How 1 plane crash can change incident command
What the aviation industry learned about reducing human error has direct application to fire and rescue operations
Our country has been experiencing an uptick in aviation accidents recently. Considering the amount of flights that takeoff and land flawlessly each day, commercial air travel is still the safest mode of transportation on the face of the earth.
One of the safety systems that have been integrated into the day-to-day operations of commercial flights is a process called Crew Resource Management or CRM. This highly effective decision-making process was developed in the late 1970s and implemented in 1980.
CRM came about after several air disasters occurred where the causes were determined to be human factors or otherwise known as pilot error. The most basic explanation of CRM is ensuring that the correct decisions are made to ensure a safe departure, flight and arrival each and every time a commercial plane moves passengers.
Removing human errors from the cockpit may sound simple. But, it is a difficult process and takes a robust, comprehensive decision-making system to correctly manage the flight operations. The best part is that the CRM system applies to fire-rescue operations.
United Flight 173 takes off for what was believed to be a routine flight from Denver to Portland, Ore. As it turned out, United 173 was anything but routine, crash landing off of the airport in suburban Portland, killing 10 passengers and injuring 23 others.
The plane and flight crew appeared to be in perfect order. Further, the weather was nearly ideal for the planned flight. The only obstacle that stood in the way of a safe and uneventful flight turned out to be the human performance of the three-person cockpit crew: pilot (captain), first officer (co-pilot) and second officer (flight engineer).
As the Boeing 707 started its initial approach, the captain noticed that the main landing gear indicator light did not change from red (not engaged) to green (down and locked into position). It was at this point that the captain added about an additional 45 minutes of flying to the flight plan. The addition routing was to allowing for the control tower to visually check 173's nose gear and to make the needed preparations for a potential emergency landing.
After the captain announced the revised flight plan to the other two pilots, both expressed concern — several times each — that the remaining fuel was too low to complete the additional flying. The second officer was direct in his communications to the captain, pointing out to the senior officer and final decision maker that there was not enough fuel to completed the revised flight plan. The pilot-in-charge responds to the concern about low fuel with, "yeah, right."
About 6 miles before the Portland runway, all four of United 173's engines flamed out from being completely fuel starved. The first officer declared a mayday and the plane crash landed in a wooded area near the airstrip.
The National Transportation Safety Board determined that the only problem with the aircraft was a burned out light bulb behind the green panel of the main (nose) landing gear. The plane was in perfect operating order with that single exception before the crash occurred.
The direct cause of this major loss of life was pilot error and was avoidable.
NTSB's final report said the pilot was distracted and did not heed the advice of the other two pilots. The notion was developed that there must be a better way to take advantage of the collective human resource in the cockpit when it comes to making the best decision possible.
The NTSB listed that a comprehensive best-practice, decision-making model would be the best way to avoid a similar plane crash in the future. The Federal Aviation Administration adopted NTSB's recommendation as a commercial aviation policy.
In the simplest terms, the belief is that CRM will help eliminate inappropriate and flawed decision making during flight operations.
A fire service need
The abbreviated history of aviation aside, what role can CRM play in the fire and rescue response operations?
The need is obvious. Avoiding human error would go a long way to improve just about every aspect of all fire and rescue operations. The human factor's scientists estimate that about 80 percent of all commercial airline crashes are caused by pilot error.
Check the list of causal factors in most National Institute of Occupational Safety and Heath firefighter line of duty death reports and you'll find poor or improper decision-making. Episodically, the 80 percent human-error model will most likely fit when determining the causal factors of firefighter LODDs.
CRM points to using all of the available crew resource (brains in most cases) to make the best decision possible the first time and every time. Please do not think that this action usurps the captain's authority and the decision making process becomes a popular vote.
It does not, the captain is always the captain and the final authority in the decision making process inside the aircraft. The captain has the legal authority, education, training and experience to operate the aircraft, end of story.
Challenge and confirm
However, CRM demands that a team approach is used whenever possible or appropriate. The captain must develop an environment inside the cockpit that seeks and values team input. This process is called challenge and confirm — the soft version might be referred to as checks and balances.
The flying pilot vocalizes what actions are to be taken at a specific time. The non-flying pilot repeats the order, than the action is carried out.
