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Near-Miss Reporting: Crew Resource Management

Infusing crew resource management (CRM) principals into the culture of the fire and emergency service is crucial to improving safety. CRM brings about the effective use of all available resources; it minimizes operational errors and improves the safety and performance of firefighters and EMTs.

CRM addresses five factors that, if not dealt with in a competent manner, will expose firefighters and EMTs to additional risk of injury or death. The five factors are communication, situational awareness, decision-making, teamwork and barriers. In the examples below, keep these factors in mind as you assess each incident.

Report #06-309 highlights how we must maintain our composure at incidents:

The on-duty shift of six personnel was dispatched for a furnace fire and possible explosion in the warehouse area …

The fire was extremely hot and the interior crews were taking a beating. Six other firefighters and I were inside, operating two 1-3/4” handlines and one 2-1/2” handline near an overhead doorway leading from the front half to the rear half of the warehouse, close to the seat of the fire.

I became more uncomfortable with our situation as we were fighting a losing battle. I communicated my thoughts to my partner, who was just doing the same thing to others inside, having arrived at the same conclusion. As we were relaying plan to get out and making sure we would leave no one behind, the evacuation air horns sounded just as the roof came down on us. Miraculously, no one was seriously injured and we began to scramble to exit together.

Our initial exit route was blocked by the downed roof; we were unable to follow our hoselines out due to debris. We saw a dim light and followed it through the debris until we realized it was a partially open overhead door to the outside. We all exited together safely, feeling very fortunate to be alive. Our lieutenant on the outside, who had collected our (accountability) tags, verified we were all accounted for.

We discovered later that this lieutenant sounded the evacuation signal and the IC had not identified the impending collapse. The IC also didn’t believe an emergency evacuation was necessary. This was a factor in the late signal to evacuate. The lieutenant couldn’t afford to debate any longer and sounded the signal as the roof came down. The only reason we weren’t injured more than bumps and bruises was that the roof in our area fell on a parked forklift to our left and vertically stacked carpet rolls to our right, creating a small umbrella area that spared us the bulk of the roof load.

Report #08-588 shows that even simple evolutions can turn bad quickly:

During an emergency response, the driver passed the dispatched location. While attempting to reposition (backing up), contact was made to another vehicle. Even though contact was made, the potential injury was the near miss.

Report #10-901 illustrates that one must be ever ready and ever vigilant:

We responded to a single story residential ranch style structure, about 1400 square feet, with type-5 building construction. Upon our arrival, we had all those evacuated from the residence stand across the street. The initial IC reported no hazardous conditions on the exterior after his 360. At this time, we had three engines, a tower ladder and a battalion chief on the scene.

A team of two entered the structure to investigate from the alpha side, carrying forcible entry tools and an AFFF water can. The IC called for a 200’ 1.75” preconnect to be stretched to the alpha-side door and it was charged as an aggressive precaution. Interior crews reported a light haze of smoke inside the structure and donned their SCBA and PPE.

At this time, the crew came back out and moved the attack line into position. The interior crew made entrance into the alpha/delta side of the structure through a narrow hallway and found active fire in a small bedroom. The crew advanced into the room to conduct a search.

The door somehow shut behind them. At about the same time, a flashover occurred, causing confusion and disorientation in the room. Ventilation efforts were coordinated on the alpha/delta windows. The interior crews heard glass breaking and made their way to the window for emergency egress with the help of exterior crews.

These reports provide examples of CRM factors that must be focused on or improved upon during a lessons-learned assessment:

  • Communication – Communicate what you mean in clear text and confirm what is being conveyed.
  • Decision-making – The company officer or incident commander needs to retain authority, but must have input from his or her crews to render more efficient and correct decisions.
  • Situational awareness – This is an ongoing process that must be updated constantly through observation and communication.
  • Teamwork – Crews must perform as a coherent team and understand their responsibilities and the need for mutual respect.
  • Barriers – Recognize considerations that inhibit the other four factors and act to neutralize their negative effects.

A key overarching element to the CRM concept is that all members of the team have input in the decision-making process. Although the final decision is the responsibility of the officer, the crew’s insight should be considered a valuable contribution.

John C. Woulfe III is the assistant director of the IAFC’s National Programs and Consulting Services.

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