Improving incident command: The ‘Bread and butter’ Australian Approach

Fire and Rescue New South Wales’ Nicholas Ferrante reports on the methodology adopted and embedded by his service taken from the lessons learnt from an incident command research project

Articles in last year’s corresponding edition of FIRE focusing on incident command by Tony Prosser and Dr Dave Sloggett outlined the fact that complex incidents do not always appear to be well managed by UK blue light agencies.

Whilst the evidence presented in the articles supports their conclusions, neither articles suggests that there is some impenetrable barrier to achieving improvements. If things really are as bad as the authors say, it should be a straightforward exercise to improve response procedures that are not working. However, this is only true when emergency service agencies have the will to develop clear standards for their own incident command performance and do not shy away from brutally honest self-evaluation.

While blue light services appear to be very keen on embracing the most recent management ideas from the corporate arena, it is not uncommon to see a service withdraw swiftly from something like high reliability organisational (HRO) theory, which places operations and a focus on identifying and rectifying failure points at the apex of its culture.

Incident Command Research Project

Through 2011-12 one Australian emergency organisation, Fire and Rescue New South Wales (FRNSW), conducted a significant research project, aiming to find more effective methods of both managing and training for management of large and complex incidents. The project was instigated on the back of a general understanding that improvements were needed and by some near miss incidents where accountability and communications played a contributing factor.

The project culminated in a complete re-write of the incident command doctrine used by FRNSW and saw changes to the way the organisation selected and trained its command staff. Whilst the methodology of the project is too complex for this paper, six of the lessons learned are summarised below:

Lesson 1 – Command Expectations

FRNSW did not previously have a simple articulation of what it expected from its commanders. This should be a simple question for any organisation to answer, but unless everyone is giving the same answer when asked the organisation does not have an effective command system. FRNSW now has four very simple absolute requirements from anyone commanding an incident:

1. Who – The commander must know who is operating on the incident ground. Not a rough idea, not pretty close, but full accountability of every responder
2. Where – The commander must know the geographical location on the incident ground of every responder
3. What – The commander must know what every responder at the incident is actually doing and that they are only undertaking tasks that are part of his/her plan to resolve the incident
4. Watch – Lastly, the commander must know who is watching out for every responder.

If the commander is confused about any of the above, you can be absolutely certain that the responders themselves will be. And if you want to kill command effectiveness, allow responders to become confused.

At first glance these requirements may seem onerous, but a commander will soon realise that being obliged to answer these questions at every moment clarifies what the commander’s role is really about. Focusing on these four elements forces the commander to get out of the weeds, set an intent for what success will look like and delegate the task level work and decision making to the front-line responders.

When FRNSW set up systems of work in consideration of these questions, it clarified for the organisation some things that were previously interfering with effective command. As an example, FRNSW realised that its previous practice of assigning one of its crew commanders into a safety officer role could break down accountability by taking this officer away from his/her crew. Assigning a safety officer was at times making the “where and watch” questions difficult to answer. This is not to say that a safety officer should not be appointed, just that his/her crew cannot be left as orphans.

More importantly, having a focus on these four questions makes safety the centre of gravity for the whole incident. Many emergency organisations tend to measure their performance against criteria such as “did the fire go out?” or “were any responders injured?” These criteria say little about process safety.

An incident end point has little to do with how safe or efficient the process was. As an example, a car full of people may drive from A to B. However, reaching point B with no passengers being injured says nothing about how safe the journey was. If you later found out that the driver was tipsy, the car was speeding and no one wore seatbelts, you should not assume the journey was a success. In fact, an agency that judges itself on some desired incident end point, or metrics such as lost time injury rates, may miss how unsafe their incident command processes actually are.

We have all heard the saying that badly managed incidents can have good outcomes and well managed incidents can have poor outcomes. Making these four questions the focal point for incident commanders means you are driving sober with your seat belt buckled. It is also very pleasing to organise a post incident debrief and have responders confirm they knew where they were meant to be, what they were meant to be doing and who they were reporting to. To be brutally honest, if any responder becomes confused, incident command has failed.

Lesson 2 – Cognitive Ergonomics Matter

In fact they really, matter. FRNSW discovered that when an initial commander gets drawn into a complex firefight, they simply will not have the bandwidth to keep checking their own performance against the four questions.

