Mayday Decisions 1

HUMAN FACTORS AFFECTING MAYDAY DECISIONS

Human Factors Affecting Mayday Decisions in Green Bay Firefighters:

Will they call for help when they need it?

Robert N. Goplin

Green Bay (WI) Fire Department

September 2009

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CERTIFICATION STATEMENT

I hereby certify that this paper constitutes my own product, that where language of other is set

forth, quotation marks so indicate, and that appropriate credit is given where I have used the

language, ideas, expressions or writings of another.

Signed:_______________________________________________

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Abstract

Green Bay Fire Department (GBFD) firefighters are reluctant to request assistance by declaring a

mayday situation even when conditions indicate the need for it. The purpose of this research is to

identify why GBFD firefighters who are trained to call a mayday when faced with a situation that

falls within certain defined parameters are not doing so. This Applied Research Project (ARP)

used descriptive research methods to provide recommendations for improvement in mayday

decision-making.

The procedures used for this ARP were a literature review, distribution of two questionnaires,

and a request for information distributed to specific departments of similar size to Green Bay.

Questionnaire responses were collected and analyzed electronically. Critical research questions

are: What nationally recognized situational parameters exist to determine when a firefighter

should declare a Mayday? What methods are other fire departments of comparable size in

Wisconsin and bordering states using to encourage firefighters to declare a Mayday when

conditions warrant? What, if any, environmental cues do GBFD firefighters use to indicate when

a mayday should be declared? What, if any, training issues impact the decision to call mayday?

What, if any, leadership issues impact the decision to call mayday?

Relevant elements of current GBFD guidelines and policies were found to be similar to those of

other organizations based on both internal and external response to questionnaires. GBFD

firefighters were found to be subject to human error when making mayday decisions. This

research also revealed that there does not appear to be nationally recognized mayday parameters

to evaluate decisions against for validity. Seven recommendations have been provided to

improve mayday decision making among GBFD firefighters.

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Table of Contents

CERTIFICATION STATEMENT ......................................................................................................................... 2

Abstract ..................................................................................................................................................................... 3

Introduction ............................................................................................................................................................ 6

Background and Significance ........................................................................................................................... 8

Literature Review .............................................................................................................................................. 13

Procedures ............................................................................................................................................................ 28 Table 1: Requests for information ............................................................................................................................. 29

Results .................................................................................................................................................................... 31 Table 2: Nationally recognized parameters (External Questionnaire) ...................................................... 32 Table 3: Environmental Cues (External Questionnaire) .................................................................................. 32 Table 4: Know when to declare mayday (External) ........................................................................................... 34 Table 5: Know when to declare mayday (Internal) ............................................................................................ 35 Table 6: Mayday Policy or Guideline (External) .................................................................................................. 35 Table 7: Mayday should have been declared (Internal) ................................................................................... 36 Table 8: Judgment if mayday is called (Internal) ................................................................................................ 37

Discussion ............................................................................................................................................................. 37

Recommendations ............................................................................................................................................. 40

References ............................................................................................................................................................ 43

Appendix A: Guideline 0201.09 Mayday ................................................................................................... 50

Appendix B: Internal Questionnaire ........................................................................................................... 53

Appendix C: External Questionnaire .......................................................................................................... 56

Appendix D: Request for information from comparable cities ........................................................ 59

Appendix E: Responses from comparable cities .................................................................................... 60

Appendix F: Cities receiving letter and response status ..................................................................... 64

Appendix G: External Questionnaire Responses ................................................................................... 65

Appendix H: Internal Questionnaire Responses .................................................................................... 69

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Human Factors Affecting Mayday Decisions in Green Bay Firefighters

Introduction

Pressure to make decisions under time constraints degrades the quality of those decisions

(Ranyard, Crozier, & Svenson, 1997). Arguably, many decisions made in the field of firefighting

are time-sensitive. This is particularly true when firefighters find themselves in situations that

pose a threat to their life. Firefighting and allied operations, including emergency medical

services, hazardous materials response, and specialized rescue are generally accepted to be

hazardous occupations. As such, firefighters have come to accept what seem to be inherently

high levels of risk. For centuries the occupation has been romanticized and revered as a noble

calling. Unfortunately, one of the hallmarks of this romance and supposed nobility is the

firefighter funeral. It is common to conduct a lavish ceremony for the lost hero; so common in

fact, that few ever question what caused the death. It is simply accepted as the nature of the job.

More often than not, firefighters die as a result of some medical issue while performing

their jobs (C2 Technologies, 2008). However, every year firefighters die or are seriously injured

in structure fires, often as a result of becoming lost or trapped in a hazardous environment (Fahy,

2002). In many of these instances, death occurs without the firefighters ever asking for

assistance. In some cases, the events leading to firefighter injury or death happen so quickly that

assistance cannot be requested. These catastrophic incidents are few and far between; the

“routine” residential structure fire appears to kill or injure firefighters more than any other type

of incident (Fahy, LeBlanc, & Molis, 2009). Truly “routine” incidents should not cause death or

serious injury, so one must question what is occurring or not occurring that causes firefighters

operating at common incidents to be subject to circumstances that ultimately claim their lives.

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While several issues may be indentified as contributing factors to these circumstances,

firefighters will continue to place themselves in harm’s way until such risks can be eliminated or

reduced. In light of this fact, firefighters must fully understand when they are in a life-

threatening situation and then react appropriately. At present, firefighters may not recognize

when they are in trouble and, as a result, they do not call for assistance or they call for it too late

(Angulo, Clark, & Auch, 2004). The Green Bay Fire Department (GBFD) has trained its

personnel to request emergency assistance when they find themselves in a dangerous situation.

GBFD firefighters request assistance by declaring a “Mayday.” In a recent incident, GBFD

firefighters failed to recognize several situations that should have prompted them to declare a

mayday. The problem is that GBFD firefighters are reluctant to declare a mayday situation even

when conditions indicate the need for it. This is a problem because a delay in declaring a mayday

when in a dangerous situation dramatically increases the risk to firefighters and others who may

be deployed to assist them (Kreis, 2003).

The purpose of this research is to identify why GBFD firefighters who are trained to call

a mayday when faced with a situation that falls within certain defined parameters are not doing

so. Descriptive research was used to examine the current situation and determine what actions

are necessary to correct it. The research will address the following questions: What nationally

recognized situational parameters exist to determine when a firefighter should declare a Mayday?

What methods are other fire departments of comparable size in Wisconsin and bordering states

using to encourage firefighters to declare a Mayday when conditions warrant? What, if any,

environmental cues do GBFD firefighters use to indicate when a mayday should be declared?

What, if any, training issues impact the decision to call mayday? What, if any leadership issues

impact the decision to call mayday?

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Background and Significance

The City of Green Bay is approximately 46 square miles located in Brown County at the

southern end of the Bay of Green Bay at the mouth of the Fox River, the river dividing the City

East and West. Besides protecting the approximately 103,000 residents of Green Bay, the GBFD

protects a vital port, several international manufacturers and a nationally recognized sporting

venue. It is the largest community in Northeast Wisconsin and the third largest in the State of

Wisconsin.

The GBFD operates out of seven fire stations staffed by 185 career employees. 172 line

positions provide primary services to the community. The remaining 13 positions provide

administrative and support functions. The department provides a variety of services including

fire and injury prevention, fire suppression, technical rescue, hazardous materials and advanced

life support services. The GBFD responded to over 10,000 calls for service in 2008. In February

2009, the department entered in to a Mutual Aid Box Alarm System agreement with all other

communities in the county (Daul, 2008). This agreement allows the department to provide aid to

other communities or receive aid as necessary.

Firefighting, like many other occupations, has inherently dangerous characteristics as part

of daily operations. In each of the past 30 years, an average of 100 firefighters has died in the

line of duty (C2 Technologies, 2008). In 2005, the National Fallen Firefighters Foundation cited

fire service culture, a lack of planning, inconsistent application of risk management principles

and various fireground factors as significant contributors to firefighter injuries and death

(National Fallen Firefighters Foundation, 2005). According to the United States Fire

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Administration, the second most common cause of firefighter fatalities after heart attack is

trauma followed by asphyxia and burns (United States Fire Administration, 2009) .

