How can we strengthen our incident commander’s decision making in complex and chaotic situations?

That was the question that we wanted to look into. We launched a project aimed that subject in relation to airport fire and security services. The updates on this  project have been posted on the FaceBook Group for Section 14 during the whole project. It can still be found there.

We took part in a national campaign where an organization called Kompetencesekretariatet, wanted to support projects that could strengthen leadership among the leaders from a variety of governmental branches. The project is funded by FUSA. It is an abbreviation in Danish that says something like: The fund to support development of governmental branches of work.

The funds derive from a sum of money that is administered by the unions. The money in this fund was safeguarded through wage negotiations.

Our project had focused on the skills that are needed during decision making in complex and chaotic situations. When a crash or another serious incident occurs in an airport or on a military air base, we are initially on our own. Soon after the initial response we will have to corporate with other essential units like our military security service. They will assist us. They will help us to secure the perimeter, evacuate people who might be endangered or affected by the accident, directing the traffic and guide the mutual auxiliary forces from the city. They are important players. Because of that, they also were important participants in our project.

Another important player is the Danish Emergency Management Agency (DEMA). They are the organization that can supply us with manpower and special trained units. They can handle advanced HAZMAT and they can supply us with almost everything. They are an important part of our predefined emergency plans.

We also invited the training officer from the Danish Helicopter Wing. So, the students attending the course originated from our FD, the Helicopter Wings FD, our security force and from DEMA.

It was our main object to develop and train decision making. Our secondary object was to redefine the report sheets that we got. After an incident, lots of information’s tend to be lost due to the facts that the reports only intends to deliver legal information about; what, where, when, who and how. From a legal point of view that’s fine and sufficient, but from our point of view we lose a whole lot of good information’s that way.

We need a report that we can learn from retrospectively. We need to know why the incident commanders make the decisions that the do during the incidents. We had questions like; what supports your decision making, why is standard procedures sometime inadequate, can newly acquired experiences be used by others etc. We must strengthen our capability of managing the unexpected and we must share our acquired knowledge. To support this process, we had hired an associate professor who is an expert in the theories behind operational decision making and sense making. She has made a lot of studies based on the work of Karl Weick and other capacities within this subject. She also works with the theories from David Snowden. He is the father of the “Cynefin framework”. This model can explain what happen if an incident commander suddenly find himself in the middle of an unexpected situation. Snowdens framework show five different situations; simple, complicated, complex, chaos and disorder. For the readers who are not familiar with the theories of David Snowden and Karl Weick, I can tell that they have a lot to say that affects fire fighters like us. Especially in the ARFF branch.

We also got assistance from one of the guys from the local Wing Reserve who happens to be an expert in learning processes. He guided us through physical/neurological aspects of learning processes and assumptions of gathered experiences.

Back to the project; how could we reach our goals? The assisting professor took us through all relevant theories and we had tabletop exercises that provoked the incident commanders/students. My job was to bring complexity and chaos into the exercises. After each tabletop exercise we made reports. It was an emergent process. Each day the students were introduced to a newly developed version of the report sheet, based on a development of yesterday’s version. Initially we had planned to develop the report in plenum, but it turned out to be too difficult to obtain consensus. Because of that I worked with the report myself. My work was based on my own observations and on input from the students.

The first part of our project vent very well. It was an immense success.
Our teacher has taken us through a lot of theories. They have all been related to everyday situations and incidents. We went through the theories of sense making, and high Reliable Organizations (HRO) By Karl Weick. We have also been made familiar with the Cynefin Framework by David Snowden.

Our first tabletop exercises were based on incidents with fighter jets. One of them was a mixture of an incident with a German Panavia Tornado that we have had on our own airbase in 2016, and the well-known incident with two F-16’s that collided on Nellis AFB back in 2015.

 

The incident commanders made their reports after the tabletop exercises. After each day, the report sheets were modified according to our progresses.

As a case story, we had an excellent presentation, based on the act of terror in the capital of Norway back in 2011. That incident is very well documented and there have been made a lot of high quality analyses.

There is a lot to be learned about decision making thanks to those analyses.

We held up our own organization up against the theories of HRO. We found some important similarities, but at the same time we found some serious short falls. The short falls are worth considering afterwards.

A part of the theory of HRO are based on studies from the US Navy carrier CVN-70 USS Carl Vinson. The deck of this ship dos represents the state of art when it comes to HRO.

The Cynefin framework was introduced to the students as well. They will have to get used to it in my part of the organization. It is an excellent tool when it comes to navigating in decision making.

Next step was a full-scale exercise. The full-scale exercise was launched at February 1.

To make a long story short: A small recreational plane with four SOB’s crashed in the residential area of the Air Base.

