The Deadly Dozen: Twelve barriers that can impact situational awareness – Part 1
Flawed situational awareness is one of the leading contributing factors in first responder near-miss and casualty events. Complicating this problem is: Most first responders know very little about what situational awareness is, how they develop it, how it is impacted and how to recover it once it has been impacted. Many first responder programs do not teach situational awareness (SA). The programs that do address SA typically only dedicate a small amount of time to it and most instructors are under prepared to speak to the complexities of the topic.
The situational awareness-related issues cited in casualty reports often include: inadequate initial and ongoing size-ups, failure to continuously evaluate the risk versus benefits during the entire operation, ineffective communication of incident conditions, and failure to recognize hazards.
When asked, many first responders struggle to explain what it means to have SA. Even worse, many responders struggle to explain how SA is impacted and what things can be done to keep it intact. In general, there is a lack of awareness… about awareness. How ironic.
Let’s start by discussing what SA is. After that, you’ll be in a better position to understand how situational awareness can be established, maintained, impacted and how to recover when impacted by barriers. I have heard several people offer simplistic definitions of situational awareness that, in some ways, capture the essence of the concept, yet do not do it justice. For example, I have heard it described as paying attention or where perception and reality meet. Can’t argue with that, but what does that really mean? To help you understand situational awareness in a meaningful way, I turn to the work of Dr. Mica Endsley, founder and President of SA Technologies. Endsley has written over 200 academic articles and several academic textbooks on issues related to situational awareness. Endsley (1988) defined situational awareness as a perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status into the near future.
Stated another way, situational awareness is a first responder’s ability to capture information – cues and clues (think of gathering up jigsaw puzzle pieces) from what is happening around you… then being able to put those clues and cues together to mean something (think of assembling some of the puzzled pieces to start forming a picture)… then being able to predict future events as a result of what you have captured and the meaning you gave to it (think of looking a partially completed jigsaw puzzle and making predictions about what the completed picture will look like). Endsley’s research discovered there are three levels of situational awareness. Level 1 is the perception phase (this is where responder’s capture the cues and clues). Level 2 is the comprehension phase (this is where responders put those cues and clues together to mean something). Level 3 is the projection phase (this is where responders predict future events based on the picture formed in the previous levels (1 and 2).
Investing time reading and learning from casualty reports can reveal some valuable lessons about how tragedies occur. I have read hundreds of casualty reports, some involved fatalities and some were significant injury reports (but not a fatality). Oftentimes I found myself asking questions that I could not answer (nor did the reports contain the answers). In 2004 I had the great fortune to enroll in a doctoral program where I had an opportunity to research situational awareness and high-risk decision making processes. Specifically, I was seeking to understand what goes wrong at emergency scenes from a cognitive neuroscience perspective. The more I learned about brain function the more I understood the role that situational awareness plays in making high-risk decisions.
Specifically, my research looked at barriers that impact first responder situational awareness. There are a lot of barriers, over one hundred in fact. However, there are some barriers that occur frequently and their impact can be catastrophic to first responder safety. This series examines some of the most pervasive barriers that can impact first responder situational awareness.
The Pre-Arrival Lens and Confirmation Bias
The process of developing situational awareness requires a responder to understand what is happening at an emergency scene. The process of understanding begins prior to arriving at the emergency scene based on information responders receive over the radio about the incident. This audible information, when processed in the brain, forms visual images of the incident scene on the mind of the responder.
The visual imagery of audible information helps responders comprehend the meaning of the information being shared by the telecommunication professional. Stated another way, the words coming over the radio paint a picture of understanding on to the minds of responders. If the words being shared are clear, concise and accurate, the picture can be remarkably vivid and reasonably accurate. If the words being shared are ambiguous or confusing – or if too much information is shared – the picture on the mind can be blurry, inaccurately drawn, or non-existent.
The images of the incident scene formed on the minds of responders while on the way to the call are their pre-arrival lens. Virtually every (experienced) responder will form a pre-arrival lens based on the information shared over the radio.
This pre-arrival lens, in turn, sets up expectations of what responders will see and hear once they arrive on the scene. This is where the pre-arrival lens can contribute to some situational awareness problems.
Receiving information about the emergency prior to arrival is valuable. Having incident scene information in advance of arrival reduces ambiguity. The information might also reduce the stress of uncertainty and the information might help responders get mentally prepared for the tasks they will have to accomplish on their arrival.
