TIMMONS Dissertation
-
Upload
ron-timmons -
Category
Documents
-
view
58 -
download
1
Transcript of TIMMONS Dissertation
SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND
COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS
by
Ronald P. Timmons
APPROVED BY SUPERVISORY COMMITTEE: ___________________________________________ Douglas J. Watson, Ph.D., Chair ___________________________________________ Kimberly A. Aaron, Ph.D. ___________________________________________ Donald R. Arbuckle, Ph.D. ___________________________________________ James W. Marquart, Ph.D.
“…our effectiveness is only as good as our ability to communicate.”
(Donald J. Burns in U.S. Fire Administration 1993, 54)
This dissertation is dedicated to the memory of Assistant Fire Chief Donald J. Burns,
New York City Fire Department.
At two of the most difficult fire department operations imaginable, there was one man
in the unique position to understand the interconnectedness of communications and
command. After facing the first World Trade Center attack in 1993, Chief Burns testified
that, “One of our biggest problems was communications” (U.S. Fire Administration
1993, 54). He returned on September 11, 2001 to command a portion of the FDNY
response to the terrorist attacks at the same skyscraper complex. Although radio
recordings prove police helicopter warnings of impending collapse of the second tower,
there is no indication that the message on the police radios made it to Chief Burns’ fire
command position at the base of the North Tower (Dwyer 2002; National Commission on
Terrorist Attacks 2004, 309). He died along with 403 other brave first responders in the
collapse of the buildings.
Befitting the man who served the citizens of New York for 39 years, many years past
retirement age, his funeral mass occurred at Saint Patrick’s Cathedral on October 9, 2001.
His wife and three children joined hundreds of uniformed firefighters lining Fifth Avenue
to salute the man, despite the unimaginable reality that his unrecovered remains were just
four miles away. The dignitaries used words such as “hero,” “patriot,” and “unparalleled
experience” to salute him at the funeral (Virasami 2001).
My experience with Chief Burns was happenstance, but indelibly memorable. I was
in need of a ride out the Long Island Expressway on a hot Friday afternoon in June 1987
and he was going in my direction. I was a rookie lieutenant from one of the smallest fire
iv
departments in the state and he was the chief in charge of the officers’ training program
for the largest fire department in the country. He was the boss and I was the student at his
training academy. Hierarchically removed from me by several ranks, it would have been
easy for him to say no to my request for a ride, but he did not. He was older and much
more experienced, but he was interested in what I had to say and impressed by my
educational and career aspirations. As much as I tried to turn the 90-minute conversation
back to him and his experiences, he was more interested in what I could tell him that he
did not know. He inspired me with his gentle, confident humility and encouraged me with
his vision of advancing our profession through formal education.
It is my fervent hope that this dissertation will inspire future generations of first
responders to address the perennially vexing problem of emergency communications, in
all its forms: technological, relational, and physiological. Chief Burns sparked that
interest in me, and now it is time for you to take it further…
Ronald P. Timmons
SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND
COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS
by
RONALD P. TIMMONS, B.S., M.P.A., M.A.
DISSERTATION
Presented to the Faculty of
The University of Texas at Dallas
in Partial Fulfillment
of the Requirements
for the Degree of
DOCTOR OF PHILOSOPHY IN
PUBLIC AFFAIRS
THE UNIVERSITY OF TEXAS AT DALLAS
May, 2009
ACKNOWLEDGEMENTS
I gratefully acknowledge the…
…loving support from my wife and daughter
…grounding and example from my beloved parents
…interest and encouragement from my brother and sister
…patience and insightful wisdom from Dr. Douglas Watson
…suggestions and generous service of the dissertation committee
…the dedicated firefighters of the Allen, Plano and McKinney Fire Departments
…assistance and inspiration from my devoted coworkers at the city of Plano, Texas March, 2009
vi
SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND
COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS
Publication No. ___________________
Ronald P. Timmons, Ph.D. The University of Texas at Dallas, 2009
Supervising Professor: Douglas J. Watson The decision-making and communications processes of community first responders are
frequent concerns at intense crisis responses. Effective command is dependent on sound
decision-making; adequate communications processes are critical elements in successful
crisis decision-making. Homeland security initiatives have reemphasized this issue. Although
the assumption may be immediate and complete improvement of communications is solely
awaiting radio hardware upgrade, this study identifies nontechnical factors impeding
successful communications. Of particular interest were those situations whereby radio
messages were clear; however, the intended recipient was unable to receive the message or
make best use of it, despite evidence of cogent message delivery on recordings.
One hypothesis tested is whether sensory overload contributes to ineffective
communications. Also tested is a prediction that commanders at emergency scenes mishandle
radio messages even when the equipment is functioning properly. Case studies of actual
incidents and observation of realistic training exercises allowed isolation and analysis of
vii
common features of communications dysfunction. A series of phenomenological studies
observed first responders in the act of communicating as they typically would at emergency
scenes. This fieldwork at fire department training exercises allowed the researcher to collect
data associated with distractions and communications dysfunctions.
Validation of both hypotheses occurred. Messages requiring repeating, as well as those going
unanswered or otherwise missed were common. Most of the dysfunctional radio
communications occurred because of inattention to the radio due to distraction from talking
in person to others nearby, confusion over proper radio channel selection, garbled, excited, or
unintelligible messages from the sender, and background noise associated with chaotic
emergency scenes. In 38 percent of the cases, there was no apparent reason for the missed
message; physiological and psychological factors from analogous studies provide potential
explanation.
The significance of this research is in studying the specific moment of radio dysfunction and
correlation with underlying causes. In those instances where no apparent reason existed for
the communications dysfunction, physiological stress reactions are theorized as underlying
factors, along with a number of equipment and human factors. Readers receive practical
solutions for improvement of emergency communications, acknowledging that some
occurrences of missed messages are inevitable in the demanding emergency environment.
viii
TABLE OF CONTENTS
Acknowledgements............................................................................................................ vi
List of Figures ................................................................................................................... xii
CHAPTER 1 INTRODUCTION .......................................................................................1
First Responder Communications Issues .................................................................4
CHAPTER 2 LITERATURE REVIEW ............................................................................7
Decision-making in the First Responder Environment............................................7
Military ....................................................................................................................9
Personal Influences ................................................................................................10
The Role of Communications in Crisis Decision-Making.....................................13
Sensory Overload and Task Interruption ...............................................................16
Inattentional Blindness...........................................................................................24
Literature Review Summary ..................................................................................27
Hypotheses.............................................................................................................28
CHAPTER 3 METHODOLOGY ....................................................................................29
Research Design.....................................................................................................29
Data Collection ......................................................................................................33
Coding of Observable Behaviors ...............................................................34
Data Organization and Analysis ................................................................34
CHAPTER 4 CASE STUDIES OF ACTUAL INCIDENTS ..........................................36
Syracuse, New York 1978 .....................................................................................37
Hackensack, New Jersey 1988...............................................................................38
North Hollywood, California 1997........................................................................39
Seattle, Washington 1998 ......................................................................................43
Prince William County, Virginia 2007 ..................................................................44
Charleston, South Carolina 2007 ...........................................................................46
ix
New York City, New York 2009 ...........................................................................52
Common Themes Among All Cases Studied ........................................................57
CHAPTER 5 CASE STUDIES OF TRAINING EXERCISES .......................................61
McKinney Fire Department Case Studies Venue Description ..............................61
Exercise Data .........................................................................................................66
McKinney Case Studies Day One..............................................................69
McKinney Case Studies Day Two.............................................................78
McKinney Exercises Analysis ...............................................................................81
Plano Fire Department Case Studies Venue Description ......................................83
Plano Case Studies Day One......................................................................86
Reevaluation of the Simulation Environment – Testing Sub-Theories .................92
Plano Case Studies Day Two.....................................................................92
Plano Case Studies Day Three...................................................................99
Plano Exercises Analysis .........................................................................106
McKinney and Plano Exercises Compared..........................................................108
Influence of Talking While Wearing A Mask .........................................109
Simulation Environments.....................................................................................109
CHAPTER 6 IMPLICATIONS AND RECOMMENDATIONS..................................112
Research Summary ..............................................................................................112
Hypotheses Results ..............................................................................................113
Why Messages Are Missed..................................................................................115
Sensory Overload.....................................................................................116
Physiological Hearing Deficit..................................................................117
Inattentional Deafness..............................................................................119
Solutions ..............................................................................................................120
Human Factors Engineering ....................................................................122
Training....................................................................................................124
Final Thought.......................................................................................................126
APPENDIX A..................................................................................................................127
APPENDIX B ..................................................................................................................128
x
APPENDIX C ..................................................................................................................129
BIBLIOGRAPHY............................................................................................................130
VITA
xi
LIST OF FIGURES
Number Page
1. Summary of Positive Scores From McKinney Day One ...............................................77
2. Summary of Positive Scores From McKinney Day Two ..............................................81
3. Ranked McKinney Scores..............................................................................................81
4. Scores Compared To Pace .............................................................................................82
5. Summary of Positive Scores For Plano Day One ..........................................................91
6. Summary of Positive Scores For Plano Day Two .........................................................98
7. Summary of Positive Scores For Plano Day Three .....................................................105
8. Collaboration Influence In Scoring..............................................................................106
9. Correlation of Collaboration With Scores ...................................................................107
10. Comparing Influence of Mask Usage on Communications Efficacy ........................109
11. Communications Deficits...........................................................................................116
xii
1
CHAPTER 1
INTRODUCTION
First responders are the police, fire, and emergency medical personnel who respond to
emergencies throughout our communities. Daily routine allows for management of incidents
in a habitual manner. Occasional intensive disasters, ranging up to the scope of the 9/11
terrorist attacks, Hurricane Katrina, the Columbine High School shooting, and the Oklahoma
City Federal Building bombing, are examples of calamitous incidents requiring the most
urgent of communications and decision-making capabilities by first responder incident
commanders.
Failure in this decision-making environment can result in dire consequences for crews
and citizens awaiting rescue. Commanders at emergencies do not have the luxury of
deliberation and debate. They often need to take instant action to achieve objectives within
very tight timelines. One study showed that fire department commanders face dynamic
conditions at emergency scenes, requiring new decisions to answer an average of five
situational changes within the typical incident (Klein 1999, 6). An interesting aspect of
emergency scene decision-making is the instant feedback provided to the decision-makers.
This allows a honing of decision-making skills and rapid development of experience in
critical situations, along with a tendency to apply heuristic decision-making as reflexive
coping mechanisms (Simon 1981, 66). People functioning as incident commanders at
2
community emergencies face a number of unique challenges. The rapidly changing
environment makes actions appropriate for one moment, yet inappropriate in new
circumstances just a short time later.
The command staff somehow has to reverse hierarchical practices used during daily para-
militaristic practices, as they seek to find creative, flexible decision solutions in infrequent
crises. Decision-making in hierarchical organizations can be problematic. Conflicting
interests of serving political or internal command structures make it difficult to provide
commanders in high-pressure situations the flexibility necessary to react to changing
circumstances (Roberts et al. 1994, 623). Mendonça (2007, 964) argued for the need to build
robust systems allowing flexibility and creativity for the proper handling of extreme events.
Analogies of jazz musicians using improvisation techniques built within the constraints of a
musical chord structure show the possibility of making procedures and rules constructed to
allow some degree of customization depending on the circumstances (Mendonça 2007, 964).
Comfort (1985, 158-159) highlighted the importance of concurrent information gathering
as the interaction of people and events generate geometric complexity in the decision-making
process at emergencies. All responders present at the incident need to make a scan of the
operational environment with relevant information fed to a centralized decision-making
authority. In one study, firefighters interviewed about their decision-making process denied
that it was a formal process of weighing several alternatives, but rather a reflexive reaction to
circumstances as they occur (Klein 1999, 16). Therefore, something significant is occurring
in the milliseconds between input of conditions stimuli and the resultant selection of an
appropriate response (Gladwell 2005, 11-15).
3
First responders rely heavily upon two-way radio equipment to communicate with one
another and to gather the information necessary to start the decision-making process before
arrival at the scene. “Inadequate fireground communication is repeatedly cited as a
contributing factor in many of the incidents reported through the United States,” according to
the U.S. Fire Administration (1999, 1-3). Chaotic communications at emergency scenes are a
frequent frustration with the assumption that only a technological improvement is necessary,
ignoring human factors (National Commission on Terrorist Attacks 2004, 280-285). The
weakest link in communications networks can be the human element. “There is a dearth of
available literature pertaining to the impact of human factors on effective fireground
communication” (U.S. Fire Administration 1999, 2). Even the most robust of radio systems
can be overwhelmed during routine incidents. Intense crisis situations can lead to almost
certain network collapse unless the users prioritize their messages. Radio traffic
management, within a fine line between too much information and not enough, needs
attention to assure that critical situational and safety information reaches incident
commanders (U.S. Fire Administration 1999, 10). The events and rapid flow of information
at emergency scenes can quickly overwhelm fireground commanders. The reduction in the
number of support personnel available in the form of chiefs’ drivers and aides may make this
concern more acute (U.S. Fire Administration 1998, 10).
This topic is ripe for further research to establish cause and effect relationships between
physiological and environmental influences in the emergency environment and the quality of
communications used by first responders. The commanders of emergency incidents measure
their successes by lives and property saved. Therein resides the difference between the
classic treatment of decision-making in the literature and the need for more research and
4
understanding of the unique challenges present in fast-paced emergency operations.
Demands for rapid decisions in compressed timeframes with limited information and
significant consequences for poor choices challenge emergency responders (Klein 1999, 9-
12; Garnett and Kouzmin 2007, 174.) Emergency commanders work in a critical decision-
making environment where the common doctrine of decision-making theory does not always
apply or it may need modification to meet the unique challenges. Decision theory literature
tends to focus on boardroom-style decision-making; slow, deliberate decision process is of
marginal value to emergency responders working in fast-paced, high stress, high stakes
environments (Klein 1999, 9, 18-19; Weick 2002, S12). Quality decisions by those
responsible for commanding emergencies are critical for the successful outcome of the
incident. Responders perform a number of critical tasks; the safety of those operating at the
scene, and the wellbeing of those affected by the incident, add to the pressure to find correct
decision solutions. One of the ironies and realities of all improvised decisions, such as those
made at emergency scenes, is the realization that a chosen tactic is not working only occurs
after it has already failed (Weick 2002, S12). Failure in the emergency services domain can
sometimes result in unnecessary death, destruction of property, and significant interruption of
commerce, which intensifies the need for sound decision-making practices.
First Responder Communications Issues
This research challenge is an outgrowth of the dissertation author’s interests and
experiences surrounding emergency scene decision making and communications processes.
Research shows human impediments to communications beyond the predominant technical
interoperability issues being address by homeland security professionals (Hutchins and
5
Timmons 2007). First responders face a work environment replete with stressful situations
and difficult choices in compressed timeframes. Since Gaines and Jermier (1983, 571-572)
claimed the literature conflicts in establishing the influences of stress and fear in decision-
making, this dissertation works to “de-conflict” the connection between environmental
influences and humans communicating and making decisions in crisis mode.
Upon arrival at an emergency scene, personnel quickly have to decide their initial tactics
from a range of choices. Years of adhering to customs and experience yield heuristic “rules
of thumb,” such as “lives first, property second.” However, within those two major
categories are dozens, or hundreds, of sub-options. Are there people in immediate danger
needing rapid rescue by the personnel already on the scene? Can the subjective assessment be
made that some victims are beyond hope of surviving their injuries, and the limited resources
available be redirected to the “savable?” The minimally injured “walking wounded” may also
be the most vociferous demanders of attention by the first responders, as they may
aggressively demand treatment, or want help to locate lost companions and family. Will the
decision-making first responders be able to transcend their daily orientation of helping people
in minor situations and go past those pleading for help, to seek those within minutes of losing
their lives from critical injury and immediate peril? The presence of multiple distraction factors
in the emergency operation environment can lead first responders not to hear critical information
on their radios due to noise at the scene and the sheer volume of radio traffic (Spahn 1989, 18;
U.S. Fire Administration 1999, 6). These are the realities of the first responder decision-
making and communications environment targeted by this research effort. There is a need to
study attention span and sensory overload as significant factors in communications efficacy.
6
This research is particularly timely since homeland security has received increased
interest and funding in this decade. Command and communications issues predate the terror
attacks of 9/11 and have been a factor for many years (Hawkins 2007, 1, 5-6; National
Commission on Terrorist Attacks 2004, 280-285; U.S. Fire Administration 1993, 14, 32, 38-
39, 51; U.S. Fire Administration 1999, 2-3, 9). Many of the same communications challenges
facing the responders to the World Trade Center in 2001 existed when they responded to the
same complex for the first terrorist attack in 1993 (U.S. Fire Administration 1993, 14, 32, 38-
39, 51). Some of the communications issues in high-rise buildings are technological, but
some part of the burden falls to the radio operators. There is a relatively low level of
consensus among emergency responders that they have a share of the responsibility in
communications failures. The tendency has been to blame the radio equipment, instead of
considering the human elements involved (Timmons 2007, 2).
This dissertation first examined the unique challenges present in the community
emergency environment and then outlined several underlying influences and biases in the
decision-making process used by command personnel at intense incidents. Communications
efficiency and the influence of distracting factors are the specific focus of this dissertation
since communications are such a critical component of the decision-making process. The
researcher presents new approaches in providing communications and decision support to
incident commanders and suggests implications and recommendations in the final section of
this dissertation. These suggested decision-support and communications improvement
opportunities customize the existing literature on generic decision-making, along with
information learned from analogous disciplines and perspectives.
7
CHAPTER 2
LITERATURE REVIEW
Decision-making in the First Responder Environment
Paradoxically, those involved in the dynamic environment of emergency services
traditionally have a systemic resistance to change (Comfort 1985, 163). Rapid, adaptive
learning, in “real-time” has to occur, yet those involved have classic attributes of traditional,
rules-bound bureaucrats. The same hierarchical orientation from daily para-militaristic
practices requires reversal by the command staff, as they seek creative, flexible decision
solutions in occasional crisis situations. A scan of the operational environment by all
responders present at the incident is valuable, with relevant information fed to a centralized
decision-making authority. Roberts and Rousseau (1989, 135) found it important for
researchers to consider the multiple levels of activity and the impact of expected and
unexpected events on people operating in high-reliability situations. Subsequent behaviors
redirected by unexpected events, make study and analysis of crisis decision-making very
complex.
Personnel in public safety agencies tend to function in rigid, linear organizations in which
inflexible rules convey organizational expectations and standardize the approach to situations
encountered. As much as the words “good discipline” may seem an oxymoron to some, they
may be desirable, if for instance they appeared on the performance appraisal of a police
sergeant, as in “maintains good discipline among subordinate personnel.” Bigley and Roberts
8
(2001, 1293) noted the conundrum generated when it becomes necessary to commingle the
tenets of hierarchical management, emphasizing rules, routine, and procedures, yet needing
to encourage procedural flexibility during occasional and intense decision environments.
The decision-making process starts before arrival, as responders build their knowledge of
what is occurring, in bits and pieces, while they monitor radio transmissions from dispatchers
and those already at the scene (Bigley and Roberts 2001, 1291). Emergency response
personnel use several terms to describe the notion of attaining pertinent information in the
operational environment. The need to establish “situational awareness,” “size-up,” and “big
picture” are terms used to acknowledge the tendency of those at the task-level to take a
myopic view of circumstances immediately affecting them, to the exclusion of considering
the overall scene.
An anecdote in decision-making literature sheds light on the conflicted association
between classical decision-making theory and the realm we are just starting to understand-
crisis decision-making. Howard Raiffa, noted scholar and author on decision-making,
received an offer in 1957 to leave his post on the faculty of Columbia University for a
position at Harvard. His relationship with his prevailing dean was such that he went to him
for advice. The dean’s alleged response was sarcastically that Raiffa should apply his own
principles of decision theory scoring, and to go where the result of the arithmetic formula
said he should. Raiffa’s response was purportedly, "No, this is a serious decision" (Bazerman
et al. 1998, 236).
Emergency responders are likely to think the same thing—that their decisions are too
serious for reduction to weighted scoring and sterile calculations. According to Bazerman et
9
al. (1998), Raiffa insisted the story was not accurate, but it amused him nonetheless. He saw
the story as proof that there is an inevitable tension between formal and informal decision-
making processes, and there is an acknowledged role for both in the arrival at the optimal
decision.
Military
Parallels in military culture exist, as similar situations have led the armed forces to pursue
adaptive behaviors. Development of situational awareness is a necessary ingredient in sound
crisis decision-making and effective communications are an important part of gaining the
necessary information to form situational awareness.
In the U.S. Navy, “having the bubble” is the phrase for maintaining a big picture view of
operations (Roberts and Rousseau 1989, 135; Bigley and Roberts 2001, 1292). Much like
counterparts in the military, our community first responders face overwhelming variables,
chaotic situations, critical decisions, and death of citizens and coworkers a potential
consequence of poor decisions.
Radios proved to be useful in the Vietnam War allowing commanders in the rear to
monitor battleground communications and attempt to piece together what was occurring at a
location they could not see. The communications at times included excited voices in which
net controllers had to exhort the senders to slow down and clearly articulate what it was they
were requesting. In one sequence of communications from the battle at la Drang Valley in
1965, a lieutenant colonel was pinned down and calling for support (Moore 1992, 246 – 248).
When he started yelling over the radio, “They're running! They're running!” his colonel
thought for a moment that he meant his own battalion was on the run, but the sender of the
10
message meant it was the enemy who were running as a result of the air strike (Moore 1992,
247). Such inappropriate assumptions of intent in phrases with double meanings occur in
both military and first responder settings. Message clarity is an important element in effective
emergency scene communications. Excited, emotionally aroused people can exhibit loud and
uncontrolled voices, making it very difficult to understand what they are saying (National
Institute for Occupational Safety 2003, 17).
Personal Influences
Want/Should
External command of the people working at emergency scenes is one aspect of the
overall decision-making arena for first responders, but there are also introspective
intrapersonal conflict considerations. Bazerman et al. (1998, 225-230) described our inner
conflict as we wrestle between what we know we should do for our own good, and that
which is more pleasing, easy, or desirable for a variety of reasons. Diet and exercise are good
examples of what we know to be good for us, yet the translation into action is missing for
many. While it seems likely that incident commanders can put aside concerns of personal
comfort or be truly altruistic in the necessity of the moment, it is important to consider that
decision-making in daily life does little to prepare incident commanders for a predominately
“should” environment. Increased focus on the safety of responders has presented additional
internal conflict between the “want” of personal safety and the “should” of rescuing people in
dangerous situations.
11
Groupthink, Stress, and Fear
Janus (1972, 9-10) established that people functioning in groups tend to form a collective
mindset and cultivate an atmosphere in which there is a strong bias for the status quo. Subtle
squelching of dissenters is common. Janus (1972, 143) juxtaposed the relative success of the
Cuban missile crisis in which President John Kennedy encouraged opposing viewpoints with
the Bay of Pigs incident where groupthink predominated. Janus cited the latter as an example
of the deleterious effect of groupthink. Schafer and Crichlow (1996, 429) noted that group
influences are presumed to be at their highest point in crises, yet the data show a lack of
documented influence under such circumstances. Since crises are the category of interest for
this research effort, and the influences delineated in their study are pertinent to first
responder operations, the findings in the Schafer and Crichlow study are applicable since
they suggest negligible groupthink influence at emergency operations. There is a need for
further study before connecting significant inferences to the emergency environment.
Occasionally, in military and community emergencies, a cascade of poor decisions makes
it difficult to bring the chaotic situation under control, as was the case in the example of the
Bay of Pigs cited by Janus. Major failures in emergency circumstances can be a product of
multiple, successive failures. Schafer and Crichlow (1996, 418-420) examined 19 different
wars throughout history to measure the influence of the following ten attributes of
groupthink: group insulation, impartial leadership, methodical procedures, group
homogeneity, time constraint, recent failure, personal stress, invulnerability illusion, closed-
mindedness, and uniformity pressures. Schafer and Crichlow were not able to validate a
significant influence to wartime decision-making from these factors, despite assumptions
they are contributing factors in crisis decision-making dysfunction. The authors admit to a
need for further study and a greater sample size beyond their cold-war era study. Bravado
12
and peer pressure play some role in influencing the decision-making process of first
responders, as customs and traditions meld with presumed deleterious elements of
groupthink. There is a need for further study to establish connectedness to the emergency
environment before making significant inferences.
