Culture: the set of shared attitudes, values, goals, and practices that characterizes an institution or organization.
The Primary Search
A Primary search taking place early in a fire is an extraordinarily dangerous and high-risk activity because it will likely occur above or in front of hose lines and in poorly ventilated spaces.
What is the search culture in your department? (Not how you do the search, but rather, when and why.)
Is it a rigidly automatic “every building must be searched NOW, regardless of circumstances” one or a more pragmatic approach based on fire conditions, rescue likelihood or available resources?
Some fire departments have a doctrine demanding that an immediate primary search be conducted regardless of the apparent risks to firefighters or the conditions in the fire building. This is the case even when there is no evidence or indication that a search would yield a victim, viable or otherwise.
If a search operation is automatic and begun without (at least) a verbalized risk appraisal, it is operating outside of the widely accepted managed risk culture now inherent in every professional activity where action carries the risk of injury or death, be it combat, search and rescue or firefighting.
Some search and rescue cultures will decline to conduct a search given the environment and the hazards to operating personnel, even when the presence of a victim is verified. Does this make them cowardly, more professional, or just calm under pressure?
One thing is for sure, at the very root of search cultures are human emotional characteristics associated with risk and danger and unless they are effectively controlled by professional behaviour and systems, the results can be devastating. Even in search professions more advanced (and professional) than firefighting, tragic slip-ups occur.
Late in the afternoon of June 9, 2009, New Mexico State Police (NMSP) received a call from a lost hiker in the Pecos Wilderness not far from Santa Fe. NMSP has an aviation section and the Chief Pilot was contacted to see if they could provide search support. He initially turned the mission down because of the winds present in the mountainous location where the hiker was lost. (He had already worked an 8-hour shift including three flights and had tried, unsuccessfully, to have other pilots take the search flight.) The Chief Pilot then re-contacted the operations center and agreed to take the flight himself.
Over the next 2 1/2 hours the helicopter with the pilot and a spotter flew to and searched the area as sunset approached. The crew eventually located the lost hiker, made the decision to land in the mountainous terrain and to pick her up. As they returned to the helicopter it was dark, sleeting and as they took off, white-out conditions prevailed. About two minutes later, the tail boom or rotor struck an object and the aircraft crashed. The hiker and the pilot were killed and the spotter survived with serious injuries.
The National Transportation Safety Board(NTSB) investigated the accident, and also studied aspects of search culture directly applicable to firefighters, and indeed, anyone who does such work. As always, there were multiple contributing factors. Many of these factors were directly related to the absence of on-going risk assessments by searchers.
Heroes Under Pressure
The Chief Pilot was a former Marine, described as a very heroic type person, aggressive, and high-spirited. But, also someone who had “difficulty saying no to managers.”
He was operating under “self-induced pressure”, first to take the flight, then to make the landing, and finally, to take-off after locating the hiker. Any of the three decisions could have been aborted. Ground search crews were on their way into the area. Once on the ground there was no reason to take off other than to complete the mission quickly.
The pilot also became “fixated” on taking off, as if no other alternative was viable when they could have simply stayed on the ground, running the engines as needed for warmth. The NTSB referred to this behavior as “tunnel vision.”
NTSB effectively concluded that the pilot appears to have consistently devalued, ignored or missed environmental and logistical obstacles to a successful completion of the mission: the lost hiker was not especially helpful, the weather deteriorated more quickly, the search took longer than expected, etc.
The Responsibility of Leadership
It’s so easy to blame the pilot, right? But, not so fast. The NTSB puts the ultimate responsibility for the accident on organizational leaders and managers.
“Upper Management plays a key role in any safety program, because, ultimately, management has control over the personnel and resources that generate exposure to risk.”
Perhaps most significantly, the NTSB is reinforcing the point that organizations engaged in search and rescue must adopt risk assessment as a key part of their culture. That risk assessment must occur continuously throughout the operation, not just at the beginning:
“The aviation system did not require its pilots to perform a structured, systematic risk assessment before accepting a mission or to reassess risks during a mission.”
Automatic searches conducted without continuous risk assessment, including an initial go/no-go decision, are simultaneously heroic, unprofessional, reckless and often futile.
Where firefighters are concerned, three questions stand out:
-How likely is a victim to be present?
-If present, are they likely to be viable?
-Is it likely we can reach them and get them out?
These are questions that other search cultures routinely ask and sometimes when the responses are largely positive they will still decline the mission or conduct it under the strictest controls to protect their personnel.
We have much to learn from their measured approach.
Take a minute and describe your department’s Search Culture by leaving a Comment .
Sources: NTSB, MassLive