Resource Management by dol15999


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									Crew Resource Management

  Presentation Prepared for:


   What is Crew Resource
                                    Crew Resource
              1                     Management
                                    (CRM) is an
     10 lost time injuries          effective use of “all”
 1000 No Loss Accidents
                                    resources to
 10,000 UNSAFE ACTS!                minimize errors and
1000 No Loss Accidents
                                    improve safety and

 Crew Resource Management

Crew Resource
evolved from
what was initially,

     Where Did It Come From?
   Aviation Community
   Air Crashes Dominated Industry Attention
   Technology Only Went So Far
   1970’s – Dr. Robert Helmreich and CVRs
 Crew Resource Management
A landmark event was United Airlines flight 173,
which occurred in 1978. Flight 173 crashed in a
wooded area outside of Portland. The problem
which occurred involved an indicator light for the
landing gear. It indicated that the landing gear was
not completely down. The pilot was informed of a
low fuel by his crew after he decided to fly around
trying to figure out the light. He either disregarded
them or misunderstood them and crashed killing 8
passengers and two crew members. Twenty three
other people were seriously injured.

             Why were so few killed?

     Aviation Industry and
       The Fire Service

Dangerous Situations

Life and Death Decisions

Safety is Paramount
      Near Miss – 1/15/2009
Flight 1549 - Emergency Landing
          Hudson River

Captain Chesley B. Sullenberger III
           Flight 1549
               “I flew thousands of flights in the
               last forty-two years, but my
               entire career is now being
               judged on how I performed on
               one of them. This has been a
               reminder to me. We need to try
               to do the right thing every time,
               to perform at our best, because
               we never know which moment
               in our lives we will be judged

           Culture of Safety

The way the best pilots see it:
A Captain’s highest duty is always to
safety. As we say it, "We have the
power of the parking brake.” The plane
will not move until we feel we can
operate it safely.

“The Power of The Parking Brake.”

  Fire Trucks have parking brakes too.

Lack of Crew Resource Management
  July 1, 1988, Hackensack, N.J., - Catastrophic collapse of
      bowstring trusses. The I.C. was on scene with portable over
      shoulder participating in firefighting. Three (3) firefighters
      killed in initial collapse, two entombed that ran out of air. After
      27 calls for help radio goes silent.

  October 27, 1997, Washington D.C., - Fire in a corner grocery
     store. Crews initiated an aggressive interior attack. Crews
     evacuated after rapid heat build up and floor shift. Engine 14
     exits crew can’t find officer. Crew reports their officer missing
     on two separate occasions to other officers. Dead officer of
     Engine14 found in basement.

    Crew Resource Management
From 1997 to 2001 –
500 firefighters died in
   structure fires and fire
   fighting operations.

   Worcester, Mass.
   Keokuk, Iowa
   Louisville, Ky.
   New York City

    Crew Resource Management
Factors that contributed to these and other fire service
   tragedies are remarkably similar to factors identified by
   an industry that began adopting CRM as a mantra more
   than 25 years ago.

The nation’s aviation industry recognized that human
   error was the prevailing cause in aviation disasters.

The lessons learned by this industry are worth study by the
   fire service because of common contributing factors to
   the deaths in both industries.

Crew Resource Management

CRM exists when all members
 of the team actively seek to
prevent adverse effects on the
      current situations.

Does the Fire Service Promote a
         Risk Culture?
 Managing risk is our business, we do a great job taking
  care of Mr. & Mrs. Smith’s risk, but how about our own?
 Human behavior patterns suggest that the well intentioned,
  best trained, consistently performing individuals and
  groups commit errors. (Titanic)

 Accidents are not random occurrences – People cause
  accidents and make errors.

 CRM has a proven history in reduction of errors.

 Aviations, Military, and Medical.

Crew Resource Management
                      Adrenaline and
                      testosterone contribute
                      to more injuries than
                      structural failure. A key
                      factor in firefighter
                      injury or death is the
                      risk a firefighter will
                      take and their
                      supervisor’s ability to
                      control it.
How Does It Work?

                         Six Principles
                          Task Allocation
 Barriers and bias block effective
 Standard language benefits all
 Practice “active” listening
 Divide duties to prevent overload
 Minimize distractions
 Establish Inquiry/Advocacy patterns
   Clear, Concise
   Respectful
   Bishop’s Assertive Statement
      Todd Bishop’s Assertive
 A CRM expert - Todd Bishop developed a
  five-step assertive statement process that
  encompasses inquiry and advocacy steps:

 Opening or attention getter - Address the
  individual. "Hey Chief," or "Captain Smith," or
  "Bob," or whatever name or title will get the
  person's attention.

      Todd Bishop’s Assertive
 State your concern - State what you see in a
  direct manner while owning your emotions
  about it. "We're low on fuel," or "I think we
  might have fire extension into the roof
 State the problem as you see it - "I don't
  think we have enough fuel to fly around this
  storm system," or "This building has a
  lightweight steel truss roof. I'm worried that it
  might collapse."
      Todd Bishop’s Assertive
 State a solution - "Let's divert to another
  airport and refuel," or "I think we should pull
  some tiles and take a look with the thermal
  imaging camera before we commit crews

 Obtain agreement (or buy-in) - "Does that
  sound good to you, Captain?"

            Decision Making
   Recognize problems
   Fight the fire
   Treat the patient
   Maintain SA
   Accept input
   Make a decision

Task Allocations
                 Know your limits
                 Know your crew’s
                 Capitalize on
                 Seek out “experts”
                 “Eat the elephant
                  one bite at a time”

 Leadership

 Followership

                                 Photo by Bob Bartosz, Camden Fire Department


 One finger cannot lift a pebble

 Can we learn to be the other fingers

 Silence is not golden, it’s deadly

         Lack Of Teamwork
 No Direction

 Trust Issues

 No Crew Cohesion

 Task Completion
Situational Awareness
                   Point where reality and
                    perception collide
                   Reality always wins
                   Beware of loss factors
                         Ambiguity
                         Distraction
                         Fixation
                         Overload
                         Complacency
                         Unresolved discrepancy
 Pre-Brief
   Topic
   Decorum
 Facilitate
 Analyze
   Operations
   Human

               For More Information
  (downloadable manual)

 Okray and Lubnau, Crew
  Resource Management for the
  Fire Service. Penwell Publishing

Crew Resource Management
The National Fire Fighter Near-Miss
         Reporting System

      4025 Fair Ridge Drive
      Fairfax, Virginia 22033

        Tel: 571 238 8287
        Fax: 703 273 0920
 Crew Resource Management
The project is administered by the International
     Association of Fire Chiefs (IAFC) in
  consultation with the National Fire Fighter
Near-Miss Reporting System Task Force. The
  project is endorsed by IAFC, International
Association of Fire Fighters and the Volunteer
 & Combination Officers Section of the IAFC.


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