at the incident, especially involving the medic crews assigned to rescue

duty. The microphone and receiver capabilities within the face-pieces of the breathing

apparatus continued to be a concern for this captain, despite experimentation with various

forms of alternative equipment. He indicated that there would likely be more adrenalin

influence in the real incident than this exercise portrayed, although he did find that this was

helpful in practicing some of the key elements of the techniques needed for successful

mayday operations. In discussing headphones, this captain gave insightful conjecture on the

possibilities of voice recognition technology in the future using digital filtering to key-in on

certain critical words and to filter undesirable scene noise and feedback. He also indicated

that studying recordings of “fires gone wrong” often disclose too much radio use occurring to

the detriment of overall command and control.

81

McKinney Day 2 Scores Comparison

50%

55%

60%

65%

Case 5 Case 6 Case 7 Average

Figure 2. Summary of Positive Scores From McKinney Day Two

McKinney Exercises Analysis

The gap between the top and bottom scores shows a 27 percent disparity.

McKinney Cases Sorted By Number of Positive Communications

Case

#

Plus

=n

Minus

=n

Total

%

of +

%

of -

Minutes

Communications/

Minute

3 17 7 24 71% 29% 16 1.5

4 26 14 40 65% 35% 26 1.5

7 15 9 24 63% 38% 19 1.3

5 12 9 21 57% 43% 36 0.6

6 17 13 30 57% 43% 27 1.1

1 12 10 22 55% 45% 25 0.9

2 7 9 16 44% 56% 17 0.9

Figure 3. Ranked McKinney Scores

82

With just one exception in the middle, the more communications per minute correlate

with a higher success rate—pace matters, more is better, although there likely is a point of

diminishing returns in high volume crisis communications; these exercises were generally

below typical incident pacing.

Percentage

Positive

Communications

per minute

65% 1.5

71% 1.5

63% 1.3

57% 1.1

44% 0.9

55% 0.9

57% 0.6

(Average=59%)

Figure 4. Scores Compared To Pace

The average pace for all seven McKinney cases was 1.1 messages per minute. By

comparison, the pace of the Fire Department of New York on 9/11 was approximately five to

six message turns per minute with almost constant overlapping communications as the World

Trade Center towers fell (Firehouse Magazine 2005). A notable observation for a department

that prides itself on not talking a lot at fire scenes is the counterintuitive data indicating the

more communications per minute in this sample, the higher the positive score. Of those

83

performing above the average effective score of 59 percent, all were at the top of the pace

list. The rapidity of the pace could easily overwhelm the incident commander, at some point,

but within the low-to-medium rate used in these drills, the medium rate led to more accurate

communications turns than did the slow-paced ones.

There was no correlation between success rate and experience level. For every positive

score by a senior member, there was nearly an exact match for an unsuccessful one in the

same experience group. The researcher anecdotally developed the impression that novice,

younger incident commanders did not seem to have the same poise or control of their older

counterparts, yet they had greater skills in other areas. The younger members appeared more

likely to juggle multiple demands for their attention, were less likely to ask for repeat of a

message, and seemed better able to retain long messages with multiple facets imbedded

within. One possible explanation for older members struggling to hear may be more than just

natural hearing loss with age, but also could have correlation to hearing loss from years of

being around loud sirens, radios and power tools, especially before more enlightened hearing

protection became common. That aspect was beyond the scope of this study and would be an

interesting area for further research.

Plano Fire Department Case Studies Venue Description

The Fire Training Center in Allen, Texas was the venue for the second series of fieldwork

observation exercises. The Allen Fire Department had just deployed a new fire simulations

lab in which firefighters are able to interact with software and video displays. Game

controllers allow participants to simulate the actions they would take at an actual structure

fire. This controlled laboratory environment gave a natural opportunity to observe the

84

participants and study their communication behaviors as well as the distractions present in

the emergency command environment. The researcher was able to interact with the subjects

immediately following the exercises during debriefing sessions, eliminating the need to

schedule follow up interviews, as was the case for the outdoor observations. The desire of

those conducting both the observation study and the training series was to recreate the issues

firefighters face at actual incident scenes and challenge the subjects to improve tactics. Fire

suppression personnel from the Plano, Texas Fire Department were the test subjects for this

series of observation exercises.

The supplier of this fire simulation software is Flame-Sim LLC. The software program

allows players to see their first-person action on the screen and to function within a virtual

emergency environment. Each participant is also able to see the perspectives and actions of

the other actors around them, while they have discretion individually to control their own

actions on individual video screens. The exercise controller formatted the variables to follow

a similar pattern of responses with the first engine arriving at the scene giving a radio report

of the conditions, followed soon after by the battalion chief who assumed command of the

incident. All parties were encouraged to make their normal radio reports. To lend an air of

realism to this exercise, as well as to provide a mutually enriching experience for all parties,

actual communications dispatchers were integrated into these exercises directly at the

simulation site. This gave an extra element of realistic radio transmissions and allowed for

re-creation of accurate radio flow and content. The dispatchers started the exercise with

realistic incident dispatch messages using addresses from the city where the firefighters

work. The instructions to the subjects were to assume tactical assignments, as they would at

an actual incident, as the incident commander reacted to the radio messages. The dispatcher

85

maintained normal benchmark times and information flow to the incident commander as they

typically would for real emergencies.

There are four different seated positions within cubicles in one room where firefighters

sit in front of standard computer screens along with game controllers typical of video

gaming. There are also two other command theaters in larger rooms with a large screen in

one room where firefighters are able to simulate tactical operations typically conducted as

they would move through the scenario. Actions include crawling in smoke-filled rooms and

making their way through the rooms of the structure searching for victims, operating as they

would typically as firefighters. The other room has a large screen where the incident

commander was able to assume a seated position at a table, which accurately simulates the

policy of this fire department to stay seated within their command cars, usually within a

sports-utility vehicle.

The exercise controller from the host department has found it is best to avoid a lengthy

briefing on the use of the system. Getting the game controllers in the hands of the

participants provided the quickest orientation, decreased the learning curve, and allowed

participants to move quickly to the valuable part of the exercise. The participants receive a

cursory walking tour of the various positions, followed by a brief introduction on the

interactive nature of the simulations. With the controllers in hand, the participants

maneuvered through a practice scenario with mentors familiar with the system in the vicinity

to answer any questions. Most of the questions and coaching centered around the various

buttons and controls on the hand pieces, which are standard gaming controls and familiar to

“gamers.” This allows the participants to interact with the system and to see cause and effect

86

relationships between the firefighters depicted on the screen and their immersion into the

gaming environment.

The video camera used by the researcher was set up in the command room. The over-the-

shoulder position provided a view of the large screen before the test subjects allowing an

understanding of the context of the video simulated incidents. The camera angle selected

allowed for a side view of the test subjects to understand some of their interaction with those

around them, as well as some other nonverbal reactions to the circumstances occurring. The

fire personnel used their portable radios as they would at a typical incident. Placement of a

radio near the camera created a soundtrack for the video, allowing later understanding for the

context of what was occurring.

Plano Case Studies Day One

The first series of case studies occurred on January 22, 2009. Groups of firefighters

stayed in the training simulation lab in half-day segments. The first group assembled and

went through an initial briefing, including information on the purposes of this observation

exercise. Following the briefing, the firefighters positioned themselves at individual

simulation stations where they had an opportunity to practice with game controllers. The first

group was acclimated to the game controllers and exercise flow. The battalion chief of

training from the participating department was the first incident commander to start the

exercise series. The purpose was to bring everyone to a comfort level with the simulation

concepts and to allow them to be acclimated to the interaction between the software and the

firefighting actions. This initial sequence was not scored since the participants, controller,

and researcher were still acclimating to the simulation environment.

87

Case Number Eight

In the second case of the day, the battalion chief who started the exercises again assumed

the role of incident commander as the first simulated scenario played out. Of the 24

communications scored the vast majority were found to be effective; 22 communications

turns were effective, versus only two flagged as ineffective for a couple of minor reasons.

Case Number Eight played quite smoothly, as could be expected, since it was a second time

through for that incident commander and he had relative familiarity with the incident

simulator software through earlier exercise planning meetings conducted between the

departments’ representatives and the researcher. The challenge level of this early incident

was also low, as the tactical difficulties and complexities increased later in each group’s

sequence.

Following Case Number Eight, the simulations staff discussed the operating conditions

present and the consensus was that the background noise was unrealistically sterile compared

to what could typically be expected at actual incidents. There was a consensus to enhance

some of the background noises to make it more like a realistic emergency scene. The

simulation software has a soundtrack that plays some relevant scene noises; we just did not

have it on in the command room. Following activation of that feature, sounds such as self-

contained breathing apparatus and a saw operating to ventilate the roof played on the

speakers in the ceiling of the command room, which more accurately reflected some of what

would exist at an incident. An extra portable radio tuned at a moderate volume level in the

command room provided realistic echo and radio sounds, typical of emergency operations

areas. Discussions with the firefighters concluded that the noise inside buildings on fire is

often even louder, especially involving the use of mechanical fans to exhaust smoke. The

88

sounds of several firefighters in close proximity breathing through their self-contained

breathing apparatus, as well as smoke detectors sounding, add to the typical noise level inside

burning buildings. Background noise presents a considerable influence upon firefighters

operating on the scene. Even though this department does typically have its incident

commanders sit within a command vehicle, it is reasonable to assume that there would be

some distraction and incident noises influencing the incident commander’s ability to

communicate effectively.

Case Number Nine

In Case Number Nine, an experienced fire captain assumed the incident command

position, along with an assistant assigned to form a two-person deployment, as if they were

sitting side by side in their vehicle commanding the incident. There were 34 communications

during this exercise with 26 effective (76 percent) with only eight judged as ineffective. The

reason for some of the missed messages included the incident commander not providing an

acknowledgement to a message and another was a missed transmission between tactical level

units. The pace caused the incident commander to move to the next radio transmission

instead of waiting for acknowledgement from the prior message. There is a risk of messages

being missed when the receiving party is not given time to acknowledge.

