Pilots Lost Situation Awareness

By now you have probably heard about Northwest flight 188. The flight’s destination was the Minneapolis-St. Paul International airport. However, for reasons that have yet to be revealed, the pilots remained at 37,000 feet and flew right past the airport. It took over an hour for them to realize what they had done and correct the error. Air traffic controllers were trying desperately and unsuccessfully to reach them. Military jets were put on standby. The White House was alerted. How could this happen?

Initial accounts say the pilots were engaged in a heated disagreement over airline policy. A subsequent report said the pilots may have been sleeping. The National Transportation Safety Board will sort all that out. What we do know is the pilots lost situation awareness and mistakes were made. How could this happen?

This incident may have left you surprised or angry. After all, you don’t want to think the very people you entrust your life to are not paying attention when they’re flying the plane. I look at it a little differently. For years I have immersed myself in the study of situation awareness in dynamic, high-risk, high consequence environments and corresponding research in neuroscience and cognitive psychology. Admittedly, it’s not the kind of reading that most of you would find enjoyable, but I do.

One of the things I have learned is there are barriers to situation awareness – stated simply – things that impact your ability to pay attention. In research I conducted with fireground commanders, I was able to identify 116 potential barriers to a fireground commander’s situation awareness. With so many potential barriers, you might wonder how commanders maintain situation awareness at an emergency scene.

Many times when a near-miss or catastrophic event occurs, a loss of situation awareness is among the culprits. That’s because it’s not as easy to pay attention as you think. In addition to the things that happen around you that can draw you off task, there are a number of things happening in your brain that work against you. From my research, I have developed a training program to help public safety personnel understand what situation awareness is, how to develop it, maintain it, and how to regain it when it’s lost. I have been humbled by the number of requests I have received to present the findings of my research to firefighters throughout the United States, Canada, and England. If you want to taste of the program, I’ve posted some clips on my website. I’ve also produced a DVD series and wrote a book on the subject. I am passionate about improving fireground command decision making and situation awareness.

Pilots lose their situation awareness, overshoot the airport, and it results in an investigation to understand what happened so the lessons can be applied industry-wide to help prevent a future occurrence. A fireground commander loses situation awareness, makes a bad decision that results in a near-miss, and what happens? What’s done to correct the problem? Educate? Change behavior? Share industry-wide?

Fire Chief (ret.) Richard B. Gasaway, PhD, EFO, CFO, MICP
http://www.richgasaway.com/
RBG3100@aol.com

[Note: This article is also posted on the Kitchen Table blog.]

Houston's 10 Rules of Survival

I read where the Houston Fire Department implemented ’10 Rules of Survival’ in the aftermath of multiple line of duty death incidents. I think they are on the right track, so long as these rules become institutionalized and are reinforced in an effort to change their culture.

The one thing that was noticeably absent from the list was the need to conduct a risk-benefit assessment prior to committing firefighters to an interior attack. Part of the risk assessment means evaluating if the fire has began to consume the structural components of the building (e.g., rafters, joints, beams, studs, etc.). It is also essential to assess the speed at which the incident is moving. To accomplish this, the officer/commander must look at the fire’s progress in the context of the passage of time. Under stress, you can lose your perception of the passage of time (temporal distortion is the term for it). Paying attention to the passage of time (even if it is just seconds or a few minutes) and looking at how fast the fire is progressing and how quickly the smoke is building and moving helps you understand the speed of the fire and whether or not your resources (firefighters and water) can get ahead of it. There is a limit as to how fast your firefighters and your water can move and if the fire is moving faster, your firefighters will be overrun but it. It’s a pretty simple concept, but one that is so often overlooked in the size-up phase of the fire.

The second part of the risk-benefit assessment is determining the benefit of engaging firefighters in an interior structural attack. Now, before the comments start flying about wimps and sissies, I will go on the record that I am a proponent of aggressive attack. However, it cannot be blind aggression. It must be a calculated attack – assessing what is to be gained from it. Is there a savable life inside? For those who may not know, skin begins to melt at 160 degrees. Crawling through a super-heated, zero-visibility environment with the objective being “search and rescue” is a misnomer. In this environment, it would be “search and recovery.” Even if you were able to extract the body before death occurred, third degree burns over 80% of the body are not injuries compatible with life and the victim will succumb to their burns.

To engage firefighters in the highest risk environments should be predicated on what benefit comes from that risk – and be realistic.We are firefighters. We are in a risky business. However, we should not be taking excessive risks to save unsavable lives and unsavable property. Nor should we be engaging in firefights when our resources (firefighters and water) are outmatched by the volume and speed of the fire.

Fire Chief (ret.) Richard B. Gasaway, PhD, EFO, CFO, MICP
www.RichGasaway.com
RBG3100@aol.com

[Note: This was also posted on the Kitchen Table blog.]

Vest wearing sissies

I was recently reading a heated debate in a forum where tempers were flaring. I may not be able to do the topic justice but I’ll try to summarize. I would refer you to the site, but I do not condone the form of childish name calling that I observed. It’s embarrassing, not to mention completely unprofessional. We wonder why we suffer to obtain and maintain the support of our elected officials and general citizenry? Some contributors have lost sight of the fact that those forums can be read by anyone. Ok, on to the topic at hand.

The sparring parties in this debate were warring on the topic of aggressive fire attack strategies. On one side of the debate was those advocating for strong command and control of the incident where the incident management team is responsible for assignments and accountable for the actions on the incident scene. On the other side of the debate were those stumping for more independent action by firefighting crews, denouncing the need for “vest-wearing sissies.” The tone of the comment led me to believe the author was of the opinion that incident and sector commanders who don identifying vests in the process of managing their incidents are fearful of aggressive structural firefighting.

As I have been a student of human motivation for many, many years, I have come to understand that all motivation is spawned from two emotions – fear and desire. Everything we do (and say) comes from fear or desire. I have to wonder… those who behave this way in forums - ironically, almost always anonymously - what are they afraid of? Or, what is it they desire?

You think you know? Feel free to post your thoughts. I just ask that you keep your comments courteous and professional. Remember… everyone has access to the forums.

Fire Chief (ret.) Richard B. Gasaway, PhD, EFO, CFO, MICP
www.RichGsaway.com
RBG3100@aol.com

[Note: Also posted in the Kitchen Table blog.]