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Transcript of Crew Resource Management & The Command Officer Partnering for Safe Leadership Ruidoso, NM May 7,...
Crew Resource ManagementCrew Resource Management&&
The Command OfficerThe Command Officer
Partnering for Safe LeadershipPartnering for Safe Leadership
Ruidoso, NMRuidoso, NM
May 7, 2008May 7, 2008
Battalion Chief John TippettBattalion Chief John Tippett
Montgomery County Fire & Rescue Service (MD)Montgomery County Fire & Rescue Service (MD)
Proven Tool for a Safer Scene ControlProven Tool for a Safer Scene Control
Bob Bartosz Photo
What do we hope to accomplish today?What do we hope to accomplish today?
Interactive discussion.Interactive discussion. Preserve “good” traditions.Preserve “good” traditions. Acquaint you with “new”Acquaint you with “new”
approach to command &approach to command &
control.control. Provide tool you can Provide tool you can
use beginning today.use beginning today.
Safety Based Culture
Non-Punitive Approach to Error
Is there a problem with the way we do business?Is there a problem with the way we do business?
Acceptable Losses?Acceptable Losses?
105 fatalities to date*105 fatalities to date*
2006 Statistics
106 firefighters died while on duty in 2006. 77 volunteer, 29 106 firefighters died while on duty in 2006. 77 volunteer, 29 career. career.
6 multiple fatality incidents, 17 killed. 6 multiple fatality incidents, 17 killed. 22 killed during brush, grass, or wildland firefighting. 22 killed during brush, grass, or wildland firefighting. 36 died at the scene of a fire. 36 died at the scene of a fire. 15 died responding to or returning from emergency incidents. 15 died responding to or returning from emergency incidents. 9 died engaged in training activities. 9 died engaged in training activities. 20 died after the conclusion of their on-duty activity. 20 died after the conclusion of their on-duty activity. 50 died from heart attacks. 50 died from heart attacks. 19 killed as a result of vehicle crashes.19 killed as a result of vehicle crashes.
Better protection, aggressive tactics, lighter weight Better protection, aggressive tactics, lighter weight construction and improved handling capabilities of construction and improved handling capabilities of heavy apparatus are putting firefighters at greater heavy apparatus are putting firefighters at greater risk.risk.
Non-fatal firefighter injuries and prevention efforts Non-fatal firefighter injuries and prevention efforts cost anywhere from $2.8 billion to $7.8 billion per cost anywhere from $2.8 billion to $7.8 billion per year. (NIST Report on Consequences of Fire Fighter year. (NIST Report on Consequences of Fire Fighter Injuries - 2005)Injuries - 2005)
Reasons & CostsReasons & Costs
Why isn’t technology enough?Why isn’t technology enough?
““Normalization of Deviance”…Normalization of Deviance”…
……becomes our nemesisbecomes our nemesis
Error ManagementError Management
……To err is To err is human…human…
Marcus Tullius CiceroMarcus Tullius Cicero
106-43 B.C.106-43 B.C.
1 Fatality
10
Lost Time Injuries
100
Minor Injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!
Human Factor Error CausesHuman Factor Error CausesGordon Dupont’s “Dirty Dozen”Gordon Dupont’s “Dirty Dozen”
Lack of Lack of CommunicationCommunication
ComplacencyComplacency Lack of KnowledgeLack of Knowledge DistractionDistraction Lack of TeamworkLack of Teamwork FatigueFatigue
Lack of ResourcesLack of Resources PressurePressure Lack of Lack of
AssertivenessAssertiveness StressStress Lack of AwarenessLack of Awareness NormsNorms
Who Carries the Load?Who Carries the Load?
When Things Go Wrong . . .When Things Go Wrong . . .