The plane disintegrated at the impact. The crash caused an explosion near the entrance to a sub terrain command center. Six persons got trapped in the command center and only one of the SOB’s in the plane survived. The only way to rescue the trapped crew was to take them out through a 180 feet long, and very narrow rescue tunnel.

The incident commander of the AFB decided to size up according to the predefined fire- and rescueplan and the severity of the accident. He got assistance from the city, the police, the military security forces and DEMA.
When the command post was established, the incident commanders from the different branches started to divide the whole operation into smaller tasks.
Due to the severity and complexity of the accident, it was decided to rescue as many as fast as possible.

Meaning; rescue the easy ones first. In a smaller scale, we would had carried out triage.

The whole idea of the exercise was to make observations of leaders that was pushed to their limit due to the complexity of the exercise. We got what we were looking for and in some instance more than we were asking for. The three leaders did a good job, but on a NCO-level, things started to happen. We got a lot of good observations to analyze. Those observations were used in the last part of the project.
The observations could indeed be linked to the Cynefin Framework that we had been working with.
The incident commanders that was involved, had the latest issue of the report sheet that we had been working on during the project. The new thing about the report is that is force/urges the incident commanders to tell about the thoughts that are behind their decision making. The main cause of the project is, as said before, to optimize the leader’s decision making during complex and chaotic situations on an accident scene.

The last half of the project was very inspiring as well. First, we had to evaluate the full-scale exercise. The incident commanders did a great job. But the most important was the observations. They gave us a lot to work with according to the theories that we had been introduced to.  We took the theories from part one a bit further. We started to combine them and we included new and more demanding theories.

 

The table top exercises were taken to a higher level as well.

 

 

 

 

 

One of the exercises was about a passenger plane that was forced down by two QRA-fighter jets. At the landing the plane overshot the end of the runway and crashed. Suddenly we had 148 people on the runway. That’s not all: The Police suspected some of the passengers to be high-jackers. Who said chaos? That exercise took the student in charge with surprise. It exercise was build up in an odd way. It had an inherent risk of blocking the students decision-making process. We succeeded and lured him to misinterpret the incident. After a short while he started to get on top of the situation again. At the end, he solved the situation in a very fine and correct way.  This incident triggered a very deep reflection in the whole group of students. It was possible to bring all the theories in action to analyze his decision-making.

Our ongoing work with the theories was based on an even deeper analyze of the Utoeya incident in Norway.  The Utoeya incident is about an act of terror that was carried out by Anders Behring Breivik against the government, the civilian population, and a Workers’ Youth League (AUF)-run summer camp. The attacks claimed a total of 77 lives 22. July 2011. It was two sequential lone wolf terrorist attacks.
We had access to the conclusion report from that incident. The Norwegian report was state of art when it comes to reflection. A lot of mistakes had been made and a lot had been learned. We also worked with the report of a tragic incident that we have had in Denmark in 2011. It is called the Praestoe Incident. It is about a group of high school pupils and teachers who had sailed out in a dragon boat in very bad weather. The boat capsized on mile ashore. All the pupils and the teachers ended in the very cold water and they were not able to recover the boat. One of the teachers, the initiator of the whole thing, lost his life. All the pupils were rescued, but they were more dead than alive when they were salvaged. They are lucky to be alive, but most of them suffers from severe neurological damage today.
This incident is very well documented, and the report served as an educational platform for us when we wanted to learn about a bad security- and decision-making culture.

One of the main purposes of the whole project was to create an appendix for our incident reports. We have managed that as well. We will launch the appendix as a pilot project over the next months to see if it will help us drag more information’s out of the reports.

But most important: We hope that we have helped the students in their future decision making in a way that will make them even more effective on the accident scenes.
We hope that we have been giving them new tools to use when they will have to cope with everyday problems and with very complicated or even chaotic situations.
Or even better; maybe we have learned them new techniques to avoid entering the chaos-zone. It is fare better to avoid chaos than to fight your way out of it.

The practical part of the project is over by now. That means that all the hard work starts now. The results must be analyzed and all the reports must be written. I am also about to create a presentation about the whole project. Later, I will also make an article about the aftermath. We are all excited to see how the incident commanders has developed and we are longing to what the new reports sheets will bring us.

I want to thank the people and the organizations that made this project possible:

The prime contributor is: Kompetencesekretariatet, FUSA, that made all this possible. They provided most of the funding’s and the framework. They made it possible to attract one on of the leading capacities when it comes to knowledge about leadership during crises and incidents.
Fighter Wing Skrydstrup provided additional funding’s, human resources and infrastructure.

 


About the Author:  Lars Andersen is the Fire Chief at Fighter Wing Skrydstrup.  He is a member of the National Military Crash Investigation Team and International Military Coordinator in ARFF Working Group Section 14.  He is currently studying for his Master of International Business Communication at The Southern Danish University.