This exercise featured a series of smooth and short commands issued effectively. There

were two instances whereby a garbled radio transmission did not receive any follow-up from

the incident commander, even though it is clear on the recording that someone called him.

This scenario included a simulated firefighter-injured situation, with all parties handling that

aspect well. The pace of radio traffic picked up slightly when the firefighter injury occurred;

89

however, that phase concluded rapidly, so it did not place undo stress on the radio

communications.

Case Number Ten

Case Number Ten involved a captain who was able to observe the previous exercises and

to assist others, so he had extra familiarity with the flow of what was to occur when he was

incident commander. There were 29 communications conducted during the fifteen-minute

exercise simulating a house fire response. Twenty-one percent of the communications were

ineffective. There were times when garble over the radio did not trigger a request to repeat by

the incident commander and there were two instances where there was no apparent reason for

ignoring the calling unit. The incident commander did not acknowledge a critical message

involving removal of the victim from the hazardous environment. In this instance, it was

apparent to the observer that he understood the action was taking place, but he did not

convey that to the units at the scene in the form of an acknowledgement over the radio.

Case Number Eleven

Case Number Eleven featured a thirteen-minute simulation in which the units were

responding to a reproduction of a structure fire. Thirty communications were conducted at

the rate of over two per minute, a relatively fast pace for this exercise series. Seventy percent

of the communications were effective. Those judged ineffective included instances where

there was no confirmation for radio messages; in some cases, the radio message was not

clear, but the officer did not request the calling unit to repeat the message. One message

repeat was necessary because a face-to-face conversation with the commander distracted

attention from the radio.

90

This exercise included a firefighter calling for help and the situation was resolved rapidly.

Since the rescue was of short duration, the dispatchers and commanders did not apply the full

procedures required in such situations. There was a great deal of interaction observed

between the incident commander and the partner assigned to the incident commander. A high

rate of collaboration occurred with ten instances of eye contact or confirming nods to

questions posed between the partners. There were times when the presence of a partner did

seem to be a distraction causing them to miss some messages because they were

collaborating at such a high level. The collaboration did seem to help at other times,

however. There was an instance during the Personnel Accountability Report process whereby

one of the units interrupted with an urgent message. The commander turned to the partner

and said, “Do what?” indicating that he heard part of the message, but was looking for help

in understanding the remaining content. The partner repeated the message so it was not

necessary to do so over the air.

Case Number Twelve

The final exercise on this day was Case Number Twelve, allowing for application of the

previous experiences gained by the crews and commander with a slight escalation in the

intensity of the variables. The scenario was more challenging with additional victims needing

rescue in the building on fire and the fire more difficult to extinguish. The incident

commander was serving in the lead position for the second time, providing the researcher an

opportunity to observe some of the learning curve improvements occurring through repetition

and familiarity. He cut his personal percentage of ineffective communications in half to a

respectable 16 percent, as compared to the overall study average of 27 percent. The exercise

lasted 21 minutes with 43 effective communications versus eight ineffective ones; the pace

91

was the fastest of any exercise on this day. In this sequence, the incident commander was

assigned alone to study the solo environment of incident command. The inference one may

draw from these results is practice and familiarization is more valuable than assignment of an

aide.

Plano Day 1 Scores Comparison

60%65%70%75%80%85%90%95%

Case 8 Case 9 Case 10 Case 11 Case 12 Average

Figure 5. Summary of Positive Scores For Plano Day One

There was a rapid pace of communication during this exercise with almost two and a half

communications per minute, which was on the high end of the range in this sequence. Most

of the communications turns were efficient. Atypically, no message repeating was required in

this sequence. Of the effective communications made, one was a situation whereby a

message went without acknowledgement and there were other instances where no

acknowledgement was given to an inbound message before moving on to new transmissions.

When messages are stacked, or “piggybacked” in such a fashion, the calling party cannot

confirm delivery of the message. There was one instance of a redirection of attention

occurring. This is the radio equivalent of a forgotten telephone call placed on hold; in other

words, the commander did not get back to a previously calling unit as redirection of his train

92

of thought occurred following a newer calling unit’s message. This incident commander

appropriately cautioned firefighters when other opposing tactics could affect their safety

during a rapid entry tactic known as “vent-enter-search.” By the end of this exercise, the

incident commander developed an effective rhythm with very efficient turns of

communication evident.

Reevaluation of the Simulation Environment – Testing Sub-Theories

After the test subjects departed the simulator for the day, a debriefing session occurred

with participation of the exercise controller from the host department, the training officer

from the department supplying the firefighters, and the researcher. The consensus was

general satisfaction with the first day of exercises, realizing that by the end of that day, we

were achieving realistic command and communications conditions. We discussed the

situation of firefighters often trying to speak with their breathing apparatus face pieces in

place, and how that muffled their voices, requiring the repeating of radio messages. The

simulation exercise on day one did not consider that influence, other than the soundtrack that

played on the individual computers when firefighters used their simulated self-contained

breathing apparatus. We agreed to introduce some element of actual wearing of face pieces

by the test subjects during the next day of exercises.

Plano Case Studies Day Two

Day number two, January 23, 2009, at the Allen simulation site began with a new set of

test subjects assigned to the training simulator. Following the routine briefing and an

explanation of purpose of this observation exercise, the test subjects deployed throughout the

93

individual stations for practice sessions with the controllers to be acclimated to the test

environment.

Case Number Thirteen

An experienced lieutenant from the first day of simulations served in the role of incident

commander for the introductory sequence. This practice exercise lasted seventeen minutes;

twenty-four communications sequences scored as effective with only three rated as

ineffective. The ineffective ones involved a garbled radio transmission that needed repeating,

as well as no answer received in two other instances during the 27 turns of communications.

The elapsed time of the exercise was seventeen minutes. The data show an impressive

efficiency rating of 89 percent, demonstrating the benefit of this incident commander’s

experience with prior exposure to the simulator environment and the relatively simple tactical

objectives. This group acclimated very quickly to the game controllers and seemed eager to

get into the actual pace of exercises.

Case Number Fourteen

An experienced fire captain served as the incident commander for Case Number Fourteen

with this case lasting 21 minutes. With 88 percent of the incident scene communications

judged effective, only 12 percent proved to be ineffective. Some reasons for the ineffective

communications included distraction during a face-to-face conference with someone else in

the command environment, no answers to messages in two other instances, and a request to

repeat for no apparent reason. The researcher was in the task-level simulation room at the

time when a firefighter bungled a radio message. It was interesting to observe that the sender

of the communication was not aware that he transposed the words of his message. He said,

“I’m putting fire on the water.” He did not realize he made the error until the incident

94

commander repeated back the incorrect phrase, prompting him to realize that he had said it

backwards. Because of the direct observation of the individual as he sent the wrong message,

it was evident to the researcher that he was engrossed in the task in front of him and the

composition of proper syntax of his message was a secondary concern to the primary

attention he had for the tactical objective (Mack and Rock 1998, 74-103).

Case Number Fifteen

In Case Number Fifteen on January 23, an exercise for simulating a structure fire with

someone trapped inside occurred during a fifteen-minute sequence. This was a relatively

short time duration within this series, but the pace of communications is nearly two turns per

minute with 21 of the messages proving to be effective and only seven were ineffective. Of

those found to be ineffective involved units transmitting over the top of each other and some

units not waiting for message exchange to conclude before attempting delivery of the next

one. Some of the transmissions were garbled, and there was an instance of no answer

received when another party was calling the incident commander. The researcher noticed

again during this exercise the repeat of messages was required for no apparent cause. Even

though the transmission was clear on the radio system, the sending party requested a repeat.

Case Number Sixteen

This group of subjects concluded the session with a more challenging nineteen-minute

exercise requiring the rescue of a firefighter injured within the building. Some stress

reactions by the incident commander were apparent. He was not as experienced in incident

command as the other officers so there was intent by the trainer to place him in this role for

practice purposes. Several of the ineffective messages were due to no immediate reaction to

the calling parties, as the subject appeared overwhelmed by the rapidly escalating cascade of

95

calling parties. In other instances, information was slow to be processed and since it needed

repeating for full comprehension, there was a delay on the air, filled with additional calling

parties transmitting partial messages, before acknowledgement of previous messages.

The incident commander’s stress reactions observed by the researcher included rubbing

his forehead and facial expressions showing that he was beginning to show frustration over

the mounting pace of the radio calls and his inability to keep up with each of them. The

incident commander was speaking slowly to begin with; however, as the stress reactions

started to mount, it seemed that he was speaking slower still and experiencing difficulties in

choosing his words even more. In this instance, when he needed to speak more quickly to

answer all of the demands for his attention, he was unable to get ahead of the flow of

communications. There were a significant number of missed transmissions during this

exercise and the calling of a mayday by one of the firefighters during the incident did not

receive the full attention a distress message would dictate. A number of instances of units

needing messages repeated or messages garbled occurred during this exercise. The

breakdown of effective communications led to a high number of ineffective ones, which

turned the analytical scores negative in this exercise.

Fifty-eight percent of the communications were ineffective. The low score (n=18) of

successful communications is partially attributable to the low experience level, and the

incident commander operated alone without assistance under relatively difficult tactical

circumstances. Although this exercise did not proceed well, both by statistical analysis and

by the impression of those present, the exercise controllers and training officer were able to

integrate lessons learned into the post-exercise debriefing session. They put the best possible

96

face on what was truly a valuable learning experience for all. The simulation environment

gave this opportunity to learn with no risk of injury to personnel.

Case Number Seventeen

A repeat of the simulation cycle occurred on the afternoon of January 23 with a new

group of test subjects. Once acclimated to the training environment, the group went through

the routine briefing and practice session. The fifteen-minute practice exercise had an

experienced command officer serving as incident commander. The number of effective

communications was high at 82 percent. Like the earlier team on this day, this group was

able to acclimate quickly to the game controls. Only four communications in this practice

session were ineffective. Ineffective communications included no answer by units hailed or

no acknowledgement received from a calling unit, indicating whether successful message

delivery occurred. There was also no apparent reason for one instance of a missed message

not reacted to by the incident commander.