In order for a firefighter to suffer from trauma, asphyxia, or burns in a structure fire, they

must become entrapped or lost in a hostile environment. Every firefighter who undergoes proper

training should be instructed in the warning signs that will most likely be present prior to them

becoming lost or entrapped. If those warning signs are recognized and acted upon appropriately,

a firefighter should not become lost or entrapped and should be able to exit a burning building

prior to the occurrence of injury or death. In order for these signs to be recognized and the proper

actions taken to facilitate escape from the situation, training must occur that adequately addresses

these issues. In a report issued by the National Institute for Occupational Safety and Health,

Ridenour et al. (2008), suggested that fire departments should have standard operating

procedures in place and ensure they are followed. The report also states that departments should

“Instruct and train fire fighters in initiating emergency traffic (mayday-mayday) and activating

their personal alert safety system (PASS) device when they become lost, disoriented, or trapped.”

(p. 14)

While it is generally accepted in the fire service that firefighters seem to have a tendency

to not want to ask for help even when they clearly need it, studies are also beginning to reflect

this (Paul J. Antonellis, 2006). One such study reflects that firefighters are prone to “tough

mindedness,” a term that could likely be translated as “stubborn” (Meronek & Tan, 2004).

Another recent study, conducted at St. Joseph’s hospital in Atlanta, yet to be published, indicates

that a firefighter’s personality is such that it may contribute to an early death ("Heart Disease: An

Epidemic For Firefighters," 2009). Any fire department wishing to ensure that its personnel will

call for help when it is needed must first overcome the obstacles of fire service culture and

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firefighter personalities. Firefighters are known for trying to adapt to any situation and rarely

aborting a mission, even when they should. As a result, firefighters around the country find

themselves in extremely dangerous or deadly situations, but fail to call for assistance.

The GBFD has experienced injuries related to work conducted at structure fires. On

August 13, 2006, the department suffered its first fatality as a result of operating at a structure

fire (Phillips, et al., 2007). In this incident, the Lieutenant of an ambulance company lost his life

and his partner suffered career-ending injuries. In that instance, those firefighters did request aid

immediately upon a disastrous failure of the structure’s floor assembly that caused them to

plummet in to the burning basement. This incident represents a situation where a firefighter must

request assistance immediately. According to an internal report, the firefighters in this instance

called for help 34 seconds after falling through the floor (Phillips, et al., 2007). Prior to this

incident, the GBFD had conducted training to instruct all personnel on emergency procedures in

various situations, including requesting emergency aid and rapid intervention operations. Since

the incident, the department has conducted additional training on emergency procedures, mayday

protocols, rapid intervention, and communications.

Despite continued efforts to train personnel to avoid unsafe situations an identify

situations that would require them to request help, the GBFD continues to experience situations

that could result in serious injury or death without receiving appropriate requests for assistance.

According to individual firefighter reports of an incident that occurred on February 3, 2009, up

to six firefighters were exposed to intense fire, high heat, and heavy smoke conditions after a

sudden change in conditions while conducting overhaul operations on the second floor of a

structure. (Jansen, 2009) In personal conversations with this author, several of the firefighters

stated that they also lost spatial orientation and could not immediately locate a hose line that they

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had with them. Despite these conditions, none of the firefighters communicated the need for

assistance. While this incident did not result in injury, it certainly had potential to do so and it

could have been prevented. The cost of a firefighter death or injury, when weighed emotionally,

psychologically, and financially, is too high for any department, individual, or family member to

bear. While a single fatal incident in the department’s 150-year history may seem like a decent

safety record given the occupation, any injury and even one fatality must be considered

unacceptable, especially if it is preventable. Continued breakdowns of mayday decision

processes can only result in further injury or death to GBFD firefighters. The impact of this

project will be to develop an organizational culture within the GBFD consistent with firefighter

safety practices and theories.

This applied research project displays relevance to the coursework of the Executive

Development, R123 course of the National Fire Academy’s Executive Fire Officer Program

(EFOP) (National Fire Academy [NFA], 2006). Specifically, this research project is relevant to

the following objectives of the Executive Development curriculum:

Unit 1: Leadership discussed how a leader can use adaptive leadership to accomplish

change within an organization. A leader must be willing to make difficult decisions and then lead

by example in order to create cultural change. These changes can only be made if the leader

displays vision and inspires trust.

Unit 2: Teams demonstrated the difficulties that leaders will face when organizing teams

within an organization. This is particularly relevant as this project is focused on creating

organizational and cultural change by assisting teams and crews to come to a common

understanding of various dynamic situations while operating in a hostile work environment.

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Unit 3: Change Management is the basic tenet of this project. To facilitate change in an

organization entrenched in tradition, the Executive Fire Officer must understand the process of

change and effects the change process has on people.

Unit 4: Research applies to the process of properly conducted research. This project will

be a component of the change process because of the research conducted and the conclusions

formed. The information contained in this project will be used as an instrument of change within

the organization.

Unit 6: Change and Creativity stresses that the leader must involve multiple perspectives

to create appropriate and accepted change. If members of an organization are included in

creatively forming a solution to a situation, they will be less likely to fear its implementation. A

leader must understand the criticality of involving all layers of an organization to come to the

best possible resolution to a problem.

Unit 7: Organizational Culture and Change examines why fire service leaders must

understand the elements of an organization’s culture. Furthermore, an Executive Fire Officer

must posses the ability to understand when change is needed in an organization. This research

project will display the need for change within our organization and the fire service.

Unit 10: Service Quality explains how the Executive Fire Officer should encourage the

delivery of a quality service. This project displays that an organization may have to undergo

change in order to be respected as a quality service delivery organization. Fire departments must

curtail injuries and fatalities as compared to other occupations and fire departments in other

countries to truly stand out as a leader and quality service provider in the fire service.

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Determining how human interaction with dynamic and hostile situations influences the

outcome of those situations will display how organizational cultural must change to redirect

outcomes to a successful conclusion. Examining how organizations perpetuate unsafe conditions

and acts at all levels will also serve to demonstrate how fire service leaders must drive for

change in culture in their own organizations and globally. These issues correlate directly to the

mission of the United States Fire Administration as it directly supports USFA operational

objective C: reduce the loss of life from fire of firefighters. This project also supports operational

objective E: respond appropriately in a timely manner to emerging issues. Furthermore, the

research supports the USFA 5-year Strategic Plan by addressing Objective 3.2 of Goal 3:

“Advocate a culture of health, fitness and behavior that enhances emergency responder safety

and survival.” Goal 4, Objective 4.1, “Enhance the professionalism of the Nation’s fire and

emergency services leaders” is also addressed (United Sates Fire Administration, 2008).

Literature Review

The literature review will discuss the current findings of research on contributing human

factors to incidents or accidents that have resulted in personal injury or death. Existing research

on management and leadership approaches to reducing injury and death in high-risk occupations

was also reviewed. The review primarily focuses on current literature pertaining to situational

awareness, crew resource management, recognition-primed decision making, and the human

factors analysis and classification system (HFACS). Secondarily, a review of reports and

material surrounding the specific areas of firefighter safety culture and firefighter mayday

decisions and protocols, including a report specific to the GBFD, is also relevant. As with any

task or series of tasks performed by a crew of personnel, firefighting relies on the entire crew to

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maintain a level of proficiency with all skills. Though firefighting is a high-risk profession,

technological advances have minimized incidents that place an individual in a life-or-death

situation. Therefore, the skills needed to survive that situation would rarely come into play. Due

to the difficulty in maintaining competency with any rarely performed skill, the crew must be

certain all members recognize the need for and are prepared to engage in such skills to ensure the

safety of the entire crew.

Firefighter safety culture, like any culture, is difficult to evaluate due to its mystique.