A tendency to scramble and hastily recover from an initial poor decision may negatively
influence subsequent decisions. Caldwell and O’Reilly (1982, 124, 134) referred to a level of
“self-justification,” in which decision-makers may get filtered information portraying
conditions being better than they really are, in an effort to mask failing courses of action and
to highlight positive cues. Another term generated from Caldwell and O’Reilly’s research is
“impression management,” which identifies the phenomenon of justifying increasingly
failing approaches in an attempt to prove the soundness of the initial premise. Watergate and
the Vietnam War are prime examples of self-justification and impression management
(Gouran 1976, 183-185; Caldwell and O’Reilly 1982, 124-125; McDermott et al. 2002, 145).
Another influence imposed upon first responders is a state of “expressive suppression,”
which involves the conscious inhibition of emotional expressions while emotionally aroused.
First responders force themselves to “stay calm” and to control their emotions as they try to
work through the formidable challenges present in the emergency theater of operations. One
study showed that people who suppress natural emotional responses experienced elevated
blood pressure, increased stress levels, disrupted communications, a reduction in rapport
building, and inhibited relationship formation (Butler et al. 2003, 48-67). Emotions play a
significant role in the operations at emergency scenes. It is not possible for the responders to
isolate themselves entirely from the effects of emotion, despite expectations of peak
efficiency. Kahneman (2003, 706) observed that it is not possible to separate emotions from
13
the decision-making process and that emotion is triggered by the dynamic conditions at the
scene. Kahneman (2003, 706) noted that the long-term environment is not where life is lived
and he cautioned decision theorists that broad, long-term views may be prescriptively sterile.
As Bazerman outlined in his subchapter on harm, omission bias, and status quo (2006,
54-55), there is a tendency to select options having even a slight possibility of doing no harm,
even when probability suggests that it may be wise to sacrifice the few in order to save a
larger group at risk. A false sense of heroics and false optimism for a miraculous outcome
can lead to overly conservative tactical strategies, even when the odds are stacked against
successfully saving everyone. The “do no harm” alternative (Bazerman et al. 2001, 1-10)
carries a strong bias, since it presumably requires the least amount of explanation, has a long
history of use in everyday situations, and is consistent with change-averse organizations,
which is a typical feature of public safety agencies.
The Role of Communications in Crisis Decision-Making
In studying common features of disaster management behaviors, Karl Weick noted the
importance of communications (Weick 1990, 589). Effective communications allow complex
systems to become more understandable. Discovery of new pieces of information allow one
to make sense of one’s experience thus allowing the situation to become linear, predictable,
and controllable. Weick argued that the situation is more complex than simply telling people
to talk more, noting the disorganization and chaos that can evolve when too many people are
talking at once. In recalling the atmosphere inside the control room at the Three Mile Island
nuclear power plant during tense moments surrounding the release of radioactive steam
during a serious accident in 1979, Weick noted there were too many people in the control
14
room talking at the same time. Each was attempting to contribute their hunches to what was
occurring and what tactics should be employed (Weick 1990, 589).
The literature reveals a contrast between classical decision-making theory, such as the
rational-comprehensive model in which exhaustive examination of all factors is made before
decision selection (Morçöl 2006, 5), and the “Thin Slicing” theory introduced by Gladwell
(2005, 23). Gladwell (2005, 23) defined thin slicing as “the ability of our unconscious to find
patterns in situations and behavior based on very narrow slices of experience.” Klein (1999,
4) noted that fire department commanders make about 80 percent of their decisions in less
than one minute. In the course of normal operations, emergency responders use recognition-
primed decisions (RPD), employing the first workable solution in the interest of time and
expediency (Klein 1999, 30).
Since rational-comprehensive models are impractical in the emergency environment
(Klein 1999, 9-12; Soelberg 1967, 26), another view is necessary to bring clarity to
emergency command situations. Lindblom (1959, 80-83) challenged those facing complex
problems to acknowledge the limits of intellectual capacities and to narrow analysis to the
most critical, non-exhaustive components. Lindblom (1959, 80-83) contended that any
attempt to take every possible factor into consideration leads to the likely outcome of narrow
definitions and a resultant limited scope. Former Secretary of State and retired U.S. Army
General Collin Powell waited for 40 percent certainty on data before considering an intuitive
solution to a problem. To overcome what some may call analysis paralysis, Powell viewed
any more than 70 percent certainty to be more information than necessary to make a sound
decision, wasting valuable resources on data acquisition (Klein 2003, 171).
15
Herbert Simon’s bounded rationality theory holds that actors in intensive decision-
making situations use a form of “rational choice that takes into account the cognitive
limitations of the decision-maker—limitations of both knowledge and computational
capacity” (Simon 1997, 291). Simon contended that people use heuristics to make decisions
instead of attempting to optimize the decision with extensive data acquisition and analysis.
Heuristics are a reflex reaction when deliberation costs are high and the actor has a base of
experience to draw upon to arrive at a rapid and usually sound decision (Simon 1981, 66).
Render et al. (2006, 68) outlined the several steps in decision-making; they essentially are
to gather information, process it, and apply the best choice. Render et al. (2006, 68)
articulated an idealistic notion of decision-making in stating that any decision based on logic,
after scrutiny of available data and alternatives, applied in a careful, systematic manner is a
good one, regardless of the outcome. Emergency responders attempt to apply all of these
steps, in milliseconds, when corporate managers can take weeks to reach decisions with far
lower consequences. Emergency responders would likely take little comfort from Render’s
sound decision disclaimer, regardless of how perfect the logic was, especially if the result of
decisions involved loss of life. Testing of counterfactual alternate endings is not possible in
the emergency environment.
For a variety of reasons, some academics and practitioners may make incorrect
assumptions about how emergency first responders make decisions (Klein 1999, 7-13). Some
portion of the body of literature tends to address boardroom style decision-making, in which
students are encouraged to gather facts, extrapolate decision formula, and choose the best
option derived from multiple options, although contemporary approaches have begun to
recognize the impracticality of doing so (Morçöl 2006, 5). Even the most ardent quantitative
16
decision-making academic may ponder the applicability of this process for the incident
command personnel if personally impacted by a disaster.
Sensory Overload and Task Interruption
Framing and Heuristics
The term decision framing refers to the situation whereby acts, outcomes, and
contingencies attributed to each choice in a decision sequence shape the decision-maker’s
perceptions. Framing is influenced by both the circumstances prevailing within the decision,
and the habits, customs, and norms possessed by that particular decision-maker (Tversky and
Kahneman 1981, 453). Therefore, there are two variables present in any major decision: the
person and the circumstances.
Bazerman (2006, 43) argued that people make decisions from their own neutral reference
point, making the location of the reference point, i.e. positively or negatively framed, an
influence on the amount of risk assumed. The decision-maker may select a different course
of action, if he had greater awareness of a slightly different decision frame or ease in which
to access and consider other alternatives. The communications process is a key factor in
alternatives awareness. Decision frame also gives the decision-maker a comfort zone of
operation, in which the single option chosen early in the process becomes more and more
fortified, shaping the point of reference, and increasing risk propensity (McDermott et al.
2002, 145).
Subtle perceptions of risk and reward, as well as the tendency of the individual to take
risk, can produce widely differing outcomes when two or more people view the same
circumstances. Tversky and Kahneman (1981, 454-458) established that seemingly
17
inconsequential shifts in circumstances, or perceptions thereof, could produce wide variation
in choices made to address a dilemma and give those frame elements weighted values within
prospect theory. Prospect theory assumes decisions have two major phases: 1) editing and
framing, and 2) evaluation, during which choice selection occurs (McDermott et al. 2002,
135). Prospect theory requires time to gather and evaluate data before reaching the decision.
The communications process is integral in gathering data for first responder consideration.
First responders must compress the timeframe of the decision process and yet arrive at sound
judgments.
The presence of uncertainly leads to psychological shortcuts in daily life to get through
the number of overwhelming choices one faces navigating through a typical day. Heuristics
are short cuts or “rules of thumb” used to transfer familiar experiences into new situations
with presumed similarities. First responders bring heuristic orientations with them to the
workplace and rely heavily upon them to seek positive outcomes. Use of heuristics occurs
especially in situations of uncertainty, where available options are imprecisely specified
(Kahneman et al. 1982, 710-712; McDermott et al. 2002, 136). People prefer heuristics under
unfamiliar or critical circumstances because they are cerebrally economical, demanding
fewer cognitive resources to reconcile the dilemma presenting itself. Bazerman et al. (1998,
236-238) acknowledged the presence and significance of “gut feelings” but also advocated
for an umpire to assure that the logical mind has an opportunity to seek any disproving
evidence through the objective examination of fact. A gut feeling can serve as a re-opener
when something does not seem quite right about a pending decision; gut feelings are an
unproven, and admittedly unscientific phenomena, but their anecdotal occurrence rate
suggests the need for greater study and quantification.
18
Tversky and Kahneman (1974, 1124) recognized the usefulness of heuristic principles in
helping people maneuver through complex tasks and in predicting the outcome of decisions
based on similar experiences, but they articulated a number of instances in which heuristics
can lead to severe systemic failures. Over-reliance on heuristics can lead to cognitive biases,
which degrade decision quality and preclude the consideration of better alternatives. Tversky
and Kahneman (1974, 1124-1131) called attention to three areas of heuristic and cognitive
bias concerns:
1. Representativeness, in which one facet of the decision is influenced by the other. In
this filtering situation, preceding actions taint the final decision. Another way of looking at
representativeness heuristic is gambler’s dilemma, in which the gambler expects a certain
outcome to be “due” despite equal odds of any of the possible outcomes occurring next.
2. Instance and scenario availability, during which people recall personal experience with
a circumstance and disproportionately assume recurrence of factors despite nuanced
differences and often-disparate time and conditions from the base experience triggering the
recollection.
3. Adjustment from an anchor refers to situations in which bias influences people in
picking a starting point presuming an outcome and/or tends to stay close to an expected
outcome and rearrange the circumstances to fulfill preconceived expectations.
Rensink et al. (1997, 372) suggested that perception of a change occurs most effectively
when the object is given focused attention. When there is a lot of changing stimuli observed,
it is unreasonable to expect all unusual events to receive equal attention. Distraction conflict
theory investigates the influence of distractions on decision performance. Speier et al. (2003,
19
773-774) used distraction conflict theory as the basis for building their interruption/decision-
making model. Their findings included:
1. Capacity interference results when the amount of incoming cues is greater than the
processing ability of the decision-maker.
2. Interference occurs when the decision-maker must attend to two or more inputs
requiring the same physiological mechanisms.
3. As people attend to multiple demands for attention, they may be unable to access the
necessary amount of additional cognitive processing capabilities needed for successful
problem resolution.
4. Memory loss and confusion are likely byproducts of such circumstances.
While processing critical information, decision-makers tend to minimize their
expenditure of scarce cognitive resources, which results in a lack of scrutiny of both relevant
and irrelevant new information (Speier et al. 2003, 775). For example, cell phone use while
driving has opened a debate about the influence a seemingly minor task (talking on the
phone) has with a relatively critical task (operating a vehicle). Bazerman (2006, 171-172)
attributed the association of traffic accidents and cell phone usage to be a result of
inattentional blindness, a phenomenon in which the majority of those viewing extreme
features of an event do not perceive critical elements. Bazerman (2006, 172) also gave the
example of spouses frequently accusing the other of not retaining something just told to them
by their partner. One study (O’Conaill and Frolich 1995, 262-263) showed that managers
spend 10 minutes out of every hour at work responding to interruptions. In 41 percent of the
cases studied, managers do not return to the original task after interruption (O’Conaill and
20
Frolich 1995, 262-263; Speier et al. 2003, 772). It is not just the actual time of the
interruption to consider. The decision-maker must cognitively re-immerse in the train of
thought prevailing before the interruption during a recovery period (Speier et al. 1999, 339).
Incident commanders experience a constant stream of interruptions and redirection of their
attention through contacts with people over two-way radios and in person. Physiological
influences detrimental to cogent information processing and articulation of optimal
communications may be a major factor in the quality of decisions made by first responder
commanders.
People in all fields of endeavors find value in taking a break when faced with a situation
in which they are stuck in finding the solution to an issue at hand. After relaxing or attending
to other matters and then returning to the work, the solution often spontaneously emerges
into consciousness (Speier et al. 2003, 790; Lyubomirsky and Nolen-Hoeksema 1995, 187).
Such “time-outs” are valuable to our decision-making abilities, yet time is a luxury not
usually available to first responders. Speier et al. (2003, 790-791) recommended taking a
break and “quiet time” as antidotes to debilitating information overload and constant
interruption. Those recommendations work in some venues, but the incident commander of
an emergency response, dealing with time-critical matters, has minimal time for fact-finding
and debate.
Like many aspects of decision theory, the absolutes elude us when it comes to
interruptions, however. Speier et al. (1999, 340-348) tested a theory whereby the assumption
is that some level of interruption is welcome and valued in the decision-making process.
After observing subjects as they perform in a problem-solving environment, Speier et al.
(1999, 344-353) found that interruptions used to gather more information input and time for
21
collaboration helped to improve the quality of decisions made on “simple tasks.” Task
complexity is increased by making later decisions dependent on imbedded decisions made
earlier in the sequence. As Speier et al. (1999, 346-350) predicted, the quality of the decision
degrades upon interruption during complex tasks, yet the quality improves after interruption
when working on simplistic, monothematic issues. Improvements in the human-machine
interface hold potential for improved decision-making in critical situations, since incident
commanders use an increasing array of technologically complex communications and
information management equipment while operating at emergencies (Speier et al. 1999, 351-
353).
The presence of stress has some positive outcomes in-group performance when low-to-
moderate levels of stress were present (Selye 1936, 32; Kerr and Tindale 2004, 630-640). So
it is likely that some level of managed stress at incidents can sharpen the decision-makers’
attention toward better processes, and therefore better decisions. Statistics show some
increased danger in public safety occupations; in addition, the perceptions of danger by first
responders is as significant as the actual risk (Jermier et al. 1989, 28). While it may be an
overstatement to label safety concerns as preoccupations or obsessions, there is a potential
connection to distraction and risk-aversion due to the state of mind of those needing
maximum faculties to make difficult decisions. First responders work in stressful situations
and make difficult decisions in rapid timeframes. An assumption may be that such stress
influences and degrades the quality of decisions made. Gaines and Jermier (1983, 571-572)
called the literature “conflicting” on the influences of stress, burnout, exhaustion, danger, and
fear. Counterintuitive subtleties, such as organizational structure and promotional
opportunity based on perceptions of fitness for command, appear to be at least as significant
22
in generation of stress, as is impending physical danger. However, Gaines and Jermier (1983,
571-572) admitted that the relationships are intricate and in need of additional study.
Entropy
In A Mathematical Theory of Communication (2001), Claude E. Shannon’s seminal piece
established entropy theory, and shaped the computer and communications systems in wide
use today. Shannon (1951, 50) defined entropy as “a statistical parameter which measures, in
a certain sense, how much information is produced on the average for each letter of a text in
the language.”
The study of patterns of letters in the English language, with pages of mathematical
proofs, establishes the probability of conveying the essence of a message without
transmission of the entire message (Shannon 2001, 1-19; Posner and Rodemich 1971, 2079-
2125). In further documentation, Shannon (1949, 700-701) reported a 50 percent redundancy
in the English language with accurate communications resulting in one study in which
removal of the vowels from passages, without essential loss of the message, occurs. The
missing letter concept advanced further another step, when Shannon calculated the
probability of predicting the next letter of a text when spelling of a word is initiated (Shannon
1951, 50). The average person can relate to those occurrences whereby someone is able to
finish the sentence of another, based on the context up to that point. Certain letters have a
greater propensity to follow others when forming words and the filling-in of missing words is
relative to familiarity with clichés, idioms, lingo, and the context in which something is
stated. Computer users have begun to discover the power of computer portholes, such as
Google, which has an automatic suggestion feature to fill in the missing word consistent with
Shannon’s theory.
23
The concept of entropy helps to explain some of the dysfunction experienced at
emergency scenes as incomplete communications are conducted and statements among first
responders jump around from topic to topic. The phenomenon of entropy also holds promise
for compression and prioritization of critical information at incident scenes. New
technologies could be aimed at abbreviated delivery of critical information among first
responders, based on the likely content of frequent messages, i.e. “send more help,” “mass
care for casualties needed,” “evacuate the area,” “building structure unsafe,” and “hazardous
substance present.”
In situations whereby a high degree of noise prevents a satisfactory message
accomplishment rate, Shannon (2001, 22) made the case for message redundancy as the
answer for greater accuracy. Message redundancy has several meanings in this context; from
a technical systems approach, it may mean multiple communications via parallel, redundant
paths, to assure a critical message makes it to the destination. Redundancy can also mean
several persons passing similar observations or key messages to a single collection point for
additional validation and the resultant improvement in the quality of information upon which
to base critical decisions (Surowiecki 2004, 4-6). Information overload, in the emergency
environment, makes it impractical to bombard incident commanders with more and
redundant information. The challenge posed to the human factors community is to devise
technological improvement in the human-machine interface, to allow critical information to
flow, without overwhelming the incident commander with sensory overload.
24
Inattentional Blindness
In a well-known study written by Simons and Chabris (1999, 1066-1073), test subjects
were instructed to focus their attention on people playing a basketball bouncing game. The
video features the introduction of a gorilla into the video frame, or more exactly a person in a
gorilla suit, who walked across the screen in front of basketball players. The person in the
gorilla suit did not just flash across the screen but rather stopped in the middle of the players,
as the action continued around the gorilla-suited person. The person in the gorilla suit
actually turned and faced the camera, thumped his chest, and resumed walking at a leisurely
pace across the field of vision. Half of the people who observed this demonstration did not
see the person in the gorilla suit at all because they focused intently on counting the number
of the passes between members of the different basketball teams.
The Simons and Chabris (1999, 1063-1064) experiment was an update of an earlier study
in which a woman with an umbrella walked across the test subjects’ screen. The study,
conducted by Becklen and Cervone (1983, 601-608), showed a similar inattention bias to
those who observed the incident because they focused their attention so sharply on the area
of interest. In the Simons and Chabris study, one team of the three basketball players wore all
white; the other team of three wore all black. Since the gorilla suit was all black, they were
able to test and control for the influences the colors and inattention had on whether subjects
noticed the gorilla walking across the frame. In a counter-intuitive result, the study
demonstrated that those who were studying the black-suited players were more likely to
notice the similarly colored black-suited gorilla walk across the screen, instead of those who
were concentrating on the players dressed in all white. This differed from the expected
outcome since we may anticipate they would notice something contrasting from the white-
25
suited players. However, the researchers concluded the observers focused so intently on those
similar to the object of their attention that they were not able to see the opposite effect.
The “Gorilla” study, “required observers to attend to one event while ignoring another
that was happening in the same region of space” (Simons and Chabris 1999, 1072). Simons
and Chabris called this a phenomenon of “directed ignoring” which could inhibit perception
of not just the event the individual is attempting to ignore, but of all unintended events that
may occur in the space studied. The subjects involved in this experiment were more likely to
notice an unexpected event that shares the same basic visual features, which in this case was
color. This would be the opposite of the phenomenon expected in which an item that differs
in basic features from the rest of the display might be easier to notice and identify. With
approximately half of the observers overall failing to notice the highly contrasting but
unexpected event that moved across the screen, Simons and Chabris were able to
demonstrate “a robust phenomenon of sustained inattentional blindness for dynamic events”
(Simons and Chabris 1999, 1069).
The next question pondered by the dissertation author is whether the previous studies
involving visual perceptions and sensory input also apply to strictly auditory worlds. This is
pertinent since so much of the emergency communications process is strictly auditory.
Neumann et al. (1986, 186-187) addressed whether there is a direct correlation between
visual and auditory sensory input. Neumann et al. cautioned that there are certain
fundamental differences between the information processing used in vision as opposed to
audition. They suggested that there should be models developed to recognize the selective
processes within the different senses individually and not treat them all as the same, because
there are fundamental differences in the critical process of deselecting information in the
26
studied space. It is important for the subject to reject, block, or at least manage in some
manner the amount of received sensory input. In the visual world, this is somewhat different
from strictly auditory input. In filtering out input received through auditory channels, it is
necessary to make some distinction between the “signal,” that is, the desirable input from the
unwanted “noise” that the individual is attempting to sort out. This notion of signal-to-noise
separation is an important feature of auditory sensory input. Neumann et al. (1986, 185-188)
left it to future researchers to make fine distinctions, inferring it is more difficult in the
auditory world to make such isolations. There are fewer layers and less depth present in the
sense of hearing to assess situations and to make the appropriate distinctions among the
images seen by participants.
The Neumann et al. (1986, 186) challenge to the research world to do more
individualized studies in auditory perception was followed up in the 1998 book Inattentional
Blindness by Mack and Rock (1998, 215-223), in which they indicated that there is a
connection between the inattention phenomenon in the visual world as well as in the auditory
world. They indicated that inattention phenomenon cuts across all sensory input settings.
Mack and Rock (1998, 215-223, 246) established that auditory deafness is analogous to
inattentional blindness. Nearly everything that could apply to inattentional blindness
translates directly into auditory deafness. They conducted a series of studies in which
individuals had input given to them over headphones while there were multiple things
occurring. Replication of the very same version of the shadowing task used in the gorilla suit
and umbrella exercises proved to apply in the strictly audible world, too. Mack and Rock
found inattention and an inability to respond to those incidents that were above an auditory
threshold. The inattention phenomenon is not unique to vision, therefore, and migrates across
27
all sensory input. Mack and Rock (1998, 223-225) did tactical studies using puffs of air
blown onto subjects’ arms at certain times to determine if they would recognize a distraction
while they focused intently on a task. Regardless of whether the input was tactical, visual, or
auditory, Mack and Rock (1998, 74-103) found similar inattention when individuals focused
intensely and exclusively on a single task.
Literature Review Summary
In summary, this review of decision-making literature reveals:
1. Communications are a critical element in successful decision-making
2. People in stressful situations experience communications deficits
3. There are a variety of circumstances and stimuli attributable to a state of
debilitating sensory overload
4. There is a relationship between stress reactions and communications difficulties
The literature suggests that humans in stressful situations are likely to exhibit verbal
communications deficits due to the nature of and influences present in such circumstances.
Communications deficits are measurable in terms of inadequate and ineffective
communications turns, especially in situations whereby radio calls go unanswered by the
intended recipient, or need repeating. There is an unmet need to study the micro factors
present in the emergency command environment causing communications inefficiencies.
28
Hypotheses
An informed review of the literature forms the basis for the issues addressed in the
empirical work contained in this dissertation.
Hypothesis #1: Sensory overload leads to ineffective communication, as measured by
missed messages, by first responder commanders under emergency conditions.
Hypothesis #2: Commanders at emergency scenes mishandle communications even when
utilizing functioning, state-of-the-art equipment and the messages prove to be clear and
concise.
CHAPTER 3
METHODOLOGY
This chapter explains the data collection methodology, analysis process, and the approach
used to test the hypotheses. Chapter Four presents a series of case studies from actual
incidents to establish common features of communications lapses. The final product of this
dissertation is a test of the hypotheses and a presentation of the findings and the implications
they have for training and formatting of first responder incident command communications.
