Crew Resource
Management
An introduction to Cultural Change
Developed by
Battalion Chief John Tippett
&
Captain Michael Collins
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-1
Student Performance Objectives
At the conclusion of today’s presentation
attendees shall:
– develop an understanding of the role human
error plays in disasters.
– be able to explain and apply the principles of
crew resource management (CRM), given
real-life practical scenarios to reduce the
impact of human error.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-2
Overview
• Error Management
• History of the development of Crew
Resource Management (CRM)
• Principles of CRM
• CRM for the Fire Service
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-3
Error Management
1
Fatality
…To err is
human…
10
Lost Time Injuries
100
Marcus Tullius Cicero
106-43 B.C.
Minor Injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-4
Human Factor Error Causes
Gordon Dupont’s “Dirty Dozen”
• Lack of
Communication
• Complacency
• Lack of Knowledge
• Distraction
• Lack of Teamwork
• Fatigue
• Lack of Resources
• Pressure
• Lack of
Assertiveness
• Stress
• Lack of Awareness
• Norms
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-5
Error Management
Traditional
thinking focused
on eliminating
human error in
the cockpit
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-6
Error Management
• Contemporary thinking acknowledges
that error is a way of life.
– given the acceptance that human error
may occur, the focus has become “How
does one effectively manage error?”
– proper error management greatly
enhances safety
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-7
Helmreich’s Error Management
Model
AVOID
TRAP
MITIGATE
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-8
Avoiding Errors
Avoid
First line of defense
Trap
against error is
avoidance.
Mitigate
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-9
Error avoidance strategies
•
•
•
•
•
•
High level of proficiency
Follow SOPs
Minimize distractions
Plan ahead
Maintain situational awareness
Use all available resources effectively
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-10
Trapping errors
Avoid
Error is detected and
Trap
Mitigate
managed before it
becomes
consequential
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-11
Error facts
• Once an error is committed, it is
difficult to catch (trap) your own error.
• Other people are often more likely to
catch your error.
• Therefore, redundancy in the crew is
one strong defense against error.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-12
Layers of Defense =
Redundancy =
Increased Safety Margin
• To trap errors, keep as much redundancy
in the crew for as long as possible.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-13
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-14
Layers of Defense
to trap crew errors
External
Alerting,
i.e., ATC
Onboard Alerting
Equipment
Pilot Not Flying
Pilot Flying
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-15
But… you can’t “proceduralize”
everything.
And even good procedures can have “holes”
in them, when applied incorrectly or with
poor timing.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-16
Barriers can have “holes”
•We can attempt to
build barriers against
error to trap errors.
•Even good barriers
have weaknesses.
•Error management
helps reduce the size
of these holes.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-17
Examples of how “holes in
defenses” can be formed
• Increasing workload
– short staffing
companies
– detailing
– older, unreliable
equipment and
apparatus
– medical factors
• Procedural noncompliance
• Poor crew
coordination
• Forgetting
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-18
You may not know where the
holes are
Use All Eyes
& Ears
Follow SOP’s
Maintain
Situational
Awareness
High Level of Proficiency
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-19
Size of holes depends on:
• Amount of attention
that the task requires
from the flight crew.
• How well the crew
manages the
resources.
Larger holes decrease safety margin
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-20
Emergency Response
How safety
margin
changes
Workload Management
Fatigue
Get Adequate Rest
Unfamiliar Location
Use MDC & Paper Printout
Inexperienced Driver
Map Drills & Driver Training
Time Pressure
Slow Down!
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-21
Layers of Defense help deflect
errors from becoming hazards
Potential
Hazard
Error Trapped,
Hazard Averted
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-22
Design System Redundancies
Take-off warning
horn will activate if
flaps are not
configured
Following
flight crew
checks flaps
on plane
ahead
F/O reminds captain if
checklist is not complete
Captain calls for checklist
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-23
Case Study
Fire Prevention Day
Live Firefighting Display
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-24
Mitigating the Consequences
When an error is not
Avoid
Trap
Mitigate
avoided or trapped,
it must be mitigated
to keep it from
adversely affecting
safety.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-25
Mitigating errors
Constantly review and cross check that what
you are doing is sensible for where you
are, and where your are going (situational
awareness)
– Example: Entering a second floor rear window
when PPV is operating at the front door.
– Responding to Nelson Street vs. Nelson Lane
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-26
Mitigating errors
Be Vigilant, Stay Focused
(BVSF)
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-27
There may be overlap
There may not always be clear lines
distinguishing avoid, trap and mitigate
• example: SOPs
– Avoid - because I am doing things correctly
(by SOP), I will avoid chance of error
– Trap - SOPs can help me to catch (trap) errors
– Mitigate - SOPs can mitigate the consequences
of error
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-28
Crew Resource Management
(CRM) is a tool created to
optimize human
performance by reducing
the effect of human error
through the use of all
resources.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-29
The aviation industry flounders to
solve a problem
The commercial
airline industry
experienced an
average of 15-20
air crashes per
year between
1929-1975.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-30
More Gadgets!