However, evidence would suggest that the culture of safety in the United States fire service falls

short when compared to that of other industrialized countries, especially the United Kingdom

(Granito, Trench, England, & Neal, 2006). Particularly, United Kingdom data show that from

1995 to 2004, less than one firefighter died per 100,000 fires, whereas the United States death

rate was seven firefighters per 100,000 fires (Pessemier). Additionally, a 2008 report issued by

the Fire Brigades Union Labour Research Department in the United Kingdom shows a total

death rate of 121 firefighters between 1978 and 2007 (Labour Research Department, 2008). This

compares to the United States average of 100 firefighter deaths every year for approximately the

same period. These numbers are certainly subject to variables such as incident volume, response

times, and severity of incidents, but either way, the evidence is compelling enough to suggest

that improvements might be made in the United States.

Typically, fire departments in the United States reflect a paramilitary structure, where

subordinate ranks do not countermand superiors. This alone may be a contributing factor in the

safety culture of fire departments. Okray and Lubnau (2004) suggest that it is not until

firefighters find a balance between authority and responsibility that they will truly develop a

safety culture. When everyone on an incident truly has the authority to stop unsafe acts and

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recognizes their responsibility to do so, the culture will finally begin to change. This paramilitary

organization also tends to lend itself to the concept of unavoidable casualties. In military

organizations, it is not uncommon for the leaders of a certain mission to assume and accept that a

given number of casualties will occur.

Okray and Lubnau (2004) argue that there are five specific steps to creating a safety

culture. They state that trust must first be gained by everyone in the organization. This trust will

allow for the honest sharing of information that will in turn allow issues to be addressed. They

then suggest that, because errors are part of human nature, a non-punitive procedure for

addressing errors should be implemented. Okray and Lubnau (2004) continue that the third step

is the organization truly working to eliminate the errors it uncovers. Fourth, personnel within the

organization must be trained to recognize and avoid errors and manage crews while operating at

an incident. This creates a natural environment of self-preservation. Lastly, the organization must

have a process in place to review incidents to detect and address errors that might have occurred.

According to an expert panel of United States and United Kingdom firefighters, fire

departments must mandate the enforcement of a safety philosophy and require performance

reviews of Incident Command personnel after large incidents (Granito, et al., 2006). Again, the

culture of an organization that allows for superior officers to be questioned or reviewed is in

direct conflict with the paramilitary structure of most fire departments. For there to be complete

buy-in of an organizational safety culture, change must occur at all levels, but the most important

level begins with the company officer (Oklahoma State University, 2006). In particular, these

officers must be willing to respectfully question actions of both subordinates and superiors. As

explained in the Final Report for LODD Project: Phases I –II (Oklahoma State University, 2006),

the nature of this type of change will affect the very image of firefighting as a profession:

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Development of a safety culture within the fire service will require a change in many of

the behaviors, practices, values, beliefs and underlying assumptions that make up the

current culture of many fire service organizations. Previous efforts over the last few

decades to improve the level of safety within the fire service have been largely

unsuccessful, as represented by the data on firefighter death rates. One of the reasons for

the lack of success in improving the safety performance of the fire service in the US may

be due to a lack of understanding about how changing the safety performance of the fire

service affects the culture and image of the fire service. People may be reluctant to

attempt to raise these issues because they are difficult issues to talk about, and dealing

with some sort of technological fix is much easier that dealing with people. (p. 58)

In addition to the cultural concerns within the fire service, there are also concerns

regarding the cultural attitude toward the occurrence of fire incidents in the United States. The

USFA (1997) reported that the U.S. fire service spends more money on fire response than on fire

prevention. They also reported that the citizens of the United States are more tolerant of fires and

view those who have a fire incident in their home or workplace as a fire “victim,” even if the fire

was started by that person’s carelessness (United States Fire Administration, 1997). This is also

supported by the fact that from 2003 to 2005, the United States experienced no less than 4,000

deaths each year whereas Japan suffered no more than 2,300 deaths from fire despite being much

more densely populated (The Geneva Association, 2008). Cultural issues facing the fire service

in the United States hinder the very changes that must occur to develop a safety culture (National

Fallen Firefighters Foundation, 2005).

However, the literature review revealed that cultural obstinacy is not solely reserved for

the fire service. Many high-risk occupations had remarkably high death, injury, or accident rates

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and ultimately reduced them by inducing cultural change. Aviators have also historically lost

large numbers of their ranks to accidents. Since the beginning of aviation until the late 1950s,

pilots were lost in large numbers due to various accidents. (Shappell & Wiegmann, 2000) In

addition to commercial aviation accidents, the literature review showed that several branches of

the United States military also realized significant losses when engaged in flight (Wiegmann &

Shappell, 2003). Cultural issues developed in the aviation industry in the days of low-altitude

barnstorming pilots. Wiegmann and Shappell (2003) report that stories of these adventures led to

“one-up-manship” by other pilots, many of whom eventually died as a result. Wiegmann and

Shappell go on to state that many of the problems resulting in aircraft crashes, both commercial

and military, were solved by technological advances.

In the early 1990s, the number of accidents was relatively stagnant when compared to the

past, perhaps suggesting that technology had done what it could for the time being (Wiegmann &

Shappell, 2003). Shortly after one accident in particular, involving a U.S. Navy F-14, a study

showed the effects of human error in aviation accidents (Wiegmann & Shappell, 2003). A system

called the Human Factors Analysis and Classification System (HFACS) was used to analyze the

aviation accident data from the U.S. Navy and Marine Corps. A panel of experts including

aerospace psychologists, flight surgeons, and naval aviators reviewed and classified over 150

accident reports using this system (Wiegmann & Shappell, 2003).Wiegmann & Shappell (2003)

report the analysis showed one third of the accidents were caused by an unsafe act, usually

involving at least one violation of rules. Further analysis of the data found that over half of the

accidents were a result of skill-based errors, not equipment or technology failure (Wiegmann &

Shappell, 2003).

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Generally, the HFACS classifies unsafe acts in two separate categories: errors and

violations (Reason, 2008). Skill-based errors are defined within HFACS in three ways. First is

attention failure, such as a failure to scan surroundings or task fixation. Secondly, memory

failures usually result in omitted items on checklists or procedures in both normal and emergency

situations. Finally, technique-based errors are variations in how tasks are completed (Wiegmann

& Shappell, 2003). In contrast, decision errors are those in which a plan goes as intended; the

plan is merely flawed. These errors are broken down into three categories: procedural, poor

choices, and problem solving. Procedural errors occur during highly structured tasks. Choice-

based errors usually occur when several options are present but time to make the decision is

short; when experience in that situation is limited; or when other pressures are present. Problem-

solving errors occur when the problem is not fully understood or procedures to address the

problem do not exist (Wiegmann & Shappell, 2003).

Violations, according to Reason (2008), are errors that occur because the organization’s

rules or policies are ignored or purposefully not followed, though bad outcomes are not the

intent. Routine violations are those where rules or procedures are commonly ignored (Wiegmann

& Shappell, 2003). These violations, such as a person driving a given number of miles over the

speed limit, are often tolerated by those who should be enforcing the rules. Exceptional

violations are those in which a person willfully chooses to violate a rule. Wiegmann and

Shappell (2003) explain that exceptional violations are labeled as such because they are a

departure from normal, do not represent typical behavior of the individual, and are not condoned

by the organization.

As a result of the findings using HFACS, the U.S. Navy and Marine Corps looked toward

management and leadership to solve their human error problems. Wiegmann and Shappell

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(2003) explain that the concept of Crew Resource Management (CRM) was integrated into

training programs at various levels. CRM is defined as the use of all available resources,

including information, equipment, and people to achieve safe and efficient flight operations

(Salas, et al., 1999). Despite the somewhat limited initial results, CRM is still popular in aviation

and used extensively to design training for specific aircraft (Wiegmann & Shappell, 2003).