Research Design
The study presented in this dissertation’s Chapter Five employed a phenomenological
case study technique to determine the non-technological influences affecting efficient first
responder radio communications at emergency scenes. The subjects for the field study were
fire department response personnel functioning as incident commanders at the scene of
simulated emergencies. Observation of personnel at training exercises and emergency
simulations served as the basis for this study. Of particular interest were simulations of
emergency scenes where large complements of personnel were operating, and the potential
for simulated injury or death was present. Participants included personnel from fire
departments in McKinney and Plano, Texas with assistance from the Allen, Texas Fire
Department. The University of Texas at Dallas Institutional Review Board granted approval
29
30
to observe first responders at the scene of training exercises and to document the occurrence
of interruptions and distractions when dysfunctional radio communications occurred.
The researcher used a degree of sensitivity and discretion to put the subjects at ease and
to assure cooperative access to their operational environments. A statement of research
purpose was included in the pre-exercise briefings along with a request for written
permission to videotape the participants. The researcher realized that it might have been
necessary to discontinue the documentation of any single incident that was particularly
emotional or sensitive out of courtesy and respect for those involved.
Video and audio recording of the command post environment, synchronized with radio
traffic recordings, formed the raw data for the study. This allowed for the documentation of
the multiple influences causing the sensory overload and the resultant degradation of fluid
verbal communication. A combination of live observation, subject interviews, and review of
the audio/visual recordings provided the documented observations germane to the study. The
first observation step was to listen and document missed radio messages and to note the
distractions and influences at that specific instant. The researcher scored an unacknowledged
or repeated message as an ineffective, or negative, communications turn. The use of a coding
scheme (Appendix A) allowed for the conversion of qualitative data into quantitative data.
The second step in the series of outdoor exercises was a post-incident interview with the
subjects, where data gathered provided balance and explanation for any factors not
observable by the researcher. Joint review of the videotape provided an opportunity to refresh
memories and present factors not perceived as they occurred. The interview style was a semi-
structured format using an outline of interview questions (Appendix B), allowing for a free-
31
flowing explanation of circumstances experienced by the subject. Standardization was less
critical at this step, since the purpose of the interview was to add richness to the observation
data. Each interview lasted between 30-45 minutes at the subject’s normal place of work.
Follow-up interviews with the commanders from the indoor simulation exercises were not
necessary due to the immediate access the researcher had with them in the laboratory
environment provided by the simulator.
This research builds upon data derived from an earlier study, whereby 428 radio
communication turns at a multi-jurisdictional fire training exercise were assessed using a
coding scheme (Timmons, 2006). The previous study established that the incident
commanders missed or did not respond to a significant number of radio calls from
operational personnel; 11.9 percent of all the radio calls at the exercise were
unacknowledged, which compared closely to actual incident recordings reviewed. Thirty-
three out of the overall fifty-one unacknowledged radio messages in that earlier study were
people trying to call the incident commanders. Incident recordings show the messages in the
earlier study were cogent, yet at incident debriefings, it was common to hear assumptions
that the radio was not working, rather than cognitive inability to receive and process multi-
sensory stimuli. The first study only examined radio recordings, which demonstrated the
presence of inattention; actual field observation in this study determines what the distracting
influences are. The precise moment of inattention is the focus of this new research, so that
the researcher can establish the type of distraction and its impact on the ability to process the
information from documented radio transmissions.
Documentation of deficiencies provides insight into specific causes of communications
failures commonly identified after disasters. The specific area of concern is radio
32
communications used by first responders in the course of their operations at emergency
scenes. Discovery of sets of negative influences in sufficient quantities and from common
sources draws cause and effect relationships, suggesting better training and compensating
strategies.
The case selection strategy used for this multi-case phenomenological study involves
simulated emergency situations routinely assigned to first responder personnel. The
interaction between the responders at an incident and the distraction factor it introduces is the
focus of these observation exercises. The researcher made a conscious effort to avoid
distraction during the observation data collection to avoid being handicapped in objective
data collection. The researcher stayed focused on the sensory influences occurring in the
communications interface between responders and commanders. In doing so, this reduced the
possibility that the same influences negatively affecting the subjects would also similarly
affect the researcher.
The subjects of the study were the response personnel, especially the command officers
from fire departments in Plano and McKinney, Texas. This study allowed for the observation
of multiple parties from two different fire departments for stronger scientific validation.
Training exercises attempted to create realistic emergency circumstances, testing and honing
skills used at actual emergencies. The study’s venues were the fire training facilities in Allen
and McKinney, Texas. Training exercises provided an environment conducive to observe
pertinent influences without an undue Hawthorne effect (Bracht and Glass 1968; Cook 1962;
Jones 1992). The participants were present primarily to solve a tactical scenario, allowing the
researcher an opportunity for separate and discreet observation of the decision-making and
communications processes.
33
Actual emergency scenes offer the opportunity to test the truest of circumstances and
influences. One drawback of this method is that access and opportunity are limited since the
case cannot be staged or scheduled, and because intense incidents are sporadic and
unpredictable (Klein 1999, 10). Because of these limitations, this project focused exclusively
on training exercises. Improvements in miniature camera technology may allow future
researchers to keep subjects “wired-up” with video and audio observation capability until the
occasional incident of interest occurs. Miniaturized biomonitoring may allow measurement
and analysis of pertinent biological factors.
Data Collection
The data collected in this study are the communications behavioral choices made by
incident commanders in emergency command situations. The research observer chronicled
the sensory influences present in the emergency environment and their impact upon the
incident commander. Comparison of observation data with any radio communications
underway at the same instant helped to determine the influence the distracting stimuli had on
the quality of the prevailing radio communications.
Data derived from the interviews provided the opportunity to compare and contrast what
the objective observer saw with what the subjects perceived was happening. This method
helped to triangulate the data (Creswell 2007, 208; Berg 2007, 5-8; Patton 2002, 248) and
give it greater quantification strength. This study observed and analyzed multiple sequences
of command decision-making and communications to establish the frequency of errors and
the trends and causes therein; the simultaneous recounting by the actors involved provided
additional perspective. The study also gave the opportunity to examine the benefit of two-
34
person command crews, as a contrast to the typical solo command operations, with the hope
of yielding valuable insights.
Coding of Observable Behaviors
Coding of the observations (Appendix A) allowed for documentation of the type of
apparent distraction leading to the missed turns of communications. The observer first noted
the existence of one of the following markers of a dysfunctional radio communications turn:
• Unacknowledged message
• Clearly delivered message needing to be repeated
• Inappropriate translation of message intent (i.e., “What color is the
sky? Answer: “three”)
At the instant when the researcher noted one of the above-named radio communications
dysfunctions, he documented the presence of influences in the incident commanders’
operational environment. The researcher observed the incident commanders as they
conducted their duties with the distractions codes list acting as a menu of specific distracters.
This allowed for the association of influences indiscernible from the incident recording
review or by either party of the communication since they are typically isolated spatially,
thus their use of the radio.
Data Organization and Analysis
As advocated by Weiss (1995, 21), the quantity of cases observed was driven by analysis
of the early results. Once returns became redundant or peripheral, there was a discontinuance
35
of additional data collection. Yin (2002, 21-22) suggested that cases can be events or entities;
in this instance, the cases are both, since the event, i.e. the emergency, is a necessary
ingredient, yet it is the actions of the actors at the emergency that are the subject of this
study. The post-incident interviews followed Creswell’s (2007, 159) suggestion to develop
generalized “meaning units” or theme categories derived from significant statements
collected from the subjects. Use of this technique promoted uniformity of the data and
assured high accuracy and validity. Collection of the raw data was through a process of
coding the behaviors and responses observed in the test environment derived from the
observations. Analysis of the coded results disclosed any discernable patterns and cause-and-
effect relationships (Creswell 2007, 152).
CHAPTER 4
CASE STUDIES OF ACTUAL INCIDENTS
This section reviews several significant emergency incidents in which use of radios
played a key role in the outcomes. Two incidents of major concern to the fire service
community occurred during the spring of 2007. In one instance, a firefighter died while
fighting a structure fire in April 2007 in Prince William County, Virginia. The second
incident was a major furniture store fire in June 2007 in Charleston, South Carolina. Both of
these incidents raised significant concerns because the mayday distress calls placed over the
radios during the incidents were associated with the firefighters’ deaths. These two fire
incidents had common factors with an incident predating them by nineteen years, in which a
building collapsed during a fatal fire at a car dealership in Hackensack, New Jersey in 1988.
Case studies of precursory fires in Syracuse and Seattle are included here to provide
additional insights into recurring communications dysfunctions. Next, the researcher presents
the case of a dramatic 1997 bank robbery and shootout in North Hollywood, California
showing the challenge of communicating during an intense police incident. The final case
study in this chapter is from a highly publicized successful emergency plane landing in the
Hudson River in New York City in February 2009. Radio transmissions during the
emergency landing hold important lessons in crisis communications.
36
37
Syracuse, New York 1978
The earliest documented case of radio communications contributing to a firefighter
fatality occurred in Syracuse, New York in 1978. Four firefighters died at a fire in an
apartment building (Varone 2003, 142; Demers 1978, 24-25). According to official radio
recordings, there was a weak radio transmission made around the sixteen-minute mark
stating, “Help me.” An investigative report indicated the radio signal was very weak on the
tape recording and there was no indication that anyone on the fireground heard it. A district
chief and deputy chief were present at the incident prior to the call for help; they had been
issuing orders for several minutes prior to the distress message.
About one minute after the original distress call, a second transmission was recorded, this
time someone stating, “Help, help, help,” followed by static. None of the fire personnel at the
scene or at the dispatch office heard any of these radio transmissions. An observer at the
incident heard a radio message on a scanner stating, “Help, help, help, third floor attic.” The
bystander immediately reported the information to a fire department command officer at the
scene. It was later determined that the four firefighters died on the third floor (Varone 2003,
142; Demers 1978, 24-25).
Recovery of the first firefighter’s body occurred 20 minutes after the original unnoticed
distress call. The remaining comrades were not located for another 54 minutes following a
search of the gutted interior and calls to local hospitals to see if they were among several
firefighters sent for treatment (Demers 1978, 15, 24-25). There was only one portable radio
issued among the four victims; it was later recovered in the debris and found to be in working
condition after drying out and being outfitted with a new battery (Demers 1978, 24-25).
38
Hackensack, New Jersey 1988
One of the most prominent early instances of miscommunications at fire scenes involved
the fire at a Ford dealership in Hackensack, New Jersey on July 1, 1988. Five firefighters
died while engaged in interior fire suppression efforts following the collapse of the building
(Klem 1988, 1). Investigators studying the fire command operations found a number of
issues with the radio communications at the incident. “Apparently due to the initial confusion
that existed on the fire ground after the collapse and the sounding of tones for the recall over
the only emergency fire ground radio frequency, the initial calls for help from the firefighters
were not acknowledged” (Klem 1988, 14).
A detailed investigative report based on radio recordings from the incident concluded
there were numerous radio messages that were unanswered, messages delivered but not
acknowledged, and there were several requests for messages to be repeated (Demers 1988,
8). Tape recordings of radio messages clearly showed the trapped firefighters articulated their
specific location several times. There was no acknowledgement for the messages over the
radio, nor were those working at the incident aware of the distress calls, as revealed during
post-incident interviews (Demers 1988, 10-15). The incident commanders did not
acknowledge one-half of the radio messages transmitted at the Hackensack fire.
Unacknowledged messages created an obvious safety hazard for the personnel at the scene,
and contributed to further overload of the radio system since the message needed to be
repeated (Varone 1996, 98). One investigator concluded, “There was a great deal of talking
on the radio but a severe lack of communication” (Demers 1988, 14). As was the case in the
Syracuse incident that preceded it, people remote from the fire scene monitored the desperate
39
messages on scanners and they called to report them, yet the incident command personnel at
the scene were unaware of such messages (Varone 2003, 141).
On the twentieth anniversary of the Hackensack fire last year, the retired fire chief, now
age 84, in command of the incident that day reflected upon the criticism involving the tactics
and communications used at the fire. The retired fire chief stated that he had asked for budget
dollars to improve the department’s radio system at least a year before the fire, but the city’s
administration denied the funding request. The Hackensack Fire Department was using hand-
me-down radios from the police department on the day of the fire; the chief’s radio was
inoperative and he had to borrow one at the scene before he could do anything (Bonamo
2008). The rationalization involving equipment failure being the major contributing factor
belies the significant command and control issues outlined in the Demers report (1988, 14).
The incident commander blamed the equipment, but people detached from the scene were
able to monitor the messages.
North Hollywood, California 1997
On February 28, 1997, a bank robbery turned into an armed standoff with the Los
Angeles police officers seriously mismatched by robbers with automatic weapons, extensive
body armor, and armor piercing ballistics. At the conclusion of the 44 minute incident, over
1000 rounds had been fired, ten police officers and six bystanders were wounded, and the
two perpetrators were dead (CNN 1997).
The incident began as a radio report from a unit in the area of a robbery in progress with
shots fired. Bystanders reported to the patrol unit that heavily armed men, wearing all black
outfits and ski masks and carrying assault rifles, had entered the bank. Immediately after
40
arrival, the excited radio communications began with the officer broadcasting, “Shots fired,
shots fired, officers need help!” As numerous units acknowledged the call for help and
radioed that they were responding, there were multiple overlapping layers of radio
transmissions, making it difficult for the dispatcher to track the messages. The conflicting
radio broadcasts of the physical descriptions of the suspects ranged from white, black, and
Hispanic, with numbers ranging from two to eight. At the conclusion of the incident, it was
determined that there were two white males involved. The dispatcher remained controlled
and helpful in reaction to a constant barrage of requests and situational updates. There were
isolated instances of the dispatchers raising their voices in anxiety level in reaction to
particularly emotionally charged messages from the field units. There were several
occurrences of officers screaming on the radio that they were injured, pinned down, and
requested assistance. At one point, the dispatcher asked if any units knew how many officers
were down. The response from an excited voice was, “more than one, more than one!”
In reviewing the incident recordings, it was obvious in several instances that units were
overlapping each other’s radio transmissions, not awaiting acknowledgement for messages,
and covering the more critical messages with less critical ones. In one interval, the suspects
had exited the bank and were shooting at officers in the area; other officers were attempting
to broadcast a warning of their movement. At that instant, an unintelligible voice started
screaming something over the radio, with a siren running in the background, similar to radio
transmissions expected during a vehicle chase. It was just barely discernible that the officer
was saying something about an injured civilian, perhaps while transporting someone to
medical treatment. The dispatcher asked the officer to roll up the car windows so the radio
message could be heard over the siren; the message was not repeated and the radio channel
41
resumed other critical information on the movement of the active shooters. There were some
instances of messages requiring repeating, but given the intensity of the event and the
number of people attempting to transmit at the same time there were surprisingly few
repeated messages, owing to the communications skill of the dispatchers and first responders
(Rigg 1997).
Review of the recordings reveals that there were three broad categories of use for the
single incident radio channel: 1) tactical consideration of where the suspects were and
strategies to engage them, 2) maintaining radio contact with the injured officers awaiting
rescue, and 3) requests for additional personnel, specialty units, and supplies such as
ammunition and radio batteries. Each of these differing yet simultaneous uses of the radio
channel created contention and inefficiencies, especially when wounded officers needed
reassurance help was on the way.
Following the incident, there was some criticism of the incident command structure used
at the scene. The dispatcher asked multiple times where the command post location would be
and where to send the additional inbound resources. The original locations attempted for
placement of the command post proved to be too close to the incident, considering the
weapons in use. Tactical commanders eventually did identify who was in command, assert
control on the radio channel, and issued orders on the rules of engagement. Even one hour
after the shooting stopped, police command officers struggled to track the number of
personnel at the scene and to determine if all elements of the incident were secure (Edwards
2002). Before a specific incident commander was established over the radio, the police
helicopter served as temporary incident commanders issued commands based on what they
were able to observe from above the incident. Interestingly, they passed along officer safety
42
updates to the units on the ground, while the ground units warned the helicopter crew as the
suspects fired their automatic weapons skyward towards them. The pilot’s voice was slightly
more controlled and less emotional than the field units due to the helicopter’s remote position
and they were able to lend valuable insights and perspective, reminiscent of the helpful,
accurate updates provided by the helicopters and fireboat during 9/11 in New York City
(Firehouse Magazine 2005).
Of the 300 officers who eventually responded to the incident, all of them survived,
including the ten officers who suffered a variety of ballistics wounds. Many involved still
carry emotional scars from the incident even those whose connection to the action was only
over the radio. Several of the officers who worked at the North Hollywood shootout
subsequently received therapeutic counseling for depression and substance abuse, and three
of the officers involved later committed suicide. One of the officers with lingering impact
from that day attributed some portion of his trauma to hearing his wounded comrades
screaming for help over the radios (Edwards 2002).
A reporter covering the story noted that one of the detectives who responded to the
incident and worked to assist an injured partner “was still gripping her police radio so tightly
that her knuckles were white,” even one-half hour after the shooting had stopped. The
detective praised her wounded partner’s presence of mind to broadcast his location so his
rescue could be arranged, showing the value of having a radio at such intense incidents
(Shuster and Rainey 1997). It was because of her monitoring the radio while working another
assignment that she became aware of the shootout and she responded to the citywide request
for officers to assist.
43
The radio also became pertinent in another one of the many subplots to this story. Two
injured officers made their way into a dentist’s office and received first aid treatment for their
wounds. Maintaining radio contact and assuring one another that more help was on the way
allowed them to stay in their protected position and overcome their instinct to go help a
wounded partner in the street below (Shuster and Rainey 1997).
Seattle, Washington 1998
A fire at a lumber company in Seattle in September 1998 resulted in the death of one fire
lieutenant and injury to two other firefighters. The Seattle fire department arrived two
minutes after a telephone report of a fire at a lumber facility at 9:23 p.m. Firefighters made
entry in the building and began extinguishing efforts. One of the fire crews became lost and
disoriented in the heat and smoke with the command officer trying several times to call for
help on his portable radio. As the lieutenant ran low on air, he handed the portable radio to a
firefighter; that same firefighter attempted radio contact with incident commanders with
negative results. The firefighter was able to hear the dispatcher sending additional fire units
so he was sure the radio was working. The National Fire Protection Association (NFPA)
investigation of the incident indicated one of the factors contributing to the death of the fire
lieutenant was an inadvertent use of the wrong radio channel by the two disoriented
firefighters. They may have selected a setting on their portable radio intended for scene use
only; the message would not have gone through a repeater system allowing monitoring and
recording at the dispatch office. Citizens in the area monitoring on their scanning radios
heard the distress calls, but the incident commander and the dispatch office did not (Isner
1990b, 20-21). The NFPA report suggested the possibility that the firefighters were not using
their radios appropriately, or that their message was lost in the flow of loosely monitored
44
incident command radio traffic by the incident commanders. The report was also critical of
the system of accountability used to track and control the operation of firefighters in the
hazardous environment (Isner 1990b, 18-19).
The firefighter with the radio somehow made it out of the building and to medical
treatment with only a vague recollection of what had occurred. It eventually became apparent
that the lieutenant he had been with was still missing. Following an extensive search, his
body was located under about two feet of debris inside the building (Isner 1990a, 31–34).
Prince William County, Virginia 2007
A fire occurred in Prince William County, Virginia on April 16, 2007 in a single-family
residence on a very windy day. The wind was a major contributing factor in the rapid spread
of the fire, just as firefighters began entry into the structure. As it turned out, the occupants
had escaped prior to the fire department’s arrival and no one was awaiting rescue within the
building. The only fatality was a firefighter conducting suppression and rescue operations
inside the house (Prince William County 2008, 4-5).
Reports from this incident indicate that the fire department did a number of things
correctly. A command structure was in place. The incident commander was operating from a
stationary position of tactical advantage across the street and from within a vehicle where the
ambient noise could be controlled. The incident commander was apparently operating alone
during the early critical stages of this incident. The command officer of the firefighter who
eventually perished, as well as the firefighter in peril, transmitted separate mayday radio calls
per the department’s policy. However, no one at the scene recalled hearing a mayday
message.
45
Review of recordings after the incident show the mayday radio message transmitted
clearly, as well as urgent follow-up messages. However, the incident commander did not hear
the mayday call; but he heard something he did not understand and requested the repeat of
the last message. When there was no reply to his request for a repeat of the last message, the
incident commander moved to other tactical messages with other units operating at the scene,
unaware of a mayday message. The fire-dispatch center operator was aware of the mayday
message; the dispatcher initially attempted to assist the incident commander in hearing and
reacting to the message, but the dispatcher did not persist in making sure the incident
commander was aware that a mayday message existed. There are other procedures in place
requiring the broadcast of an emergency announcement over the radio channels from the
dispatch center when a mayday is declared, but the dispatcher did not interrupt the steady
flow of tactical messages on the radio channel (Prince William County 2008, 64-66).
Prudent practice dictates establishment of radio contact with a firefighter declaring a
mayday emergency. In this instance, the firefighter was in peril several minutes until he made
his final anguished request for water, which proved to be his final transmission. Review of
the recording showed two ways to interpret his request for water. It is clear now that it was
the extreme heat he was experiencing and he was referring to the life-threatening situation he
was experiencing when pleading for water. It is also common for firefighters to radio
requests for more water, for tactical application to extinguish the fire, while still in tenable
conditions within their turnout gear. The typically muffled voice of the firefighter trying to
speak while wearing a self-contained breathing apparatus mask may have contributed to the
misinterpretation of message intent. The distressed firefighter was indicating a life-
46
threatening situation. The twenty-four year old firefighter was later found deceased within
the structure (Prince William County 2008, 16-18).
The investigator’s report of the incident is critical of the radio discipline used at the
incident (Prince William County 2008, 68, 121). After declaration of the mayday, radio units
at the scene continued to make radio transmissions unrelated to the mayday event, as well as
items of non-emergent nature. The report recommended the way to overcome this in the
future is to designate individual radio channels for specific tasks. However, a person must be
dedicated at the command post to monitor each of these radio channels, assuring continuity
of critical communications on all channels (Prince William County 121, 2008).
Charleston, South Carolina 2007
Nine firefighters died while fighting a fire at the Sofa Super Store in Charleston, South
Carolina on June 18, 2007. The city of Charleston commissioned a panel of nationwide
experts to examine the handling of the fire. The investigation reports indicated a number of
radio communication failures. In most instances, it was not equipment failure, but rather the
practices that were in use by the individuals operating at the scene. The committee generated
a number of recommendations and observations about the operations during the incident
(City of Charleston 2007).
As in several other incidents, radio communications were ineffective at the Charleston
furniture store fire. Recordings show a typical tangle of incomplete, indiscernible, and
disconnected communications segments. A number of firefighters were calling for help
within the building, yet the incident commanders at the scene did not hear the distress
messages. In fact, no one at the scene recalled hearing the radio messages that contained calls
47
for help (City of Charleston 2007, 22). During the fire, firefighters transmitted 16 different
distress messages from inside the building. They were emotionally charged radio messages,
including firefighters praying and asking comrades to send sentiments to their loved ones
with the assumption that they would not survive the incident. No one involved at the incident
scene heard any of these distress messages (City of Charleston 2007, 70).
An off-duty fire department employee gave the first indication of firefighters awaiting
rescue inside the raging fire. He was able to monitor the radio communications on his car
radio as he was responding. Upon arrival at the scene, he made the incident commanders
aware that there were firefighters calling for help within the building. His notification was
the first indication anyone in charge at the incident had that there were firefighters in peril.
Confusion followed as to how many were missing, where they were, and whether they had
already been rescued (City of Charleston 2007, 74).
There were a number of complicating matters at this incident combining to form a
paralyzed and ineffective communications situation.
• Many fire departments use standardized alarm levels, i.e. second alarm, third
alarm, to streamline the calling for additional resources and to minimize
contention for airtime. The practice at Charleston involved requesting and station
radio dispatching of each unit individually, one by one, over the same radio
channel used for tactical level conversations at the fire scene (City of Charleston
2007, 111).
48
• During the incident, a civilian inside the building called 911 indicating he could
not escape and was awaiting rescue. This created additional urgent radio traffic on
top of that typically expected at a routine incident.
• This was a rapidly developing fire with plenty of fuel load in a very large non-
standard building, which placed additional responsibilities on the fire department.
The experience base of the typical fire department is in much smaller structures,
such as single-family residences.