How It Is Now . . . How It Should Be . . .You are humanYou are highly trained
and
If you did as trained, you would not make mistakes
Humans make mistakes
so
You weren’t careful enough
Let’s also explore why the system allowed, or failed to accommodate your mistake
so
You should be PUNISHED! Let’s IMPROVE THE SYSTEM!
and
so
and
Layers of Defense Trap Crew ErrorsLayers of Defense Trap Crew Errors
Use All ResourcesMaintain Situational
Awareness
Follow SOPs
High Level of Proficiency
You may not know where the holes areYou may not know where the holes are
High Level of Proficiency
Maintain SituationalAwareness
Follow SOP’s
Use All Resources
James Reason’s “Swiss Cheese”
When the holes line up…When the holes line up…
High Level of Proficiency
Maintain SituationalAwareness
Follow SOP’s
Use All Resources
James Reason’s “Swiss Cheese”
DISASTER!
What it isWhat it is Where it came fromWhere it came from How it worksHow it works Why we should use itWhy we should use it How we know it worksHow we know it works
Crew Resource ManagementCrew Resource Management
What Is Crew Resource What Is Crew Resource Management?Management?
Force multiplierForce multiplier Uses all Uses all
resourcesresources Enhances Enhances
supervisionsupervision Improves safetyImproves safety Raises level ofRaises level of
awareness forawareness for
those engagedthose engaged
Crew Resource Management Crew Resource Management (CRM) is a tool created to (CRM) is a tool created to
optimize human optimize human performance by reducing the performance by reducing the
effect of human error effect of human error through the use of all through the use of all
resources.resources.
Where Did It Come From?Where Did It Come From?
Aviation CommunityAviation Community Air Crashes Dominated Industry AttentionAir Crashes Dominated Industry Attention Technology Only Went So FarTechnology Only Went So Far 1970’s –Dr. Robert Helmreich and CVRs1970’s –Dr. Robert Helmreich and CVRs
Error ManagementError Management
Helmreich’s Error Management ModelHelmreich’s Error Management Model
AVOID
TRAP
MITIGATE
How Does It Work?How Does It Work?
Six PrinciplesSix Principles
CommunicationCommunication Decision-MakingDecision-Making Task AllocationTask Allocation TeamworkTeamwork SituationalSituational AwarenessAwareness Debrief*Debrief*
CommunicationCommunication
Barriers and bias block effective communicationBarriers and bias block effective communication Standard language benefits allStandard language benefits all Practice “active” listeningPractice “active” listening Divide duties to prevent overloadDivide duties to prevent overload Minimize distractionsMinimize distractions Establish Inquiry/Advocacy patternsEstablish Inquiry/Advocacy patterns
Clear, Concise, CompleteClear, Concise, Complete RespectfulRespectful Bishop’s Assertive StatementBishop’s Assertive Statement
CommunicationCommunication
Active ListeningActive Listening Face individual(s)Face individual(s) Maintain eye contactMaintain eye contact Only one person Only one person
speaks at a timespeaks at a time Formulate reply after Formulate reply after
other person other person speaking finishes speaking finishes talkingtalking
DistractionsDistractions Turn down radio(s)Turn down radio(s) Phones on vibratePhones on vibrate No multi-tasking No multi-tasking
during periods of high during periods of high stressstress
Ambient noiseAmbient noise Adjourn to quiet Adjourn to quiet
locationlocation
““Sterile” Command PostSterile” Command Post
Everyone needs to Everyone needs to be “all business” be “all business” when it’s time for when it’s time for business.business.
IC sets the tone for IC sets the tone for the CP.the CP.
Photo by Carlos Alfaro
Todd Bishop’s Assertive StatementTodd Bishop’s Assertive Statement
How to talk “up” How to talk “up”
the chain of commandthe chain of command If you are a If you are a
subordinate:subordinate:
– – use the techniqueuse the technique If you are a If you are a
supervisor:supervisor:
– – LISTEN FOR THE LISTEN FOR THE PROCESS!PROCESS!