Additionally, CRM has moved into the corporate side of aviation with somewhat improved

results (Okray & Lubnau, 2004).

In their book, Crew Resource Management for the Fire Service, Okray & Lubnau (2004)

discuss the role of CRM in the fire service as well as organizational safety culture and situational

awareness. Specifically, they draw a parallel between research in the aviation field and the

firefighting occupation, stating that the fire service is in the same position the aviation industry

was 25 years ago and further hold that aviation accidents resulting from human error have been

virtually eliminated as a result of using CRM principles. In fact, they state that the lessons

learned by the aviation industry are the future of firefighter training. A report on the Storm King

Mountain fire, in which 14 wild land firefighters were lost, also draws parallels between the

concepts of CRM used in the aviation industry and firefighting (Putnam, 1995). Okray and

Lubnau (2004) suggest that to improve, the fire service must accept that firefighters and incident

commanders are human and will make mistakes but use CRM principles to isolate the mistake in

such a way that it will not cause injury or death. To further support this philosophy of human

error, Salas reports that the latest evolution of CRM for the aviation industry holds that human

error is inevitable but can provide invaluable knowledge and education (Salas, Burke, Bowers, &

Wilson, 2001).

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One of the key elements to safe operation is situational awareness. Utilizing an entire

crew of personnel to maintain situational awareness is one of the primary reasons to use CRM

principles. Situational awareness is defined as "'the perception of the elements in the

environment within a volume of time and space, the comprehension of their meaning and the

projection of their status in the near future' (Endsley, 1988)." (Garland, Wise, & Hopkin, 1999)

More simply defined, this is the skill of becoming aware of a situation as it actually exists (Okray

& Lubnau, 2004). Literature on this topic suggests that one’s perception of a given situation is

generally significantly different than reality. These lapses in situational awareness result in

mistakes such as controlled flight into terrain while focusing on a burnt out light bulb in an

aircraft cockpit. (Okray & Lubnau, 2004) Situational awareness can be divided into several

elements including Level 1 SA, Level 2 SA, Level 3 SA (Endsley, Garland, & Erlbaum, 2000).

Level 1 SA involves perceptual cues that assist a person in forming the correct mental image of

the situation he or she faces, according to Endsley, Garland, and Erlbaum (2000). Level 2 SA

relates to the interpretation of incoming information, including the determination of whether or

not it is relevant to the person and their situation. Level 3 SA is the highest level of situational

awareness. At this level, the individual is able to conduct an analysis of current information to

predict future events and weigh the implications of those events (Endsley, et al., 2000); they go

on to discuss how the issues of time and highly dynamic situations affect an individual’s ability

to keep up with incoming information and how a failure to do so renders one’s picture of the

situation irrelevant.

The process of gaining situational awareness is distinctly separate from the decision-

making process in the Endsley model (Endsley, et al., 2000). The process by which information

is obtained, processed, and evaluated influences eventual decisions. While a high level of

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situational awareness is desired for the decision maker, it does not ensure that the proper decision

will be made (Endsley, et al., 2000).

While several models for decision making exist, the literature focused on the Recognition

Primed Decision (RPD) model. This model was developed by Gary Klein to explain how

experienced fireground commanders use situations they have previously encountered to make

decisions regarding the current situation (Klein, 1998; Zsambok, Klein, & Erlbaum, 1997). RPD

allows the decision maker to choose the first course of action, based on situational awareness,

that is expected to lead to the desired outcome without comparing it to other courses of action

(Davison, 2008). The concept of RPD has gained empirical support through a study conducted

on chess players showing that the first move chosen by experienced players was often a much

stronger move, as rated by a pool of chess grandmasters, than one randomly selected from a pool

of legal moves (Zsambok, et al., 1997). According to Zsambok et al. (1997) this would imply

that the generation of multiple options through prolonged analysis of a situation might be less

important than researchers originally thought. Literature revealed that, specifically in military

operations and therefore comparable to fire service situations, those with the most up-to-date

situational awareness are those positioned at the lower end of the organizational hierarchy

(Davison, 2008). As a result, a concept of “uni-minded” thinking, similar to CRM, was

developed for the military’s use (Davison, 2008).

Recognition-primed decision making requires the decision maker to have some past

experience with a given situation. This experience then allows the person making the decision to

filter the incoming information as relevant or not in order to form a mental simulation of the

situation and its future course. (Davison, 2006) The combination of this process and the

experience supporting it then allows the individual to make decisions in a very short timeframe.

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Davison (2006) states that a critical element to the process of making recognition primed

decisions is the intuition gained by experience, a statement also supported by Klein (1998).

Firefighters will likely base their decision to transmit a mayday on a predefined set of

circumstances set out in a standard operating procedure (Clark, Auch, & Angulo, 2002). An

accepted set of parameters does exist, but agreement on whether or not to transmit a mayday

when reaching those parameters varies widely (Clark, et al., 2002). Clark defines the parameters

that have been published nationally in six specific words; those words are fall, collapse,

activated, caught, lost, and trapped (Clark, 2004). Clark (2004) also defines three steps to

transmitting a mayday. First the firefighter activates an emergency button on their radio, and then

announces the words MAYDAY, MAYDAY, MAYDAY. The third step is to give a situation

report using the assisting acronym, L.U.N.A.R., which stands for location, unit number, name,

assignment, and resources. (Clark, 2004) A U.S. Fire Administration report on how to avoid the

need for rapid intervention teams lists the desired elements of a mayday transmission as

including a situation report, location and crew size (Williams & Stambaugh, 2003). The National

Fire Protection Association states that fire department standard operating procedures must have a

provision for the declaration of “emergency traffic” which can be initiated by a member in an

emergency situation, but does not define what the situation might be or what information should

be relayed. (National Fire Protection Association, 2007)

Green Bay Fire Department Standard Operating Guidelines, specifically 0201.09 Mayday

(see Appendix A), do contain information that direct firefighters to transmit a mayday in certain

situations (Green Bay Fire Department, 2007). These situations are listed as “fall,” “collapse,”

“activation of alarms,” “entanglement,” “lost,” “trapped,” “significant fire event,” and “at any

time a firefighter believes the safety of a crew or crewmember is or may soon be at risk.” (Green

Mayday Decisions 23

Bay Fire Department, 2007) GBFD (2007) guideline 0201.09 also directs the firefighter to give a

situation report using the acronym P.L.A.N., which stands for person, location, action and needs.

GBFD guideline 0202.01, Command of RIT Incidents, also provides guidance on when a

firefighter would transmit a mayday and guides dispatchers to follow a procedure when a

mayday is transmitted (Green Bay Fire Department, 2008).

Several reports written by the National Institute on Occupational Safety and Health

(NIOSH) on incidents where firefighters lost their lives were reviewed to determine the instances

when assistance was requested versus those when it was not. A report from an incident in 2005

explained that despite eight firefighters having been inside a structure when the roof collapsed,

causing several of them to be engulfed in flames, only one of them called for assistance

(National Institute for Occupational Safety and Health, 2005c). The report further indicates that

this call for help did not necessarily follow any structured reporting procedure that would quickly

outline the situation in detail and the term “mayday” was not used (National Institute for

Occupational Safety and Health, 2005c).

Another report from 2005 indicates that six firefighters were trapped by heavy fire in two

separate rooms on the fourth floor of a structure. One of the firefighters, who would later die,

called a mayday twice, though no specific information as to the content of the message is

discussed. Another firefighter called a mayday well into the incident, just prior to escaping the

situation, albeit with severe injuries. The second firefighter to die in this incident did not call a

mayday. This report recommends training firefighters to call a mayday “immediately when they

become trapped.” (National Institute for Occupational Safety and Health, 2005d).

Mayday Decisions 24

NIOSH report number F2005-05 describes an incident where two firefighters were lost in

a smoke-filled environment. The victim gave two mayday calls before becoming unresponsive.

The other lost firefighter became more disoriented and low on air supply; despite his situation, he

did not call a mayday before escaping. The report suggests training firefighters to know what

actions to take while waiting to be rescued and specifically recommends mayday procedures

(National Institute for Occupational Safety and Health, 2005a).