• Inaccurate assumptions of radio message content and intent occurred between the
commanders. In one particularly poignant radio exchange, the fire chief called his
assistant chief at another side of the building and a message was transmitted;
however, each thought the message meant something else, so ineffective
communication was occurring. The fire chief said that he wanted to know how
things were looking inside of the store. The assistant chief replied, “I am trying to
get back to it now.” The fire chief heard the message but inaccurately interpreted
it as, “we’re getting to it now,” which he assumed to mean that they were starting
to make progress on the fire and that no extension of the fire into the remainder of
the showroom was anticipated. It was in that area where a majority of firefighters
eventually died (City of Charleston 2007, 105).
• The report is highly critical of the incident command principles used by the
Charleston fire department at the incident. The National Fire Protection
Association 1500 firefighter safety standard indicated the incident commander has
49
a responsibility to “initiate, maintain, and control incident communications” (City
of Charleston 2007, 115).
• The fire chief and command staff did not establish a fixed command post at a
single location. Video recordings from the scene show chiefs moving across a
wide area of the building’s exterior and doorways. The fire chief operated at the
tactical level directly supervising tasks at one side of the building as the assistant
chief was similarly directing tactical level tasks at another side of the building,
each giving conflicting orders to the other’s and neither attaining an overview of
the incident scene itself. Stationary command allows for better, more effective
overall scene management from a calm, controlled position (City of Charleston
2007, 97). The fire chief was not in a position to manage the overall incident. The
type of posturing and pacing during radio communications at the Charleston
incident was very similar to that seen during the training exercises of this
observation study (see Chapter Five). These practices were reflective of how fire
departments operated 20 to 25 years ago, where the fire chief typically was much
closer to the operation and was in a position to command directly the forces at the
incident. This worked well for incidents of relatively minor significance, which
comprise the large majority of situations to which fire departments respond. It is
at incidents such as the Sofa Super Store fire where commanders need to
transition to a different style of command in contrast to daily practices.
• The culture of the Charleston fire department dictated minimal use of portable
radios; they were ostensibly reserved only for dire emergencies. Firefighters and
officers had portable radios issued to them, but they typically kept them within
50
their turnout gear pockets and did not use speaker microphones or receive tactical
updates and commands over those radios. The radios were for personal distress,
yet there was very little practice with the radios for firefighters ahead of such need
(City of Charleston 2007, 113).
• Use of the term “mayday” only occurred once on the incident recordings of the
Sofa Super fire. This is inconsistent with the policies that were in place by the
Charleston Fire Department. However, the lack of training and practice with the
use of that phrase can contribute to the lack of inclination on the part of those
needing immediate assistance to use the phrase “mayday” (City of Charleston
2007, 113).
In summarizing the influences pertinent in the inability to communicate effectively at the
scene, the report cited a number of factors. Heavy radio traffic was a significant aspect
inhibiting the ability of those at the scene to communicate effectively. Ambient noise at the
fire scene impeded firefighting personnel from hearing the radios adequately. The report also
listed the absence of a fixed command post as one of the contributing factors and the report
flagged the importance of designating someone at the incident scene specifically to monitor
the tactical radio channels in use at the incident (City of Charleston 2007).
51
Charleston firefighters did not have adequate training in effective radio communications
techniques. The report advocated the use of the “order model”1 to indicate who is calling,
exchange clear information, and confirm message receipt (City of Charleston 2007, 140;
Brunacini 2003, 532-533). Use of standardized phrases helps to make clarity the first priority
for each radio communication. The report recommended training for firefighters to monitor
the tactical radio channel, so that they may receive instructions and advisories from the
incident commanders and fellow firefighters, as well as relaying periodic updates to the
incident commander.
An interesting observation was noted within the Charleston report whereby not only did
firefighters and command officers report not hearing radio calls but they also testified that
they heard certain things over the radio system that cannot be verified after the fact in
reviewing the recordings (City of Charleston 2007, E-5). This indicated another interesting
phenomenon whereby people under stress may imagine they are hearing things, or interpret
information in very different ways than radio recordings show after the fact.
1 The Fire Chief's Handbook (Brunacini 2003, 532-533), provides this sample communications sequence using the order model:
Command to Engine 1. This is Engine 1-go ahead Command. I want you to lay a 2 ½" line to the north side of and advance a 2 ½" attack line into the east exposure for search, rescue and to keep the fire from extending. You will be East Sector. Engine 1 copy-lay a 2 ½" line to the north and a 2 ½" attack line to the east exposure for search, rescue and to keep the fire from extending. We will be East Sector.
Having the receiver “parrot” the order back ensures that they completely understood the order and eliminates confusion.
52
In addition to the significant disruption to operations that the tragedy of losing nine
firefighters triggers, as well as all of the personal lives that were impacted by that incident,
the Charleston fire department underwent a considerable period of disruption and
introspection in the months following the incident. The recommendations from the report
received national attention while the fire chief resigned. The new chief implemented major
organizational changes, while other elements of the critical report remain unfulfilled.
In the most recent news from December 2008, the Charleston Fire Department has
experienced a drop in its fire insurance rating score. It was a Class One fire department, the
coveted highest ranking on the scale issued by the Insurance Services Office (ISO), a de facto
national ratings system for fire departments from which a community’s fire insurance rates
are established. Charleston dropped to a Class Three following re-examination of the fire
department’s capabilities last year. The ISO system grades fire departments on their
resources to stop major fires, but does not address the safety of operational personnel or the
quality of incident communications and command. The fatal fire at the Sofa Super
Showroom did not directly trigger this drop in fire insurance ratings. However, ISO
conducted a considerable re-examination of all the fire department’s capabilities at the time
of the 10-year cycle for re-inspection (Insurance Services Office 2008; Gentile 2008, 12, 16;
Menchaca 2008; Jennings 2008).
New York City, New York 2009
On January 15, 2009, U.S. Airways Flight 1549 with 155 people aboard landed safely in
the Hudson River in New York after a flock of birds entered the jet engines resulting in loss
of all engine thrust. “The pilot radioed air traffic controllers on Long Island that his plane had
sustained a ‘double bird strike.’ Without power, returning to the airport was out of the
53
question, aviation experts said. He (the pilot) saw a small airport in the distance, apparently
at Teterboro, New Jersey, but (he) decided to head down the Hudson and make a water
landing, a rare event …” (McFadden 2009).
All of the passengers and crew survived the landing in icy waters. On February 5, 2009,
the Federal Aviation Administration released the recording of radio traffic between the New
York Terminal Radar Approach Control in Long Island, New York and the pilot of the
disabled plane (Otterman and Wald 2009). Pilots and air traffic controllers are experienced in
using radios to communicate with one another in clipped and fast-paced phrases (Levin
2009a). The flight of 1549 started in a routine manner, but soon after the pilot with many
years of experience was at the controls of a fully loaded plane with no power over the densest
population center in the country. What followed was a calm yet urgent set of radio messages
with the air traffic controller, a ten-year veteran. In just three minutes, the flight went from
uneventful takeoff to a risky emergency landing in a river. The transcript of the radio
communications showed an incident analogous to what often occurs in critical first-responder
situations.
Flight Communications Transcript
Below are selected passages between the doomed plane and the controller. “Cactus” is a
call sign used on flight radios denoting U.S. Airways, a remnant from its Phoenix, Arizona
partner company’s heritage. The same controller was also juggling other high-pressure
telephone demands between these transmissions, such as stopping the departures from
LaGuardia airport, since the original plan called for 1549 to return there. The controller also
spoke with Teterboro airport, the back-up landing site requested by the pilot. Late in the
sequence, an America Eagle flight in the area helped to repeat what he heard the disabled
plane’s pilot say. All times shown are local, Eastern Standard Time.
54
Selected passages from “Full Transcript, Aircraft Accident, New York City, NY,
January 15, 2009” (Federal Aviation Administration 2009):
(The plane’s passages have been underlined to aid the reader).
3:27:36 Flight 1549: "Ah, this, uh, Cactus 1539. Hit birds, we lost thrust in both engines. We're turning back towards LaGuardia."
3:27:42 Air Traffic Control: "Okay, yea, you need to return to Laguardia. Turn left heading of uh, 2-2-0."
3:27:46 Flight 1549: 2-2-0.
3:28:05 Air Traffic Control: "Cactus 1529, if we can get it to you, do you want to try to land runway 1-3?"
3:28:11 Flight 1549: "We're unable. We may end up in the Hudson."
3:28:31 Air Traffic Control: "Alright cactus 1549. It's going to be a left. Traffic to runway 3-1."
3:28:34 Flight 1549: "Unable."
3:28:36 Air Traffic Control: "Okay, what do you need to land?"
3:28:46 New York Tower: "Cactus 1549, runway four is available if you want to make left traffic to runway four."
3:28:50 Flight 1549: "I am not sure if we can make any runway. Oh, what's that over to our right? Anything in New Jersey, maybe Teterboro?"
3:28:55 Air Traffic Control: "Okay yea, off to your right is Teterboro airport."
3:29:02 Air Traffic Control: "Do you want to try and go to Teterboro?"
3:29:03 Flight 1549: "Yes."
3:29:21 Air Traffic Control: "Cactus 1529, turn right 2-8-0, you can land runway one at Teterboro."
3:29:25 Flight 1549: "We can't do it."
3:29:26 Air Traffic Control: "Okay, which runway would you like at Teterboro?"
3:29:28 Flight 1549: "We're gonna be in the Hudson."
3:29:33 Air Traffic Control: "I'm sorry, say again, Cactus."
3:29:51 Air Traffic Control: "Cactus, ah, cactus 1549, radar contact is lost. You also got Newark airport off your two o'clock and about seven miles."
55
3:30:09 Eagle Flight 4718: "… I don't know, I think he said he was going in the Hudson."
3:30:14 Air Traffic Control: "Cactus 1529, uh, you still on?"
3:30:22 Air Traffic Control: "Cactus 1529, if you can, ah, you got, ah, runway 2-9 available at Newark off your two o'clock and seven miles."
Flight Communications Analysis
Both voices on the recording do not reflect the amount of stressful decision-making
occurring in a compressed timeframe, especially considering the immediate risk to
passengers, crew, and people on the ground. The only hint of a stress reaction is the
misstating of the correct flight number—the pilot used “1539” instead of the correct 1549
when reporting the initial problem, then the controller later used “1529” in the middle and
end of the sequence. Both knew what the other meant since they were concentrated on
helping each other to a safe conclusion.
The pilot and controller had a lot to do other than talking on the radio, thereby placing
extensive cognitive demands upon them. The pilot was atypically both flying and talking on
the radio, while the copilot worked the emergency checklist and tried to restart the engines.
The controller, who usually acknowledges the departure of multiple flights and assigns
navigational levels and headings, had to contact other airports while focusing on just one
flight (Otterman and Wald 2009). The pilot started to interpose hints that he was not going to
make it to any airport, yet the controller couched his response assuming that first it would be
LaGuardia, then Teterboro, and finally Newark airports. Thirty-five seconds after hitting the
birds, the pilot said, “…We may end up in the Hudson.” The controller does not
acknowledge that statement, but rather he responded by giving a runway assignment. In the
subsequent one minute of conversations, they discussed landing at Teterboro in New Jersey,
56
but the pilot quickly stated, “We can't do it." The controller stayed focused on runway
selection, but the pilot meant that he was not going to attempt a runway landing.
Finally, after using the word “unable’ twice, and including phrases such as "I am not sure
if we can make any runway,” and "We can't do it," the pilot stated, “"We're gonna be in the
Hudson." The controller, who had been trading communication turn-for-turn up until that
point, did not understand the message and asked the pilot of the ditching plane to repeat. The
controller continued to send messages about alternate airport options and noted that radar
contact was lost. Another plane on the frequency received departure information and told the
controller that he thought the pilot said they were going to land in the Hudson River. The
inability of the controller to accept an eventuality different from the expected one is
reminiscent of Simons and Chabris’ (1999, 1072) inattentional blindness study with the
gorilla. In his testimony before a House Aviation Subcommittee, the air traffic controller
later commented on his reaction to the pilot's radio call saying he planned to splashdown in
the river. “I asked him to repeat himself, even though I heard him just fine. I simply could
not wrap my mind around those words. People don’t survive landings on the Hudson River; I
thought it was his own death sentence. I believed at that moment, I was going to be the last
person to talk to anyone on that plane alive” (Harten 2009; Levin 2009b). The controller
reported extreme emotional disturbance since the event, although asserting that, “During the
emergency itself, I was hyper-focused. I had no choice but to think and act quickly, and
remain calm. But when it was over, it hit me hard” (Harten 2009). Due to the trauma he
experienced over the radio, the air traffic controller remained off the job for at least a month
and a half (Harten 2009).
57
The presence of slightly mismatched communications with answers not precisely
matching the questions, and the condition of not acknowledging subtle nuances of message
intent is reminiscent of first responder communications recordings. The occurrence of a third
party on the same frequency hearing the critical message, while the primary recipient had to
ask for message repeat, has similar precedence in first responder communications.
Common Themes Among All Cases Studied
Based on the cases presented above, the researcher was able to identify common
themes. They fall into six separate categories, as follows:
Missed Messages
• No one at the scene hears urgent radio messages, despite recordings and others
hearing it
• People remote from the scene hear and understand messages better
• Inaccurate recollections not verifiable on recordings
• Tendency to blame the equipment and ignore human factors
Command and Control Issues
• Confusion and chaos over the radio
• Incident command structure lacking
• Command post designated late or not at all
58
• Too few people initially to support command post functions
• Inability to rapidly transition from frequent routine incidents habits to practices
and reactions appropriate for low frequency intense crisis events
• Lack of standardized phrases limiting optimal message clarity and efficient use of
air time
• Agency culture: either too much or too little radio use at the tactical level
• Not enough practice using the portable radios and reacting to distress calls
Message Construct
• Request to repeat the message
• Message delivered but not acknowledged
• Not waiting for acknowledgement
• Double meanings, misinterpreted messages
• Barrage of reports and requests without spacing, reply or acknowledgement
• Multiple layers of overlapping communications
• Emergency messages formatted in incomplete, clipped syntax, open to multiple
meanings and interpretation
• Prioritization of messages lacking
• Calls for additional resource not abbreviated or optimized
59
• Failure to use the order model (standardize message format, including
acknowledging party repeating back message received for verification)
Stress Reactions and Perspective
• Remote command positioning gives better perspective and voice control,
especially from a helicopter
• Emotionally charged, loud, and strained voices are common
• Stressful events are magnified by listening on the radio, emotional impact lasts for
years
• Physiological changes in voice pitch
• Unknowingly misstating or transposing numbers and phrases
• Answers not matching questions
• Failure to accept the oddity of the situation, i.e. Hudson River Landing Controller:
“…could not wrap my mind around (the) words” (Levin 2009b)
User Ergonomics
• Manipulating the settings on the radio is cumbersome and not intuitive
• Confusion when switching radio channels in the midst of the operation
• Operating in direct or conventional mode, causing no monitoring or recording
capability beyond the scene
60
• Self-contained breathing apparatus obscures vocal clarity
• Background noise causes voices to strain
Conflicting Purposes of Radio Traffic
Multiple, overlapping uses for the same radio channel:
1. Tactical- direction of the operations
2. Direct contact with responder in distress- gaining information, providing
reassurance
3. Call for additional resources- Overly wordy requests for help and logistical
support
CHAPTER 5
CASE STUDIES OF TRAINING EXERCISES
McKinney Fire Department Case Studies Venue Description
The first venue for the command communications and distraction studies was an
abandoned house in the city of McKinney Texas. The McKinney Fire Department used the
house for training purposes before final demolition. The site allowed for realistic apparatus
staging and crew deployment since there are roadway access points isolated from nearby
busy roads. Fire crews assembled at the site with the same groups participating in two sets of
evolutions before lunch. When those crews returned to their stations, a new set of firefighters
rotated to the site for the afternoon sessions. Crews mustered for a briefing on an adjacent
street where the exercise controller gave a general overview of the purposes and goals of the
drill. Following introduction of the researcher to the group by the training facilitator, the
researcher gave the participants a brief overview of this study’s purpose.
In this sequence of drills, firefighters practiced their reaction to a firefighter in distress
within the building, known as a "mayday" condition. Use of non-lethal theatrical fog
machines created realistic visibility obscuration within the building. The phrase “mayday”
has come into common practice over the last few years as the distinctive indication that there
is a firefighter in immediate peril, needing rescue (U.S. Fire Administration 1999, 15). The
origins of the use of the word “mayday” transmitted over radios to indicate a perilous
61
62
situation is traced to mariner operations and is said to be an Anglicization of the French
words for “help me” (“Mayday,” in The American Heritage Dictionary of the English
Language, 4th ed.).
High profile incidents nationwide (including those outlined in this dissertation’s Chapter
Four), at which firefighters lost their lives while awaiting rescue, have emphasized the need
for improved policies and practices concerning coordinated command and communications
during these intense events. Members of the McKinney Fire Department training staff were
the controllers for the exercises along with staff from the Collin College Fire Academy.
Members of the college staff were dressed in full firefighter turnout gear and were talking on
the radios as if they were the first arriving engine company crew at the incident. Per the
policy of the McKinney Fire Department, the first arriving engine company in such
circumstances worked as a team to start suppression and rescue activities (“fast attack”),
while the command officer on the second-arriving apparatus sought to establish command of
the incident. Deployment of the personnel in this manner for these exercises helped to target
the specific skills needing practice, creating the most realistic circumstances possible. The
controllers allowed the crews to attend to their usual tactical objectives, and then upon cue, a
confederate facilitator inside the structure, fully equipped in turnout gear and self-contained
breathing apparatus, made a realistic mayday call over the radio system. The commander and
crews needed to continue the firefighting operations with some of their personnel, while a
Rapid Intervention Team (RIT) deployed to aid the downed firefighter in the building. Once
crews reached the area where the mayday originated, they found a life-size and weight
mannequin in turnout gear needing removal to a treatment area outside. After the firefighter
replica was outside, the incident commander went through the process of a roll call on the
63
radio (referred to as PAR—Personnel Accountability Report). Upon completion of the PAR
process, the drill sequence concluded, the firefighters were debriefed, and reloading of the
hose and equipment occurred in preparation for the next sequence.
Videotaping of the exercises was a critical component for the researcher to be able to
recall the observations, to glean factors not apparent “in real time,” and to provide a platform
for the post-incident interviews with the subjects. The exercise controllers were reluctant to
script the sessions too tightly in the interests of maintaining realism. As a result, the exact
position of the incident commanders could not be determined for the researcher to establish a
fixed camera position. These exercises featured actual firefighters and their fire trucks,
rolling onto the scene from a staging area at the end of a short roadway on the property. Fire
personnel took positions on the exterior of the house, just as they would for an actual
incident. As such, there was a degree of discretion on the part of the subjects, as well as
randomness created by the mix of people for each session and the various options of where
the vehicles could park and where the commander could stand. These factors led to the need
for flexibility and some degree of anticipation on the part of the researcher, finding camera
angles to document the command environment with full-facial view of the incident
commander and the interactions with those around him. There was also the imperative to
maintain some distance so the researcher did not influence the observation environment
(Berg 2007, 179, 186-189). In some instances, abrupt changes of the camera position were
necessary as the scenario unfolded, especially when arriving vehicles blocked the camera
angle, or when the incident commander wandered out of view. The incident radio traffic on a
radio near the camera provided a continuous soundtrack and allowed for documentation
64
continuity in the rare case when the camera was on the move and the incident commander
was temporarily out of view.
At the choice of the hosting department, engine and truck company captains remained in
command throughout the duration of the exercise. It would be common for the captain to
transition to operations positions after transferring command following the eventual arrival of
a battalion chief. Allowing the captains to continue in command throughout the exercise
served several objectives:
1. There is an everyday possibility of delayed or no response of the battalion
chief due to other incidents working, distance, or response accident.
2. A mayday can be called at any point in an incident and the most critical
challenge of logistics and low resources is at the early stages of the operation, when
the captain is still typically in charge before elaborate support and command
contingencies can be established.
3. Captains fill in for whole shifts when battalion chiefs are absent.
4. Even with experience levels ranging from eight to 27 years, the captains have
a relatively low experience base with multi-company command situations. Their
department has experienced few working structure fires in recent years, despite rapid
growth of the community; conversely, earlier in their careers, the department was
much smaller with simpler tactics and smaller contingents to command.
Some fire departments have adopted a policy of stationing the incident commander
within a vehicle, i.e. cab of the fire engine, or a sports-utility command vehicle. The observed
65
department generally adhered to the more traditional posture of the commander being on foot
within a general area around the first arriving apparatus, usually in front of the structure.
Although the focus of this study was to determine the type and quantity of environmental
influences and distractions leading to communications dysfunctions, it was interesting to note
the body English displayed by the commanders as they moved around a predictable
footprint—often within 20 feet of where they started. Perhaps this was because the subjects
were all suppression captains and recognizing that they are closer to the day-to-day, hands-on
tactical environment than chief officers are. There was a noted tendency for them to pace
around a lot, especially as the tempo and severity of the simulation increased. When the
practice mayday calls occurred, some of the captains/incident commanders took a few steps
toward the structure, as opposed to their previous back-and-forth pacing, in symbolic or
perhaps even subconscious reflexive desire to help a comrade. There was a lot of movement
observed whenever they transmitted on the radio and even some while in the act of listening
to a specific radio message.
The weather conditions came into play to a certain extent; the first day was mild and very
windy with the wind carrying the fog from the house toward the incident commander. While
the volume of fog did lend an air of realism, it also caused some obscuration of the people in
the camera view. Day two was much cooler with a wind shift allowing better viewing
contrast on the video. Day three turned very cold, causing postponement of the exercises for
that day. Another factor needing sensitive treatment was the death of a co-worker during the
series of drills. A McKinney firefighter died from injuries sustained off-duty after a hospital
stay wrought with emotions for his family and fellow firefighters. Fire departments are tight-
knit communities with death of active members invoking elaborate funeral traditions and
66
redirection of the usual daily routine. The researcher was able to gain sufficient data before
the postponed sequence occurred. The researcher acknowledged their loss during the
personal follow-up interviews. It was an interesting coincidence that the death occurred
within the month of the training exercises aimed at rescuing a firefighter in perilous
situations. While no one articulated as much, it is intriguing to ponder whether the sudden
death had any impact on the intensity and eagerness in preparing for firefighter rescue
missions.
Exercise Data
The researcher based his determination of subjective rating of communications as either
inadequate or ineffective on messages remaining unanswered or needing repeating. Seventy-
four instances of radio inattention occurred during the two-day series of exercises comprised
of seven distinct exercise sequences. No apparent reason could be determined in a majority
of the situations (n=28). The next most common reason for inattention was distraction by
talking in person to someone nearby (n=14). The emergency command environment demands
a high level of collaboration and information transfer with those in the immediate area.
Although the number of influences was few due to the absence of common real-scene
distractions, such as redirection of attention while conducting conversations with others, the
exercise controller adequately mimicked some of the distraction factors inhibiting full
attention to the radio by the incident commanders. In real-life situations, there likely would
be victims, neighbors, onlookers, media, representatives of other agencies, and other
firefighters awaiting deployment trying to access the incident commander. The noise around
the simulated incident scene also contributed to the inability to hear the messages clearly.
67
Interviewees cited engine noise, power tools, road noise, and people yelling as factors
influencing the typical listening environment.