5 Easy Steps5 Easy Steps
Opening/attention Opening/attention (Call the supervisor by (Call the supervisor by name or rank)name or rank)
State concern/owned emotion State concern/owned emotion (I’m concerned (I’m concerned about…)about…)
State the problem as you see it State the problem as you see it (Someone is (Someone is going to get hurt if we…)going to get hurt if we…)
State a solution State a solution (I think we can do it another (I think we can do it another way…)way…)
Obtain agreement (aka buy-in) Obtain agreement (aka buy-in) (Does this (Does this make sense to you?)make sense to you?)
Recognize problemsRecognize problems Continue to “fight Continue to “fight
the fire”the fire” Maintain SAMaintain SA Assess hazardsAssess hazards Assess resourcesAssess resources Solicit solutionsSolicit solutions Make a decision!Make a decision!
Critical Decision MakingCritical Decision Making
KleinKlein
MethodMethod
Recognition Primed Recognition Primed NaturalisticNaturalistic Cue BasedCue Based
Decision MakingDecision Making
Cue BasedCue Based Compare existing Compare existing
knowledge base knowledge base against situationagainst situation
Improve base throughImprove base through TrainingTraining ExperienceExperience KnowledgeKnowledge Case studiesCase studies
““blink”blink”
Rapid CognitionRapid CognitionThin-slicingThin-slicing
Ability of the unconscious to find patterns in Ability of the unconscious to find patterns in situations and behaviors based on very narrow situations and behaviors based on very narrow slices of experience. slices of experience.
Automated, accelerated recognition of identifiable Automated, accelerated recognition of identifiable patterns.patterns.
““Coup d’oeil” - the power of the glanceCoup d’oeil” - the power of the glance
- - Malcolm GladwellMalcolm Gladwell
Klein, Gladwell & Today’s Fire OfficerKlein, Gladwell & Today’s Fire Officer
Task AllocationTask Allocation
Know your limitsKnow your limits Know your crew’s Know your crew’s
limitslimits Capitalize on Capitalize on
strengthsstrengths Seek out “experts”Seek out “experts” ““Eat the elephant Eat the elephant
one bite at a time”one bite at a time”
Task Allocation ExerciseTask Allocation Exercise
What You HaveWhat You Have
3 Story MFD3 Story MFD Fire on 2 Fire on 2
floors and floors and through roofthrough roof
Type V Type V Construction Construction
Wood Truss Wood Truss RoofRoof
Who’s On the Way…Who’s On the Way…
BC1
• 28 years, 6 as Ops BC
• 14 years in busiest areas
• EFO Grad
• Bachelor’s in Fire Protection
Fire Prevention AC
• 20 years
• 6 in Ops as FF, Remainder of time in Fire Prevention
• EFO Grad
• Bachelor’s in Fire Protection
• NIMS Instructor
Operations AC
• 34 years, 2 as Ops Chief
• 12 as Training DC
• 4 as Arson BC
• 8 as Safety Captain
• Bachelor’s in Fire Service Management
EMS BC
• 16 years, 2 as EMS BC
• 12 years in Suppression ranks
• 2 years as Training Captain
• Associates’ Degree, EMS
Who Gets the Job?Who Gets the Job?
• Fire Attack
• Safety Officer
• Senior Advisor
• Roof Sector
TeamworkTeamwork
LeadershipLeadership
FollowershipFollowership
Photo by Bob Bartosz, Camden Fire Department
TeamworkTeamwork
LeadershipLeadership AuthorityAuthority
Mandated by rankMandated by rank Derived through respectDerived through respect
MentoringMentoring Lead by exampleLead by example Admit mistakesAdmit mistakes Be technically competentBe technically competent Share knowledgeShare knowledge
TeamworkTeamwork
Conflict ResolutionConflict Resolution Focus on issueFocus on issue Keep ego in checkKeep ego in check Listen Listen
Mission AnalysisMission Analysis
#1 Priority:#1 Priority:
Continuous Continuous
Risk vs RewardRisk vs Reward
EvaluationEvaluation
TeamworkTeamwork
FOLLOWERSHIPFOLLOWERSHIP
Self AssessmentSelf Assessment
Physical ConditionPhysical Condition Mental ConditionMental Condition
AttitudeAttitude Understands human Understands human
behaviorsbehaviors
TeamworkTeamwork
Respect authorityRespect authority Personal SafetyPersonal Safety Crew SafetyCrew Safety Accepts authorityAccepts authority Knows authority Knows authority
limitslimits Leader successLeader success Good communication Good communication
skillsskills
Learning attitudeLearning attitude Ego in checkEgo in check Balance Balance
assertiveness/authorityassertiveness/authority Accept ordersAccept orders Demand clear tasksDemand clear tasks Admit errorsAdmit errors Provide feedbackProvide feedback AdaptAdapt
Followership
How Well Do You Team?How Well Do You Team?