According to NIOSH (2005b), seven firefighters were located in the basement of a

structure when rapidly deteriorating conditions forced them to exit. While exiting, one of the

firefighters was knocked over, causing his helmet and breathing apparatus face piece to be

dislodged. He set the nozzle of the hose line he was operating on the stairwell to replace his face

piece and then exited the structure without calling a mayday. Once outside, a fire Captain

realized that one of the seven was missing. The Captain reentered the home and heard an alarm

from a Personal Alert Safety System (PASS) alarm, a device that sounds an alarm when a

firefighter has not moved for 30 seconds. The Captain called a mayday for the missing

firefighter. The deceased firefighter was later found on the steps to the basement; the victim

never declared a mayday. This report recommended that mayday procedures should be followed

and refresher training conducted on those procedures (National Institute for Occupational Safety

and Health, 2005b).

NIOSH (2006) report F2006-24 cites an incident in which a Deputy Chief fell through a

hole in the floor of a burning structure and became entrapped in the basement. The Deputy Chief

did not call a mayday. The Assistant Chief of the department saw a hose going through the floor

and yelled to the trapped Deputy Chief, who responded by yelling for help. Another firefighter

then joined the Assistant Chief in placing a ladder down to the trapped Deputy Chief; neither the

Mayday Decisions 25

firefighter nor the Assistant Chief called a mayday for the trapped Deputy Chief. The Deputy

Chief was later removed from the structure but could not be revived. This report specifically

states that firefighters must promptly transmit a mayday when they become lost, disoriented,

injured, low on air, or trapped (National Institute for Occupational Safety and Health, 2006c).

Two other reports from NIOSH (2006) detail situations where fatalities occurred without

a mayday being transmitted by anyone on the scene of the incident. In one instance, a Lieutenant

died in a structure fire after apparently becoming entrapped; he did not transmit a mayday.

Despite crewmembers noting the Lieutenant’s absence and the sounding of a PASS device, no

one called a mayday (National Institute for Occupational Safety and Health, 2006b). In the

second instance, a firefighter died after rapidly changing conditions forced him and two other

firefighters to begin evacuating the structure. The victim began running, apparently in distress,

and knocked over both of the other firefighters. They were all trapped near the front door, one of

them with the victim lying on top of him. None of the three trapped firefighters nor those

facilitating rescue called a mayday (National Institute for Occupational Safety and Health,

2006a).

An internal Green Bay Fire Department report indicates that while two personnel were

trapped in a burning basement after the floor they were on collapsed, a Lieutenant and a

Firefighter, only one of them called for assistance immediately by transmitting a mayday. The

Lieutenant transmitted the mayday within seconds after the collapse, but no details followed the

call (Phillips, et al., 2007). Information on his location followed in other transmissions. The

firefighter called for assistance and relayed important information several times, but did not use

the term mayday. The Lieutenant died in the basement and the firefighter was rescued by rapid

intervention crews (Phillips, et al., 2007).

Mayday Decisions 26

NIOSH reports from 2007 outline similar occurrences. A structure fire in Texas claimed

the lives of a Captain and a Firefighter. The incident commander requested an update twice

because intense fire conditions had developed after the attack team entered. The commander got

no response after the two had been in the building for over 21 minutes while operating on a 30-

minute air bottle. The two members of the attack team did not declare a mayday. While

attempting to rescue one of the victims, a member of the rescue team became ill and was forced

to exit the building; neither he nor his partner declared a mayday or asked for assistance. This

report specifically states that crews should be trained on how to initiate emergency radio traffic

when in distress (National Institute for Occupational Safety and Health, 2007b). NIOSH (2007a)

report F2007-28 outlines another incident in which two firefighters died without issuing a

mayday after being overrun by a sudden fire event in a residential structure (National Institute

for Occupational Safety and Health, 2007a).

According to NIOSH (2007c), a firefighter died when a canopy collapsed on him and his

partner. Neither the surviving member nor the victim called a mayday, even though both were

talking to each other after the collapse. A chief officer called a mayday for both firefighters after

a civilian reported the collapse to him (National Institute for Occupational Safety and Health,

2007c). Also in 2007, a firefighter died after falling through a hole in the floor in to a burning

basement. A firefighter who witnessed the event ran out of the structure to find the Incident

Commander and notify him. Another firefighter stayed near the collapse area and yelled for the

victim, yet no one on the scene transmitted a mayday (National Institute for Occupational Safety

and Health, 2007d).

NIOSH (2008) recommends firefighters immediately send a distress signal while they are

still capable and have sufficient air supply left if they become lost, trapped, or disoriented. These

Mayday Decisions 27

recommendations come after two firefighters were lost in a residential fire. One of the victims

was a Captain who called a mayday three times; none of the maydays could be heard due to radio

difficulties. Earlier in the incident, a firefighter noticed the Captain was having radio problems

and had to use his radio to speak for the Captain. This firefighter saw and heard the Captain

attempting to call the maydays before the Captain ordered him to leave the structure. That

firefighter did as ordered, but did not call a mayday for the Captain or the other victim. The

second victim never called a mayday and it is unclear in the report if the Captain was calling a

mayday for herself or for the other victim (National Institute for Occupational Safety and Health,

2008a).

Report number F2008-34 (NIOSH, 2008) recommends that procedures be developed on

issuing a mayday so that firefighters and dispatch centers know how to respond. This

recommendation stems from an incident in which a firefighter died after becoming lost in

blinding smoke at a residential structure fire. The victim, operating alone inside the structure,

requested assistance but did not clearly indicate if he was in distress. Two other firefighters on

the scene assumed he was in distress but did not transmit a mayday for him. This report also

recommends that firefighters immediately transmit a mayday on becoming lost, trapped, or

disoriented (National Institute for Occupational Safety and Health, 2008c). Another 2008 report

explains that a firefighter died when he and his Lieutenant became disoriented in a smoke-filled

structure. The Lieutenant radioed for help while the victim did not. The Lieutenant did not

specifically transmit a mayday. As a result, the report suggests developing and following mayday

protocols (National Institute for Occupational Safety and Health, 2008b).

Existing literature on relevant topics clearly illustrates several areas where failures could

occur in a firefighter’s mayday decision-making process. A loss of situational awareness, cultural

Mayday Decisions 28

roadblocks to safe actions, failure to recognize dangerous situations, and human error can all

compound or act singularly to result in a failed decision process. Understanding the recognition-

primed process firefighters use to make decisions and the importance of CRM to maintain

situational awareness is critical to providing accurate recommendations for changes in the

GBFD. These findings will assist GBFD management in instituting policies and guidelines, or

creating cultural change that will disrupt the chain of events leading to firefighter injury or death.

Procedures

This ARP used the Descriptive Research Method to determine the current human factors

that affect a firefighter’s decision to transmit a mayday. The descriptive method focused on the

research surrounding organizational culture, situational awareness, crew resource management,

recognition-primed decision making, and the human factors analysis and classification system

(HFACS), current firefighter mayday decision parameters, and mayday protocols. To understand

the current situation in the U.S. fire service with regard to firefighters and their decision whether

or not to declare a mayday, reports of various incidents were reviewed to gain insight about the

situations firefighters are in when they require assistance and whether or not they requested it.

Two separate questionnaires were distributed randomly to firefighters. One specific

question was also sent to target fire departments to gather information. Target fire departments

are listed in Table 1. The questionnaires were constructed using online resources; the first

questionnaire uses the site surveymonkey.com and the second used the site kwik surveys. An

internal questionnaire (see Appendix B) was sent by department e-mail to all employees of the

GBFD. Two of the questions required open-ended responses; choices were not provided. These

questions were intended to specifically determine if firefighters understood the circumstances in

Mayday Decisions 29

which they should call a mayday. Employees were asked to complete the questionnaire by using

a supplied Internet link to navigate to the questions. They were informed that the questions

would be answered anonymously. Each employee was instructed to answer the questions only

once and they were given 23 days to do so. This amount of time was chosen so that the three

shifts of the fire department would all have an adequate number of days to answer the questions

while at work. The questionnaire was voluntary.