Case Number Eighteen

Case Number Eighteen for the day used the same incident commander who conducted the

practice session, so he was able to use some of his experience from the earlier exercise. He

achieved a very high efficiency rating (n=94%), attributable to his prior experience. He was

able to speak at a much more rapid pace with over two and a half messages per minute,

which is on the high end of the range for all of these exercises. Only two instances of

ineffective communication occurred, involving no answer by the incident commander to an

incoming message. In the other instance, units covered each other. When the incident

commander did not understand a message, he turned to those around him to ask, “What did

he say?” There was an abrupt need to conclude this exercise at the twelve-minute mark due

97

to a software failure; however, sufficient data collection had occurred to that point with 31

turns of communication occurring in the short period allowing for comparing and contrasting

with the earlier set of data from the same incident commander.

Case Number Nineteen

Case Number Nineteen on this afternoon featured an exercise lasting thirteen minutes,

during which personnel responded to a simulated structure fire. There were 24 radio

communication turns during this exercise with 21 judged effective and just three messages

were ineffective. Of those deemed ineffective, the test subjects were distracted by attention

paid to tasks in front of them on the screen and, therefore, did not react to a radio call made,

as well as another instance of message inattention for no apparent reason.

Case Number Twenty

Case Number Twenty, the next to the last exercise for this afternoon, featured the use of

self-contained breathing apparatus masks by the engine company units for the first time in

this simulation exercise series. A much more realistic simulated communication environment

existed by adding this common feature leading to muffled radio communications. The

positive rating predictably dropped in this exercise because of the introduction of these

muffled transmissions, which all of the experienced controllers and trainers at the site agreed

were accurately reflective of the typical incident communication challenge. Thirty-one

percent of the messages in this fifteen-minute exercise were ineffective. Some of the reasons

for the ineffective radio communications included no answer provided to a call and multiple

instances in which individuals transmitting while wearing their facemasks required message

repeating since they were unintelligible. This exercise was also tactically challenging because

of the presence of a firefighter mayday, as well as the need to switch extinguishment tactics

98

to a defensive mode, whereby units withdraw from the interior of the building due to rapid,

dangerous fire spread.

Case Number Twenty-one

The final exercise of this day, Case Number Twenty-one, also featured the use of self-

contained breathing apparatus masks by those at the task level, including hose line operations

and search and rescue within the building. There were 22 communications turns in this

exercise at a common pace of 1.8 per minute. There was a high degree of command

teamwork observed in this exercise as the incident commander had a partner to assist. Nine

messages (n=29%) were deficient in some manner. Some of the messages were garbled or

muffled, requiring message repeat. The use of self-contained breathing apparatus masks

required some repeating of messages, but there were also clear communications with them in

use. The sender clearly played a role in selecting simple words to convey the concept and to

space and articulate them well within the limits of talking with a mask over the face. In two

Plano Day 2 Scores Comparison

35%

45%55%

65%75%

85%

95%

Case 13 Case 14 Case 15 Case 16 Case 17 Case 18 Case 19 Case 20 Case 21 Average

Figure 6. Summary of Positive Scores For Plano Day Two

99

of the repeated message situations, the cause was distraction by chatting between the incident

commander and his aide. The time of this exercise was just seventeen minutes before

accomplishment of the tactical objectives and exercise conclusion.

Plano Case Studies Day Three

The final series of case studies at the Allen Fire Department Training Facility simulators

occurred on January 26, 2009. As was typical throughout the series, the purpose of the first

sequence was to familiarize the participants with the use of the controllers and the flow of the

exercise.

Case Number Twenty-two

In Case Number Twenty-two, an experienced fire captain assumed the role of incident

commander. This familiarization sequence lasted fourteen minutes; there were 29

communications turns, of which 23 were effective. Of the ineffective messages (n=6), there

were instances in which the calling units covered one another, yet the incident commander

did not ask either unit to stand-by or repeat the communication. In other instances, there was

no waiting for an acknowledgement that the incident commander had received the message

before moving on to the next communications turn. There was no apparent reason for one

message repeat request; the content was clear on the recording. The researcher observed a

high degree of collaboration in this sequence with a partner assigned to assist the incident

commander.

Case Number Twenty Three

The duration of Case Number Twenty Three was seventeen minutes with 40

communication turns for a high rate of communications per minute (n=2.4). The delivery of

100

31 of the communication turns was efficient with the remaining nine exhibiting a variety of

common inefficiency concerns. A closer look at the nine inefficient communications revealed

a variety of common issues. There were three instances of no answer given to a unit calling.

In other instances, it was apparent that the incident commander received messages from the

dispatcher, but they were unacknowledged over the radio channel. There were other instances

of units calling without receiving an acknowledgement. In some instances, the incident

commander’s assistant prompted him that someone was calling on the radio. The incident

commander in this sequence strained while listening to the speaker microphone by holding it

close to his ear and slightly pitching his head downward. This was the same posture observed

in the previous venue of case studies with incident commanders operating outdoors in a

standing position near the street.

Case Number Twenty Four

The same incident commander from the previous case repeated incident command

responsibilities for Case Number Twenty Four. In this sequence, there were fewer

communications delivered (n=32) for a rate of 1.8 per minute, which is lower than the

previous experience with the same incident commander. The error rate of 25 percent was

similar to the previous case with the same incident commander (n=23%). Some of the same

deficiencies were present in this case as well as in the previous situation when he was

commanding. Once again, he was straining to listen to the speaker microphone, especially as

the pace increased or additional distractions were present. Much like the previous example,

there were instances of messages from the dispatcher being apparently received, but not

acknowledged over the radio. Units were covering one another during other ineffective

communication sequences without redirection, or untangling by the incident commander.

101

This case featured a mayday call, which did increase the amount of confusing and tense radio

traffic. The time duration of the mayday was very short, so the normal pace of

communication restored quickly. One of the eight inefficient communication turns involved

messages that needed repeating. The apparent reason for the repeated messages was

background noise and there was distraction present from a face-to-face meeting leading to a

missed message. One of the inefficient communications turns involved an earlier forgotten

message pushed from attention span by a subsequent message redirecting full attention from

the incident commander. This can be informally considered a “squeaky wheel situation,”

commonly observed through all actual and simulated incidents, in which the more aggressive

or urgent-sounding message tends to redirect attention, causing the earlier incomplete

message to be ignored entirely.

Case Number Twenty Five

Case Number Twenty Five involved a return of an incident commander from a previous

sequence earlier in the morning. The captain who handled the first sequence was incident

commander for this Case Number Twenty Five. A high number of communication turns

occurred during this case (n=47) at a rate of 2.1 per minute. The duration of this case was 22

minutes; the incident commander made good use of the aide provided to him. Thirty-four

communication turns, or 72 percent, were effective. This incident commander had a high

degree of collaboration with his assistant with at least nine instances of verbal exchange or

confirming glances between them. This case introduced the first use of self-contained

breathing apparatus masks by the participants during this day’s simulations, increasing the

amount of muffled radio traffic. This sequence also used face-to-face discussion elements

intended to recreate this common distraction in the command environment. Three of the

102

thirteen missed radio messages occurred while a face-to-face conference was underway. In

other instances, there was no answer provided to units calling and some messages became

too long for retention and cognitive processing. Truncation of the messages often required

repeating of some part of the message, or resulted in complete ignoring of that part of the

message.

Case Number Twenty Six

Case Number Twenty Six included the use of an experienced battalion chief as incident

commander. This case was the first in the sequence for the afternoon session involving a new

set of firefighters and command officers. This introductory case familiarized the subjects

with the use of the controllers and flow of the simulations. At just ten minutes, it was the

shortest in the entire series, but a relatively rapid pace of communications per minute (n=2.4)

occurred. An unusual aspect of this case involved the switching of radio channels just as the

exercise was beginning. The incident commander assumed that the exercise controllers

instigated it; however, one of the command officers at the tactical level issued the order. This

department has a procedure to switch to a different radio mode when radio communications

are insufficient. There was some degraded radio service in the building where the simulator

is located, which was different for those accustomed to an area of better radio coverage. The

decision to switch to “conventional mode” or direct unit-to-unit mode without use of radio

infrastructure is an emergency procedure. Operating in conventional mode removes

dispatchers from the conversations, there are no recordings of the incident and others remote

from the scene cannot monitor the event. The incident commander assumes significant

additional responsibility when operating in conventional mode, as outlined in the Syracuse

and Seattle case studies in Chapter Four. The switching to the alternate radio platform just as

103

units were arriving at the simulated location created a period of confusion at the early portion

of the exercise. It was during this segment of the operation when a majority of the

miscommunications occurred, as units were in the process of switching channels and

reestablishing their communications bearings. The experience level and poise of the battalion

chief allowed for a quick restoration of radio order, so there were only five ineffective

communications, most of which involved unacknowledged messages or needs to repeat due

to radio noise and feedback.

Case Number Twenty Seven

Case Number Twenty Seven featured an experienced fire captain serving as incident

commander. This case lasted eighteen minutes and featured communications at a rate of 1.9

per minute. There was a high completion rate of effective radio communications at 85

percent for this sequence. The incident commander made good use of a partner assigned to

him in spotting information unfolding on the simulation projection screen. Of the five

ineffective radio messages, three involved no acknowledgment provided to calling parties,

one instance of a message needing repeating for no apparent reason, and other distractions

involving face-to-face meetings causing missed radio messages.

Case Number Twenty Eight

In Case Number Twenty Eight, the same incident commander from the previous

sequence repeated incident command duty. The exercise lasted just twelve minutes and the

rate of communications was a normal range per minute (n=1.9). The results are noteworthy

since the same incident commander had a high degree of efficiency in the previous sequence

with 85 percent of the messages handled effectively; the rate dropped to 61 percent during

this exercise. The major difference in this sequence involved the use of self-contained

104

breathing apparatus masks by the participants. Of the nine ineffective messages, some of

them were unit-to-unit communications muffled due to the presence of the self-contained

breathing apparatus masks. In other instances, there was no acknowledgement provided to

radio messages, and there were situations in which the incident commander did not return to

bumped or supplanted messages overridden by more urgent-sounding ones.