The aviation industry has become master of understanding how important it is to appreciate the mental load on pilots and to design systems of work to keep this load manageable. Whilst some fire agencies acknowledge cognitive load management, it is rarely one of their key focal points.

For FRNSW, the realisation that cognitive load management could be improved led to major changes in commander training. This became especially important when considering the question of whether an early arriving commander should be hands on assisting his/her crew, or removed from the physical aspects and distractions of the incident.

FRNSW began training its early arriving commanders (station commanders) to recognise that if they could not answer the four key who, where, what, watch questions, they had no choice but to disengage from the physical work. If you cannot keep track of these questions in your head, you need to find a quiet place, sit down and start putting pen to paper.

An early arriving station commander may begin managing an incident whilst also helping his/her crew to bowl out hose, one of two things will happen from there. The incident will be quickly resolved and the initial commander’s mental workload will begin to decrease, or the incident complexity will increase to a point where they will begin to lose situational awareness regarding other responders. At this point the commander must disengage. Inability to answer the four questions therefore becomes a trigger point for the trainee commander to recognise that they are losing the level of control expected of them.

Be on your feet assisting with the firefight until the incident complexity means you cannot track everyone in your head, then disengage, develop a plan B (and C and D), start writing stuff down and be available on radio for the incoming cavalry.

When a later arriving senior officer fronts up at a FRNSW major incident, it is expected that the initial commander will begin their handover by locking down the four key questions. If at any stage answers to the four key questions are in doubt, the initial commander has, by definition, lost control of the incident. The importance of this cannot be stressed enough.

Whilst there will be plenty of responders at the incident who will find a hydrant, drag a hose or breach a door, none of these people would intuitively try to shore up answers to the who, where, what, watch questions. If the commander does not address these elements, it is almost guaranteed that no one else will. And when the commander loses situational awareness, incident management has failed.

“For all the changes to command procedures introduced by FRNSW, none gave a bigger bang for the buck than mandatory staging”

Lesson 3 – Mandatory Staging

For all the changes to command procedures introduced by FRNSW, none gave a bigger bang for the buck than mandatory staging. Prior to the research project FRNSW allowed response vehicles to drive straight to an incident, park wherever they could and begin doing whatever each crew thought was most important. Whilst this approach would often deal with the incident problem very quickly, it made moving to a plan B if not impossible, then extremely difficult. This is true because the one thing worse than having no plan will be having several plans in operation at the same time. And that is exactly what you get when responders just pull up and begin working.

Whilst many emergency managers seem to think staging is principally about traffic management, it is actually about preventing the incident from snowballing into a free for all. The FRNSW procedure specifies the first two vehicles go directly to the incident address. This allows for an early arriving station officer to assume the role of initial commander and for a “single” plan to be developed. Subsequent arriving vehicles drive to a nearby designated staging area and sit tight until needed.

Although this looks like it may slow the overall response down, in practice it has numerous benefits. Firstly, it forces the first on scene commander to adopt a strong command presence, take on the strategic functions of a commander and to deploy the later arriving crews in line with a single overall plan. Secondly, it means the initial commander’s span of control can be kept to a manageable level because he/she need only speak with the first vehicle to arrive in the staging area, not to each vehicle as they arrive.

The officer in charge (OIC) of the first vehicle will speak to later arriving vehicle OICs face-to-face on behalf of the commander. Lastly, it allows the commander to build up a small army of resources close to the incident for unanticipated contingencies, but without creating the problem of having dozens of responders walking all over the incident. Mandatory staging means the commander will always have just the right amount of people on the incident ground.

Lesson 4 – Not Too Many Moving Parts

Because, even at the best of times, emergency incidents can be noisy confusing places. Response plans must not add unnecessary layers of complexity. FRNSW has attempted to simplify incident plans by specifying that all emergency incidents will have the same set of three overarching objectives: 1) The saving of saveable lives, 2) Preventing incidents from expanding beyond a chosen boundary, and 3) Minimising impact on the surrounding community.

