To Err Is Human     

Human factors determine the success of any operation

The world is not a safe place. I’m not referring to natural disasters or terrorism, but to human error, which causes injury and death every day.

People everywhere, every day, are touched or affected by the decisions or actions of others. An incorrect dose of medication given by paramedics in the field can result in a fatally slow heart rate. A simple maintenance error on an airplane can trigger a mechanical malfunction that causes the pilot to lose control and the plane to crash. A complacent firefighter, working at what appears to be a mundane fire, can become trapped by a collapsed roof. A sizeable number of people are harmed every day as a result of human error, or the human element.

This month’s Firefighting 360 column addresses the human element, or human factors, and how it applies to the fire service, which, in this article, includes all aspects of emergency response: firefighting, emergency medical services, hazmat mitigation, high-angle rescue, etc.

You may be wondering what human factors have to do with the fire service. As I’ve stated before, firefighting is all about people; it’s not about technology. All the resources firefighters draw from during an emergency event, including the equipment (hose, tools, generators, etc.) and the systems (fire detection/suppression, water, operational procedures, training programs, etc.), are controlled, influenced and/or operated by people—firefighters. Therefore, firefighters’ performance at an emergency event determines how well the equipment and the systems—and the overall operation—will work.

Mann Gulch
Named “The Gates of the Mountains” in 1805 by the famed explorer Meriwether Lewis, Mann Gulch was an almost inaccessible area located on the Missouri River in central Montana. It’s the kind of place that has always worried firefighters.

On a hot August day in 1949, the region was dry and the potential for fire was high. A thunderstorm rolled through in the afternoon, and lightning ignited a fire. Later that day, a crew of 16 smokejumpers exited their plane and hit the ground ready to work all night to contain what appeared to be a routine fire. Within 56 minutes of their feet hitting the ground, 11 firefighters were dead in the gulch; two more died later in a hospital.
Three firefighters survived the event: R. Wagner Dodge, the foreman who lit a backfire and laid down in it as the fire burned around him; and two teenagers, Robert Sallee and Walter Rumsey, who found protection in some rocks out of the fire’s path.

Many accounts of this tragic story have been told (see reading list below), and they all include some of the same human factors: communication, situational awareness, decision making, followership, leadership and teamwork—all of which must be exhibited by firefighters while operating at a dynamic and challenging event.

What are Human Factors?
Firefighting 360 will look at a variety of human factor topics directly related to the fire service. What do I mean by “human factors?” Simply put, it involves the study of how people interact with their environment. It examines how an individual or a team is influenced by their surroundings, their bodies, their emotions and their interactions with other people.

For a visual explanation of how human factors influence everything that happens in our daily lives, visit the Dow Company Web site at www.dow.com/Hu and watch the video provided.

The Swiss Cheese Model
The study of human factors can be very complex since it encompasses several psychological and physiological disciplines. In its simplest form, the human element or human error is a “breakdown in a productive system.” Below is a model based on James Reason’s “Swiss Cheese” Model of Human Error, in which he describes the four levels of human error, each one influencing the next (see diagram below).

The breakdown of a productive system based on James Reason’s “Swiss Cheese” Model of Human Error. Bad things happen when the holes line up!

The first level of Reason’s model, Unsafe Acts, involves “active” conditions that represent individual firefighter actions or inactions. These are personal behaviors, such as not following operational procedures or not hearing or following instructions. These can be easily detected and corrected.

The last three levels are considered “latent” failures, which may go unnoticed. The first level of latent failure is the Preconditions for Unsafe Acts. It can best be described as firefighter fatigue, poor interpersonal communication, a loss of situational awareness or the inability to work as a team.

The second level of latent failure is Unsafe Supervision. This ineffective leadership has a direct impact on a firefighter’s actions or inactions, resulting in a loss of command and control. These failures can go unnoticed as well.

Obviously, organizations have an impact at all levels, so the last level of latent failure concerns Organizational Factors. This level describes inadequate training or policies, or a lack of leadership development as factors that influence a breakdown in the system.
The holes in the “Swiss cheese” represent inadequate defenses that are meant to prevent an accident from occurring. When there’s a breakdown in the system, the holes line up and accidents or injuries happen.