Several of the participants moved in a variety of ways when performing radio calls. Some
immediately started walking away from the huddle of others at the command post upon
receiving a message. Some even turned their backs to the incident entirely in an attempt to
gain some control of the listening environment. When questioned later, most indicated that
their experiences in using portable radios taught them that a feedback squeal would result if
they stay close to others who typically keep their radios at a loud volume. This causes a lot of
movement around the command environment with some portion of cognition reassigned to
ensuring the movers go to appropriate alternate positions, do not step on something, do not
move into a lane of traffic, or in any other way endanger themselves. The researcher
observed a great deal of body movement and contortion with subjects often craning their
necks in some fashion to get their mouths or ears closer to a fixed speaker/microphone
position. Some bent at the waist in an attempt to create a slightly better listening vantage
point. Several interview participants indicated a degree of frustration over the
speaker/microphone situation. They stated that the operation of the external microphone
assembly is especially ineffective after recent exposure to water at fire scenes. Although
there are headphones available within the cab of the trucks, the respondents were not
enthusiastic about using headsets within the fire command environment. They contended that
headphones make it too difficult to hear other important things, like people yelling, subtle
changes in sounds coming from the structure (which could signal sudden failure of the
building systems), or other timely safety factors. When prompted on whether they could
envision any circumstance in which they would simply stay in the cab of the truck to
68
command an intense incident, most said they would consider it only in dire circumstances.
They admitted that their culture and practice have patterned them to assume the exterior
command position, consistent with the common practice of captains being relieved of
command soon after assuming it.
The researcher was able to draw upon more than thirty years of public safety experience
in determining whether replication of realistic command and radio conditions were present at
the exercise. Although the pace and volume of radio traffic were below that which can
typically be expected under the circumstances being simulated, the conditions were enough
of an accurate reflection of pertinent factors to derive data and gain insights. The slower pace
did allow for better examination of the interactions of relationships, distractions, and
influences, both while observing in person, as well as during later replay of the video tapes
for data collection. The slower pace and volume allowed for something akin to slow motion
video, whereby nuances and subtleties are more apparent than when they occur at usual
speed.
In conversations with the exercise controllers on the days of observation and at most of
the post-exercise interviews with the incident commanders, the researcher learned that the
participants’ department does not typically generate a lot of radio traffic at incidents. They
have made a conscious effort toward scripted tactical objectives, conveyed in shortened,
“bullet-point” radio transmissions in lieu of verbose, lengthy radio turns. There was some
evidence of this, especially during Case Number Four, where short tactical commands proved
to be very effective in rapid and efficient relay of commands. Most of the interviewees
conceded that an actual situation of a firefighter calling for help would have triggered a
higher degree of anxiety and emotions with one subject indicating that adrenaline production
69
would be a physiological factor influencing radio traffic management. One of the captains
interviewed indicated that studying recordings of “fires gone wrong” often disclose too much
radio use occurring to the detriment of overall command and control.
McKinney Case Studies Day One
Case Number One
In Case Number One, a captain with eight years of experience assumed the role of
incident commander. One of the observations made during the exercise was that he
frequently took notes on a small notepad in an attempt to keep track of company assignments
as they were occurring. He assumed a standing position of command near one of the fire
engines during most of the exercise. Between the establishment of command and the calling
for the simulated mayday, he took notes trying to track the location and assignment of units
at the scene.
Six minutes into the exercise, the incident commander did ask for a progress report. This
was notable since this fire department does not use automatic time checks for updates. Some
departments have a procedure whereby the dispatcher signals the incident commander at
specific timed intervals, triggering a reevaluation of circumstances and the issuance of an
update report. The number of radio transmissions occurring at this exercise was 22; twelve of
them or 55 percent were effective communications turns with 10 sequences or 45 percent
judged ineffective. Some of the reasons for the ineffective communications during Case One
were distractions from talking to other individuals in person while people were calling on the
radio, as well as background noise and scene-generated noise. In other instances, there was
no apparent reason for the inattention to the radio calls.
70
In a post-exercise interview with the captain from Case Number One, he recalled there
was some switching of channels to segment units at the scene, which he believed confused
people more often than aiding effective scene communication. When asked whether he was
aware that he had missed any calls, he said, “No,” he was not aware that he had missed any
radio transmissions. When asked if he was aware of any distraction that may have caused a
missed radio transmission, he indicated that there were instances where he was meeting face-
to-face with other individuals at the command post, which could have led to missed radio
transmissions. He also emphasized empathically that he was against changing channels in the
midst of an operation, essentially splitting up those at the scene on the two different radio
channels, in an attempt to allow the mayday operation to be separate from the suppression
efforts.
In response to a question about whether the exercise was realistic, the captain from this
case indicated that he thought it was realistic. His fire department normally has a relatively
quiet pace on the radio channel. He believed that many of the operationally flawed fires that
he had studied in other parts of the country had a feature of too much radio use occurring as a
contributing factor. In making recommendations for future improvement, he indicated the use
of a scribe or aide would be very helpful, but it is best if that occurred right from the very
beginning. He felt that the exercise facilitation process interrupted his normal command flow,
creating a distraction factor that was somewhat unrealistic; he suggested improvement in the
facilitation process in future training exercises.
When questioned about the use of headphones, he responded that he could not envision
their practical use for routine incidents, but perhaps under unusual circumstances they would
be appropriate. His biggest concern for headphones was that they cause an audible separation
71
from all the people he commands, inhibiting cognitive awareness of what is occurring around
him. He did see room for technological improvement in the headphones and microphone
arrangements used inside self-contained breathing apparatus since they frequently led to
muffled transmissions requiring message repeating.
The overall time of Case Number One was 25 minutes with the mayday called 13
minutes into the operation; the time from the mayday to the conclusion of the drill was an
additional 12 minutes.
Case Number Two
In Case Number Two, the captain with over 20 years experience was observed during an
exercise lasting 17 minutes. The time from dispatch to the first mayday call was eight
minutes, followed by a sequence from mayday until the simulated firefighter victim removal
and drill conclusion of nine minutes. There were 16 radio communications during this
incident at a pace of nearly one per minute. The number of communications effectively
occurring were 44 percent (n=7) and the ineffective communications totaled nine for a 56
percent overall negative rating.
The captain said in the interview that he was not aware of missing any radio messages as
they occurred, but he noted that the tone of voice and inflection used by some of the parties
as they called gave him an indication that it was not the first time they attempted contact.
Several of the radio transmissions needed repeating, although they were clear on the
recording. In some instances, there was no acknowledgement or answer given to radio
messages, once again being clear on the recording but apparently going unheard by those at
the scene.
72
In the post-exercise interview, the captain recalled the communication situation as
somewhat frustrating, especially recalling the confusion upon splitting the radio channels.
The split occurred at the time of mayday, keeping the operation for firefighting on one
channel and the rescue for the downed firefighter diverted to a secondary channel. When
asked if he missed any communications, he estimated that there was at least one missed.
The captain in Case Number Two indicated that face-to-face discussions with bystanders
was a likely distraction leading to missed communications, and he projected that it will be
even worse at real incidences since they often need to interview victims, or neighbors, or
other individuals in the area while simultaneously listening to the radio.
Observations during this case, as well as in other evolutions in the series, showed that the
incident commander was also responsible for maintenance of an accountability tag system.
Tags helped command personnel track the specific personnel operating at the scene. This
proved unwieldy since it interrupted the manual dexterity needed to use his portable radio,
and did redirect some cognitive attention away from radio communications and incident
command concerns. Engine noise and general scene background noise also contributed to
missed radio transmissions and those requiring repeating. There was some feeling of
frustrations on the part of the incident commander since the changing of radio channels did
not work exactly as hoped. Improvement in changing of radio channels when splitting
incident communications into two or more radio channels is an unmet need. When
questioned about how realistic the exercise was, the captain indicated that it was somewhat
realistic, but, certainly, emotions would have been running much higher during an actual
incident, especially if a mayday is declared.
73
The captain for Case Number Two recommended further improvement by assignment of
a scribe or aide from whatever source possible, especially in the early stages of an incident.
However, he admitted that it is very difficult to have the available staff to accomplish that.
The irony is the longer the incident goes, the more support there is for the incident
commander. However, it is during the critical early stages of the incident where the most
acute communication needs are present. In this instance with an overall 17-minute evolution,
it was obvious that the units on the scene would have to work with a limited number of
personnel before establishment of formalized support.
Case Number Three
Case Number Three involved a captain with eight years of experience. He moved around
continually while transmitting messages on his radio. He would often take a few steps away
from anyone he was nearby when transmitting and that same habit was consistent when there
was no one near him. When questioned, he indicated that feedback squeal and additional
noise is often an issue at the company officer level. Company officers become accustomed to
having to move away from other people as they are keying up their portable radios. This
distracts and redirects some of the officer’s attention span to figure out where to move just to
transmit routine radio messages.
Case Number Three lasted for 16 minutes with the mayday declaration seven minutes
into the operation with an additional nine minutes to rescue the firefighter and conclude the
drill. There was a considerable amount of fumbling with the radio channel controls to
accomplish the radio channel change. The channel change occurred as a part of the mayday
operation and the incident commander was uncomfortable with the radio change. This
incident commander did not huddle very often with others around him, except for a battalion
74
chief and the exercise controller in the area. Of the 17 radio transmissions, again at a pace of
about one per minute, the number of effective communications was seven at a 41 percent
rating and this series had the highest rate of error for communications at 59 percent with 10
radio turns judged as ineffective.
Some of the researcher’s observations made during the missed radio messages were they
happened while conducting a face-to-face conversation with an observing battalion chief and
there were other missed radio calls for unknown reasons. Some cross-channel dysfunction
occurred with people talking on one channel receiving their answers on the other channel not
monitored by the unit calling. When asked in the post-incident follow-up what he recalled
about this incident, the captain indicated that the pace was slower than the real thing but he
felt it was somewhat unrealistically controlled and contrived, but still helpful and useful as
practice. When asked if he missed any radio communications, he did indicate “a few” and
guessed maybe five. He had the highest guess rate of any of the post interviewees, which
mirrored the data, but was still under-estimated. His guess was only accurate by one-half
since the number of negative communications was actually ten. When asked about what
some of the distractions were that caused the missed radio traffic, he stated there was radio
traffic on other channels drawing his attention. In other words, hearing other radio channels
nearby split his peripheral attention. Background noise was a contributing factor; this captain
also indicated that there was a gap in getting his battery changed on his radio as he started to
get a low battery signal.
This incident commander also readily admitted that the emotion present in this exercise
was not to the full intensity expected at an actual incident, especially where a mayday was
involved. He hoped that in future exercises there could include randomized sequencing of
75
variables, so it did not feel as rehearsed and predictable. Apparently, there had been
information sharing occurring from previous participants, causing some lack of spontaneity
and challenge. Despite this, this incident commander missed 59 percent of the radio turns.
This captain stated that he would like to see more training on mayday operations and
integration of an aide to assist in the sensory attention needed by a solo incident commander.
He advocated the use of a single operations channel making urgent radio traffic more
difficult to ignore. When asked about the use of headphones, he saw some value but he was
not sure how to integrate its use into the McKinney Fire Department’s emergency command
environment.
Case Number Four
Case Number Four, involving a captain with over 20 years experience, had the longest
duration of the series observed with the exercise lasting 26 minutes. There was an 18-minute
period from dispatch until declaration of the mayday with the personnel accountability report
(PAR) called between the dispatch and the first mayday, which prolonged some of the
overall timeframe. This gave the observer the opportunity to study the additional radio turns.
The time from the mayday until the drill’s conclusion was an additional eight minutes for an
overall 26-minute evolution. The number of radio transmissions in this exercise was the
largest studied in the series with 40 radio sequences; 26 were completely effective for a rate
of 65 percent, and only 14 assessed as ineffective for the lowest rate of 35 percent.
This incident commander started out by giving a series of short tactical commands in the
pre-mayday environment, which proved to be very effective. He assigned specific tasks and
they generally were able to understand them and respond appropriately. One interesting
feature in this case was that the incident commander seemed best able to understand short
76
messages. The longer the message got, the less likely he seemed to retain all of the content
and to understand the message clearly. Some degree of such truncation deficit existed in
other sequences, but this case was particularly notable. He successfully repeated the last parts
of longer messages to verify what it was he was hearing. Such instances counted as a
miscommunication for the purposes of scoring, because it amounted to repeated information
by the sending party.
There was a well-balanced mix of causes identified for the missed radio transmissions. In
some instances, the garbled message was attributable to background noise or muffled words
while the sender tried to talk with a self-contained breathing apparatus mask over his mouth.
Repeating of the whole message was necessary in some instances for longer messages and
yet, in some instances, there was no known reason why a repeat or no answer occurred.
The presence of feedback squeal over the radio system was also a considerable concern in
this sequence. That was puzzling because the incident commander was not obviously near an
open speaker, yet feedback squeal occurred during some portions of the exercise, perhaps
because of high radio volume on trucks nearby. During the interview, he was not able to state
which open speaker was causing the squeal. In the post-incident interview, the captain from
this case recalled that the splitting of the radio channels did not go very smoothly. He was
emphatic that he could not do multiple, simultaneous tasks with equal efficiency.
When asked whether he missed any radio traffic, he thought maybe there was one missed
radio transmission during a face-to-face conversation. The face-to-face conversations and the
noise of the command environment were commonly cited reasons in all exercises for missed
radio traffic. The use of the radio itself is felt to be sometimes cumbersome and not a smooth
77
interface for the user. He asserted that the key is to split the radio channels for some
appropriate division of duty, taking the radio off the scan position when segmenting duties,
and assigning separate command officers on each channel. This captain was able to delegate
radio monitoring to a second individual and appeared the most comfortable of all those
studied to ignore completely the other radio channel and focus exclusively on the radio
channel command that he retained. The assistant assigned to monitor the other channel was
more animated than the others observed. He was pacing, posturing, and bending at the waist
as he strained to hear the radio held up to his ear. This created even more movement around
the command post footprint, adding to what looked like something of a clunky ballet from
the observation position.
McKinney Day 1 Scores Comparison
30%35%40%45%50%55%60%65%70%75%
Case 1 Case 2 Case 3 Case 4 Average
Figure 1. Summary of Positive Scores From McKinney Day One
78
McKinney Case Studies Day Two
Case Number Five
Case Number Five involved a captain with about 10 years of experience. There were 21
radio communications during this exercise with 12 found to be effective for a 57 percent
positive rating and nine were ineffective for 43 percent occurrence rate. The drill lasted for
36 minutes. This captain turned his back to the scene and walked around quite a bit while
transmitting. He shifted from a stationary position and started pacing or turning directly away
from the incident while making radio calls.
There were several instances during Case Number Five where the recording is clear but
the incident commander did not understand the message. There was some confusion created
when the split of the radio channels occurred. The attention of the incident commander was
distracted whenever the designation of “rescue command” occurred on the other radio
channel with an open speaker nearby. The phrase “command” on the other channel seemed to
get his attention since it was the same designator for him on the channel he was working. He
would then look at the radio that he was holding and questioned if it was still functioning
appropriately, not immediately cognizant that it was someone on another channel calling
someone else.
Of the nine communications found to be ineffective, there were some whereby repeating
was necessary, although the recording was clear. In other instances, calling units received no
answers without apparent reasons. In one interesting situation where the incident commander
looked puzzled by the transmission, it was possible to read his lips, as he shrugged his
shoulder and looked at those around him, mouthing the words, “What did he say?” The
79
captain for Case Number Five declined the post-exercise interview, deferring comments to
his command officers.
Case Number Six
The captain for Case Number Six has approximately 15 years of experience. The exercise
lasted 27 minutes with a 13-minute timeframe from dispatch to declaration of the mayday
and an additional 14 minutes then from mayday to a conclusion. This captain was observed
to step away from the grouping or huddle of individuals whenever transmitting on the radio.
There was also some confusion noted during the channel change with some missed
transmissions along with some individuals missing the mayday message as a result.
The captain in Case Number Six did have an aide or scribe assigned. The aide seemed
diligent in tracking information on a clipboard. However, the captain maintained an interval
of distance between them during almost all of the exercise only approaching the aide in a
couple of instances when he needed specific information. There was not a high level of
teamwork or collaboration observable between them.
The communications were very efficient at the start of the exercise but they tended to get
scattered as the exercise played out, especially following the split of the radio channels.
Some messages triggered a request for a repeat for no apparent cause. There was some
feedback squeal contributing to the inefficiency of messages. There were also several
instances where the requests and the answers were on two different channels when the
channel split occurred. There were 30 communications during Case Number Six and,
interestingly, the efficiency rating was the same as the one (Case Number Five) preceding it
on the same day, with a 57 percent efficiency rating for positive communications, while 43
percent were ineffective. Due to scheduling conflicts, there was no interview conducted.
80
Case Number Seven
Case Number Seven involved a captain with 20 years experience as an incident
commander. There was a 14-minute timeframe from dispatch until declaration of the mayday
with the mayday-to-rescue time only five minutes in this exercise, overall time was 19
minutes. There were 24 radio communications during this exercise with 15 deemed as
positive for 62 percent efficiency rating and nine found to be ineffective for a 38 percent
score.
When asked in the post-exercise interview whether he missed any radio communications,
the captain indicated “maybe a couple.” He recalled some confusion about the
communications at the incident, especially involving the medic crews assigned to rescue
duty. The microphone and receiver capabilities within the face-pieces of the breathing
apparatus continued to be a concern for this captain, despite experimentation with various
forms of alternative equipment. He indicated that there would likely be more adrenalin
influence in the real incident than this exercise portrayed, although he did find that this was
helpful in practicing some of the key elements of the techniques needed for successful
mayday operations. In discussing headphones, this captain gave insightful conjecture on the
possibilities of voice recognition technology in the future using digital filtering to key-in on
certain critical words and to filter undesirable scene noise and feedback. He also indicated
that studying recordings of “fires gone wrong” often disclose too much radio use occurring to
the detriment of overall command and control.
81
McKinney Day 2 Scores Comparison
50%
55%
60%
65%
Case 5 Case 6 Case 7 Average
Figure 2. Summary of Positive Scores From McKinney Day Two
McKinney Exercises Analysis
The gap between the top and bottom scores shows a 27 percent disparity.
McKinney Cases Sorted By Number of Positive Communications
Case
#
Plus
=n
Minus
=n
Total
%
of +
%
of -
Minutes
Communications/
Minute
3 17 7 24 71% 29% 16 1.5
4 26 14 40 65% 35% 26 1.5
7 15 9 24 63% 38% 19 1.3
5 12 9 21 57% 43% 36 0.6
6 17 13 30 57% 43% 27 1.1
1 12 10 22 55% 45% 25 0.9
2 7 9 16 44% 56% 17 0.9
Figure 3. Ranked McKinney Scores
82
With just one exception in the middle, the more communications per minute correlate
with a higher success rate—pace matters, more is better, although there likely is a point of
diminishing returns in high volume crisis communications; these exercises were generally
below typical incident pacing.
Percentage
Positive
Communications
per minute
65% 1.5
71% 1.5
63% 1.3
57% 1.1
44% 0.9
55% 0.9
57% 0.6
(Average=59%)
Figure 4. Scores Compared To Pace
The average pace for all seven McKinney cases was 1.1 messages per minute. By
comparison, the pace of the Fire Department of New York on 9/11 was approximately five to
six message turns per minute with almost constant overlapping communications as the World
Trade Center towers fell (Firehouse Magazine 2005). A notable observation for a department
that prides itself on not talking a lot at fire scenes is the counterintuitive data indicating the
more communications per minute in this sample, the higher the positive score. Of those
83
performing above the average effective score of 59 percent, all were at the top of the pace
list. The rapidity of the pace could easily overwhelm the incident commander, at some point,
but within the low-to-medium rate used in these drills, the medium rate led to more accurate
communications turns than did the slow-paced ones.
There was no correlation between success rate and experience level. For every positive
score by a senior member, there was nearly an exact match for an unsuccessful one in the
same experience group. The researcher anecdotally developed the impression that novice,
younger incident commanders did not seem to have the same poise or control of their older
counterparts, yet they had greater skills in other areas. The younger members appeared more
likely to juggle multiple demands for their attention, were less likely to ask for repeat of a
message, and seemed better able to retain long messages with multiple facets imbedded
within. One possible explanation for older members struggling to hear may be more than just
natural hearing loss with age, but also could have correlation to hearing loss from years of
being around loud sirens, radios and power tools, especially before more enlightened hearing
protection became common. That aspect was beyond the scope of this study and would be an
interesting area for further research.
Plano Fire Department Case Studies Venue Description
The Fire Training Center in Allen, Texas was the venue for the second series of fieldwork
observation exercises. The Allen Fire Department had just deployed a new fire simulations
lab in which firefighters are able to interact with software and video displays. Game
controllers allow participants to simulate the actions they would take at an actual structure
fire. This controlled laboratory environment gave a natural opportunity to observe the
84
participants and study their communication behaviors as well as the distractions present in
the emergency command environment. The researcher was able to interact with the subjects
immediately following the exercises during debriefing sessions, eliminating the need to
schedule follow up interviews, as was the case for the outdoor observations. The desire of
those conducting both the observation study and the training series was to recreate the issues
firefighters face at actual incident scenes and challenge the subjects to improve tactics. Fire
suppression personnel from the Plano, Texas Fire Department were the test subjects for this
series of observation exercises.
The supplier of this fire simulation software is Flame-Sim LLC. The software program
allows players to see their first-person action on the screen and to function within a virtual
emergency environment. Each participant is also able to see the perspectives and actions of
the other actors around them, while they have discretion individually to control their own
actions on individual video screens. The exercise controller formatted the variables to follow
a similar pattern of responses with the first engine arriving at the scene giving a radio report
of the conditions, followed soon after by the battalion chief who assumed command of the
incident. All parties were encouraged to make their normal radio reports. To lend an air of
realism to this exercise, as well as to provide a mutually enriching experience for all parties,
actual communications dispatchers were integrated into these exercises directly at the
simulation site. This gave an extra element of realistic radio transmissions and allowed for
re-creation of accurate radio flow and content. The dispatchers started the exercise with
realistic incident dispatch messages using addresses from the city where the firefighters
work. The instructions to the subjects were to assume tactical assignments, as they would at
an actual incident, as the incident commander reacted to the radio messages. The dispatcher
85
maintained normal benchmark times and information flow to the incident commander as they
typically would for real emergencies.
There are four different seated positions within cubicles in one room where firefighters
sit in front of standard computer screens along with game controllers typical of video
gaming. There are also two other command theaters in larger rooms with a large screen in
one room where firefighters are able to simulate tactical operations typically conducted as
they would move through the scenario. Actions include crawling in smoke-filled rooms and
making their way through the rooms of the structure searching for victims, operating as they
would typically as firefighters. The other room has a large screen where the incident
commander was able to assume a seated position at a table, which accurately simulates the
policy of this fire department to stay seated within their command cars, usually within a
sports-utility vehicle.
The exercise controller from the host department has found it is best to avoid a lengthy
briefing on the use of the system. Getting the game controllers in the hands of the
participants provided the quickest orientation, decreased the learning curve, and allowed
participants to move quickly to the valuable part of the exercise. The participants receive a
cursory walking tour of the various positions, followed by a brief introduction on the
interactive nature of the simulations. With the controllers in hand, the participants
maneuvered through a practice scenario with mentors familiar with the system in the vicinity
to answer any questions. Most of the questions and coaching centered around the various
buttons and controls on the hand pieces, which are standard gaming controls and familiar to
“gamers.” This allows the participants to interact with the system and to see cause and effect
86
relationships between the firefighters depicted on the screen and their immersion into the
gaming environment.
The video camera used by the researcher was set up in the command room. The over-the-
shoulder position provided a view of the large screen before the test subjects allowing an
understanding of the context of the video simulated incidents. The camera angle selected
allowed for a side view of the test subjects to understand some of their interaction with those
around them, as well as some other nonverbal reactions to the circumstances occurring. The
fire personnel used their portable radios as they would at a typical incident. Placement of a
radio near the camera created a soundtrack for the video, allowing later understanding for the
context of what was occurring.
Plano Case Studies Day One
The first series of case studies occurred on January 22, 2009. Groups of firefighters
stayed in the training simulation lab in half-day segments. The first group assembled and
went through an initial briefing, including information on the purposes of this observation
exercise. Following the briefing, the firefighters positioned themselves at individual
simulation stations where they had an opportunity to practice with game controllers. The first
group was acclimated to the game controllers and exercise flow. The battalion chief of
training from the participating department was the first incident commander to start the
exercise series. The purpose was to bring everyone to a comfort level with the simulation
concepts and to allow them to be acclimated to the interaction between the software and the
firefighting actions. This initial sequence was not scored since the participants, controller,
and researcher were still acclimating to the simulation environment.