Depending on the quality of the information shared over the radio, coupled with the experience level of the responder, pre-arrival information can also contribute to confusion and increase stress. Company officers, as well as command-level officers, may begin making assignments to crewmembers based on the pre-arrival information. In other words, an action plan and assignments are being formulated before an on-scene size-up has been conducted.
One of the problems with the pre-arrival lens is the brain can be very stubborn about changing the picture of understanding (sometimes referred to as the mental model) once it has been set. Of course this is not a phenomenon unique to emergency responders on the way to incident scenes. This is true of most humans.
It takes a lot of brain energy to sort out information and to make conclusions about what is happening. Once the brain has completed this laborious task, it tends to be satisfied with its findings and is not inclined to want to start the process over again. Arriving responders may then forgo the process of size-up. Not because they are lazy. Because in their mind, they already know what the situation is and they have likely already concocted a solution to the problem prior to arriving on the scene.
Once the picture of understanding is painted on the brain, it can be hard to erase the picture, either in part or in whole. The danger with this is a responder may arrive on the scene of an emergency with a perceived “complete understanding” of what is happening based on information shared over the radio.
There is a possibility, and under certain circumstances a high probability, the picture of understanding on the minds of the responders is incomplete and/or inaccurate. Responders may then arrive – under the belief they accurately know what is happening – and implement a tactical plan based on assumed information.
This situation can be complicated by a phenomenon known as confirmation bias. A responder experiencing confirmation bias may arrive on an emergency scene and may only see (or hear) the information that confirms what they already know (or think they know) about what is happening. If confronted with a piece of novel information or conflicting information, their brain may dismiss that information as inaccurate or simply coincidental and unimportant.
Here are some ideas for how responders can combat the challenges created by the pre-arrival lens. First, when receiving information about the call via radio, at the end of the transmission think: “maybe.” In other words mentally cast doubt on the accuracy of the information. This does not mean the responder is doubting the truthfulness or accuracy of the tele-communicator. It means the responder is doubting the ability of the CALLER to provide truthful and accurate information to the tele-communicator. By saying “maybe” it helps to keep the picture painted on the brain from drying and becoming a permanent (non-changeable) picture.
Second, when arriving on the scene of the emergency, conduct an original size-up. The arrival size-up affords responders the first factual depiction of what is actually happening. However, it should be noted the process of conducting a size-up is not without its challenges due to other situational awareness barriers we will discuss in this series.
Third, avoid making premature decisions. Because the initial awareness a crew has is formed based on information shared over the radio (based on information gathered from the caller) the company officer should avoid making premature decision and action plans prior to arrival on the scene. It is tempting (based on the picture of understanding the officer has in his or her head) to begin giving assignments to crews prior to arriving on the scene.
In some jurisdictions, these pre-arrival instructions are established in the department’s standard operating procedures/guidelines. For example, if it is a working residential structure fire, the first arriving engine crew may be pre-assigned to attack. The crew on the second arriving engine may be assigned to back up the first crew. The crew on the second arriving engine may be pre-assigned to search. As companies arrive, their action are automatic based on pre-scripted SOPs and automatic performance developed in training exercises.
While it may be popular to prescript action plans, it can also be very dangerous because the crews can implement actions without first determining if the actions fit the conditions. When the actions fit the conditions the outcome may look like poetry in motion. Crews perform their tasks so quickly and with such precision it looks impressive. Again, that’s if the actions fit the fire conditions.
When the actions do not fit the fire conditions the outcomes can be catastrophic. Critics may wonder: “What were they thinking when they did that?” The truth of the matter is, they may not have been thinking about whether their great plan fit the fire conditions. Rather, they may have been so focused on implementing the pre-arrival action plan – a plan based on assumed information shared over the radio, in standard operating guidelines and through habits developed in training.
The size-up is critical to the formation of situational awareness. Yet it is so often, for one reason or another, overlooked by first arriving crews. For this reason, it may be a good idea to remind the first arriving officer to complete a size-up. This can be accomplished by having the tele-communicator say the crew “We are standing by for your 360-degree size-up.”
Once the 360-degree size-up is complete, the officer announces the findings over the radio for the benefit of all in-coming personnel. The announcement should begin with the words “Upon completion of the 360 size up, we have…” and provide the details. This preamble tells all incoming personnel the 360-degree size-up was, indeed, completed. If the first arriving officer is not able to complete a 360 size up, that becomes the preamble to their size-up: “Upon sizing up sides A, B and D, we have…” This tells subsequent incoming crews the C-side of the structure was not sized-up.
In part two of this series we will look at the situational awareness barriers of task fixation, mission myopia, auditory exclusion, sensory domination, confabulation and flawed perceptions of reality.
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