10 Important Clues
“A Chain of Errors” is another way to describe a breakdown in a productive system. It occurs when multiple errors are committed during a sequence of events. Each link in the chain brings those involved closer to an incident or accident. Every action has an equal and opposite reaction (error), thus the chain grows. The following are 10 important clues, or links in the chain of errors, that can lead to a breakdown in a productive system.

1. Failure to meet benchmarks, tactical objectives or targets. Example: Fire attack has been underway for at least 10 minutes with no reduction in fire volume or change in tactics.
2. The use of undocumented or unauthorized procedures. Example: Directing a master stream into a structure where firefighters are operating.
3. A departure from standard operating procedures. Example: Failing to wear personal protective equipment when entering a hazardous environment.
4. Violating limitations. Example: Operating apparatus outside or beyond its limitations.
5. No one is in command, and there’s no accountability. Example: A firefighter goes to work on the fireground without reporting to command.
6. No one is aware of the overall operating environment. Example: Firefighters are allowed to work a defensive fire inside the collapse zone.
7. Incomplete or poor communication. Example: A firefighter withholds observations or knowledge of existing hazards.
8. Complacency. Example: Firefighters with a high level of experience play down the harmful conditions.
9. Confusion or an empty feeling. Example: The entire operation is moving so rapidly, firefighters are unable to keep up with the pace.
10. Belief of invulnerability. Example: Firefighters believe that the job must be painful and accidents are the “nature of the beast.”

The days of blaming mistakes on technology are long gone. In the last 25 years, firefighters have developed better equipment; they’re better educated in modern strategy and tactics; they have time-tested operational procedures; and they now operate safely and effectively within an incident management system. So who or what is to blame now? The human element that contributes to a “chain of errors” or a “breakdown in a productive system” is still the primary cause of most accidents.

Conclusion
Error is part of human life; we cannot engage in human activity without introducing it. So how do we effectively manage our errors? How do we break a chain of errors or plug the holes in the Swiss cheese? The answer: We incorporate error management into every aspect of our training and operations by adopting and practicing crew resource management.

The next Firefighting 360 column will discuss strategies for error management and explain the history and growth of crew resource management. Until next time, get prepared, be ready and be safe!

Billy Schmidt is a district chief assigned to the 3rd battalion with Palm Beach (Fla.) County Fire Rescue. An adjunct instructor for the department’s Training and Safety Division, he has a bachelor’s degree in Human Resource Management and an associate’s degree in Fire Science.

References, Further Reading & Research

1. Norman Maclean, Young Men and Fire. Chicago: University of Chicago Press, 1990.
2. Richard Rothermel, Mann Gulch: A Race that Couldn’t Be Won. U.S. Forest Service: Intermountain Research Station, 1993 (available at www.treesearch.fs.fed.us/pubs/viewpub.jsp?index=4613). 
3. Michael Useem, The Leadership Moment: Nine True Stories of Triumph and Disaster and Their Lessons for Us All, Chapter 2. New York: Random House, 1998.
4. Karl E. Weich, “The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster,” Administrative Science Quarterly. Cornell University, 1993. Vol. 38, pp. 628–652. 
5. Wildland Fire Accident virtual site, www.nifc.gov/safety//mann_gulch/index.htm.
6. Dennis Smith, San Francisco Is Burning: The Untold Story of the 1906 Earthquake and Fires. New York: Penguin Group, 2005.
7. Randy Okray and Thomas Lubnau II, Crew Resource Management for the Fire Service, Chapters 1 and 2. Tulsa, Okla.: PennWell Corporation, 2004.
8. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine, To Err Is Human: Building a Safer Health System. National Academies Press, 2000.
9. The Human Factors Research and Engineering Group, Federal Aviation Administration, www.hf.faa.gov/index.htm.
10. FAA Human Factors Awareness Web Course, Federal Aviation Administration, www.hf.faa.gov/Webtraining/index.htm.