Crew Resource Management Threat & Error Management
Transcript of Crew Resource Management Threat & Error Management
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National Fire Fighter Near-Miss Reporting System (January 2007)
The National Fire Fighter Near-Miss Reporting System
Crew Resource Management Threat & Error Management
www.firefighternearmiss.com www.iafc.org/safetyAndHealthResources
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National Fire Fighter Near-Miss Reporting System (January 2007)
Goals
• Introduce the concepts of Crew Resource Management and Threat & Error Management to fire fighters.
• Use the concept as a tool that can be
used to save fire fighters’ lives, reduce injuries and the adverse impacts of human error.
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National Fire Fighter Near-Miss Reporting System (January 2007)
…To err is human…
Marcus Tullius Cicero
106-43 B.C.
Managing error acknowledges that
humans make mistakes.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Error Management
Traditional
thinking focused on improving technology to prevent disasters.
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National Fire Fighter Near-Miss Reporting System (January 2007)
The Human Factor
• Cockpit Voice Recordings led analysts to
conclude that 70% of all aviation accidents were the result of human error.
• Discovery reformed approach to preventing aviation disasters.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Innate Abilities & Learned Behaviors
• Led to the development of Cockpit
Resource Management, then (CRM), Crew Resource Management, now Threat & Error Management (TEM).
• CRM proponents claim improved decision-making and reduced errors.
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Error Management: Introducing Cultural Change
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.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Heinreich’s Theory (1930’s)
• Intervening at the lowest level saves more lives, pain and suffering.
1 Fatality
10 Lost Time Injuries
100 Minor Injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!
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National Fire Fighter Near-Miss Reporting System (January 2007)
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
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National Fire Fighter Near-Miss Reporting System (January 2007)
Helmreich’s Error Management Model
AVOID
TRAP
MITIGATE
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Error Trapping
Layers of Defense =
Redundancy = Increased Safety Margin
• To trap errors, keep as much redundancy
in the crew for as long as possible.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Layers of defense (redundancy) trap crew errors
Officer-in-charge
On-Board computer provides running route and incident information
Driver Familiar with area
Crew member grew up in complex
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National Fire Fighter Near-Miss Reporting System (January 2007)
Even good barriers have holes . . . James Reason’s “Swiss Cheese”
High Level of Proficiency
Follow SOPs
Maintain Good Situational Awareness
Use All Eyes & Ears
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Error Mitigation
Be Vigilant, Stay Focused (BVSF)
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National Fire Fighter Near-Miss Reporting System (January 2007)
“BVSF”
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
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Overlap
“Redundancy” of the three layers fosters effective error management
• Example: SOPs – Avoid – because I am doing things by the
SOP, I will avoid the chance of error. – Trap – SOPs can help catch (trap) errors. – Mitigate – Referring back to SOPs when
things go awry mitigate error.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Crew Resource Management Threat & Error Management
• Force multiplier • Error Management • Maximizes all
resources • Proven • Institutionalizes
Instincts Photo by Carlos Alfaro, MCFRS
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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.
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Principles
• Communication • Task Allocation • Teamwork • Critical Decision
Making • Situational
Awareness Photo by Bob Bartosz, Camden Fire Department
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Communication
• Formulate idea • Select medium • Transmit • Receive • Interpret • Feedback
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National Fire Fighter Near-Miss Reporting System (January 2007)
Do You Hear What I Say?
• Barriers and bias block communication • “Standard” language benefits all • Practice “active” listening • Divide duties to prevent overload • Minimize distractions
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National Fire Fighter Near-Miss Reporting System (January 2007)
Barriers, Roadblocks & Standard Language
• Barriers & Roadblocks – Hazardous Attitudes – Fatigue – Inattention
• Standard Language – 500 most common 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.
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National Fire Fighter Near-Miss Reporting System (January 2007)
Inquiry & Advocacy Skills
Inquiry Skills
• Be Proactive • Use Clear, Concise
Questions
• Express Concerns Accurately
Advocacy Skills
• Be Respectful
• Offer a Solution with your Concern
• Know When to Say
When
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Assertive Behavior
• Authority with Participation
• Assertiveness with Respect The genuine, complete & direct
communication of ideas, wants & needs.
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National Fire Fighter Near-Miss Reporting System (January 2007)
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).