Situational AwarenessSituational Awareness
Point where perception Point where perception and reality collideand reality collide
Reality Reality alwaysalways winswins Beware of loss factorsBeware of loss factors
AmbiguityAmbiguity DistractionDistraction FixationFixation OverloadOverload ComplacencyComplacency Unresolved discrepancyUnresolved discrepancy
Hazardous AttitudesHazardous Attitudes
InvulnerabilityInvulnerability Anti-authorityAnti-authority ImpulsivityImpulsivity MachoMacho ResignationResignation
““Air Show Syndrome”Air Show Syndrome” ““Pressing”Pressing”
Good Situational AwarenessGood Situational Awareness
Good crew Good crew coordinationcoordination
Proper task Proper task completioncompletion
UnderstandingUnderstanding Smooth rideSmooth ride Crisp and appropriate Crisp and appropriate
radio callsradio calls Use of checklistsUse of checklists
Preventing Loss of Situational Preventing Loss of Situational AwarenessAwareness
Crew mental joggersCrew mental joggers ““What do we have What do we have
here?”here?” ““What’s going on What’s going on
here?”here?” ““How are we doing?”How are we doing?” ““Does this look right?”Does this look right?”
Preventing loss of Situational Preventing loss of Situational AwarenessAwareness
Personal mental joggersPersonal mental joggers ““What do I know that they need What do I know that they need
to know?”to know?” ““What do they know that I need What do they know that I need
to know?”to know?” ““What do we all need to What do we all need to
know?”know?”
DebriefDebrief
Pre-BriefPre-Brief TopicTopic DecorumDecorum
FacilitateFacilitate AnalyzeAnalyze
OperationsOperations Human BehaviorsHuman Behaviors
Why Should We Use CRM?Why Should We Use CRM?
Error is a fact of all Error is a fact of all performanceperformance
Command becoming Command becoming more complicatedmore complicated
Command successes Command successes are a function of are a function of teamwork teamwork
Proven success in Proven success in multiple industries with multiple industries with similar structuresimilar structure
How Do We Know It Works?How Do We Know It Works?
55thth Generation in Aviation Industry Generation in Aviation Industry U. S. Marine Corps Adopting as Basic U. S. Marine Corps Adopting as Basic
PhilosophyPhilosophy Significant Reductions in Injuries and ErrorSignificant Reductions in Injuries and Error
Commercial Aviation IndustryCommercial Aviation Industry U.S. Coast GuardU.S. Coast Guard U.S. NavyU.S. Navy U.S. Air ForceU.S. Air Force Veterans’ Administration Hospital SystemVeterans’ Administration Hospital System
ReviewReview
What CRM isWhat CRM is Where it came fromWhere it came from How it worksHow it works Why we should use itWhy we should use it How we know it worksHow we know it works
For More InformationFor More Information
http://www.iafc.org/http://www.iafc.org/associations/4685/files/CRMassociations/4685/files/CRM%20Manual.pdf %20Manual.pdf (downloadable manual)(downloadable manual)
Okray and Lubnau, Okray and Lubnau, Crew Crew Resource Management for Resource Management for the Fire Servicethe Fire Service. Penwell . Penwell PublishingPublishing
Contact InformationContact Information
[email protected]@montgomerycountymd.gov
[email protected]@iafc.org
240-832-6563240-832-6563
QUESTIONS?QUESTIONS?