Table 1: Requests for information Appleton, WI Eau Claire, WI Des Moines, IA Peoria, IL Bloomington, MN

Oshkosh, WI Kenosha, WI Elgin, IL Waukegan, IL Duluth, MN

Madison, WI Racine, WI Aurora, IL Evanston, IL St. Cloud, MN

La Crosse, WI Dubuque, IA Naperville, IL Rochester, MN

An external questionnaire (see Appendix C) was submitted to the Wisconsin State Fire

Chiefs Association list serve database and was in turn sent to every member of the association.

This questionnaire was also sent to training officers or chief officers of departments in states

bordering Wisconsin. Two methods were used to select fire departments in bordering states: the

first method considered departments to be similar to the GBFD based on having a population

within plus or minus 50,000 people of Green Bay’s population; the second considered the overall

run volume of the department. If the randomly selected department ran over 5,000 calls based on

annual run data, a questionnaire was sent. These methods were used because of a perceived lack

of cities with a population of between 50,000 and 150,000 in Wisconsin and bordering states.

This perception is based solely on this author’s opinion. The first questionnaire was accompanied

by a request for as many members of the department complete it as possible. The communication

Mayday Decisions 30

also included an Internet link to the questions and a deadline for responding. The questionnaire

was made available for 21 days.

Finally, a single question was sent to the training officer or a chief officer of selected

departments in Wisconsin and bordering states. These departments had a population of 50,000

people or more. This selection method was used because of a perceived lack of cities with a

population of between 50,000 and 150,000 in Wisconsin and bordering states. This perception is

based solely on this author’s opinion. Additionally, the potential rate of return was a concern, so

the question was distributed to larger number of departments. These departments received the

second research question for this ARP via e-mail: What methods are other fire departments of

comparable size in Wisconsin and bordering states using to encourage firefighters to declare a

Mayday when conditions warrant?

The questionnaires were designed to gather minimal demographic information and to

address research questions 1, 3, 4, and 5 of this ARP. The answers to the questions in the

questionnaire support the descriptive research method by providing examples of what firefighters

are doing right now with regard to mayday decisions. The questionnaires and the method used to

distribute them are subject to some notable limitations. First, the questions were not scientifically

developed, as a survey would be, and therefore may not fully elicit the desired response. Second,

the respondents are not tightly controlled, which allows opportunity for data from the answers to

be skewed. This is particularly of concern with the number of people in certain ranks within a

department responding versus that of other ranks. Lastly, the method of distribution to external

fire departments was not scientific, which may also skew the data.

Mayday Decisions 31

The answers to the internal and external questionnaires were then compared to the

findings in the literature review. This comparison allowed for an understanding of what is

expected human behavior while engaged in high-stress or mayday decision making versus what

GBFD firefighters are doing to make mayday decisions. Additionally, answers to internal and

external questionnaires were compared to determine if Green Bay firefighters use mayday

decision parameters similar to those of other firefighters. These comparisons also elicited

similarities or differences in culture surrounding mayday decisions to determine if leadership

affected the decision to transmit a mayday. The answers submitted for research question number

two were compiled for comparison to the current operations of the GBFD to determine if the

GBFD operations were adequate.

Results

The results of research conducted for this ARP are provided in conjunction with the

research questions addressed by each finding. The descriptive research yielded significant insight

in to mayday decision made by firefighters. The research also showed variations in what

departments and individuals consider accepted as mayday parameters. The full results of each

questionnaire can be found in appendices G and H.

Research question one, “What nationally recognized situational parameters exist to

determine when a firefighter should declare a Mayday?” found that there does not appear to be a

nationally recognized set of parameters that would prompt a firefighter to declare a mayday.

Though several different organizations or individuals made suggestions, expectations varied. The

research also indicates that firefighters must have previous experience with situations described

in the parameters for them to be effective. (Davison, 2006)

Mayday Decisions 32

Review of questionnaire responses for research question one, “What nationally

recognized situational parameters exist to determine when a firefighter should declare a

Mayday?” show that firefighters believe that there are nationally recognized mayday parameters.

These results are displayed in Table 2. Question 11 of the external questionnaire establishes that

most firefighters who answered agree on several environmental cues that would be probable

mayday situations. However, Table 3 shows unexpectedly low agreement on the cues of “sudden

onset of high heat” and “sudden onset of thick smoke that significantly limits visibility,” both of

which can be considered signs of impending flashover (International Fire Service Training

Association, 1998). Question 12 of the external questionnaire shows that almost all respondents

agree with the eight mayday parameters defined by the GBFD (Green Bay Fire Department,

2007).

Table 2: Nationally recognized parameters (External Questionnaire) Are you aware of any nationally recognized situational parameters defining when a firefighter should declare a Mayday?

Answer Options Response Percent

Response Count

Yes 59.3% 64 No 40.7% 44

Table 3: Environmental Cues (External Questionnaire) Assuming that you are operating at a structure fire, which of the following environmental cues would prompt you to call a Mayday? (Check all that apply)

Answer Options Response Percent

Response Count

Sudden onset of high heat 12.0% 13 Sudden onset of thick smoke that significantly limits visibility 10.2% 11

Loss of Situational Awareness (Disorientation) 98.1% 106 Sudden, unexpected loss of water supply in high heat 56.5% 61 Another firefighter needs assistance 92.6% 100

Mayday Decisions 33

The research pertaining to research question two, “What methods are other fire

departments of comparable size in Wisconsin and bordering states using to encourage firefighters

to declare a Mayday when conditions warrant?” indicates that fire departments similar to Green

Bay are using similar mayday practices. No responses to this question described practices that

were significantly different from what the Green Bay Fire Department currently does to

encourage firefighters to transmit a mayday. Furthermore, some departments indicated less

encouragement than presently given by the GBFD. Responses to the question are attached in

Appendix F.

Questions one, eleven, and twelve of the external questionnaire also addressed research

question two. The first question showed the number of people who responded from similarly

sized departments. Slightly more than 65% of the respondents were from departments in cities

with populations of less than 50,000 people. The responses to questions 11 and 12 show that

other departments are also training firefighters to use environmental cues and situational

awareness to make mayday decisions.

Research question three, “What, if any, environmental cues do GBFD firefighters use to

indicate when a mayday should be declared?” was addressed by the internal questionnaire.

Question number two showed that GBFD firefighters use several environmental cues to make

their mayday decision. Most of the cues described by GBFD firefighters where exact statements

of those found in the GBFD mayday guideline or variations thereof (Green Bay Fire Department,

2007). Some notable additions included the development of fire between the crew and their

intended exit point and an inability to control the fire. Notable exceptions to this question

included answers of “not sure” and “Unless trapped, I wouldn’t (call a mayday). If the situation

was deteriorating that quickly, one should exit immediately.”

Mayday Decisions 34

Research question four, “What, if any, training issues impact the decision to call

mayday?” found that several firefighters are told what situations should prompt a mayday. In

some cases, they are placed in those situations and required to call the mayday (Clark, 2004). On

the external questionnaire, question three showed that most firefighters believe there are

nationally recognized parameters that should prompt a mayday. Most respondents to external

questionnaire question four feel they have been properly trained to know when and how to call

for assistance by declaring a mayday. On the same questionnaire, question five indicates that

almost 50% of respondents felt that not everyone on their department knew when and how to

declare a mayday. This is illustrated in Table 4. As shown in Table 5, these results were also

confirmed in the GBFD ranks on questions three and four of the internal questionnaire. Table 6

shows the responses to question 10 on the external questionnaire which indicates that a majority

of comparable departments have a policy or guideline with similar intent to the mayday guideline

used by the GBFD (2007).

Table 4: Know when to declare mayday (External)

Do you feel that the firefighters you work with know when it is necessary to declare a Mayday?