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National Fire Fighter Near-Miss Reporting System (January 2007)
Teamwork
• Leadership
• Followership
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Leadership
• Authority
• Mentoring
• Conflict Resolution
• Mission Analysis
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National Fire Fighter Near-Miss Reporting System (January 2007)
Leadership
• Mandated by rank • Truly derived through respect
– Personal competence – Technical competence – Social competence
• Risk vs. Gain • Develop strategy
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National Fire Fighter Near-Miss Reporting System (January 2007)
Followership
• Self Assessment Physical Condition Mental Condition Attitude Understand Human
Behavior
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National Fire Fighter Near-Miss Reporting System (January 2007)
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
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National Fire Fighter Near-Miss Reporting System (January 2007)
Task Allocation
• Know your limits. • Know your crew’s
limits. • Capitalize on
strengths. • “Eat the elephant
one bite at a time.”
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National Fire Fighter Near-Miss Reporting System (January 2007)
Task Allocation
• Proper use of
automation • Control distractions • Follow SOPs • Delegate • ICS
• Use CRM
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National Fire Fighter Near-Miss Reporting System (January 2007)
Critical Decision Making
Traditional Decision Making
• Identify problem • Assess hazard • Assess resources • Solicit solutions • Select best option • Monitor results
Fire Service Decision Making
• Recognition Primed Decision Making
• Naturalistic Decision
Making • Cue Based Decision
Making
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National Fire Fighter Near-Miss Reporting System (January 2007)
Recognition Decision Making
– Rapid, intuitive process – Looks for critical causes – Relates to previous experiences – Recalls previous conclusions & best actions
taken – Issues direction – Experience
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National Fire Fighter Near-Miss Reporting System (January 2007)
Cue Based Decision Making
• Individual is prompted to act based on
“cues” from event.
• Cues are sensory elements (sights, sounds, smells) that recall previous actions under similar circumstances.
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Ways to Improve Decision-Making
• Experience • Training • Communication • Preplanning
Photo by Carlos Alfaro, MCFRS
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National Fire Fighter Near-Miss Reporting System (January 2007)
Situational Awareness
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The skill of becoming aware of the situation as it actually exists.
Reality times Perception still equals Reality.
- The Killer Equation
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• “ 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!
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National Fire Fighter Near-Miss Reporting System (January 2007)
Situational Awareness Loss Factors
• Ambiguity • Distraction • Fixation • Overload • Complacency • Improper Procedure • Unresolved Discrepancy • “Nobody Fighting the Fire”
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National Fire Fighter Near-Miss Reporting System (January 2007)
Elements of Good Situational Awareness
• Good crew coordination • Proper task completion • Understanding • Smooth ride • Crisp and appropriate radio calls • Use of checklists
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National Fire Fighter Near-Miss Reporting System (January 2007)
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?”
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National Fire Fighter Near-Miss Reporting System (January 2007)
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?
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National Fire Fighter Near-Miss Reporting System (January 2007)
If we continue on the current LODD/injury path, the fire
service will experience 1000 fatalities and 100,000 injuries in
the next ten years.
“ If not now, when? If not us, who?”
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National Fire Fighter Near-Miss Reporting System (January 2007)
• Human error is the leading cause of
accidental injury, death and property damage.
• Errors can be effectively managed and mitigated through the consistent use of CRM.
• The aviation, military and medical industries have over 25 years of experience that validates the value of Crew Resource Management and Near Miss Reporting.
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National Fire Fighter Near-Miss Reporting System (January 2007)
CRM & Near Miss
• What are the ties between the two?
• Can you do one without the other?
• Which one is more effective?
• Who else is using this stuff?
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National Fire Fighter Near-Miss Reporting System (January 2007)
Ties That Bind
• Near Miss Reporting – Intervenes @ “Unsafe
Acts” – Greater ratio of opportunity
for intervention – All members participating
• CRM – Targets “Unsafe Acts” area – Most eyes/ears working – All member commitment
1 Fatality
10 Lost Time Injuries
100 Minor Injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!
Lowest Level Intervention Minimizes Impact on Pain, Suffering and Property Loss!
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National Fire Fighter Near-Miss Reporting System (January 2007)
CRM & Near Miss
• Compliment and support each other. • Effectiveness is based on commitment
and support of department leadership.
• All major U.S. air carriers, U.S. Military, Wildland fire service, individual fire departments.
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National Fire Fighter Near-Miss Reporting System (January 2007)
www.firefighternearmiss.com
• Voluntary • Confidential • Secure • Web based • Free
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ROTW
• Free feature • Good training tool • Provides quick, Effective drill • [email protected] – type “subscribe-crm”
in subject line.
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National Fire Fighter Near-Miss Reporting System (January 2007)
QUESTIONS?