87
Case Number Eight
In the second case of the day, the battalion chief who started the exercises again assumed
the role of incident commander as the first simulated scenario played out. Of the 24
communications scored the vast majority were found to be effective; 22 communications
turns were effective, versus only two flagged as ineffective for a couple of minor reasons.
Case Number Eight played quite smoothly, as could be expected, since it was a second time
through for that incident commander and he had relative familiarity with the incident
simulator software through earlier exercise planning meetings conducted between the
departments’ representatives and the researcher. The challenge level of this early incident
was also low, as the tactical difficulties and complexities increased later in each group’s
sequence.
Following Case Number Eight, the simulations staff discussed the operating conditions
present and the consensus was that the background noise was unrealistically sterile compared
to what could typically be expected at actual incidents. There was a consensus to enhance
some of the background noises to make it more like a realistic emergency scene. The
simulation software has a soundtrack that plays some relevant scene noises; we just did not
have it on in the command room. Following activation of that feature, sounds such as self-
contained breathing apparatus and a saw operating to ventilate the roof played on the
speakers in the ceiling of the command room, which more accurately reflected some of what
would exist at an incident. An extra portable radio tuned at a moderate volume level in the
command room provided realistic echo and radio sounds, typical of emergency operations
areas. Discussions with the firefighters concluded that the noise inside buildings on fire is
often even louder, especially involving the use of mechanical fans to exhaust smoke. The
88
sounds of several firefighters in close proximity breathing through their self-contained
breathing apparatus, as well as smoke detectors sounding, add to the typical noise level inside
burning buildings. Background noise presents a considerable influence upon firefighters
operating on the scene. Even though this department does typically have its incident
commanders sit within a command vehicle, it is reasonable to assume that there would be
some distraction and incident noises influencing the incident commander’s ability to
communicate effectively.
Case Number Nine
In Case Number Nine, an experienced fire captain assumed the incident command
position, along with an assistant assigned to form a two-person deployment, as if they were
sitting side by side in their vehicle commanding the incident. There were 34 communications
during this exercise with 26 effective (76 percent) with only eight judged as ineffective. The
reason for some of the missed messages included the incident commander not providing an
acknowledgement to a message and another was a missed transmission between tactical level
units. The pace caused the incident commander to move to the next radio transmission
instead of waiting for acknowledgement from the prior message. There is a risk of messages
being missed when the receiving party is not given time to acknowledge.
This exercise featured a series of smooth and short commands issued effectively. There
were two instances whereby a garbled radio transmission did not receive any follow-up from
the incident commander, even though it is clear on the recording that someone called him.
This scenario included a simulated firefighter-injured situation, with all parties handling that
aspect well. The pace of radio traffic picked up slightly when the firefighter injury occurred;
89
however, that phase concluded rapidly, so it did not place undo stress on the radio
communications.
Case Number Ten
Case Number Ten involved a captain who was able to observe the previous exercises and
to assist others, so he had extra familiarity with the flow of what was to occur when he was
incident commander. There were 29 communications conducted during the fifteen-minute
exercise simulating a house fire response. Twenty-one percent of the communications were
ineffective. There were times when garble over the radio did not trigger a request to repeat by
the incident commander and there were two instances where there was no apparent reason for
ignoring the calling unit. The incident commander did not acknowledge a critical message
involving removal of the victim from the hazardous environment. In this instance, it was
apparent to the observer that he understood the action was taking place, but he did not
convey that to the units at the scene in the form of an acknowledgement over the radio.
Case Number Eleven
Case Number Eleven featured a thirteen-minute simulation in which the units were
responding to a reproduction of a structure fire. Thirty communications were conducted at
the rate of over two per minute, a relatively fast pace for this exercise series. Seventy percent
of the communications were effective. Those judged ineffective included instances where
there was no confirmation for radio messages; in some cases, the radio message was not
clear, but the officer did not request the calling unit to repeat the message. One message
repeat was necessary because a face-to-face conversation with the commander distracted
attention from the radio.
90
This exercise included a firefighter calling for help and the situation was resolved rapidly.
Since the rescue was of short duration, the dispatchers and commanders did not apply the full
procedures required in such situations. There was a great deal of interaction observed
between the incident commander and the partner assigned to the incident commander. A high
rate of collaboration occurred with ten instances of eye contact or confirming nods to
questions posed between the partners. There were times when the presence of a partner did
seem to be a distraction causing them to miss some messages because they were
collaborating at such a high level. The collaboration did seem to help at other times,
however. There was an instance during the Personnel Accountability Report process whereby
one of the units interrupted with an urgent message. The commander turned to the partner
and said, “Do what?” indicating that he heard part of the message, but was looking for help
in understanding the remaining content. The partner repeated the message so it was not
necessary to do so over the air.
Case Number Twelve
The final exercise on this day was Case Number Twelve, allowing for application of the
previous experiences gained by the crews and commander with a slight escalation in the
intensity of the variables. The scenario was more challenging with additional victims needing
rescue in the building on fire and the fire more difficult to extinguish. The incident
commander was serving in the lead position for the second time, providing the researcher an
opportunity to observe some of the learning curve improvements occurring through repetition
and familiarity. He cut his personal percentage of ineffective communications in half to a
respectable 16 percent, as compared to the overall study average of 27 percent. The exercise
lasted 21 minutes with 43 effective communications versus eight ineffective ones; the pace
91
was the fastest of any exercise on this day. In this sequence, the incident commander was
assigned alone to study the solo environment of incident command. The inference one may
draw from these results is practice and familiarization is more valuable than assignment of an
aide.
Plano Day 1 Scores Comparison
60%65%70%75%80%85%90%95%
Case 8 Case 9 Case 10 Case 11 Case 12 Average
Figure 5. Summary of Positive Scores For Plano Day One
There was a rapid pace of communication during this exercise with almost two and a half
communications per minute, which was on the high end of the range in this sequence. Most
of the communications turns were efficient. Atypically, no message repeating was required in
this sequence. Of the effective communications made, one was a situation whereby a
message went without acknowledgement and there were other instances where no
acknowledgement was given to an inbound message before moving on to new transmissions.
When messages are stacked, or “piggybacked” in such a fashion, the calling party cannot
confirm delivery of the message. There was one instance of a redirection of attention
occurring. This is the radio equivalent of a forgotten telephone call placed on hold; in other
words, the commander did not get back to a previously calling unit as redirection of his train
92
of thought occurred following a newer calling unit’s message. This incident commander
appropriately cautioned firefighters when other opposing tactics could affect their safety
during a rapid entry tactic known as “vent-enter-search.” By the end of this exercise, the
incident commander developed an effective rhythm with very efficient turns of
communication evident.
Reevaluation of the Simulation Environment – Testing Sub-Theories
After the test subjects departed the simulator for the day, a debriefing session occurred
with participation of the exercise controller from the host department, the training officer
from the department supplying the firefighters, and the researcher. The consensus was
general satisfaction with the first day of exercises, realizing that by the end of that day, we
were achieving realistic command and communications conditions. We discussed the
situation of firefighters often trying to speak with their breathing apparatus face pieces in
place, and how that muffled their voices, requiring the repeating of radio messages. The
simulation exercise on day one did not consider that influence, other than the soundtrack that
played on the individual computers when firefighters used their simulated self-contained
breathing apparatus. We agreed to introduce some element of actual wearing of face pieces
by the test subjects during the next day of exercises.
Plano Case Studies Day Two
Day number two, January 23, 2009, at the Allen simulation site began with a new set of
test subjects assigned to the training simulator. Following the routine briefing and an
explanation of purpose of this observation exercise, the test subjects deployed throughout the
93
individual stations for practice sessions with the controllers to be acclimated to the test
environment.
Case Number Thirteen
An experienced lieutenant from the first day of simulations served in the role of incident
commander for the introductory sequence. This practice exercise lasted seventeen minutes;
twenty-four communications sequences scored as effective with only three rated as
ineffective. The ineffective ones involved a garbled radio transmission that needed repeating,
as well as no answer received in two other instances during the 27 turns of communications.
The elapsed time of the exercise was seventeen minutes. The data show an impressive
efficiency rating of 89 percent, demonstrating the benefit of this incident commander’s
experience with prior exposure to the simulator environment and the relatively simple tactical
objectives. This group acclimated very quickly to the game controllers and seemed eager to
get into the actual pace of exercises.
Case Number Fourteen
An experienced fire captain served as the incident commander for Case Number Fourteen
with this case lasting 21 minutes. With 88 percent of the incident scene communications
judged effective, only 12 percent proved to be ineffective. Some reasons for the ineffective
communications included distraction during a face-to-face conference with someone else in
the command environment, no answers to messages in two other instances, and a request to
repeat for no apparent reason. The researcher was in the task-level simulation room at the
time when a firefighter bungled a radio message. It was interesting to observe that the sender
of the communication was not aware that he transposed the words of his message. He said,
“I’m putting fire on the water.” He did not realize he made the error until the incident
94
commander repeated back the incorrect phrase, prompting him to realize that he had said it
backwards. Because of the direct observation of the individual as he sent the wrong message,
it was evident to the researcher that he was engrossed in the task in front of him and the
composition of proper syntax of his message was a secondary concern to the primary
attention he had for the tactical objective (Mack and Rock 1998, 74-103).
Case Number Fifteen
In Case Number Fifteen on January 23, an exercise for simulating a structure fire with
someone trapped inside occurred during a fifteen-minute sequence. This was a relatively
short time duration within this series, but the pace of communications is nearly two turns per
minute with 21 of the messages proving to be effective and only seven were ineffective. Of
those found to be ineffective involved units transmitting over the top of each other and some
units not waiting for message exchange to conclude before attempting delivery of the next
one. Some of the transmissions were garbled, and there was an instance of no answer
received when another party was calling the incident commander. The researcher noticed
again during this exercise the repeat of messages was required for no apparent cause. Even
though the transmission was clear on the radio system, the sending party requested a repeat.
Case Number Sixteen
This group of subjects concluded the session with a more challenging nineteen-minute
exercise requiring the rescue of a firefighter injured within the building. Some stress
reactions by the incident commander were apparent. He was not as experienced in incident
command as the other officers so there was intent by the trainer to place him in this role for
practice purposes. Several of the ineffective messages were due to no immediate reaction to
the calling parties, as the subject appeared overwhelmed by the rapidly escalating cascade of
95
calling parties. In other instances, information was slow to be processed and since it needed
repeating for full comprehension, there was a delay on the air, filled with additional calling
parties transmitting partial messages, before acknowledgement of previous messages.
The incident commander’s stress reactions observed by the researcher included rubbing
his forehead and facial expressions showing that he was beginning to show frustration over
the mounting pace of the radio calls and his inability to keep up with each of them. The
incident commander was speaking slowly to begin with; however, as the stress reactions
started to mount, it seemed that he was speaking slower still and experiencing difficulties in
choosing his words even more. In this instance, when he needed to speak more quickly to
answer all of the demands for his attention, he was unable to get ahead of the flow of
communications. There were a significant number of missed transmissions during this
exercise and the calling of a mayday by one of the firefighters during the incident did not
receive the full attention a distress message would dictate. A number of instances of units
needing messages repeated or messages garbled occurred during this exercise. The
breakdown of effective communications led to a high number of ineffective ones, which
turned the analytical scores negative in this exercise.
Fifty-eight percent of the communications were ineffective. The low score (n=18) of
successful communications is partially attributable to the low experience level, and the
incident commander operated alone without assistance under relatively difficult tactical
circumstances. Although this exercise did not proceed well, both by statistical analysis and
by the impression of those present, the exercise controllers and training officer were able to
integrate lessons learned into the post-exercise debriefing session. They put the best possible
96
face on what was truly a valuable learning experience for all. The simulation environment
gave this opportunity to learn with no risk of injury to personnel.
Case Number Seventeen
A repeat of the simulation cycle occurred on the afternoon of January 23 with a new
group of test subjects. Once acclimated to the training environment, the group went through
the routine briefing and practice session. The fifteen-minute practice exercise had an
experienced command officer serving as incident commander. The number of effective
communications was high at 82 percent. Like the earlier team on this day, this group was
able to acclimate quickly to the game controls. Only four communications in this practice
session were ineffective. Ineffective communications included no answer by units hailed or
no acknowledgement received from a calling unit, indicating whether successful message
delivery occurred. There was also no apparent reason for one instance of a missed message
not reacted to by the incident commander.
Case Number Eighteen
Case Number Eighteen for the day used the same incident commander who conducted the
practice session, so he was able to use some of his experience from the earlier exercise. He
achieved a very high efficiency rating (n=94%), attributable to his prior experience. He was
able to speak at a much more rapid pace with over two and a half messages per minute,
which is on the high end of the range for all of these exercises. Only two instances of
ineffective communication occurred, involving no answer by the incident commander to an
incoming message. In the other instance, units covered each other. When the incident
commander did not understand a message, he turned to those around him to ask, “What did
he say?” There was an abrupt need to conclude this exercise at the twelve-minute mark due
97
to a software failure; however, sufficient data collection had occurred to that point with 31
turns of communication occurring in the short period allowing for comparing and contrasting
with the earlier set of data from the same incident commander.
Case Number Nineteen
Case Number Nineteen on this afternoon featured an exercise lasting thirteen minutes,
during which personnel responded to a simulated structure fire. There were 24 radio
communication turns during this exercise with 21 judged effective and just three messages
were ineffective. Of those deemed ineffective, the test subjects were distracted by attention
paid to tasks in front of them on the screen and, therefore, did not react to a radio call made,
as well as another instance of message inattention for no apparent reason.
Case Number Twenty
Case Number Twenty, the next to the last exercise for this afternoon, featured the use of
self-contained breathing apparatus masks by the engine company units for the first time in
this simulation exercise series. A much more realistic simulated communication environment
existed by adding this common feature leading to muffled radio communications. The
positive rating predictably dropped in this exercise because of the introduction of these
muffled transmissions, which all of the experienced controllers and trainers at the site agreed
were accurately reflective of the typical incident communication challenge. Thirty-one
percent of the messages in this fifteen-minute exercise were ineffective. Some of the reasons
for the ineffective radio communications included no answer provided to a call and multiple
instances in which individuals transmitting while wearing their facemasks required message
repeating since they were unintelligible. This exercise was also tactically challenging because
of the presence of a firefighter mayday, as well as the need to switch extinguishment tactics
98
to a defensive mode, whereby units withdraw from the interior of the building due to rapid,
dangerous fire spread.
Case Number Twenty-one
The final exercise of this day, Case Number Twenty-one, also featured the use of self-
contained breathing apparatus masks by those at the task level, including hose line operations
and search and rescue within the building. There were 22 communications turns in this
exercise at a common pace of 1.8 per minute. There was a high degree of command
teamwork observed in this exercise as the incident commander had a partner to assist. Nine
messages (n=29%) were deficient in some manner. Some of the messages were garbled or
muffled, requiring message repeat. The use of self-contained breathing apparatus masks
required some repeating of messages, but there were also clear communications with them in
use. The sender clearly played a role in selecting simple words to convey the concept and to
space and articulate them well within the limits of talking with a mask over the face. In two
Plano Day 2 Scores Comparison
35%
45%55%
65%75%
85%
95%
Case 13 Case 14 Case 15 Case 16 Case 17 Case 18 Case 19 Case 20 Case 21 Average
Figure 6. Summary of Positive Scores For Plano Day Two
99
of the repeated message situations, the cause was distraction by chatting between the incident
commander and his aide. The time of this exercise was just seventeen minutes before
accomplishment of the tactical objectives and exercise conclusion.
Plano Case Studies Day Three
The final series of case studies at the Allen Fire Department Training Facility simulators
occurred on January 26, 2009. As was typical throughout the series, the purpose of the first
sequence was to familiarize the participants with the use of the controllers and the flow of the
exercise.
Case Number Twenty-two
In Case Number Twenty-two, an experienced fire captain assumed the role of incident
commander. This familiarization sequence lasted fourteen minutes; there were 29
communications turns, of which 23 were effective. Of the ineffective messages (n=6), there
were instances in which the calling units covered one another, yet the incident commander
did not ask either unit to stand-by or repeat the communication. In other instances, there was
no waiting for an acknowledgement that the incident commander had received the message
before moving on to the next communications turn. There was no apparent reason for one
message repeat request; the content was clear on the recording. The researcher observed a
high degree of collaboration in this sequence with a partner assigned to assist the incident
commander.
Case Number Twenty Three
The duration of Case Number Twenty Three was seventeen minutes with 40
communication turns for a high rate of communications per minute (n=2.4). The delivery of
100
31 of the communication turns was efficient with the remaining nine exhibiting a variety of
common inefficiency concerns. A closer look at the nine inefficient communications revealed
a variety of common issues. There were three instances of no answer given to a unit calling.
In other instances, it was apparent that the incident commander received messages from the
dispatcher, but they were unacknowledged over the radio channel. There were other instances
of units calling without receiving an acknowledgement. In some instances, the incident
commander’s assistant prompted him that someone was calling on the radio. The incident
commander in this sequence strained while listening to the speaker microphone by holding it
close to his ear and slightly pitching his head downward. This was the same posture observed
in the previous venue of case studies with incident commanders operating outdoors in a
standing position near the street.
Case Number Twenty Four
The same incident commander from the previous case repeated incident command
responsibilities for Case Number Twenty Four. In this sequence, there were fewer
communications delivered (n=32) for a rate of 1.8 per minute, which is lower than the
previous experience with the same incident commander. The error rate of 25 percent was
similar to the previous case with the same incident commander (n=23%). Some of the same
deficiencies were present in this case as well as in the previous situation when he was
commanding. Once again, he was straining to listen to the speaker microphone, especially as
the pace increased or additional distractions were present. Much like the previous example,
there were instances of messages from the dispatcher being apparently received, but not
acknowledged over the radio. Units were covering one another during other ineffective
communication sequences without redirection, or untangling by the incident commander.
101
This case featured a mayday call, which did increase the amount of confusing and tense radio
traffic. The time duration of the mayday was very short, so the normal pace of
communication restored quickly. One of the eight inefficient communication turns involved
messages that needed repeating. The apparent reason for the repeated messages was
background noise and there was distraction present from a face-to-face meeting leading to a
missed message. One of the inefficient communications turns involved an earlier forgotten
message pushed from attention span by a subsequent message redirecting full attention from
the incident commander. This can be informally considered a “squeaky wheel situation,”
commonly observed through all actual and simulated incidents, in which the more aggressive
or urgent-sounding message tends to redirect attention, causing the earlier incomplete
message to be ignored entirely.
Case Number Twenty Five
Case Number Twenty Five involved a return of an incident commander from a previous
sequence earlier in the morning. The captain who handled the first sequence was incident
commander for this Case Number Twenty Five. A high number of communication turns
occurred during this case (n=47) at a rate of 2.1 per minute. The duration of this case was 22
minutes; the incident commander made good use of the aide provided to him. Thirty-four
communication turns, or 72 percent, were effective. This incident commander had a high
degree of collaboration with his assistant with at least nine instances of verbal exchange or
confirming glances between them. This case introduced the first use of self-contained
breathing apparatus masks by the participants during this day’s simulations, increasing the
amount of muffled radio traffic. This sequence also used face-to-face discussion elements
intended to recreate this common distraction in the command environment. Three of the
102
thirteen missed radio messages occurred while a face-to-face conference was underway. In
other instances, there was no answer provided to units calling and some messages became
too long for retention and cognitive processing. Truncation of the messages often required
repeating of some part of the message, or resulted in complete ignoring of that part of the
message.
Case Number Twenty Six
Case Number Twenty Six included the use of an experienced battalion chief as incident
commander. This case was the first in the sequence for the afternoon session involving a new
set of firefighters and command officers. This introductory case familiarized the subjects
with the use of the controllers and flow of the simulations. At just ten minutes, it was the
shortest in the entire series, but a relatively rapid pace of communications per minute (n=2.4)
occurred. An unusual aspect of this case involved the switching of radio channels just as the
exercise was beginning. The incident commander assumed that the exercise controllers
instigated it; however, one of the command officers at the tactical level issued the order. This
department has a procedure to switch to a different radio mode when radio communications
are insufficient. There was some degraded radio service in the building where the simulator
is located, which was different for those accustomed to an area of better radio coverage. The
decision to switch to “conventional mode” or direct unit-to-unit mode without use of radio
infrastructure is an emergency procedure. Operating in conventional mode removes
dispatchers from the conversations, there are no recordings of the incident and others remote
from the scene cannot monitor the event. The incident commander assumes significant
additional responsibility when operating in conventional mode, as outlined in the Syracuse
and Seattle case studies in Chapter Four. The switching to the alternate radio platform just as
103
units were arriving at the simulated location created a period of confusion at the early portion
of the exercise. It was during this segment of the operation when a majority of the
miscommunications occurred, as units were in the process of switching channels and
reestablishing their communications bearings. The experience level and poise of the battalion
chief allowed for a quick restoration of radio order, so there were only five ineffective
communications, most of which involved unacknowledged messages or needs to repeat due
to radio noise and feedback.
Case Number Twenty Seven
Case Number Twenty Seven featured an experienced fire captain serving as incident
commander. This case lasted eighteen minutes and featured communications at a rate of 1.9
per minute. There was a high completion rate of effective radio communications at 85
percent for this sequence. The incident commander made good use of a partner assigned to
him in spotting information unfolding on the simulation projection screen. Of the five
ineffective radio messages, three involved no acknowledgment provided to calling parties,
one instance of a message needing repeating for no apparent reason, and other distractions
involving face-to-face meetings causing missed radio messages.
Case Number Twenty Eight
In Case Number Twenty Eight, the same incident commander from the previous
sequence repeated incident command duty. The exercise lasted just twelve minutes and the
rate of communications was a normal range per minute (n=1.9). The results are noteworthy
since the same incident commander had a high degree of efficiency in the previous sequence
with 85 percent of the messages handled effectively; the rate dropped to 61 percent during
this exercise. The major difference in this sequence involved the use of self-contained
104
breathing apparatus masks by the participants. Of the nine ineffective messages, some of
them were unit-to-unit communications muffled due to the presence of the self-contained
breathing apparatus masks. In other instances, there was no acknowledgement provided to
radio messages, and there were situations in which the incident commander did not return to
bumped or supplanted messages overridden by more urgent-sounding ones.
Case Number Twenty Nine
The final sequence in this series, Case Number Twenty Nine, was 24 minutes, and
featured a more difficult fire suppression and rescue challenge. The engine company
participants were communicating while wearing their self-contained breathing apparatus
masks. There were 34 radio turns during the exercise with 71 percent occurring efficiently. A
high degree of collaboration existed in this exercise between the incident commander and the
assistant assigned to him. There were at least eleven instances of brief discussions and
confirming glances. The pace of communications was relatively slow at 1.4 per minute. Of
the ten radio turns occurring ineffectively, five involved no acknowledgment provided to
information delivered, although the command post parties apparently heard and understood
the message. The one initiating the message has to wait for an acknowledgement to know
delivery is complete (see the order model in the Charleston section of Chapter Four). One
message was garbled and there were some messages needing repeating for no apparent
reason, including unit-to-unit communications.
Additional radio traffic was necessary during this final exercise to clarify the assignments
and radio designators preferred by the incident commander. There was an attempt to assign
radio call designators to tactical units, i.e. instead of referring to engine one and engine three,
the consolidated units were to refer to themselves as “fire attack group.” When stressed with
105
challenging tactical objectives, the units tended to revert to their previous designators, as an
engine company and number, instead of their newer call sign as a tactical level group, which
dissipated from short-term memory. Confusion about relabeling tactical units into groups or
divisions during incidents existed throughout the entire series of exercises. This generated
additional radio traffic and potentially caused critical confusion, especially during the PAR
roll call process. During the roll call, dispatchers monitoring the incident commander were
able to perform a critical independent audit of units known to be on-scene. Dispatchers are in
a remote position of informed perspective and have access to an array of technology to be
aware of which units are at the scene, including automatic vehicle location plotted to a map
and radio unit call number displays. It is possible for the incident commander to miss a unit
number during a roll call or for units to be on-scene without the knowledge of the
commander, such as those self-dispatched, replacement units, or otherwise operating beyond
the awareness of the incident commander. Switching to a nomenclature of group or physical
divisions introduces an element of confusion into the PAR process.