Technological “fixes”
were installed to
prevent the same
factor from causing
a crash a second
time.
…Planes still
crashed.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-31
CVRs reveal a solution
Crash investigators identified failures to
capture errors and pilots ignoring
advice/observations from crew as the
leading cause of air disasters.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-32
Eureka!
 By 1976 the aviation
industry recognized
human error was the
primary cause in
approximately 60 A new approach to
preventing disasters was
80% of aviation
born when the industry
accidents.
looked at ways to “fix”
the primary cause of
aviation accidents.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-33
A new approach to address the
new conclusion
• Originally called “Cockpit Resource
Management.”
• Title changed to “Crew Resource
Management” to incorporate all
members of the flight team.
• Program adopted by the U. S. Military in
the 1990’s.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-34
Has it worked?
1-2 per year.
USCG has realized a 74% reduction in
• Air disasters reduced to
•
injuries and fatalities since implementing
CRM.
• U.S. Navy A-6 aircrews reduced accidents by
81% .
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-35
More Validation
• Bell Helicopters, U.S.
Jetranger pilots
48% accident reduction
• Petroleum Helicopters
Inc.
54% accident reduction
• US Air Force,
MAC Transports
51% accident reduction
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-36
What does this have to do with us?
• Firefighter line of duty deaths and
injuries have remained relatively static
for the last 10 years (100/100,000).
• Three key elements responsible for
firefighter deaths:
»adrenaline
»over-aggressiveness
»cholesterol
- Chief Bill Peterson, Plano, TX
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-37
NIOSH LODD reports cite
poor decision making as a
causal factor.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-38
Watershed Fire Service Tragedies
Involving Human Factor Errors
•
•
•
•
•
•
•
•
Lairdsville, NY
Thirty Mile Fire, WA
Worcester, MA
Keokuk, IA
Washington, DC
Lake Worth, TX
Houston, TX
Memphis, TN
• Kansas City, MO
• Storm King
Mountain, CO
• Oklahoma City, OK
• Hackensack, NJ
• Seattle, WA
• Boulder, CO
• Milford, MI
• Mann Gulch, MT
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-39
Principles of CRM
• Error management through improved
training/skills development in six areas:
»Communication skills
»Teamwork
»Task Allocation
»Critical Decision Making
»Situational Awareness
»Debrief
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-40
CRM
Resources include:
People
Hardware
Information
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-41
Communication
Skills
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-42
Who’s on First?
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-43
6 Step Process
•
•
•
•
•
•
Formulate idea
Select medium
Transmit
Receive
Interpret
Feedback
IDEA
TRANSMIT
INTERPRET
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-44
•
•
•
•
Barriers and bias block communication
“Standard” language benefits all
Practice “active” listening
Divide duties to
prevent overload
• Minimize
distractions
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-46
Barriers/Roadblocks
• Hazardous Attitudes
• Fatigue
• Inattention
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-47
Standard Language
• 500 most commonly used words have
14,000 meanings.
• Say what you mean and mean what you
say, but know that what you mean to
say may not be taken as what you
meant to say.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-48
How well do you hear what is
said?
(Exercise)
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-49
SOPs
*Review*
What are the benefits?
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-50
“Sterile” Cab
• Everyone needs to be
“all business” when it’s
time for business.
• Officer sets the tone for
cab activity.
• IC sets the tone for the
CP.
Photo by Carlos Alfaro
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-51
Inquiry Skills
• Be Proactive
• Use Clear, Concise
Questions
• Express Concerns
Accurately
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-52
Advocacy Skills
“Selling” your view
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-53
Teamwork
• Leadership
• Followership
Photo by Bob Bartosz, Camden Fire Department
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-54
LEADERSHIP
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-55
Authority
• Mandated by rank.
• Truly derived
through respect.
– Personal
Competence
– Technical
Competence
– Social Competence
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-56
Mentoring
• Lead by example
• “They” see more
than you think
• Admit mistakes
• Be technically
competent
• Share knowledge
freely
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-57
Conflict Resolution
•
•
•
•
Check your ego
Be open
Listen effectively
Stay focused on
issue
• Check emotions
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-58
Mission Analysis
– Assess risk vs
gain
– Develop strategy
& tactics
– Implement
– Expect
unexpected
– Monitor
– Prepare
alternatives
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-59
Teamwork
FOLLOWERSHIP
Self Assessment
 Physical Condition
 Mental Condition
 Attitude
 Understands human
behaviors
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-60
Followership Skills
•
•
•
•
•
•
•
Respect authority
Personal Safety
Crew Safety
Accepts authority
Knows authority limits
Leader success
Good communication
skills
• Learning attitude
• Ego in check
• Balance
assertiveness/authority
• Accept orders
• Demand clear tasks
• Admit errors
• Provide feedback
• Adapt
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-61
How well do you “Team”?