Case Number Twenty Nine

The final sequence in this series, Case Number Twenty Nine, was 24 minutes, and

featured a more difficult fire suppression and rescue challenge. The engine company

participants were communicating while wearing their self-contained breathing apparatus

masks. There were 34 radio turns during the exercise with 71 percent occurring efficiently. A

high degree of collaboration existed in this exercise between the incident commander and the

assistant assigned to him. There were at least eleven instances of brief discussions and

confirming glances. The pace of communications was relatively slow at 1.4 per minute. Of

the ten radio turns occurring ineffectively, five involved no acknowledgment provided to

information delivered, although the command post parties apparently heard and understood

the message. The one initiating the message has to wait for an acknowledgement to know

delivery is complete (see the order model in the Charleston section of Chapter Four). One

message was garbled and there were some messages needing repeating for no apparent

reason, including unit-to-unit communications.

Additional radio traffic was necessary during this final exercise to clarify the assignments

and radio designators preferred by the incident commander. There was an attempt to assign

radio call designators to tactical units, i.e. instead of referring to engine one and engine three,

the consolidated units were to refer to themselves as “fire attack group.” When stressed with

105

challenging tactical objectives, the units tended to revert to their previous designators, as an

engine company and number, instead of their newer call sign as a tactical level group, which

dissipated from short-term memory. Confusion about relabeling tactical units into groups or

divisions during incidents existed throughout the entire series of exercises. This generated

additional radio traffic and potentially caused critical confusion, especially during the PAR

roll call process. During the roll call, dispatchers monitoring the incident commander were

able to perform a critical independent audit of units known to be on-scene. Dispatchers are in

a remote position of informed perspective and have access to an array of technology to be

aware of which units are at the scene, including automatic vehicle location plotted to a map

and radio unit call number displays. It is possible for the incident commander to miss a unit

number during a roll call or for units to be on-scene without the knowledge of the

commander, such as those self-dispatched, replacement units, or otherwise operating beyond

the awareness of the incident commander. Switching to a nomenclature of group or physical

divisions introduces an element of confusion into the PAR process.

Plano Day 3 Scores Comparison

50%55%60%65%70%75%80%85%90%

Case 22 Case 23 Case 24 Case 25 Case 26 Case 27 Case 28 Case 29 Average

Figure 7. Summary of Positive Scores For Plano Day Three

106

Plano Exercises Analysis

Case

Number Efficiency

Score Number of

Collaborations Case

NumberEfficiency

Score Number of

Collaborations18 94% 2 18 94% 2 8 92% 4 8 92% 4 13 89% Solo Top 13 89% Solo 14 88% Solo Top Third 14 88% Solo 19 88% Solo Half 19 88% Solo 27 85% 5 27 85% 5 12 84% Solo 12 84% Solo 17 82% 2 17 82% 2 10 79% 7 10 79% 7 22 79% 6 22 79% 6 26 79% 1 Middle 26 79% 1 23 78% 4 Third 23 78% 4 9 76% 4 9 76% 4 15 75% Solo 15 75% Solo 24 75% 4 Bottom 24 75% 4 25 72% 9 Half 25 72% 9 21 71% 8 21 71% 8 29 71% 11 Bottom 29 71% 11 11 70% 10 Third 11 70% 10 20 69% 2 20 69% 2 28 61% 4 28 61% 4 16 42% 2 16 42% 2

Figure 8. Collaboration Influence In Scoring

In the top half of the scores (left column in Figure 8), eight out of the 12 top performing

incident commanders were functioning with the aid of an assistant. The remainders were solo

commanders. This may create an assumption that aides provide an indisputable value to

incident command efficiency. Closer examination of the data suggests a counterintuitive

result. When examining the data in top, middle and bottom thirds (right column in Figure 8),

an interesting pattern emerges.

107

Case #

Percentage

of Positive

Number of

Collaborations

11 70% 10

21 71% 8

25 72% 9

29 71% 11

Overall

Averages 77% 5

Figure 9. Correlation of Collaboration With Scores

There is a cluster of the four highest collaboration occurrences in the bottom third of

efficiency, and four out of the seven top performers were performing solo (Figure 9). This

suggests that aides can become a distraction factor when assigned to incident commanders

(Speier et al. 1999, 344-353). There is a delicate balance and sets of influences, depending on

the quality of the working relationship between the command post members. During the

exercises, observation revealed that aides who tended to talk a lot obscured other important

input, such as changes in visual cues and inbound radio traffic, triggering the need for

repeated messages or unacknowledged ones. The most effective teams minimized verbal

communication and used nonverbal glances, confirming nods, and hand gestures, reminiscent

of Gladwell’s Blink principles (2005, 13-14, 194-195).

108

McKinney and Plano Exercises Compared

Comparing Walking Command vs. Stationary Command

An average of 59 percent of the McKinney messages was effective while an average of

77 percent of the Plano message sequences was successfully completed. The experience level

of the subjects was similar between the departments. There were some significant differences

between the two exercise venues. The McKinney exercises had a higher degree of difficulty

since they were dealing with a mayday situation, which is challenging in its own right. The

McKinney venue also featured a greater variety of typical noise producers, such as apparatus

engine noise. McKinney practiced splitting of the on-scene communications into two

channels upon declaration of the mayday, which proved problematic and led to a lot of the

missed radio traffic and confusion. The report of the Prince William fire outlined in Chapter

Four only recommended splitting the radio channel for a mayday when command staffing

permits separate channel responsibilities. Otherwise, radio silence should prevail until the

rescue is complete (Prince William County B8, 2008).

Despite several key differences, some of the gap between 59 and 77 percent efficiency

rating is attributable to the value of stationary command. The comparatively quiet and

controlled setting of the Plano incident command simulator room, which mimics the

environment inside a command vehicle’s cab, is a more conducive listening and organizing

environment than the McKinney commanders’ wide footprint of pacing and posturing. In the

outdoors, McKinney commanders exhibited considerable movement whenever they used

their radios around fire apparatus and other personnel in the street in front of the operations

building.

109

Influence of Talking While Wearing A Mask

The Plano case studies established an eleven percent efficiency drop when firefighters

used self-contained breathing apparatus. The use of masks introduced muffled voices and

unintelligible voice sequences. The wearer had a responsibility to articulate and enunciate

each word in something of an exaggerated manner to achieve message delivery. Decades of

equipment experimentation by the fire service have not yielded a satisfactory solution to this

vexing problem.

Cases With Masks Used

69%71% 72%

61%

71%

55%

60%

65%

70%

75%

80%

85%

Case 20 Case 21 Case 25 Case 28 Case 29

Series Average Without Air Masks=80%

Figure 10. Comparing Influence of Mask Usage on Communications Efficacy

Simulation Environments

Beroggi et al. (2001) tested the design and use of gaming simulation as a means for

gauging group decision support systems. As of 2001, Beroggi et al. determined that

developing and implementing simulation environments was prohibitively expensive and time

consuming. Improvements in hardware and software in the ensuing eight years has made

110

simulations now feasible for emergency training. The degree of realism is critical to the

success of simulation programs if the results are to be useful and maintain the interest of the

participants. Slater et al. (2000, 46-50) were able to demonstrate that people can move

between virtual and real worlds, bringing with them skills and relationships developed in

each realm. Virtual worlds offer opportunity to develop skills and to practice critical

command and control behaviors in regulated and predictable settings. In discussing her work

at the Naval Postgraduate School, Professor Amela Sadagic (2008) saw parallels in the

challenges facing the U.S. military and community first responders in training for infrequent

yet intense decision-making challenges. The U.S. military has found that simulator

environments closely approximate real world challenges, allowing for skills development not

otherwise possible during intermittent battlefield experience situations (Sadagic 2007, 2008).

The logistics involved in “putting boots on the ground” to conduct training exercises in the

field are considerable and sometimes difficult to control due to outside influences, such as

environmental variables and continuous-service mission demands. Although it may not be

desirable for virtual simulation environments to entirely replace field exercises, there is an

indication of a synergistic opportunity to meld both styles to best advantage.

The post-exercise debriefings revealed a level of concurrence and enthusiasm on the part

of the participants for the simulation form of training. While the simulations had many

elements of realism, there remained opportunities to refine and enhance the gaming

environment to reflect realistic operational conditions. Representatives of the simulation

software company were present during these exercises and were accommodating to all

suggestions for enhancement. The simulation environment allowed for the identification of

many of the micro factors and nuances present in the emergency command environment.

111

Immersion of the participants in the challenges presented to them allowed realistic

observation of decision-making and use of radio communications. Much like the use of

instant replay and slow motion at sporting events, videotaping of these exercises allowed the

researcher to review factors after observing the events in real-time. Influences and factors not

apparent as events unfolded in person were sometimes observable upon examination of the

videotape. There was even an opportunity to discern patterns by using fast forward. For

instance, the researcher used fast-forward when studying the pacing patterns of incident

commanders operating outdoors beyond the confines of a vehicle.

CHAPTER 6

IMPLICATIONS AND RECOMMENDATIONS

This final chapter provides a summary of the hypotheses testing results, reasons and

explanations for ineffective communications, and practical improvement recommendations.

Research Summary

The problem explored in this project is the cause of missed radio messages during

emergency operations by community first responders. This research is important to the field

of study since communications are a major operational issue in emergency responses and

efforts focused solely on technological improvements have not solved the problem. Review

of audio recordings does not give the necessary insight into the reasons for a missed radio

message.

The researcher studied the communications process from a phenomenological perspective

and identified the source of distractions influencing effective communications. The author

found that the obstacle to substantive improvement in emergency communications has been

the lack of understanding of the complex human factors involved beyond the capabilities of

even the most robust hardware imaginable. The researcher hypothesized that sensory

overload is a major contributing influence restricting effective communications flow; data

collected during the observations showed multiple instances of message delivery being clear,

but still mishandled by the recipient. This study isolated specific influences in the emergency

112

113

command environment, which when combined with human tendencies and limitations

impeded the flow of effective radio communications.