Plano Day 3 Scores Comparison
50%55%60%65%70%75%80%85%90%
Case 22 Case 23 Case 24 Case 25 Case 26 Case 27 Case 28 Case 29 Average
Figure 7. Summary of Positive Scores For Plano Day Three
106
Plano Exercises Analysis
Case
Number Efficiency
Score Number of
Collaborations Case
NumberEfficiency
Score Number of
Collaborations18 94% 2 18 94% 2 8 92% 4 8 92% 4 13 89% Solo Top 13 89% Solo 14 88% Solo Top Third 14 88% Solo 19 88% Solo Half 19 88% Solo 27 85% 5 27 85% 5 12 84% Solo 12 84% Solo 17 82% 2 17 82% 2 10 79% 7 10 79% 7 22 79% 6 22 79% 6 26 79% 1 Middle 26 79% 1 23 78% 4 Third 23 78% 4 9 76% 4 9 76% 4 15 75% Solo 15 75% Solo 24 75% 4 Bottom 24 75% 4 25 72% 9 Half 25 72% 9 21 71% 8 21 71% 8 29 71% 11 Bottom 29 71% 11 11 70% 10 Third 11 70% 10 20 69% 2 20 69% 2 28 61% 4 28 61% 4 16 42% 2 16 42% 2
Figure 8. Collaboration Influence In Scoring
In the top half of the scores (left column in Figure 8), eight out of the 12 top performing
incident commanders were functioning with the aid of an assistant. The remainders were solo
commanders. This may create an assumption that aides provide an indisputable value to
incident command efficiency. Closer examination of the data suggests a counterintuitive
result. When examining the data in top, middle and bottom thirds (right column in Figure 8),
an interesting pattern emerges.
107
Case #
Percentage
of Positive
Number of
Collaborations
11 70% 10
21 71% 8
25 72% 9
29 71% 11
Overall
Averages 77% 5
Figure 9. Correlation of Collaboration With Scores
There is a cluster of the four highest collaboration occurrences in the bottom third of
efficiency, and four out of the seven top performers were performing solo (Figure 9). This
suggests that aides can become a distraction factor when assigned to incident commanders
(Speier et al. 1999, 344-353). There is a delicate balance and sets of influences, depending on
the quality of the working relationship between the command post members. During the
exercises, observation revealed that aides who tended to talk a lot obscured other important
input, such as changes in visual cues and inbound radio traffic, triggering the need for
repeated messages or unacknowledged ones. The most effective teams minimized verbal
communication and used nonverbal glances, confirming nods, and hand gestures, reminiscent
of Gladwell’s Blink principles (2005, 13-14, 194-195).
108
McKinney and Plano Exercises Compared
Comparing Walking Command vs. Stationary Command
An average of 59 percent of the McKinney messages was effective while an average of
77 percent of the Plano message sequences was successfully completed. The experience level
of the subjects was similar between the departments. There were some significant differences
between the two exercise venues. The McKinney exercises had a higher degree of difficulty
since they were dealing with a mayday situation, which is challenging in its own right. The
McKinney venue also featured a greater variety of typical noise producers, such as apparatus
engine noise. McKinney practiced splitting of the on-scene communications into two
channels upon declaration of the mayday, which proved problematic and led to a lot of the
missed radio traffic and confusion. The report of the Prince William fire outlined in Chapter
Four only recommended splitting the radio channel for a mayday when command staffing
permits separate channel responsibilities. Otherwise, radio silence should prevail until the
rescue is complete (Prince William County B8, 2008).
Despite several key differences, some of the gap between 59 and 77 percent efficiency
rating is attributable to the value of stationary command. The comparatively quiet and
controlled setting of the Plano incident command simulator room, which mimics the
environment inside a command vehicle’s cab, is a more conducive listening and organizing
environment than the McKinney commanders’ wide footprint of pacing and posturing. In the
outdoors, McKinney commanders exhibited considerable movement whenever they used
their radios around fire apparatus and other personnel in the street in front of the operations
building.
109
Influence of Talking While Wearing A Mask
The Plano case studies established an eleven percent efficiency drop when firefighters
used self-contained breathing apparatus. The use of masks introduced muffled voices and
unintelligible voice sequences. The wearer had a responsibility to articulate and enunciate
each word in something of an exaggerated manner to achieve message delivery. Decades of
equipment experimentation by the fire service have not yielded a satisfactory solution to this
vexing problem.
Cases With Masks Used
69%71% 72%
61%
71%
55%
60%
65%
70%
75%
80%
85%
Case 20 Case 21 Case 25 Case 28 Case 29
Series Average Without Air Masks=80%
Figure 10. Comparing Influence of Mask Usage on Communications Efficacy
Simulation Environments
Beroggi et al. (2001) tested the design and use of gaming simulation as a means for
gauging group decision support systems. As of 2001, Beroggi et al. determined that
developing and implementing simulation environments was prohibitively expensive and time
consuming. Improvements in hardware and software in the ensuing eight years has made
110
simulations now feasible for emergency training. The degree of realism is critical to the
success of simulation programs if the results are to be useful and maintain the interest of the
participants. Slater et al. (2000, 46-50) were able to demonstrate that people can move
between virtual and real worlds, bringing with them skills and relationships developed in
each realm. Virtual worlds offer opportunity to develop skills and to practice critical
command and control behaviors in regulated and predictable settings. In discussing her work
at the Naval Postgraduate School, Professor Amela Sadagic (2008) saw parallels in the
challenges facing the U.S. military and community first responders in training for infrequent
yet intense decision-making challenges. The U.S. military has found that simulator
environments closely approximate real world challenges, allowing for skills development not
otherwise possible during intermittent battlefield experience situations (Sadagic 2007, 2008).
The logistics involved in “putting boots on the ground” to conduct training exercises in the
field are considerable and sometimes difficult to control due to outside influences, such as
environmental variables and continuous-service mission demands. Although it may not be
desirable for virtual simulation environments to entirely replace field exercises, there is an
indication of a synergistic opportunity to meld both styles to best advantage.
The post-exercise debriefings revealed a level of concurrence and enthusiasm on the part
of the participants for the simulation form of training. While the simulations had many
elements of realism, there remained opportunities to refine and enhance the gaming
environment to reflect realistic operational conditions. Representatives of the simulation
software company were present during these exercises and were accommodating to all
suggestions for enhancement. The simulation environment allowed for the identification of
many of the micro factors and nuances present in the emergency command environment.
111
Immersion of the participants in the challenges presented to them allowed realistic
observation of decision-making and use of radio communications. Much like the use of
instant replay and slow motion at sporting events, videotaping of these exercises allowed the
researcher to review factors after observing the events in real-time. Influences and factors not
apparent as events unfolded in person were sometimes observable upon examination of the
videotape. There was even an opportunity to discern patterns by using fast forward. For
instance, the researcher used fast-forward when studying the pacing patterns of incident
commanders operating outdoors beyond the confines of a vehicle.
CHAPTER 6
IMPLICATIONS AND RECOMMENDATIONS
This final chapter provides a summary of the hypotheses testing results, reasons and
explanations for ineffective communications, and practical improvement recommendations.
Research Summary
The problem explored in this project is the cause of missed radio messages during
emergency operations by community first responders. This research is important to the field
of study since communications are a major operational issue in emergency responses and
efforts focused solely on technological improvements have not solved the problem. Review
of audio recordings does not give the necessary insight into the reasons for a missed radio
message.
The researcher studied the communications process from a phenomenological perspective
and identified the source of distractions influencing effective communications. The author
found that the obstacle to substantive improvement in emergency communications has been
the lack of understanding of the complex human factors involved beyond the capabilities of
even the most robust hardware imaginable. The researcher hypothesized that sensory
overload is a major contributing influence restricting effective communications flow; data
collected during the observations showed multiple instances of message delivery being clear,
but still mishandled by the recipient. This study isolated specific influences in the emergency
112
113
command environment, which when combined with human tendencies and limitations
impeded the flow of effective radio communications.
Study of actual incidents featuring significant radio factors allowed for identification of
common lapses and features in the communications processes, along with fieldwork to study
the communications interface environment. In answering the gap in experiential data, this
dissertation project observed and analyzed multiple sequences of command communications
to establish the frequency of errors and the trends and causes therein. Documentation of the
recollections and insights by the actors involved through interviews lends additional
perspective. The evidence collected during the fieldwork is the distractions and influences
operative at the instant an ineffective communication occurred (Appendix C contains a
summary of the fieldwork data). The project delineates the broad categories of impediment
and provides conjecture on likely causes for future study. The studies are replicable allowing
other researchers the opportunity to revisit the same conditions and study the nuances
identified.
Hypotheses Results
Hypothesis number one was validated since major human causal factors and not hardware
failure occurred. There was confirmation that sensory overload leads to ineffective
communications and that sensory overload plays a role in the non-technical impediments. In
numerous instances, people experienced distraction in the form of multiple conversations,
noisy environments, and multi-sensory demands for their attention. Hypothesis number two
was verified accurately by the documented presence of communications delivered to the
receiver for which an inattentive reaction occurred. The study confirmed that even when
114
radio equipment successfully delivered a message, misinterpretation by the intended recipient
or unintentional lack of awareness that the message occurred was common.
The innovation of this dissertation research is in testing the operational environment of
first responder incident commanders to delineate the distraction influences and measure the
effect they have on the radio communications conducted at the incident. This dissertation
examined and established the presence of communications impediments in the multi-sensory
world of first responder incident command. The finding of this research is that emergency
personnel operating in critical decision-making situations experience sensory overload
leading to communications deficits. The communications deficits result in ineffective
communications, potentially influencing the quality of decisions made (Klein 1999, 30;
Simon 1997 291; Gladwell 2005, 23). Effective emergency command relies upon the quality
of communications. First responders need to make decisions in an imperfect information
environment with imperfect information. Communications clarity is therefore essential to
close some of the imperfection gap.
Communication failures among key personnel are a recurring issue during disaster
operations with over $6 billion spent by the federal government this decade to improve two-
way radio capability at state and local government agencies with the presumed result of
better communications (Timmons 2006). This research effort exposes the fallacy in the
tendency to expect operational improvement merely by the deployment of new technology
(National Commission on Terrorist Attacks, 2004, 280-285; U.S. Fire Administration 1993,
3, 7). As established by Klein (1999, 277-279), new technologies do not guarantee immediate
improvement; instead, they may actually complicate matters, as we have seen in the recent
115
distraction debate about driving while talking on cell phones or text messaging (Hancock et
al. 2003, 503; Strayer and Johnston 2001, 465-466; Strayer et al. 2003, 30-31).
The fieldwork phase of this dissertation endeavored to identify the distraction factors
present at typical emergency scenes impairing effective communications by and among first
responders. Of particular interest were those situations in which the same individual had
multiple demands imposed simultaneously, amounting to a condition of sensory overload.
Information overload is the expected result when the volume of input exceeds the processing
capability of those involved (Milord and Perry 1977, 131-136; Speier et al. 1999, 338). The
researcher’s observation of a variety of emergency personnel operating in critical decision-
making situations provided insight into specific causes of communications failures. Data sets
based on field observations allowed for trend and factors identification. Discovery of sets of
influences in sufficient quantities and from common sources led to the identification of cause
and effect relationships.
Why Messages Are Missed
It is possible to reconcile many of the reasons for missed radio traffic. Some missed
messages were attributable to the noisy environment typical of emergency scenes with
various distraction factors involved. Some ineffective communications turns involved
hardware failure or voice obscuration due to the use of protective respirator masks. Yet more
than a third of the messages missed during the study had no apparent cause. The message
was clear to the observer and on recordings, yet the recipient was not able to handle the
message (Figure 11). Missed messages for which there is no apparent cause invites
theoretical conjecture.
116
Reasons For Missed Radio Traffic
No apparent reason
38%
Talking in person to others
19%
Other channel19%
Garbled14%
Background noise5%
Feedback squeal5%
Figure 11. Communications Deficits
The researcher expected two or three major factors would emerge during the study as
leading causes for ineffective radio communications. Instead, the researcher found that there
were multiple layers of complexity to this situation. While there are predictable factors that
degrade communication effectiveness, there are also nuanced aspects occurring at various
stages and under differing circumstances, creating a greater influence at certain times, and
not as much at other times.
Sensory Overload
The study showed that the quality of communications decreased in proportion to the
amount and types of stimuli and distractions occurring around the incident commanders.
Some commanders were able to handle the complicated environment better than others were
and even the most experienced commanders missed a lot of radio traffic. There is an
117
interrelationship between the influences and dysfunctions found in the test and work
environments. Inferences from the analyzed data make a convincing case for the deleterious
effect of sensory overload in the emergency environment. As a result, practitioners may be
compelled to seek ways to manage sensory input and distractions with the expected outcome
of better communications and decisions at critical incidents.
Signs of sensory overload included ignoring messages if another message immediately
following sounds more urgent, failure to return to unfinished earlier messages, and jumping
to the loudest or most tense communication when multiple messages contended for attention.
Observation disclosed inattention to changing factors on the periphery when micro
conversations or isolated visual stimuli were present. Instances of truncated message content
and inability to recall the whole message also indicated a state of being overwhelmed.
Age and experience were not major factors separating the high and low performers. The
pressure of the circumstances and the level of risk faced played a role in the physiological
response, increasing the likelihood of sensory overload. Management of distractions is a
critical factor for calm, controlled incident command and communications. Command
operation from within enclosed vehicles appears to give the best opportunity to manage
sensory overload and chaotic scene background noise. Beyond the quantity and intensity of
the circumstances creating sensory overload, this research points to plausible physiological
and psychological contributing factors leading to missed messages.
Physiological Hearing Deficit
The human body undergoes significant physiological change in the face of a perceived
threat or other stressful situations. Muchnik et al. (1980, 228) found that emotional stress can
affect hearing, especially if severe enough or if exposure is prolonged. Experimentation on
118
laboratory animals demonstrated hearing impediment under stress, attributable to fight or
flight hormones and involuntary sympathetic nervous system reactions (Muchnik et al. 1980,
297). Redirection of blood to major muscle groups occurs, as survival of the host becomes
the primal priority. In discussing the effects on the human body in stressful situations,
Gladwell entitled a subchapter in his book Blink (2005, 221-229) “Arguing With a Dog,”
based on the experiences of a retired army lieutenant colonel and his observations of people
functioning in a state of extreme arousal. As heart rate increases in response to threatening or
stressful circumstances, performance actually improves in the 115 to 145 beats per minute
range. After 145 beats per minute, motor skills become difficult. After 175 beats per minute,
cognitive processing begins a selective shutdown sequence with brain functioning then
becoming similar to that of a dog. People in such high states of arousal have difficulty
speaking (Gladwell 2005, 225-226). A former high-ranking Los Angeles police official noted
that officers broadcasting in the middle of a chase yell and exhibit signs of hysteria. Upon the
termination of pursuits, officers experience bodily shaking symptoms and the inability to
construct radio messages. Recognition of this debilitating phenomenon has led to modified
police pursuit policies (Gladwell 2005, 226-227). When responders experience physiological
arousal in reaction to the intense situations unfolding around them, their ability to construct
cogent messages is impacted, lending a potential explanation for the frequent need to have
messages repeated and the observation that phrases selected are ambiguous and subject to
misinterpretation. Those impacted do not even have to be present at the incident scene.
Participating in radio conversations is an emotionally arousing experience, as demonstrated
in the North Hollywood shooting and Hudson River landing case studies in this dissertation’s
Chapter Four.
119
Police officers involved in shootings often experience altered states of sensory cognition.
They report, “extreme usual clarity, tunnel vision, diminished sound, and the sense that time
is slowing down. Our mind, faced with a life-threatening situation, drastically limits the
range and amount of information that we have to deal with. Sound and memory and broader
social understanding are sacrificed in favor of heightened awareness of the threat directly in
front of us” (Gladwell 2005, 224). In recounting their experiences from officer-involved
shootings, police officers report they focused so intently on the part of the suspect’s body
creating the threat that they did not even hear the sound of gunshots occurring. Larry Bird,
basketball star, experienced similar reactions in big game situations. For Bird, it was as if the
crowd noise of thousands of screaming fans went silent and the movement of the players
around him reverted to slow motion (Gladwell 2005, 225). This phenomenon helps to explain
why people operating at intense emergency scenes often miss radio traffic and later insist that
it never happened. Even if radio capacity allows message transmission at the high rate
experienced at intense emergencies, consideration of the physiological limitations of the
receiver are appropriate. We should modify our expectations for the incident commander
regarding clear message construct, delivery, and acknowledgement, providing adequate
levels of compensating redundancy.
Inattentional Deafness
The lack of awareness of radio calls occurring during the studied exercises, as well as the
other incidents reviewed from actual occurrences around the country, are consistent with
earlier cognition studies, as outlined in this dissertation’s Chapter Two (Becklen and Cervone
1983; Simons and Chabris 1999). The study involved a video tape played for test subjects
observing basketball players inside the elevator lobby of a building. Upon introduction of a
120
distraction in the form of a person in a gorilla suit into the frame of view, only half of the test
subjects noticed the figure, which was obvious to them in subsequent viewings. This holds an
important implication for this dissertation because of the number of unexplained missed
messages and subsequent denial that the message ever existed. It is plausible that clearly
delivered messages do not receive attention from incident commanders engrossed in
challenging circumstances because of Inattentional Deafness (Mack and Rock 1998, 215-
223, 246). Responders may be focusing so intently on a narrow expected set of circumstances
and outcomes that they ignore even gross deviations varying from the prevailing
circumstances. First responders facing challenging, intense, and worsening circumstances do
not expect to receive a distress call. Unexpected features beyond the target of focused
attention do not reach their consciousness. Conversely, those in a position of detached
perspective do hear them, explaining the frequent occurrence of people remote from the
scene monitoring urgent radio messages missed by those in close proximity.
Solutions
The National Fire Protection Association (NFPA) has advocated for several years that
staff aides be “deployed to” supervisory chief officers. Staff aides also known as Field
Incident Technicians (FIT) or chiefs’ drivers (National Fire Protection Association, NFPA
1710, 5.2.2.2.5). The wording of this consensus standard implies flexibility on the part of the
jurisdiction to provide the capacity utilizing a variety of staffing sources. Limited resources
do not allow many small to medium-sized fire departments to assign permanent aides to
incident commanders. Although fire departments may have the capacity to assemble an
incident management team eventually, it is in the early minutes of many emergency
operations when the communications demands are greatest.
121
This study demonstrated the value in assigning an assistant to the incident commander,
providing that they function effectively together. An automatic assumption that two heads are
better than one is not always true in the emergency command environment. The aide can
become a distraction leading to missed radio traffic because of increased conversations
around the command post. In studying the cockpit behaviors of commercial airline pilots
during in-flight emergencies, Gladwell (2008, 184-185) found that a disproportionate number
of flights with tragic outcomes had flight crews not used to working together. The optimal
flight deck approach is when partners catch each other’s errors, rather than one trying to do
too much and the other there ostensibly just to take over in the event of complete
incapacitation. Any team comprised of an incident commander and an aide needs to feature
rapport, boundaries, expectations, and anticipation of each other’s tendencies. This reality
tends to support the notion of permanently assigned aides, despite fiscal constraints.
Increased emphasis on standardized incident management principles, including the
federal mandate for responders training on the National Incident Management System
(NIMS) as a condition of federal grant funding brings even more peripheral support
personnel and technology into the command post environment. The additional
representatives may exacerbate the distraction level influencing incident commanders and
their ability to maintain clear and immediate radio contact with personnel. Although
collaboration will likely improve by adding more representatives, the addition of more
people may make it difficult to focus on what responders involved in active operations are
saying and doing (Weick 1990, 589).
This study establishes that there is a limit to the amount of sensory input that
commanding personnel at disaster scenes can manage before they are overwhelmed to the
122
detriment of effective communications and the quality of decisions made. Fire department
management should assign independent command post personnel to monitor signatures of
critical information and report them to the incident commander. Layers of redundancy can
provide assurance of critical messages continuity, including independent, remote monitoring
of incident radio channels in support vehicles at the scene as well as at the dispatch center.
Human Factors Engineering
Technological Improvements
This study recognizes the value of properly designed new equipment in providing greater
situational awareness and better quality of decisions reached using the information from the
technology. Data transmission is more efficient in transfer of some information, such as
rosters of personnel assigned to the incident and situational awareness updates. Ready access
to information has the risk of debilitating, instead of facilitating. Klein (1999, 279) noted that
in the past, “information was missing because no one collected it; in the future, information
will be missing because no one can find it.” Best use of new data technology requires
specially trained personnel, deployed to arrive soon after field operations commence. The
need for better technology and practices are a natural extension of this dissertation’s findings
that communications practices are limited and often dysfunctional; critical errors are a likely
byproduct of the status quo in emergency scene operations. There have been a number of
failures in military applications and civilian airliner design over the years, despite the hopes
of system improvement and greater aid to humans making decisions (Perrow 1983, 521, 531-
532). Even where properly designed radio systems exist, the success of communications is
dependent on the skill of the person utilizing it. The field of human factors engineering
recognizes the importance of considering human design factors in equipment and systems
123
designed to aid workers in a variety of workplaces (Perrow 1983, 521). The incident
commanders indicated difficulty in hearing their portable radios, but they also resisted the
notion of wearing headphones out of concern for missing something in person at the scene.
Perrow (1983, 533-534) establishes the importance of considering social structure and
operator behaviors when designing technically complex systems. Human factors such as
proper use of the radio, positioning of the microphone, and conscious decision of when to use
the radio or not is a critical factor in successful emergency communications (National
Institute for Occupational Safety 2003, 4, 11, 16).
Equipment Needs
The design of radio hand pieces considers serviceability needs in the rugged emergency
environment. Radios are at once sophisticated computerized devices in need of a stable
operating environment, yet they must be capable of working in hostile conditions. Exposure
to extreme heat and cold, water, and general rough handling of the equipment can lead to
diminished capabilities. Proper maintenance of batteries is also necessary to assure continued
reliable operation (National Institute for Occupational Safety 2003, 11-12). Several
participants appeared for simulator training with low battery strength on the radio assigned to
them for the twenty hours remaining on their shift. Poor hand piece maintenance can be the
major cause of communications hardware failure rather than falsely blaming infrastructure or
system design issues. There still exists considerable opportunity to improve portable radio
design allowing easier access to alternate channel banks. Changing channels or
communications mode during an incident consistently proved to be awkward and
problematic. Radios capable of dynamic regrouping (changing channel without user
intervention) on the emergency scene, upon a reconfiguration order from the command post,
seem to be one potential solution within technological reach. Unfortunately, technically
124
competent people deployed immediately to act as something akin to air traffic controllers at
the scene of community emergencies is out of the reach financially for most agencies.
Self-Contained Breathing Apparatus
“In general, the most common communication problem encountered by firefighters is the
inability to effectively communicate while wearing self-contained breathing apparatus
(SCBA)” (National Institute for Occupational Safety 2003, 11). When trying to talk while
wearing self-contained breathing apparatus, it is essential to speak in a calm voice, at
moderate volume, and with clear word enunciation. Trials of a variety of microphone
configurations have only yielded varying degrees of success (U.S. Fire Administration 1999,
5-6). Selection of simple, standardized phrases is necessary, so they are familiar to the
receiver and heard the first time. Future technological improvement of synthesized voice
features may allow broadcast of standardized phrases at the radio interface, yet manual
dexterity to push corresponding buttons is limited while wearing protective equipment.