(Exercise)
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-62
“Two Challenge Rule”
“Challenging” authority helps us
sense a discrepancy between
what is going on and what
should be going on.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-63
Assertive Behavior
• Authority with Participation
• Assertiveness with Respect
– The genuine, complete & direct
communication of ideas, wants & needs.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-64
Appropriate Assertive Behavior
Todd Bishop’s Assertive Statement
•
•
•
•
•
Opening/attention
State concern/owned emotion
State the problem as you see it
State a solution
Obtain agreement (aka buy-in)
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-65
S.T.A.A.R.
Response to Challenge
• Stop
• Think
• Ask
• Ask
• Review
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-66
Task Allocation
• Know your limits.
• Know your crew’s
limits.
• Capitalize on
strengths.
• “Eat the elephant
one bite at a time.”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-67
Critical Decision Making
• Recognize problems
• Continue to “fly the
plane”
• Maintain SA
• Assess hazards
• Assess resources
• Solicit solutions
• Make a decision!
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-68
Critical Decision Making
• Recognition Primed
Decision Making
• Naturalistic
Decision Making
Ways to improve
decision making
skills
Experience
Training
Communication
Preplanning
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-69
Situational Awareness
• “Fight the fire!”
• Assess problems in the
time available.
• Gather info from all
sources.
• Choose the best option.
• Monitor results – alter
as necessary.
• Beware of SA loss
factors!
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-70
Situational Awareness Loss Factors
•
•
•
•
•
•
•
Ambiguity
Distraction
Fixation
Overload
Complacency
Improper Procedure
Unresolved
Discrepancy
• “Nobody Fighting the
Fire”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-71
Elements of good Situational
Awareness
• Good crew
coordination
• Proper task
completion
• Understanding
• Smooth ride
• Crisp and appropriate
radio calls
• Use of checklists
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-72
Preventing loss of
Situational Awareness
• Crew mental joggers
–“What do we have here?”
–“What’s going on here?”
–“How are we doing?”
–“Does this look right?”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-73
Preventing loss of
Situational Awareness
• Personal mental joggers
–“What do I know that they need
to know?”
–“What do they know that I need
to know?”
–“What do we all need to
know?”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-74
Debrief
Check your feelings at the door!
Pre-brief
Topic(s)
Decorum
Facilitate
Analyze
Operations
Human Behaviors
Keep discussion
focused!
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-75
Principles of CRM
• A high degree of technical proficiency is
essential for safe and efficient operations.
• CRM alone cannot overcome a lack of
proficiency.
• Technical proficiency alone cannot
guarantee safe operations in the absence of
effective crew coordination.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-76
Principles of CRM
• Must be taught to all members of the
organization.
• Requires a lifestyle change.
• Team leader retains authority.
• Authority is enhanced through the use of all
available resources.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-77
Why CRM for us?
• We have improved technology and still
experience preventable deaths and
injuries.
• Parallels between aviation, military,
medical industry and fire service errors
suggest CRM will work for the fire
service.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-78
Why CRM for us?
• Safer fire ground operations
• Safer patient care
• Safer driving operations
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-79
How do we get there?
We begin now
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-80
How do we get there?
• Create the “Safety Culture”
– Establish trust at ALL levels
– Share safety information among all levels
– No member of the organization should fear
reprisal or retaliation
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-81
How do we get there?
• Adopt a non-punitive policy toward
error
– ALL humans make errors
– Construct plans with controls that trap errors
– Develop non-punitive policy toward handling
error
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-82
How do we get there?
• Demonstrate a willingness to reduce error
in the system
• Train in error avoidance, detection and
management
• Provide training in evaluation to reinforce
error avoidance, detection, and
management
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-83
Campbell County, WY
Fire Department Experience
• TRAIN TO TECHNICAL PROFICIENCY
• TRAIN TO CRM PROFICIENCY
• INCLUDE CRM IN DEPARTMENT
CULTURE, TRAINING, DEBRIEFING
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-84
Campbell County, WY
Fire Department Experience
• TRAIN RISK VERSUS GAIN
– “Risk a lot to save a lot. Risk a little to save a
little.”
– Is what you are doing worth a lifetime of
constant pain or worse?
– “What are we trying to accomplish here?”
– The “STUPID RULE”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-85
What do we do NOW?
• Listen to the concerns of everyone.
• Preplan at lineup.
• Debrief after incidents.
• Don’t be afraid to speak up.
• Adopt the “to err is human” attitude.
• Review the CRM Principles in every training event
and incident review.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-86
REVIEW
• Error management
• History of Crew Resource Management
• The Six Principles of Crew Resource
Management
• How MCFRS will infuse Crew Resource
Management
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-87
Watch your email
In about 3 weeks you will receive an email
with a short quiz on CRM.
Use the attached answer sheet and send to
Capt. Michael Collins
Fire Sta 31 “B”
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-88
This program was developed by the
Montgomery County Fire/Rescue Training Academy
© 2005
No part may be used or copied without the expressed
written consent of the Training Officer.
© 2005 Montgomery County Fire Rescue Training Academy
CRMI-05-89