Whilst this is very similar to most other fire agencies, FRNSW commanders are empowered to delegate how these objectives will be met to lower level tactical officers. At a fast moving, complex incident, a FRNSW commander can simply send crews into a geographical portion of the incident with a broad mission designed to meet the principle objectives. The commander has the expectation that the crew will report back what their needs are to achieve, as best they can, these pre-determined overarching objectives.

In military command philosophy this approach is very similar to the articulation of a “commander’s’ intent”. Once the objectives are understood by all, anything about the incident that prevents the objective being met is considered as a “critical factor” that the crew must address at their level. So, if fire prevents a crew getting to a victim, this is what they address; if a locked door prevents a crew getting to a victim, this is what they address; if vehicle congestion is impacting the surrounding community, this is addressed.

Without the incident commander needing to issue order after order, the crew have autonomy to deal with each critical factor, one after the other, until all three principle objectives have been met. At any time the crew can call on the commander to supply them with additional personnel or equipment as required, or to let the commander know if there are hold ups in dealing with a critical factor, which in turn may delay an objective being met.

Another advantage of the approach is that it can give context to the complex issue of risk acceptance. FRNSW now uses a stratified level of risk acceptance marked by which objectives are being worked on. In practice this means that whilst fire crews may be allowed to enter a burning structure in an attempt to save lives, they may not be expected to enter the building if the objective was only to prevent fire spreading beyond a chosen boundary. In this case the pay-off for accepting risk is less, so the chosen boundary may simply be moved beyond the affected building and the fire crews would establish a cut-off point at the next unaffected structure.

Lesson 5 – The Answer to Communications Problems is Not More Talking

Previously, FRNSW would identify an incident management problem and respond by introducing a new acronym into its operational communications lexicon. By the mid 2000s there were over 60 acronyms to learn. Command courses had become heavy on learning strings of letters, light on using radios to get real things done. Previously, even relatively small incidents were marked by copious amounts of radio traffic, most of which was not mission specific.

Assuming that radio hardware works, the answer to communications issues is not in how much communicating goes on, it lays in the commander rigorously managing the amount and type of communications. More specifically, it is about ensuring that the objectives or tasks that need to be addressed within the plan are the only thing that are spoken about.

When the incident commander has developed a simple plan without too many moving parts and has made a commitment to delegate decisions regarding how the objective will be achieved to the lowest level possible, there should not be that much to talk about.

Once a crew, or crews, have been tasked, the only thing the commander needs to know is if he/she can tick the objective off the list for each geographical sector of the incident. Reports back from crews can be as short as two or three words, so long as these words are specifically addressing their tactical mission. If their mission has not been achieved, do they need something from the commander to get it done? If the mission is achieved, what is their next mission?

An indicator of a well-managed incident should be how little radio traffic is required to confirm that the incident objectives have been met. FRNSW discovered that this was an area in which they were able to make significant improvements. When training and practice became less about talking and more about conveying only the most critical information, in the fewest words possible, many communications problems simply disappeared.

Whilst many commanders who have organised a complex incident debrief would be expecting communications failures to be common and strongly articulated, there have been many FRNSW debriefs where radio communications did not rate a mention or were even spoken about in complimentary terms.

Lesson 6 – Simulate, Simulate, Simulate

There is no doubt that like UK fire services, Australian commanders get less opportunity to practice their craft at real emergency incidents. However, there is little to prevent commanders practicing incident command skills through simulations instead. In fact, simulation presents a perfect way to push a commander to the point of error, whilst not suffering the consequences of a mistake. Simulations offer the opportunity to stop, rewind and demonstrate to command students how common errors can be rectified.

There are several sophisticated computer-based platforms for command simulation, but good training results can be achieved with little more than a few radios and a couple of white boards. In fact, the most sophisticated software/hardware platform in the world is worth very little until the agency has a sound command philosophy and standards to measure the training against.

Bread and Butter Process

In conclusion, the above lessons are not a comprehensive list of changes that have been made to FRNSW incident command procedures over the previous decade. They merely represent some areas in which FRNSW has made the most significant changes to its command practices. Those familiar with the writing and command philosophy of Alan, Nick and John Brunacini will recognise where many of these practices were borne.

FRNSW would be happy to share our research and experiences with other fire agencies and it is our sincere hope that the command of large and complex incidents can truly become a bread and butter process.