Training
The quality of decision-making and effective communications skills used in the
emergency environment are highly depended on recall of experience and honing of heuristic
skills, yet truly cataclysmic events are very rare. Habits are developed and practiced in daily
routine, yet infrequent disasters requires responders to operate in unfamiliar, chaotic
environments, where their experience betrays them and they must devise new coping
mechanisms to meet the unfamiliar challenges. Simulation environments hold potential to
train and practice communications and skills among emergency responders, in an effort to
replicate some of the unique challenges present during infrequent disaster situations (Sadagic
2007, 2008; Kiel 2005, 271-273).
125
Syntax and Message Formation
One of the most famous comedy routines of the twentieth century was “Who’s on First”
by Abbott and Costello (Cox and Lofflin 1997, 183-184). The premise of the play on words
was the surnames of players on a supposed baseball team matched common phrases with
double meanings. The “Who’s on first, What’s on second” was based on two people
essentially talking about different things at the same time. Each rightfully thought they were
on the right path toward articulating a clear message. Such simultaneous yet disconnected
conversations are reminiscent of those heard on emergency incident recordings.
There is an identified need for first responder training in active listening skills. Merely
providing the hardware for a voice path does not guarantee effective communications.
Although most may assume that speaking and listening are basic capabilities learned in
everyday life and easily transportable to emergency environments, the demanding
environment of crisis communication requires specialized training. Screening for hearing loss
should also factor into communications capabilities assessment of incident commanders.
First responders have an obligation to communicate in the most unambiguous manner
possible, yet the pressures of high stress emergency environments create significant speech
challenges. Clear choice of simple words conveying rich concepts requires the sender to
anticipate potential misunderstandings and instead phrase and couch words in the clearest
possible syntax. Training and experience allow users to transcend the moment and
understand the context of the situation in which they are communicating. Many incidents
studied either showed too much radio use, or not enough. If over utilized, the channels
become clogged and gridlocked. If used too sparingly, opportunities to build greater
situational awareness are lost and crews in distress are unpracticed and not inclined to call for
126
help soon enough. First responder agencies need training to focus on the elusive sweet spot
between too little and too much talkativeness.
Final Thought
This dissertation has examined the contention that there are recurring elements of sensory
overload and limits to human ability in crisis situations inhibiting optimal communications.
Communications are an inextricable component of sound decision-making. Realistic
expectations of emergency communications demand modification in recognition of the
inherent limitations. A combination of behavioral improvements, consistent with enlightened
human factors design considerations, needs matching with procedural, cultural, and
technological enhancements to overcome recurring emergency communications
impediments.
APPENDIX A
Distractions Codes
Ronald P. Timmons
First Responder Commanders’ Distraction Study
Dissertation Research Project
The researcher reviewed video tapes of the subjects and documented the presence of one
or more of the following influences noted at the time of radio communication inattention.
1. No apparent reason (n=28)
2. Talking in person to another (n=14)
3. Talking on telephone (n=0)
4. Talking on another radio (n=2)
5. Reading/looking at hardcopy/text device (0)
6. Other Channel (n=12)
7. Background noise (n=4)
8. Feedback (n=4)
9. Garbled (n=10)
10. Radio malfunction (n=0)
127
APPENDIX B
Interview Questions
Ronald P. Timmons
First Responder Commanders’ Distraction Study
Dissertation Research Project 2008-2009
1. What do you recall about the radio communications portion of the exercise?
2. Were you aware of any missed radio messages?
3. About how many radio messages sent to you do you believe were unanswered on the
first try?
4. Were there any distractions in the command post environment that may have caused
the missed messages?
5. How would you describe the feelings you had about the radio portion of the exercise?
6. How realistic was the exercise, compared to the challenges present in actual
emergency command?
What do you recommend to prevent the missed radio messages in the future?
128
APPENDIX C
McKinney and Plano Case Studies Data
Case Number
Positive Comms.
Negative Comms.
Total Comms.
Percentage Positive
Percentage Negative
Collab-orations
Duration (Minutes)
Comms./ Minute
1 12 10 22 55% 45% (solo) 25 0.9 2 7 9 16 44% 56% (solo) 17 0.9 3 17 7 24 71% 29% (solo) 16 1.5 4 26 14 40 65% 35% (solo) 26 1.5 5 12 9 21 57% 43% (solo) 36 0.6 6 17 13 30 57% 43% (solo) 27 1.1 7 15 9 24 63% 38% (solo) 19 1.3 8 22 2 24 92% 8% 4 13 1.8 9 26 8 34 76% 24% 4 15 2.3 10 23 6 29 79% 21% 7 15 1.9 11 21 9 30 70% 30% 10 13 2.3 12 43 8 51 84% 16% (solo) 21 2.4 13 24 3 27 89% 11% (solo) 17 1.6 14 37 5 42 88% 12% (solo) 21 2.0 15 21 7 28 75% 25% (solo) 15 1.9 16 18 25 43 42% 58% 2 19 2.3 17 18 4 22 82% 18% 2 15 1.5 18 29 2 31 94% 6% 2 12 2.6 19 21 3 24 88% 13% (solo) 13 1.8 20 22 10 32 69% 31% 2 15 2.1 21 22 9 31 71% 29% 8 17 1.8 22 23 6 29 79% 21% 6 14 2.1 23 31 9 40 78% 23% 4 17 2.4 24 24 8 32 75% 25% 4 18 1.8 25 34 13 47 72% 28% 9 22 2.1 26 19 5 24 79% 21% 1 10 2.4 27 29 5 34 85% 15% 5 18 1.9 28 14 9 23 61% 39% 4 12 1.9 29 24 10 34 71% 29% 11 24 1.4
Average 22 8 31 73% 27% 5 18 1.8
129
BIBLIOGRAPHY
Bazerman, Max, Ann E. Tenbrunsel, and Kimberly Wade-Benzoni. “Negotiating with Yourself and Losing: Making Decisions with Competing Internal Preferences.” The Academy of Management Review 23 (1998): 225-241.
Bazerman, Max, Jonathan Baron, and Katherine Shonk. You Can’t Enlarge the Pie: Six Barriers to Effective Government. Cambridge, MA: Basics Books, 2001.
Bazerman, Max. Judgment in Managerial Decision Making. 6th ed. New York: John Wiley and Sons, 2006.
Becklen, R., and D. Cervone. “Selective Looking and the Noticing of Unexpected Events.” Memory & Cognition 11 (1983): 601 - 608.
Berg, Bruce L. Qualitative Research Methods for the Social Sciences, 6th ed. Boston: Allyn & Bacon, 2007.
Beroggi, G. E. G., D. Van Gent, D. Mendonça, and W. A. Wallace. “Assessing Group Decision Support Systems for Emergency Response Using Gaming Simulation.” International Conference on Emergency Management, Oslo, June 19-22, 2001.
Bigley, Gregory A., and Karlene H. Roberts. “The Incident Command System: High-Reliability Organizing for Complex and Volatile Task Environments.” The Academy of Management Journal 44 (2001): 1281-1299.
Bonamo, Mark J., “Confusion Remains About How Fire Was Fought.” Hackensack Chronicle, July 02, 2008. www.hackensackchronicle.com/NC/0/329.html (accessed February 18, 2009).
Bracht, G. H., and G. V. Glass. “The External Validity of Experiments.” American Educational Research Journal 5 (1968): 437-474.
Brunacini, Nick. “Incident Command.” In The Fire Chief's Handbook, edited by Robert C. Barr, and John M. Eversole, 527-542. Tulsa, Oklahoma: PennWell Books, 2003.
Butler, Emily, Boris Egloff, Frank Wilhelm, eds. “The Social Consequences of Expressive Suppression.” Emotion 3 (2003): 48–67.
Caldwell, David F., and Charles A. O'Reilly, III. “Responses to Failure: The Effects of Choice and Responsibility on Impression Management.” The Academy of Management Journal 25 (1982): 121-136.
City of Charleston, “Sofa Super Store Post Incident Assessment and Review Team, Phase II Report,” June 18, 2007.
130
131
CNN.com. “Botched L.A. Bank Heist Turns Into Bloody Shootout.” February 28, 1997 http://www.cnn.com/US/9702/28/bank.shootout (accessed March 1, 2009).
Comfort, Louise K. “Integrating Organizational Action in Emergency Management: Strategies for Change.” Public Administration Review 45 (1985): 155-164.
Cook, D. L. “The Hawthorne Effect in Educational Research.” Phi Delta Kappan 44 (1962): 116-122.
Cox, Stephen, and John Lofflin. The Abbott & Costello Story: Sixty Years of “Who's on First?” Nashville, TN: Cumberland House, 1997.
Creswell, John W., Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage Publications, 2007.
Demers, David P., Fire in Syracuse: Four Fire Fighters Die, Quincy, MA: National Fire. Protection Association, 1978.
_________. Five Fire Fighter Fatalities: Hackensack, New Jersey: July 1, 1988. Lunenberg, MA: Demers Associates, 1988.
Dwyer, Jim, Kevin Flynn, and Ford Fessenden. “Fatal Confusion: A Troubled Emergency Response; 9/11 Exposed Deadly Flaws In Rescue Plan.” New York Times, July 7, 2002.
Edwards, Holly. “LAPD Bears Shootout Scars.” Los Angeles Daily News, February 25, 2002.
Federal Aviation Administration. “Air Traffic Control Communications US Airways 1549, January 15, 2009.” http://www.faa.gov/data_statistics/accident_incident/1549. 2009. (accessed February 14, 2009).
Firehouse Magazine. “The FDNY 9/11 Documents - Audio Download & Resources, posted August 15, 2005.” http://www.radiofirehouse.com/broadcast/wp-content/2005/fdny/FDNY_Tape16.mp3. (accessed February 26, 2009).
Gaines, Jeannie, and John M. Jermier. “Emotional Exhaustion in a High Stress Organization.” The Academy of Management Journal 26 (1983): 567-586.
Garnett, James L., and Alexander Kouzmin. “Communicating throughout Katrina: Competing and Complementary Conceptual Lenses on Crisis Communication.” Public Administration Review 67 (2007): 171-188.
Gentile, Annie. “ISO Rating System Comes Under Fire.” American City & County 123 (2008): 12, 16.
Gladwell, Malcolm. Blink: The Power of Thinking. Without Thinking. New York: Little, Brown and Company, 2005.
_________. Outliers: The Story of Success. New York: Little, Brown and Company, 2008.
132
Goodman, Michael J., Louis Tijerina, Frances D. Bents, and Walter W. Wierwille. “Using Cellular Telephones in Vehicles: Safe or Unsafe?” Transportation Human Factors 1 (2000): 3-42.
Gouran, D. “The Watergate Cover-up: Its Dynamics and Its Implications.” Communication Monographs 43 (1976): 176-186.
Hancock, P.A., M. Lesch, and L. Simmons. “The Distraction Effects of Phone Use During a Crucial Driving Maneuver.” Accident Analysis and Prevention 35 (2003): 501–514.
Harten, Patrick, Air Traffic Controller. “Before the U.S. House of Representatives Transportation & Infrastructure Subcommittee on Aviation. US Airways Flight 1549 Accident, February 24, 2009.” http://www.natca.org/assets/Documents/mediacenter/NATCAHartentestimonyN3FINAL.pdf (accessed March 8, 2009).
Hawkins, Dan. “Communications in the Incident Command System.” COPS Interoperable Communications Technology Program: Issue Brief Number 2, May 2007.
Hutchins, Susan. G., and Ronald P. Timmons. “Radio Interoperability: There is More to it Than Hardware.” In Proceedings of the 12th
International Command and Control
Research & Technology Symposium, Newport, RI, June 2007.
Insurance Services Office, “Public Protection Summary Report.” Charleston, South Carolina, December 10, 2008.
Isner, Michael. “Firefighter Dies In Warehouse Fire.” Fire Command 57 (1990a): 30-35.
_________. Fire Investigation Report, Vacant Warehouse Fire. Seattle, WA, September 9, 1989. Quincy, MA: National Fire Protection Association 1990b.
Janus, Irving. Victims of Groupthink. Boston: Houghton Mifflin, 1972.
Jennings, Charles. “ISO System Obsolete.” Fire Chief Magazine, December 17, 2008.
Jermier, John M., Jeannie Gaines, and Nancy J. McIntosh. “Reactions to Physically Dangerous Work: A Conceptual and Empirical Analysis.” Journal of Organizational Behavior 10 (1989): 15-33.
Jones, Stephen R. G. “Was There a Hawthorne Effect?” The American Journal of Sociology 98 (1992): 451-468.
Kahneman, Daniel, P. Slovic, and A. Tversky, eds. Judgment Under Uncertainty: Heuristic and Biases. Cambridge: Cambridge University Press, 1982.
Kahneman, Daniel. “A Perspective on Judgment and Choice: Mapping Bounded Rationality.” American Psychologist 58 (2003): 697–720.
Kerr, Norbert L., and R. Scott Tindale. “Group Performance and Decision Making.” Annual Review of Psychology 55 (2004): 623-655.
133
Kiel, L. Douglas. “A Primer for Agent-based Modeling in Public Administration: Exploring Complexity in ‘Would-be’ Administrative Worlds.” Public Administration Quarterly 29 (2005): 268-296.
Klein, Gary A. Sources of Power: How People Make Decisions. Cambridge, MA: Massachusetts Institute of Technology, 1999.
_________. Intuition at Work. New York: Currency Doubleday, 2003.
Klem, Thomas J. Five Fire Fighter Fatalities: Hackensack, New Jersey--July 1, 1988. Quincy, MA: National Fire Protection Association, 1988.
Lindblom, Charles E. “The 'Science' of Muddling Through.” Public Administration Review 19 (1959): 79-88.
Levin, Alan, “We're Gonna Be in the Hudson.” USA Today, February 5, 2009a.
_________, “Controller Thought Ditching in Hudson Spelled Doom.” USA Today, February 24, 2009b.
Lyubomirsky, Sonja, and Susan Nolen-Hoeksema. “Effects of Self-Focused Rumination on Negative Thinking and Interpersonal Problem Solving.” Journal of Personality and Social Psychology 69 (1995): 176-190.
Mack, Arien, and Irvin Rock. Inattentional Blindness. Cambridge, MA: MIT Press, 1998.
“Mayday,” in The American Heritage Dictionary of the English Language, 4th ed.
McDermott, Rose, Jonathan Cowden, and Cheryl Koopman. “Framing, Uncertainty, and Hostile Communications in a Crisis Experiment.” Political Psychology 23 (2002): 133-149.
McFadden, Robert D., “Pilot Is Hailed After Jetliner’s Icy Plunge.” The New York Times, January 15, 2009.
Menchaca, Ron. “Fire Dept. Loses Top Rating.” The Post And Courier, December 20, 2008.
Mendonça, D. “Decision Support for Improvisation in Response to Extreme Events.” Decision Support Systems 43 (2007): 952-967.
Milord, James T., and Raymond P. Perry. “A Methodological Study of Overload.” Journal of General Psychology 97 (1977): 131-137.
Moore, Harold G., and Joseph L. Galloway. We Were Soldiers Once...And Young: Ia Drang--The Battle That Changed The War In Vietnam. NY: Harper Collins, 1992.
Morçöl, Göktuğ. Handbook of Decision Making. Boca Raton, FL: CRC Press, 2006.
Muchnik, C., M. Hildesheimer, and M. Rubinstein. “Effect of Emotional Stress on Hearing.” Journal European Archives of Oto-Rhino-Laryngology 228 (1980): 228, 295-298.
134
National Commission on Terrorist Attacks Upon the United States. Eleventh Public Hearing. New York: W. W. Norton & Company, 2004.
National Fire Protection Association. “NFPA 1710: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments.” Quincy, Massachusetts, 2004.
National Institute for Occupational Safety (NIOSH). “Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio Communication Systems.” September 2003.
Neumann, Odmar, A.H. Van der Heijden, and D. Alan Allport. “Visual Selective Attention: Introductory Remarks.” Psychological Research 48 (1986): 185–188.
O’Conaill, Brid, and David Frohlich. “Timespace in the Workplace: Dealing With Interruptions.” In Proceedings of Computer-Human Interaction ’95, 262–263, Denver, Colorado: ACM Press, 1995.
Otterman, Sharon, and Matthew L. Wald. “F.A.A. Releases Flight 1549 Tapes.” The New York Times. February 5, 2009
Patton, Michael Quinn. Qualitative Research and Evaluation Methods 3rd ed. Thousand Oaks: Sage Publications, 2002.
Perrow, Charles. “The Organizational Context of Human Factors Engineering.” Administrative Science Quarterly 28 (1983): 521-541.
Posner, Edward C., and Eugene R. Rodemich. “Epsilon Entropy and Data Compression.” The Annals of Mathematical Statistics 42 (1971): 2079-2125.
Prince William County, Department of Fire and Rescue. “Line of Duty Death Investigative Report: Technician I Kyle Wilson, 15474 Marsh Overlook Structure Fire, April 16, 2007.”
Render, Barry, Ralph Stair, and Michael Hanna. Quantitative Analysis for Management. 9th ed. Englewood Cliffs, NJ: Prentice Hall, 2006.
Rensink, Ronald A., J. Kevin O'Regan, and James J. Clark. “To See or Not To See: The Need for Attention to Perceive Changes in Scenes.” Psychological Science 8 (1997): 368-373.
Rigg, Nancy J. “Maintaining Control, North Hollywood Bank Robbery & Shootout.” 9-1-1 Magazine, September/October 1997.
Roberts, Karlene H., and Denise M. Rousseau. “Research in Nearly Failure-Free, High-Reliability Organizations: Having the Bubble.” IEEE Transactions On Engineering Management 36 (1989): 132-139.
135
Roberts, Karlene H., Suzanne K. Stout, and Jennifer J. Halpern. “Decision Dynamics in Two High Reliability Military Organizations.” Management Science 40 (1994): 614-624.
Rohr, David L., “Challenges of Mayday Operations” Proceedings of the International Association of Fire Chiefs, Denver, Colorado, August 12, 2008.
Sadagic, Amela. Research Associate Professor, Naval Postgraduate School. Interviewed by author, January 29, 2008.
_________. “The Deployment and Use of Virtual Training Simulations: What Does it Take to Serve the Needs of Majority Of Its Users?” In New Learning Technologies Orlando 2007 SALT Conference, Orlando, FL, January 31-February 2, 2007.
Schafer, Mark, and Scott Crichlow. “Antecedents of Groupthink: A Quantitative Study.” Journal of Conflict Resolution 40 (1996): 415-435.
Selye, Hans. “A Syndrome Produced by Diverse Nocuous Agents.” Nature 138 (1936): 32.
Shannon, Claude B. “A Mathematical Theory of Communication.” Reprinted with corrections from The Bell System Technical Journal 27 (1948): 379–423, 623–656. In Mobile Computing and Communications Review 5 (2001): 3-55.
_________. “Communication Theory of Secrecy Systems.” 1949. Transcribed by Jiejun Kong from the original unpublished paper reproduced at http://www.prism.net/user/dcowley/docs.html. Also see: http://netlab.cs.ucla.edu/ wiki/files/shannon1949.pdf (accessed June 18, 2007).
_________. “Prediction and Entropy of Printed English.” 1951. http://www.cs.brown.edu/courses/cs195-5/extras/shannon-1951.pdf (accessed June 12, 2007).
Shuster, Beth, and James Rainey. “Officers Face Barrage of Bullets to Take Comrades Out of Line of Fire.” Los Angeles Times, March 1, 1997.
Simon, Herbert. The Scientific Artificial. Cambridge, Massachusetts: The MIT Press, 1981.
_________. Models of Bounded Rationality, Volume 3, Empirically Grounded Economic Reason. Cambridge, Massachusetts: The MIT Press, 1997.
Simons, Daniel J., and Christopher F. Chabris. “Gorillas In Our Midst: Sustained Inattentional Blindness For Dynamic Events.” Perception 28 (1999): 1059-1074.
Slater, Mel, Amela Sadagic, Martin Usoh, and Ralph Schroeder. "Small-Group Behavior.” Presence 9 (2000): 37-51.
Soelberg, P. O. “Unprogrammed Decision Making.” Industrial Management Review 8 (1967): 19-29.
Spahn, E. J., Fire Service Radio Communications. New York: Fire Engineering, 1989.
136
Speier, Cheri, Iris Vessey, and Joseph S. Valacich. “The Influence of Task Interruption on Individual Decision Making: An Information Overload Perspective.” Decision Sciences 30 (1999): 337-360.
_________. “The Effects of Interruptions, Task Complexity, and Information Presentation on Computer-supported Decision-making Performance.” Decision Sciences 34 (2003): 771–797.
Strayer, David L., and William A. Johnston. “Driven To Distraction: Dual-Task Studies of Simulated Driving and Conversing on a Cellular Telephone.” Psychological Science 12 (2001): 462-466.
Strayer, David L., Frank A. Drews, and William A. Johnston. “Cell Phone-Induced Failures of Visual Attention During Simulated Driving.” Journal of Experimental Psychology 9 (2003): 23–32.
Surowiecki, James. The Wisdom of Crowds: Why the Many Are Smarter Than the Few and How Collective Wisdom Shapes Business, Economies, Societies, and Nations. New York: Doubleday, 2004.
Timmons, Ronald P. “Radio Interoperability: Addressing the Real Reasons We Don’t Communicate Well During Emergencies.” Master’s thesis, Naval Postgraduate School, 2006.
_________. "Interoperability: Stop Blaming The Radio.” Homeland Security Affairs 3 (2007): 1-17.
Tversky, Amos, and Daniel Kahneman. “Judgment Under Uncertainty: Heuristics and Biases.” Science 185 (1974): 1124-1131.
_________. “The Framing of Decisions and the Psychology of Choice.” Science 211 (1981): 453-458.
U.S. Fire Administration/Technical Report Series. “The World Trade Center Bombing: Report and Analysis.” New York, 1993.
_________. “Special Report: The Aftermath of Firefighter Fatality Incidents, Preparing for the Worst.” September 1998.
_________. “Improving Firefighter Communications.” Emmitsburg, Maryland, 1999.
Varone, J. Curtis. “Fireground Radio Communication and Firefighter Safety.” Executive Fire Officer Program, National Fire Academy, 1996.
_________. “Firefighter Safety and Radio Communication.” Fire Engineering (March, 2003): 141–164.
Virasami, Bryan, “Farewell to 'Exceptional' Firefighter.” Chicago Tribune, October 10, 2001.
Weick, K. E. “The Vulnerable System: An Analysis of the Tenerife Air Disaster.” Journal of Management 16 (1990): 571-593.
137
_________. “Puzzles in Organizational Learning: An Exercise in Disciplined Imagination.” British Journal of Management 13 (2002): S7–S15.
Weiss, Robert S. Learning From Strangers: The Art and Method of Qualitative Interview Studies. New York: The Free Press, 1995.
Yin, Robert K. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: Sage Publications, 2002.
VITA
Ronald P. Timmons was born in Rochester, New York, the son of Marilyn Stephany
Timmons and Charles Ronald Timmons. After completing high school in Greece, New York,
he entered public service as a police dispatcher and volunteer firefighter. In 1979, he began
as a dispatcher for the Ridge Road Fire District in suburban Rochester, New York, followed
by appointment as a firefighter in 1981. He received Associate of Science Degrees in
Criminal Justice and Fire Protection Technology in 1978 and 1982, respectively. The State
University of New York, Empire State College, bestowed the degree of Bachelor of Science
in Fire Service Administration upon him in 1984. He earned a Masters in Public
Administration in 1987 at the State University of New York, Brockport State College. From
1987 through 2000, he served as an adjunct assistant professor, at the undergraduate and
graduate levels, at four colleges in the State University of New York system. His 22-year
tenure at the Ridge Road Fire District culminated with service as chief of the fire department
from 1997 through 2001. He relocated to Plano, Texas in 2001 to assume the position of
Director of Public Safety Communications for the city of Plano. A return to the classroom as
a student in 2004 resulted in a Masters Degree in Homeland Security and Defense from the
Naval Postgraduate School in Monterey, California in 2006. In August 2006, he entered the
Graduate School of The University of Texas at Dallas. He is married to Debra Timmons of
Rochester and is the father of Stephany Timmons.