Study of actual incidents featuring significant radio factors allowed for identification of

common lapses and features in the communications processes, along with fieldwork to study

the communications interface environment. In answering the gap in experiential data, this

dissertation project observed and analyzed multiple sequences of command communications

to establish the frequency of errors and the trends and causes therein. Documentation of the

recollections and insights by the actors involved through interviews lends additional

perspective. The evidence collected during the fieldwork is the distractions and influences

operative at the instant an ineffective communication occurred (Appendix C contains a

summary of the fieldwork data). The project delineates the broad categories of impediment

and provides conjecture on likely causes for future study. The studies are replicable allowing

other researchers the opportunity to revisit the same conditions and study the nuances

identified.

Hypotheses Results

Hypothesis number one was validated since major human causal factors and not hardware

failure occurred. There was confirmation that sensory overload leads to ineffective

communications and that sensory overload plays a role in the non-technical impediments. In

numerous instances, people experienced distraction in the form of multiple conversations,

noisy environments, and multi-sensory demands for their attention. Hypothesis number two

was verified accurately by the documented presence of communications delivered to the

receiver for which an inattentive reaction occurred. The study confirmed that even when

114

radio equipment successfully delivered a message, misinterpretation by the intended recipient

or unintentional lack of awareness that the message occurred was common.

The innovation of this dissertation research is in testing the operational environment of

first responder incident commanders to delineate the distraction influences and measure the

effect they have on the radio communications conducted at the incident. This dissertation

examined and established the presence of communications impediments in the multi-sensory

world of first responder incident command. The finding of this research is that emergency

personnel operating in critical decision-making situations experience sensory overload

leading to communications deficits. The communications deficits result in ineffective

communications, potentially influencing the quality of decisions made (Klein 1999, 30;

Simon 1997 291; Gladwell 2005, 23). Effective emergency command relies upon the quality

of communications. First responders need to make decisions in an imperfect information

environment with imperfect information. Communications clarity is therefore essential to

close some of the imperfection gap.

Communication failures among key personnel are a recurring issue during disaster

operations with over $6 billion spent by the federal government this decade to improve two-

way radio capability at state and local government agencies with the presumed result of

better communications (Timmons 2006). This research effort exposes the fallacy in the

tendency to expect operational improvement merely by the deployment of new technology

(National Commission on Terrorist Attacks, 2004, 280-285; U.S. Fire Administration 1993,

3, 7). As established by Klein (1999, 277-279), new technologies do not guarantee immediate

improvement; instead, they may actually complicate matters, as we have seen in the recent

115

distraction debate about driving while talking on cell phones or text messaging (Hancock et

al. 2003, 503; Strayer and Johnston 2001, 465-466; Strayer et al. 2003, 30-31).

The fieldwork phase of this dissertation endeavored to identify the distraction factors

present at typical emergency scenes impairing effective communications by and among first

responders. Of particular interest were those situations in which the same individual had

multiple demands imposed simultaneously, amounting to a condition of sensory overload.

Information overload is the expected result when the volume of input exceeds the processing

capability of those involved (Milord and Perry 1977, 131-136; Speier et al. 1999, 338). The

researcher’s observation of a variety of emergency personnel operating in critical decision-

making situations provided insight into specific causes of communications failures. Data sets

based on field observations allowed for trend and factors identification. Discovery of sets of

influences in sufficient quantities and from common sources led to the identification of cause

and effect relationships.

Why Messages Are Missed

It is possible to reconcile many of the reasons for missed radio traffic. Some missed

messages were attributable to the noisy environment typical of emergency scenes with

various distraction factors involved. Some ineffective communications turns involved

hardware failure or voice obscuration due to the use of protective respirator masks. Yet more

than a third of the messages missed during the study had no apparent cause. The message

was clear to the observer and on recordings, yet the recipient was not able to handle the

message (Figure 11). Missed messages for which there is no apparent cause invites

theoretical conjecture.

116

Reasons For Missed Radio Traffic

No apparent reason

38%

Talking in person to others

19%

Other channel19%

Garbled14%

Background noise5%

Feedback squeal5%

Figure 11. Communications Deficits

The researcher expected two or three major factors would emerge during the study as

leading causes for ineffective radio communications. Instead, the researcher found that there

were multiple layers of complexity to this situation. While there are predictable factors that

degrade communication effectiveness, there are also nuanced aspects occurring at various

stages and under differing circumstances, creating a greater influence at certain times, and

not as much at other times.

Sensory Overload

The study showed that the quality of communications decreased in proportion to the

amount and types of stimuli and distractions occurring around the incident commanders.

Some commanders were able to handle the complicated environment better than others were

and even the most experienced commanders missed a lot of radio traffic. There is an

117

interrelationship between the influences and dysfunctions found in the test and work

environments. Inferences from the analyzed data make a convincing case for the deleterious

effect of sensory overload in the emergency environment. As a result, practitioners may be

compelled to seek ways to manage sensory input and distractions with the expected outcome

of better communications and decisions at critical incidents.

Signs of sensory overload included ignoring messages if another message immediately

following sounds more urgent, failure to return to unfinished earlier messages, and jumping

to the loudest or most tense communication when multiple messages contended for attention.

Observation disclosed inattention to changing factors on the periphery when micro

conversations or isolated visual stimuli were present. Instances of truncated message content

and inability to recall the whole message also indicated a state of being overwhelmed.

Age and experience were not major factors separating the high and low performers. The

pressure of the circumstances and the level of risk faced played a role in the physiological

response, increasing the likelihood of sensory overload. Management of distractions is a

critical factor for calm, controlled incident command and communications. Command

operation from within enclosed vehicles appears to give the best opportunity to manage

sensory overload and chaotic scene background noise. Beyond the quantity and intensity of

the circumstances creating sensory overload, this research points to plausible physiological

and psychological contributing factors leading to missed messages.

Physiological Hearing Deficit

The human body undergoes significant physiological change in the face of a perceived

threat or other stressful situations. Muchnik et al. (1980, 228) found that emotional stress can

affect hearing, especially if severe enough or if exposure is prolonged. Experimentation on

118

laboratory animals demonstrated hearing impediment under stress, attributable to fight or

flight hormones and involuntary sympathetic nervous system reactions (Muchnik et al. 1980,

297). Redirection of blood to major muscle groups occurs, as survival of the host becomes

the primal priority. In discussing the effects on the human body in stressful situations,

Gladwell entitled a subchapter in his book Blink (2005, 221-229) “Arguing With a Dog,”

based on the experiences of a retired army lieutenant colonel and his observations of people

functioning in a state of extreme arousal. As heart rate increases in response to threatening or

stressful circumstances, performance actually improves in the 115 to 145 beats per minute

range. After 145 beats per minute, motor skills become difficult. After 175 beats per minute,

cognitive processing begins a selective shutdown sequence with brain functioning then

becoming similar to that of a dog. People in such high states of arousal have difficulty

speaking (Gladwell 2005, 225-226). A former high-ranking Los Angeles police official noted

that officers broadcasting in the middle of a chase yell and exhibit signs of hysteria. Upon the

termination of pursuits, officers experience bodily shaking symptoms and the inability to

construct radio messages. Recognition of this debilitating phenomenon has led to modified

police pursuit policies (Gladwell 2005, 226-227). When responders experience physiological

arousal in reaction to the intense situations unfolding around them, their ability to construct

cogent messages is impacted, lending a potential explanation for the frequent need to have

messages repeated and the observation that phrases selected are ambiguous and subject to

misinterpretation. Those impacted do not even have to be present at the incident scene.

Participating in radio conversations is an emotionally arousing experience, as demonstrated

in the North Hollywood shooting and Hudson River landing case studies in this dissertation’s

Chapter Four.

119

Police officers involved in shootings often experience altered states of sensory cognition.

They report, “extreme usual clarity, tunnel vision, diminished sound, and the sense that time

is slowing down. Our mind, faced with a life-threatening situation, drastically limits the

range and amount of information that we have to deal with. Sound and memory and broader

social understanding are sacrificed in favor of heightened awareness of the threat directly in

front of us” (Gladwell 2005, 224). In recounting their experiences from officer-involved

shootings, police officers report they focused so intently on the part of the suspect’s body

creating the threat that they did not even hear the sound of gunshots occurring. Larry Bird,

basketball star, experienced similar reactions in big game situations. For Bird, it was as if the

crowd noise of thousands of screaming fans went silent and the movement of the players

around him reverted to slow motion (Gladwell 2005, 225). This phenomenon helps to explain

why people operating at intense emergency scenes often miss radio traffic and later insist that

it never happened. Even if radio capacity allows message transmission at the high rate

experienced at intense emergencies, consideration of the physiological limitations of the

receiver are appropriate. We should modify our expectations for the incident commander

regarding clear message construct, delivery, and acknowledgement, providing adequate

levels of compensating redundancy.

Inattentional Deafness

The lack of awareness of radio calls occurring during the studied exercises, as well as the

other incidents reviewed from actual occurrences around the country, are consistent with

earlier cognition studies, as outlined in this dissertation’s Chapter Two (Becklen and Cervone

1983; Simons and Chabris 1999). The study involved a video tape played for test subjects

observing basketball players inside the elevator lobby of a building. Upon introduction of a

120

distraction in the form of a person in a gorilla suit into the frame of view, only half of the test

subjects noticed the figure, which was obvious to them in subsequent viewings. This holds an

important implication for this dissertation because of the number of unexplained missed

messages and subsequent denial that the message ever existed. It is plausible that clearly

delivered messages do not receive attention from incident commanders engrossed in

challenging circumstances because of Inattentional Deafness (Mack and Rock 1998, 215-

223, 246). Responders may be focusing so intently on a narrow expected set of circumstances

and outcomes that they ignore even gross deviations varying from the prevailing

circumstances. First responders facing challenging, intense, and worsening circumstances do

not expect to receive a distress call. Unexpected features beyond the target of focused

attention do not reach their consciousness. Conversely, those in a position of detached

perspective do hear them, explaining the frequent occurrence of people remote from the

scene monitoring urgent radio messages missed by those in close proximity.