Answer Options Response Percent

Response Count

All of them do 50.9% 55 More than 50% of them do 38.9% 42 Less than 50% of them do 9.3% 10 None of them do 0.9% 1

Mayday Decisions 35

Table 5: Know when to declare mayday (Internal)

Do you feel that the firefighters you work with know when it is necessary to declare a Mayday? Answer Options Response

Percent Response

Count All of them do 23% 18 50% or more of them do 65% 51 50% or less of them do 13% 10 None of them do 0% 0

Table 6: Mayday Policy or Guideline (External) Does your department have a policy defining situational parameters that recommend or require you to call a Mayday? Answer Options Response

Percent Response

Count Yes 73.1% 79 No 26.9% 29

The training issues referenced in research question four were also addressed exclusively

by the internal questionnaire. In questions one and two, Green Bay firefighters displayed a good

understanding of what circumstances and environmental cues should prompt a mayday

declaration. Table 7 shows the responses to question seven of the same questionnaire,

demonstrating that a significant number of GBFD firefighters have witnessed or been a part of a

situation in which a mayday should have been transmitted but was not. Internal question number

10 explains that GBFD firefighters feel there is a need to conduct more training on when and

how to call a mayday.

Mayday Decisions 36

Table 7: Mayday should have been declared (Internal) Have you ever been on a fire scene where, in your opinion, someone should have declared a mayday but did not do so? Answer Options Response

Percent Response

Count Yes 23% 18 No 77% 61 No Answer 0% 0

The leadership issues suggested in research question five, “What, if any, leadership issues

impact the decision to call a mayday?” were the focus of several questions on both

questionnaires. Both questionnaires were designed to gather information on this issue to allow a

comparison could between leadership issues facing the GBFD and those of other departments.

On the external questionnaire, question five elicited information on the number of respondents

from each rank. Responses indicated whether individuals would be considered a formal leader,

that is to say, one who holds rank, in their organization. External questionnaire items eight and

nine specifically revealed that firefighters are encouraged by their department’s leadership to

request assistance by declaring a mayday. These results are similar to those targeted at GBFD

personnel in questions five and six of the internal questionnaire. As shown in Table 8, responses

to internal question eight reveal that a majority of Green Bay firefighters feel that some in the

department would look down upon them, judge them unfairly, or make fun of them if they called

a mayday. Responses to internal survey question nine show that only three GBFD firefighters

believe there would not be a negative consequence with officers or department management if

they declared a mayday.

Mayday Decisions 37

Table 8: Judgment if mayday is called (Internal) Do you feel that if you called a mayday you would be looked down upon, judged unfairly, or made fun of later? Answer Options Response

Percent Response

Count Yes, but only by certain people. 49% 39 Yes 3% 2 No 48% 38

Discussion

While some parameters have been made available nationally, such as those suggested by

Clark (2004), there does not appear to be a set of universally accepted mayday parameters. The

GBFD has established its parameters for mayday decisions based on Clark’s (2004) suggestions,

with two additions. Furthermore, there is little consistency in the expectations of what

firefighters should say or do when transmitting a mayday. Parameters established by Clark

(2004) would have the firefighter transmit a mayday in the event of a fall, collapse, activated

alarm, becoming caught on something, and becoming lost or trapped. Firefighters should also

state their location, unit, name, assignment and resources (Clark, 2004). The National Fire

Protection Association says simply that a firefighter should initiate emergency traffic in an

“emergency situation” (National Fire Protection Association, 2007). The U.S. Fire

Administration states that firefighters should transmit a mayday when firefighters using self-

rescue techniques are unable to free themselves from a perilous situation (Williams &

Stambaugh, 2003). The organizational implication is that the widely varied advice makes it

difficult for the GBFD to determine if its mayday policies and guidelines are effective.

The development of immediately recognizable mayday parameters is critical for the

safety of Green Bay firefighters because this recognition is essential for making a rapid,

Mayday Decisions 38

recognition-primed decision (Klein, 1998). Green Bay firefighters are expected to call a mayday

in eight situations, six of which echo Clark’s parameters, the other two being a significant fire

event or when another firefighter is believed to be in distress (Green Bay Fire Department,

2007). Without coherent, scientifically based guidance on the subject, the only way to judge the

efficacy of the GBFD’s parameters is through comparison such as that offered by the

questionnaire distributed for this ARP. Based on this comparison, it appears that the GBFD is

essentially equal with other departments in addressing the human factors that drive firefighters to

make mayday decisions.

From a cultural standpoint, some of the responses to questions about the leadership view

of firefighters who transmit a mayday were concerning. Fire service culture is a contributing

factor to line of duty deaths (National Fallen Firefighters Foundation, 2005). Overall, the

employees of the GBFD feel that the chief officers of the department will support them if they

decide to declare a mayday. Responses to the external questionnaire indicate that policy makers

understand the need for a policy on mayday. This is proven by the fact that many departments

have developed and implemented such policies. However, GBFD firefighters do not seem as

confident that their peers or direct supervisors (i.e., company-level officers) will feel the same

way. A cultural willingness to accept over 100 firefighter deaths annually undoubtedly fosters

this unsupportive attitude (C2 Technologies, 2008). This is undoubtedly an impediment to the

decision-making process regarding mayday declarations and is best removed from our culture.

The organizational implications of an unsupportive attitude toward mayday decisions and

transmissions from peers, including line officers, is devastating considering that the most

important person to effect cultural change is the company officer (Oklahoma State University,

2006).

Mayday Decisions 39

With regard to training and the tools that other departments use to encourage firefighters

to ask for assistance, including declaring a mayday, it appears that Green Bay firefighters are

confident in their level of competency. Although the number of people answering the questions

from similarly sized cities was, unfortunately, lower than anticipated, it also seems to be true that

other departments are not engaged in significantly different techniques to encourage firefighters

to ask for help. Though individuals express confidence in their own abilities with regard to

mayday decision making, it appears they are not as confident that those around them are well

trained in this area. These results were similar in the internal versus external comparisons,

suggesting that it may be a widespread issue in the fire service. This could also have an impact

on one’s decision whether or not to declare a mayday.

The number of Green Bay firefighters who said they were personally involved with or

witness to a situation where a mayday should have been transmitted but was not is alarming.

This suggests that while parameters have been defined, they may not be recognizing the

situations when they arise. This may be due to a loss of situational awareness, although this

cannot be verified at this time. Situational awareness is enhanced by utilization of Crew

Resource Management (CRM) principles (Okray & Lubnau, 2004). Research indicates that

firefighters must have previous experience with these situations for recognition-primed decision

making to be effective (Davison, 2006). The process of recognition primed decision-making was

discovered when researchers analyzed how fireground commanders made decisions. (Klein,

1998) The process proved that firefighters use previous experiences to successfully make

decisions at an unprecedented rate. In light of this, methods of training that place firefighters in

these situations in a safe environment would most likely address these recognition problems.

Mayday Decisions 40

It appears that the firefighters of Green Bay are as prone to human error in decision

making as other professionals in high-risk occupations. Despite this, the experiences of the Navy

and Marine Corps aviators prove that it is possible to change the trend by implementing Human

Factors Analysis and Classification System and Crew Resource Management principles in to our

operations (Okray & Lubnau, 2004; Wiegmann & Shappell, 2003). This could easily be done,

particularly when conducting a post-incident analysis. HFACS analysis of situations where a

mayday was declared or should have been declared but was not would provide valuable insight

in to the mental processes GBFD firefighters use to make mayday decisions. The organizational

implication is that maydays could be avoided all together if we learn how and why GBFD

firefighters get into situations requiring them to declare a mayday.

Recommendations

The literature review and original research conducted for this ARP revealed several areas

that would benefit from continued review or action. Specific action in some areas of the

organization would most likely allow for a safer operation for all personnel. Furthermore, some

actions may be taken immediately while others would require further development prior to

implementation.