If the second pilot's opinion differs from what is being ordered, the pilot rapidly considers the discrepancy. Next, the captain makes the swift and final decision with action to quickly follow. The "yeah right” attitude is discouraged and the pilot is obligated to resolve the discrepancy quickly after considering the entire team's input.
Along with the verbalization of actions to be followed, both pilots use checklists to make sure that no steps are skipped. The checklists are broken down into manageable component parts — about five to 10 steps per list — that follow the logical process of flying the plane.
Long lists were found to be a detriment. With a short list, when unavoidable interruptions occurred (perhaps a critical radio message from air traffic control), the cockpit team could quickly resume the steps starting again at the top of the list.
Where's the fire?
Likely you are thinking, that this concept is great for pilots. But the fire-rescue command vehicle is no airplane. Agreed, however, making the best incident decision the first time, every time should have a great appeal to anyone that has been in the role of incident commander at least once.
The CRM concept has been very slow to catch on in our business. Most times looking to our past can help solve our current problems, if one knows how and where to look.
The role of incident commander has been a one-person show for a very long time. In fact, in some outfits that I have been a part of, an incident commander needing assistance was viewed as a weakness rather than a strength. To improve incident operations, we must change these behaviors.
The commercial aviation community always has redundancy on the flight line, meaning two pilots are in the pointy end all of the time the plane is moving. The fire-rescue service needs to start the CRM journey by grabbing this page for the manual. We could call it redundancy at the command post.
Command team structure
Ideally, there should be a command team consisting of at least four members, whenever our troops are placed into an immediately dangerous to life and health environment or any other type hazard zone. The command team roles must include:
- Incident commander, the pilot — one, well-supported, qualified individual in charge of the operation.
- Deputy incident command, the first officer — an equally qualified, experienced and trained to play a supporting role using checklists and be the challenger and confirmer.
- Incident safety officer to look for and eliminate unsafe acts, unsafe behaviors and unsafe conditions.
- Accountability officer to track and record the who, what, where, conditions, and escape routes of the hazard zone.
When I roll out this command team suggestion during classroom presentations, there is generally a lot of eye rolling going on. A brave soul will final bust out with that if four people fill the command team rolls, no one will be left to fight the fire.
This is a major change in how we do business. Adding to the human resource needs at IDLH events is a reality if we are going to attempt to eliminate human errors being made at the command post.
Increasing the initial response to a likely event that will present an IDLH hazard look to automatic/mutual aid, to use of staff officers or to increase company staffing. I have always believed that if there is a will to get something accomplished in the fire-rescue service, there is a way to make it happen.
There are four mission-critical components that make up the CRM system.
- Teamwork and leadership
- Task allocation
- Critical decision making
The teamwork and leadership aspect, reminds the incident command to work hard to establish an operational environment that well-timed and mission-critical challenges are welcome. The complete application of the CRM process mandates that effective and comprehensive checklists are developed to guide the team to make the correct decision every time.
Communication is the backbone of what incident command does to add value to resolving any emergency. Simply put, without the ability to effectively and efficiently communication, command is out of business. CRM focuses on all aspects of communication to include good listening skills and being assertive enough without being confrontational.
The task-allocation process refers to the ability to delegate all tasks that are mission-critical to flying the aircraft. Nothing can be left to chance or otherwise ambiguous when the plane is underway. The pilot is obligated to make sure that all tasks are assigned and carried out properly.
This may sound like a small detail in the overall scheme of flight line operations, but there are case studies in which distractions caused the cockpit crew to be preoccupied and they simply forgot to fly the aircraft resulting in a crash landing.
Critical decision-making is perhaps the strongest element of the CRM process. The flying pilot is obligated to have the non-flying pilot challenge and confirm the decisions in a smooth, rapid and transparent way. As the flying pilot calls for the landing gear to be retracted, the non-flying team member repeats the order and takes action.
If the confirmation doesn't happen quickly, and the non-flying pilot expresses concern, the pilot swings into role of conflict resolver. The pilot quickly makes the final decision and action occurs upon his or her directions. This process takes only a few seconds to implement, but may prevent a lifetime of regret.
The CRM program is the primary way that the aviation community drives out the dreaded human error from flight operations. I am a firm believer that every incident must be managed by using the CRM rules and principals. If we are to lower firefighter deaths and injuries as well as provide best-in-class response services to our customers, the time for CRM has arrived.
Please do take a closer look at CRM by using the wealth of information that is at the tips of your fingers.