Solutions

The National Fire Protection Association (NFPA) has advocated for several years that

staff aides be “deployed to” supervisory chief officers. Staff aides also known as Field

Incident Technicians (FIT) or chiefs’ drivers (National Fire Protection Association, NFPA

1710, 5.2.2.2.5). The wording of this consensus standard implies flexibility on the part of the

jurisdiction to provide the capacity utilizing a variety of staffing sources. Limited resources

do not allow many small to medium-sized fire departments to assign permanent aides to

incident commanders. Although fire departments may have the capacity to assemble an

incident management team eventually, it is in the early minutes of many emergency

operations when the communications demands are greatest.

121

This study demonstrated the value in assigning an assistant to the incident commander,

providing that they function effectively together. An automatic assumption that two heads are

better than one is not always true in the emergency command environment. The aide can

become a distraction leading to missed radio traffic because of increased conversations

around the command post. In studying the cockpit behaviors of commercial airline pilots

during in-flight emergencies, Gladwell (2008, 184-185) found that a disproportionate number

of flights with tragic outcomes had flight crews not used to working together. The optimal

flight deck approach is when partners catch each other’s errors, rather than one trying to do

too much and the other there ostensibly just to take over in the event of complete

incapacitation. Any team comprised of an incident commander and an aide needs to feature

rapport, boundaries, expectations, and anticipation of each other’s tendencies. This reality

tends to support the notion of permanently assigned aides, despite fiscal constraints.

Increased emphasis on standardized incident management principles, including the

federal mandate for responders training on the National Incident Management System

(NIMS) as a condition of federal grant funding brings even more peripheral support

personnel and technology into the command post environment. The additional

representatives may exacerbate the distraction level influencing incident commanders and

their ability to maintain clear and immediate radio contact with personnel. Although

collaboration will likely improve by adding more representatives, the addition of more

people may make it difficult to focus on what responders involved in active operations are

saying and doing (Weick 1990, 589).

This study establishes that there is a limit to the amount of sensory input that

commanding personnel at disaster scenes can manage before they are overwhelmed to the

122

detriment of effective communications and the quality of decisions made. Fire department

management should assign independent command post personnel to monitor signatures of

critical information and report them to the incident commander. Layers of redundancy can

provide assurance of critical messages continuity, including independent, remote monitoring

of incident radio channels in support vehicles at the scene as well as at the dispatch center.

Human Factors Engineering

Technological Improvements

This study recognizes the value of properly designed new equipment in providing greater

situational awareness and better quality of decisions reached using the information from the

technology. Data transmission is more efficient in transfer of some information, such as

rosters of personnel assigned to the incident and situational awareness updates. Ready access

to information has the risk of debilitating, instead of facilitating. Klein (1999, 279) noted that

in the past, “information was missing because no one collected it; in the future, information

will be missing because no one can find it.” Best use of new data technology requires

specially trained personnel, deployed to arrive soon after field operations commence. The

need for better technology and practices are a natural extension of this dissertation’s findings

that communications practices are limited and often dysfunctional; critical errors are a likely

byproduct of the status quo in emergency scene operations. There have been a number of

failures in military applications and civilian airliner design over the years, despite the hopes

of system improvement and greater aid to humans making decisions (Perrow 1983, 521, 531-

532). Even where properly designed radio systems exist, the success of communications is

dependent on the skill of the person utilizing it. The field of human factors engineering

recognizes the importance of considering human design factors in equipment and systems

123

designed to aid workers in a variety of workplaces (Perrow 1983, 521). The incident

commanders indicated difficulty in hearing their portable radios, but they also resisted the

notion of wearing headphones out of concern for missing something in person at the scene.

Perrow (1983, 533-534) establishes the importance of considering social structure and

operator behaviors when designing technically complex systems. Human factors such as

proper use of the radio, positioning of the microphone, and conscious decision of when to use

the radio or not is a critical factor in successful emergency communications (National

Institute for Occupational Safety 2003, 4, 11, 16).

Equipment Needs

The design of radio hand pieces considers serviceability needs in the rugged emergency

environment. Radios are at once sophisticated computerized devices in need of a stable

operating environment, yet they must be capable of working in hostile conditions. Exposure

to extreme heat and cold, water, and general rough handling of the equipment can lead to

diminished capabilities. Proper maintenance of batteries is also necessary to assure continued

reliable operation (National Institute for Occupational Safety 2003, 11-12). Several

participants appeared for simulator training with low battery strength on the radio assigned to

them for the twenty hours remaining on their shift. Poor hand piece maintenance can be the

major cause of communications hardware failure rather than falsely blaming infrastructure or

system design issues. There still exists considerable opportunity to improve portable radio

design allowing easier access to alternate channel banks. Changing channels or

communications mode during an incident consistently proved to be awkward and

problematic. Radios capable of dynamic regrouping (changing channel without user

intervention) on the emergency scene, upon a reconfiguration order from the command post,

seem to be one potential solution within technological reach. Unfortunately, technically

124

competent people deployed immediately to act as something akin to air traffic controllers at

the scene of community emergencies is out of the reach financially for most agencies.

Self-Contained Breathing Apparatus

“In general, the most common communication problem encountered by firefighters is the

inability to effectively communicate while wearing self-contained breathing apparatus

(SCBA)” (National Institute for Occupational Safety 2003, 11). When trying to talk while

wearing self-contained breathing apparatus, it is essential to speak in a calm voice, at

moderate volume, and with clear word enunciation. Trials of a variety of microphone

configurations have only yielded varying degrees of success (U.S. Fire Administration 1999,

5-6). Selection of simple, standardized phrases is necessary, so they are familiar to the

receiver and heard the first time. Future technological improvement of synthesized voice

features may allow broadcast of standardized phrases at the radio interface, yet manual

dexterity to push corresponding buttons is limited while wearing protective equipment.

Training

The quality of decision-making and effective communications skills used in the

emergency environment are highly depended on recall of experience and honing of heuristic

skills, yet truly cataclysmic events are very rare. Habits are developed and practiced in daily

routine, yet infrequent disasters requires responders to operate in unfamiliar, chaotic

environments, where their experience betrays them and they must devise new coping

mechanisms to meet the unfamiliar challenges. Simulation environments hold potential to

train and practice communications and skills among emergency responders, in an effort to

replicate some of the unique challenges present during infrequent disaster situations (Sadagic

2007, 2008; Kiel 2005, 271-273).

125

Syntax and Message Formation

One of the most famous comedy routines of the twentieth century was “Who’s on First”

by Abbott and Costello (Cox and Lofflin 1997, 183-184). The premise of the play on words

was the surnames of players on a supposed baseball team matched common phrases with

double meanings. The “Who’s on first, What’s on second” was based on two people

essentially talking about different things at the same time. Each rightfully thought they were

on the right path toward articulating a clear message. Such simultaneous yet disconnected

conversations are reminiscent of those heard on emergency incident recordings.

There is an identified need for first responder training in active listening skills. Merely

providing the hardware for a voice path does not guarantee effective communications.

Although most may assume that speaking and listening are basic capabilities learned in

everyday life and easily transportable to emergency environments, the demanding

environment of crisis communication requires specialized training. Screening for hearing loss

should also factor into communications capabilities assessment of incident commanders.

First responders have an obligation to communicate in the most unambiguous manner

possible, yet the pressures of high stress emergency environments create significant speech

challenges. Clear choice of simple words conveying rich concepts requires the sender to

anticipate potential misunderstandings and instead phrase and couch words in the clearest

possible syntax. Training and experience allow users to transcend the moment and

understand the context of the situation in which they are communicating. Many incidents

studied either showed too much radio use, or not enough. If over utilized, the channels

become clogged and gridlocked. If used too sparingly, opportunities to build greater

situational awareness are lost and crews in distress are unpracticed and not inclined to call for

126

help soon enough. First responder agencies need training to focus on the elusive sweet spot

between too little and too much talkativeness.

Final Thought

This dissertation has examined the contention that there are recurring elements of sensory

overload and limits to human ability in crisis situations inhibiting optimal communications.

Communications are an inextricable component of sound decision-making. Realistic

expectations of emergency communications demand modification in recognition of the

inherent limitations. A combination of behavioral improvements, consistent with enlightened

human factors design considerations, needs matching with procedural, cultural, and

technological enhancements to overcome recurring emergency communications

impediments.

APPENDIX A

Distractions Codes

Ronald P. Timmons

First Responder Commanders’ Distraction Study

Dissertation Research Project

The researcher reviewed video tapes of the subjects and documented the presence of one

or more of the following influences noted at the time of radio communication inattention.

1. No apparent reason (n=28)

2. Talking in person to another (n=14)

3. Talking on telephone (n=0)

4. Talking on another radio (n=2)

5. Reading/looking at hardcopy/text device (0)

6. Other Channel (n=12)

7. Background noise (n=4)

8. Feedback (n=4)

9. Garbled (n=10)

10. Radio malfunction (n=0)

127

APPENDIX B

Interview Questions

Ronald P. Timmons

First Responder Commanders’ Distraction Study

Dissertation Research Project 2008-2009

1. What do you recall about the radio communications portion of the exercise?

2. Were you aware of any missed radio messages?

3. About how many radio messages sent to you do you believe were unanswered on the

first try?

4. Were there any distractions in the command post environment that may have caused

the missed messages?

5. How would you describe the feelings you had about the radio portion of the exercise?

6. How realistic was the exercise, compared to the challenges present in actual

emergency command?

What do you recommend to prevent the missed radio messages in the future?

128

APPENDIX C

McKinney and Plano Case Studies Data

Case Number

Positive Comms.

Negative Comms.

Total Comms.