Results of this research indicate that the GBFD should incorporate HFACS principles

into the current post-incident analysis format. This will allow fireground commanders and

department management to better understand why firefighters took certain actions during an

incident. Armed with an understanding of the actions taken, training efforts, strategy, tactics,

cultural changes, and management initiatives can be tailored to organizational needs. A post-

Mayday Decisions 41

incident analysis program that incorporates HFACS principles must be fully developed prior to

implementation.

The GBFD should also incorporate HFACS principles in to all department accident

investigations. HFACS has been proven to reveal thought processes and actions that placed a

person in a position to make a mistake. An understanding of these processes and actions will

help GBFD management understand how to eliminate the threats their firefighters face.

To facilitate accident and injury reduction, the GBFD should provide initial training on

CRM principles to enhance situational awareness. An increase in situational awareness will help

Green Bay firefighters recognize mayday situations more readily. Early recognition of these

situations should lead to either avoidance of the hazard or requests for assistance so that the

potential for injuries or death is reduced.

Annual refresher training on the current mayday decision parameters currently outlined in

GBFD Standard Operating Guideline 0201.09 should be provided. Research suggests that

recognition- primed decision making is integral to firefighting. Refresher training at least

annually will keep firefighters familiar with the defined parameters, while enhancing

recognition- primed decision-making skills.

Development of a safety culture that eliminates all roadblocks to mayday decision

making must be a top priority for the GBFD. Reports and logic both indicate that a lack of safety

culture contributes to firefighter deaths in the line of duty. The removal of these cultural

roadblocks will lead to safer organizational operations.

GBFD should work with nationally recognized agencies or organizations to advocate the

development of standard situational parameters for mayday declarations. Evidence shows that

Mayday Decisions 42

people need to be familiar with parameters prior to the situation to make correct decisions. A

nationally recognized standard would assist in standardizing training internally and with mutual

aid departments affiliated with the GBFD.

The fire service in general would benefit from future study of issues related to firefighter

mayday decisions. Areas of study should include continued review of incidents that cause injury

or death to firefighters, a scientific survey of firefighter attitudes and opinions regarding mayday

declarations, and development of a standardized methodology for investigating accidents and

deaths that incorporates HFACS principles. A method to teach firefighters how to evaluate their

surroundings in a hostile environment, integrating information from all members of their crew,

should be developed to improve situational awareness. Studies in these areas could benefit all

fire departments in the United States by reducing risk and improving organizational culture.

Mayday Decisions 43

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Appendix A: Guideline 0201.09 Mayday

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Appendix B: Internal Questionnaire

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Appendix C: External Questionnaire

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Appendix D: Request for information from comparable cities

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Appendix E: Responses from comparable cities

Appleton, Wisconsin

Evanston, Illinois

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St. Cloud, Minnesota

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Oshkosh, Wisconsin

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Madison, Wisconsin

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Appendix F: Cities receiving letter and response status

Response Status

Appleton, WI

Responded

Eau Claire, WI

Responded

Des Moines, IA

No Response

Peoria, IL

No Response

Bloomington, MN

No Response

Oshkosh, WI

Responded

Kenosha, WI

No Response

Elgin, IL

No Response

Waukegan, IL

No Response

Duluth, MN

Responded

Madison, WI

Responded

Racine, WI

No Response

Aurora, IL

No Response

Evanston, IL

Responded

St. Cloud, MN

Responded

La Crosse, WI

No Response

Dubuque, IA

No Response

Naperville, IL

No Response

Rochester, MN

No Response

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Appendix G: External Questionnaire Responses

External Questionnaire Question 1

What population range does your fire department serve?

Answer Options Response Percent Response

Count

Less than 50,000 66.7% 72 51,000 to 100,000 25.9% 28 101,000 to 150,000 3.7% 4 Over 150,000 3.7% 4

answered question 108

skipped question 0

External Questionnaire Question 2 What rank do you hold on your fire department?

Answer Options Response Percent Response

Count

Chief Officer (Chief, Asst. Chief, Battalion Chief, etc.) 47.2% 51 Line Officer (Captain, Lieutenant, etc.) 28.7% 31 Apparatus Operator (Engineer, Chauffeur, etc.) 7.4% 8 Firefighter 16.7% 18

answered question 108

skipped question 0

External Questionnaire Question 3 Are you aware of any nationally recognized situational parameters defining when a firefighter should declare a Mayday?

Answer Options Response Percent Response

Count Yes 59.3% 64 No 40.7% 44

answered question 108

skipped question 0

External Questionnaire Question 4 Do you feel your department personnel are properly trained on when and how to declare a Mayday?

Answer Options Response Percent Response

Count Yes 89.8% 97 No 10.2% 11

answered question 108

skipped question 0

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External Questionnaire Question 5 Do you feel that the firefighters you work with know when it is necessary to declare a Mayday?

Answer Options Response Percent Response

Count All of them do 50.9% 55 More than 50% of them do 38.9% 42 Less than 50% of them do 9.3% 10 None of them do 0.9% 1

answered question 108

skipped question 0

External Questionnaire Question 6 Have you ever declared a Mayday while operating on an incident scene?

Answer Options Response Percent Response

Count Yes 6.5% 7 No 93.5% 101

answered question 108

skipped question 0

External Questionnaire Question 7 If the answer to question 6 was yes, was the incident a structure fire? (If you answered "No" to question 6, please select "Not Applicable")

Answer Options Response Percent Response

Count Yes 6.5% 7 No 0.0% 0 Not Applicable 93.5% 101

answered question 108

skipped question 0

External Questionnaire Question 8 Do you feel that your department’s leadership encourages you to call for assistance, including declaring a Mayday, when you feel you need to?

Answer Options Response Percent Response

Count Yes 90.7% 98 No 0.9% 1 Somewhat 8.3% 9

answered question 108

skipped question 0

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External Questionnaire Question 9 Do you feel that your fellow firefighters and line officers encourage you to call for assistance, including declaring a Mayday, when you feel you need to?

Answer Options Response Percent Response

Count Yes 88.0% 95 No 0.0% 0 Somewhat 12.0% 13

answered question 108

skipped question 0

External Questionnaire Question 10 Does your department have a policy defining situational parameters that recommend or require you to call a Mayday?

Answer Options Response Percent Response

Count Yes 73.1% 79 No 26.9% 29

answered question 108

skipped question 0

External Questionnaire Question 11 Assuming that you are operating at a structure fire, which of the following environmental cues would prompt you to call a Mayday? (Check all that apply)

Answer Options Response Percent Response

Count

Sudden onset of high heat 12.0% 13 Sudden onset of thick smoke that significantly limits visibility 10.2% 11 Loss of Situational Awareness (Disorientation, uncertain of what is happening around you)

98.1% 106

Sudden, unexpected loss of water supply in high heat, low visibility environment

56.5% 61

Another firefighter needs assistance 92.6% 100 answered question 108

skipped question 0

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External Questionnaire Question 12 Assuming you are operating at a structure fire, in which of the following situations would you declare a Mayday? (Check all that apply)

Answer Options Response Percent Response

Count

Fall: May include falling down stairs, falling through a floor or roof, or falling through any other opening

83.3% 90

Collapse: May include ceiling collapse, floor or roof collapse, collapse of large or heavy materials, or the collapse of any other structural member

71.3% 77

Activation of Alarms: May include low air alarm activation, personnel cannot locate an exit immediately, or PASS device activation

75.0% 81

Entanglement: May include becoming entangled in wires or any other debris that restricts or limits movement

94.4% 102

Lost: May include off hoseline or search line in a large/open area with zero visibility, an inability to locate a door or window for exit, or disorientation

97.2% 105

Trapped: May include inability to move or cannot exit due to structural or other problems

100.0% 108

Significant fire event: May include flashover, backdraft, or "smoke explosion"

54.6% 59

If you belief the safety of a crew or crewmember is or may soon be at risk

71.3% 77

answered question 108

skipped question 0

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Appendix H: Internal Questionnaire Responses

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