Percentage Positive

Percentage Negative

Collab-orations

Duration (Minutes)

Comms./ Minute

1 12 10 22 55% 45% (solo) 25 0.9 2 7 9 16 44% 56% (solo) 17 0.9 3 17 7 24 71% 29% (solo) 16 1.5 4 26 14 40 65% 35% (solo) 26 1.5 5 12 9 21 57% 43% (solo) 36 0.6 6 17 13 30 57% 43% (solo) 27 1.1 7 15 9 24 63% 38% (solo) 19 1.3 8 22 2 24 92% 8% 4 13 1.8 9 26 8 34 76% 24% 4 15 2.3 10 23 6 29 79% 21% 7 15 1.9 11 21 9 30 70% 30% 10 13 2.3 12 43 8 51 84% 16% (solo) 21 2.4 13 24 3 27 89% 11% (solo) 17 1.6 14 37 5 42 88% 12% (solo) 21 2.0 15 21 7 28 75% 25% (solo) 15 1.9 16 18 25 43 42% 58% 2 19 2.3 17 18 4 22 82% 18% 2 15 1.5 18 29 2 31 94% 6% 2 12 2.6 19 21 3 24 88% 13% (solo) 13 1.8 20 22 10 32 69% 31% 2 15 2.1 21 22 9 31 71% 29% 8 17 1.8 22 23 6 29 79% 21% 6 14 2.1 23 31 9 40 78% 23% 4 17 2.4 24 24 8 32 75% 25% 4 18 1.8 25 34 13 47 72% 28% 9 22 2.1 26 19 5 24 79% 21% 1 10 2.4 27 29 5 34 85% 15% 5 18 1.9 28 14 9 23 61% 39% 4 12 1.9 29 24 10 34 71% 29% 11 24 1.4

Average 22 8 31 73% 27% 5 18 1.8

129

BIBLIOGRAPHY

Bazerman, Max, Ann E. Tenbrunsel, and Kimberly Wade-Benzoni. “Negotiating with Yourself and Losing: Making Decisions with Competing Internal Preferences.” The Academy of Management Review 23 (1998): 225-241.

Bazerman, Max, Jonathan Baron, and Katherine Shonk. You Can’t Enlarge the Pie: Six Barriers to Effective Government. Cambridge, MA: Basics Books, 2001.

Bazerman, Max. Judgment in Managerial Decision Making. 6th ed. New York: John Wiley and Sons, 2006.

Becklen, R., and D. Cervone. “Selective Looking and the Noticing of Unexpected Events.” Memory & Cognition 11 (1983): 601 - 608.

Berg, Bruce L. Qualitative Research Methods for the Social Sciences, 6th ed. Boston: Allyn & Bacon, 2007.

Beroggi, G. E. G., D. Van Gent, D. Mendonça, and W. A. Wallace. “Assessing Group Decision Support Systems for Emergency Response Using Gaming Simulation.” International Conference on Emergency Management, Oslo, June 19-22, 2001.

Bigley, Gregory A., and Karlene H. Roberts. “The Incident Command System: High-Reliability Organizing for Complex and Volatile Task Environments.” The Academy of Management Journal 44 (2001): 1281-1299.

Bonamo, Mark J., “Confusion Remains About How Fire Was Fought.” Hackensack Chronicle, July 02, 2008. www.hackensackchronicle.com/NC/0/329.html (accessed February 18, 2009).

Bracht, G. H., and G. V. Glass. “The External Validity of Experiments.” American Educational Research Journal 5 (1968): 437-474.

Brunacini, Nick. “Incident Command.” In The Fire Chief's Handbook, edited by Robert C. Barr, and John M. Eversole, 527-542. Tulsa, Oklahoma: PennWell Books, 2003.

Butler, Emily, Boris Egloff, Frank Wilhelm, eds. “The Social Consequences of Expressive Suppression.” Emotion 3 (2003): 48–67.

Caldwell, David F., and Charles A. O'Reilly, III. “Responses to Failure: The Effects of Choice and Responsibility on Impression Management.” The Academy of Management Journal 25 (1982): 121-136.

City of Charleston, “Sofa Super Store Post Incident Assessment and Review Team, Phase II Report,” June 18, 2007.

130

131

CNN.com. “Botched L.A. Bank Heist Turns Into Bloody Shootout.” February 28, 1997 http://www.cnn.com/US/9702/28/bank.shootout (accessed March 1, 2009).

Comfort, Louise K. “Integrating Organizational Action in Emergency Management: Strategies for Change.” Public Administration Review 45 (1985): 155-164.

Cook, D. L. “The Hawthorne Effect in Educational Research.” Phi Delta Kappan 44 (1962): 116-122.

Cox, Stephen, and John Lofflin. The Abbott & Costello Story: Sixty Years of “Who's on First?” Nashville, TN: Cumberland House, 1997.

Creswell, John W., Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage Publications, 2007.

Demers, David P., Fire in Syracuse: Four Fire Fighters Die, Quincy, MA: National Fire. Protection Association, 1978.

_________. Five Fire Fighter Fatalities: Hackensack, New Jersey: July 1, 1988. Lunenberg, MA: Demers Associates, 1988.

Dwyer, Jim, Kevin Flynn, and Ford Fessenden. “Fatal Confusion: A Troubled Emergency Response; 9/11 Exposed Deadly Flaws In Rescue Plan.” New York Times, July 7, 2002.

Edwards, Holly. “LAPD Bears Shootout Scars.” Los Angeles Daily News, February 25, 2002.

Federal Aviation Administration. “Air Traffic Control Communications US Airways 1549, January 15, 2009.” http://www.faa.gov/data_statistics/accident_incident/1549. 2009. (accessed February 14, 2009).

Firehouse Magazine. “The FDNY 9/11 Documents - Audio Download & Resources, posted August 15, 2005.” http://www.radiofirehouse.com/broadcast/wp-content/2005/fdny/FDNY_Tape16.mp3. (accessed February 26, 2009).

Gaines, Jeannie, and John M. Jermier. “Emotional Exhaustion in a High Stress Organization.” The Academy of Management Journal 26 (1983): 567-586.

Garnett, James L., and Alexander Kouzmin. “Communicating throughout Katrina: Competing and Complementary Conceptual Lenses on Crisis Communication.” Public Administration Review 67 (2007): 171-188.

Gentile, Annie. “ISO Rating System Comes Under Fire.” American City & County 123 (2008): 12, 16.

Gladwell, Malcolm. Blink: The Power of Thinking. Without Thinking. New York: Little, Brown and Company, 2005.

_________. Outliers: The Story of Success. New York: Little, Brown and Company, 2008.

132

Goodman, Michael J., Louis Tijerina, Frances D. Bents, and Walter W. Wierwille. “Using Cellular Telephones in Vehicles: Safe or Unsafe?” Transportation Human Factors 1 (2000): 3-42.

Gouran, D. “The Watergate Cover-up: Its Dynamics and Its Implications.” Communication Monographs 43 (1976): 176-186.

Hancock, P.A., M. Lesch, and L. Simmons. “The Distraction Effects of Phone Use During a Crucial Driving Maneuver.” Accident Analysis and Prevention 35 (2003): 501–514.

Harten, Patrick, Air Traffic Controller. “Before the U.S. House of Representatives Transportation & Infrastructure Subcommittee on Aviation. US Airways Flight 1549 Accident, February 24, 2009.” http://www.natca.org/assets/Documents/mediacenter/NATCAHartentestimonyN3FINAL.pdf (accessed March 8, 2009).

Hawkins, Dan. “Communications in the Incident Command System.” COPS Interoperable Communications Technology Program: Issue Brief Number 2, May 2007.

Hutchins, Susan. G., and Ronald P. Timmons. “Radio Interoperability: There is More to it Than Hardware.” In Proceedings of the 12th

International Command and Control

Research & Technology Symposium, Newport, RI, June 2007.

Insurance Services Office, “Public Protection Summary Report.” Charleston, South Carolina, December 10, 2008.

Isner, Michael. “Firefighter Dies In Warehouse Fire.” Fire Command 57 (1990a): 30-35.

_________. Fire Investigation Report, Vacant Warehouse Fire. Seattle, WA, September 9, 1989. Quincy, MA: National Fire Protection Association 1990b.

Janus, Irving. Victims of Groupthink. Boston: Houghton Mifflin, 1972.

Jennings, Charles. “ISO System Obsolete.” Fire Chief Magazine, December 17, 2008.

Jermier, John M., Jeannie Gaines, and Nancy J. McIntosh. “Reactions to Physically Dangerous Work: A Conceptual and Empirical Analysis.” Journal of Organizational Behavior 10 (1989): 15-33.

Jones, Stephen R. G. “Was There a Hawthorne Effect?” The American Journal of Sociology 98 (1992): 451-468.

Kahneman, Daniel, P. Slovic, and A. Tversky, eds. Judgment Under Uncertainty: Heuristic and Biases. Cambridge: Cambridge University Press, 1982.

Kahneman, Daniel. “A Perspective on Judgment and Choice: Mapping Bounded Rationality.” American Psychologist 58 (2003): 697–720.

Kerr, Norbert L., and R. Scott Tindale. “Group Performance and Decision Making.” Annual Review of Psychology 55 (2004): 623-655.

133

Kiel, L. Douglas. “A Primer for Agent-based Modeling in Public Administration: Exploring Complexity in ‘Would-be’ Administrative Worlds.” Public Administration Quarterly 29 (2005): 268-296.

Klein, Gary A. Sources of Power: How People Make Decisions. Cambridge, MA: Massachusetts Institute of Technology, 1999.

_________. Intuition at Work. New York: Currency Doubleday, 2003.

Klem, Thomas J. Five Fire Fighter Fatalities: Hackensack, New Jersey--July 1, 1988. Quincy, MA: National Fire Protection Association, 1988.

Lindblom, Charles E. “The 'Science' of Muddling Through.” Public Administration Review 19 (1959): 79-88.

Levin, Alan, “We're Gonna Be in the Hudson.” USA Today, February 5, 2009a.

_________, “Controller Thought Ditching in Hudson Spelled Doom.” USA Today, February 24, 2009b.

Lyubomirsky, Sonja, and Susan Nolen-Hoeksema. “Effects of Self-Focused Rumination on Negative Thinking and Interpersonal Problem Solving.” Journal of Personality and Social Psychology 69 (1995): 176-190.

Mack, Arien, and Irvin Rock. Inattentional Blindness. Cambridge, MA: MIT Press, 1998.

“Mayday,” in The American Heritage Dictionary of the English Language, 4th ed.

McDermott, Rose, Jonathan Cowden, and Cheryl Koopman. “Framing, Uncertainty, and Hostile Communications in a Crisis Experiment.” Political Psychology 23 (2002): 133-149.

McFadden, Robert D., “Pilot Is Hailed After Jetliner’s Icy Plunge.” The New York Times, January 15, 2009.

Menchaca, Ron. “Fire Dept. Loses Top Rating.” The Post And Courier, December 20, 2008.

Mendonça, D. “Decision Support for Improvisation in Response to Extreme Events.” Decision Support Systems 43 (2007): 952-967.

Milord, James T., and Raymond P. Perry. “A Methodological Study of Overload.” Journal of General Psychology 97 (1977): 131-137.

Moore, Harold G., and Joseph L. Galloway. We Were Soldiers Once...And Young: Ia Drang--The Battle That Changed The War In Vietnam. NY: Harper Collins, 1992.

Morçöl, Göktuğ. Handbook of Decision Making. Boca Raton, FL: CRC Press, 2006.

Muchnik, C., M. Hildesheimer, and M. Rubinstein. “Effect of Emotional Stress on Hearing.” Journal European Archives of Oto-Rhino-Laryngology 228 (1980): 228, 295-298.

134

National Commission on Terrorist Attacks Upon the United States. Eleventh Public Hearing. New York: W. W. Norton & Company, 2004.

National Fire Protection Association. “NFPA 1710: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments.” Quincy, Massachusetts, 2004.

National Institute for Occupational Safety (NIOSH). “Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio Communication Systems.” September 2003.

Neumann, Odmar, A.H. Van der Heijden, and D. Alan Allport. “Visual Selective Attention: Introductory Remarks.” Psychological Research 48 (1986): 185–188.

O’Conaill, Brid, and David Frohlich. “Timespace in the Workplace: Dealing With Interruptions.” In Proceedings of Computer-Human Interaction ’95, 262–263, Denver, Colorado: ACM Press, 1995.

Otterman, Sharon, and Matthew L. Wald. “F.A.A. Releases Flight 1549 Tapes.” The New York Times. February 5, 2009

Patton, Michael Quinn. Qualitative Research and Evaluation Methods 3rd ed. Thousand Oaks: Sage Publications, 2002.

Perrow, Charles. “The Organizational Context of Human Factors Engineering.” Administrative Science Quarterly 28 (1983): 521-541.

Posner, Edward C., and Eugene R. Rodemich. “Epsilon Entropy and Data Compression.” The Annals of Mathematical Statistics 42 (1971): 2079-2125.

Prince William County, Department of Fire and Rescue. “Line of Duty Death Investigative Report: Technician I Kyle Wilson, 15474 Marsh Overlook Structure Fire, April 16, 2007.”

Render, Barry, Ralph Stair, and Michael Hanna. Quantitative Analysis for Management. 9th ed. Englewood Cliffs, NJ: Prentice Hall, 2006.

Rensink, Ronald A., J. Kevin O'Regan, and James J. Clark. “To See or Not To See: The Need for Attention to Perceive Changes in Scenes.” Psychological Science 8 (1997): 368-373.

Rigg, Nancy J. “Maintaining Control, North Hollywood Bank Robbery & Shootout.” 9-1-1 Magazine, September/October 1997.

Roberts, Karlene H., and Denise M. Rousseau. “Research in Nearly Failure-Free, High-Reliability Organizations: Having the Bubble.” IEEE Transactions On Engineering Management 36 (1989): 132-139.

135

Roberts, Karlene H., Suzanne K. Stout, and Jennifer J. Halpern. “Decision Dynamics in Two High Reliability Military Organizations.” Management Science 40 (1994): 614-624.

Rohr, David L., “Challenges of Mayday Operations” Proceedings of the International Association of Fire Chiefs, Denver, Colorado, August 12, 2008.

Sadagic, Amela. Research Associate Professor, Naval Postgraduate School. Interviewed by author, January 29, 2008.

_________. “The Deployment and Use of Virtual Training Simulations: What Does it Take to Serve the Needs of Majority Of Its Users?” In New Learning Technologies Orlando 2007 SALT Conference, Orlando, FL, January 31-February 2, 2007.

Schafer, Mark, and Scott Crichlow. “Antecedents of Groupthink: A Quantitative Study.” Journal of Conflict Resolution 40 (1996): 415-435.

Selye, Hans. “A Syndrome Produced by Diverse Nocuous Agents.” Nature 138 (1936): 32.

Shannon, Claude B. “A Mathematical Theory of Communication.” Reprinted with corrections from The Bell System Technical Journal 27 (1948): 379–423, 623–656. In Mobile Computing and Communications Review 5 (2001): 3-55.

_________. “Communication Theory of Secrecy Systems.” 1949. Transcribed by Jiejun Kong from the original unpublished paper reproduced at http://www.prism.net/user/dcowley/docs.html. Also see: http://netlab.cs.ucla.edu/ wiki/files/shannon1949.pdf (accessed June 18, 2007).

_________. “Prediction and Entropy of Printed English.” 1951. http://www.cs.brown.edu/courses/cs195-5/extras/shannon-1951.pdf (accessed June 12, 2007).

Shuster, Beth, and James Rainey. “Officers Face Barrage of Bullets to Take Comrades Out of Line of Fire.” Los Angeles Times, March 1, 1997.

Simon, Herbert. The Scientific Artificial. Cambridge, Massachusetts: The MIT Press, 1981.

_________. Models of Bounded Rationality, Volume 3, Empirically Grounded Economic Reason. Cambridge, Massachusetts: The MIT Press, 1997.

Simons, Daniel J., and Christopher F. Chabris. “Gorillas In Our Midst: Sustained Inattentional Blindness For Dynamic Events.” Perception 28 (1999): 1059-1074.

Slater, Mel, Amela Sadagic, Martin Usoh, and Ralph Schroeder. "Small-Group Behavior.” Presence 9 (2000): 37-51.

Soelberg, P. O. “Unprogrammed Decision Making.” Industrial Management Review 8 (1967): 19-29.

Spahn, E. J., Fire Service Radio Communications. New York: Fire Engineering, 1989.

136

Speier, Cheri, Iris Vessey, and Joseph S. Valacich. “The Influence of Task Interruption on Individual Decision Making: An Information Overload Perspective.” Decision Sciences 30 (1999): 337-360.

_________. “The Effects of Interruptions, Task Complexity, and Information Presentation on Computer-supported Decision-making Performance.” Decision Sciences 34 (2003): 771–797.

Strayer, David L., and William A. Johnston. “Driven To Distraction: Dual-Task Studies of Simulated Driving and Conversing on a Cellular Telephone.” Psychological Science 12 (2001): 462-466.

Strayer, David L., Frank A. Drews, and William A. Johnston. “Cell Phone-Induced Failures of Visual Attention During Simulated Driving.” Journal of Experimental Psychology 9 (2003): 23–32.

Surowiecki, James. The Wisdom of Crowds: Why the Many Are Smarter Than the Few and How Collective Wisdom Shapes Business, Economies, Societies, and Nations. New York: Doubleday, 2004.

Timmons, Ronald P. “Radio Interoperability: Addressing the Real Reasons We Don’t Communicate Well During Emergencies.” Master’s thesis, Naval Postgraduate School, 2006.

_________. "Interoperability: Stop Blaming The Radio.” Homeland Security Affairs 3 (2007): 1-17.

Tversky, Amos, and Daniel Kahneman. “Judgment Under Uncertainty: Heuristics and Biases.” Science 185 (1974): 1124-1131.

_________. “The Framing of Decisions and the Psychology of Choice.” Science 211 (1981): 453-458.

U.S. Fire Administration/Technical Report Series. “The World Trade Center Bombing: Report and Analysis.” New York, 1993.

_________. “Special Report: The Aftermath of Firefighter Fatality Incidents, Preparing for the Worst.” September 1998.

_________. “Improving Firefighter Communications.” Emmitsburg, Maryland, 1999.

Varone, J. Curtis. “Fireground Radio Communication and Firefighter Safety.” Executive Fire Officer Program, National Fire Academy, 1996.

_________. “Firefighter Safety and Radio Communication.” Fire Engineering (March, 2003): 141–164.

Virasami, Bryan, “Farewell to 'Exceptional' Firefighter.” Chicago Tribune, October 10, 2001.

Weick, K. E. “The Vulnerable System: An Analysis of the Tenerife Air Disaster.” Journal of Management 16 (1990): 571-593.

137

_________. “Puzzles in Organizational Learning: An Exercise in Disciplined Imagination.” British Journal of Management 13 (2002): S7–S15.

Weiss, Robert S. Learning From Strangers: The Art and Method of Qualitative Interview Studies. New York: The Free Press, 1995.

Yin, Robert K. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: Sage Publications, 2002.

VITA

Ronald P. Timmons was born in Rochester, New York, the son of Marilyn Stephany

Timmons and Charles Ronald Timmons. After completing high school in Greece, New York,

he entered public service as a police dispatcher and volunteer firefighter. In 1979, he began

as a dispatcher for the Ridge Road Fire District in suburban Rochester, New York, followed

by appointment as a firefighter in 1981. He received Associate of Science Degrees in

Criminal Justice and Fire Protection Technology in 1978 and 1982, respectively. The State

University of New York, Empire State College, bestowed the degree of Bachelor of Science

in Fire Service Administration upon him in 1984. He earned a Masters in Public

Administration in 1987 at the State University of New York, Brockport State College. From

1987 through 2000, he served as an adjunct assistant professor, at the undergraduate and

graduate levels, at four colleges in the State University of New York system. His 22-year

tenure at the Ridge Road Fire District culminated with service as chief of the fire department

from 1997 through 2001. He relocated to Plano, Texas in 2001 to assume the position of

Director of Public Safety Communications for the city of Plano. A return to the classroom as

a student in 2004 resulted in a Masters Degree in Homeland Security and Defense from the

Naval Postgraduate School in Monterey, California in 2006. In August 2006, he entered the

Graduate School of The University of Texas at Dallas. He is married to Debra Timmons of

Rochester and is the father of Stephany Timmons.