Building and maintaining individual and team situation awareness is vital across all safety critical activities. SCT’s Mario Pierobon reports.
In the modern complex and tightly coupled systems built around safety critical industries we can easily get swamped into the multitude of tasks we undertake. One key tactic to safely navigate through complexity and tight coupling is to maintain good situation awareness for oneself and the whole team. In this article we shall cover situation awareness by first reviewing the concept and looking at why it is important. We shall then consider possible causes of loss of situation awareness and recommendations for how this loss can be prevented or handled. We will conclude with a review of training items for maintaining good situation awareness.
What is Situation Awareness?
According to the US National Research Council, in everyday jargon ‘situation awareness’ means the up-to-the-minute cognisance or awareness required to move about, operate equipment, or maintain a system[i].
It is knowledge, experience and education that enable us to understand what is going on around us and helps us to determine if it is safe, according to the UK Health & Safety Executive (HSE)[ii].
“This means that everyone’s situational awareness is individual and potentially different,” the UK HSE says. “Our situational awareness is only as accurate as our own perception or reading of the situation, so what we think is happening may not accurately reflect reality. How we read a situation can be influenced by many things such as the type of information we have been given, our own experience and distractions in the workplace.”
According to the US National Research Council, one particular dimension of situation awareness has to do with the extent to which various personnel involved in a particular activity have a common mental image of what is happening as well as a common understanding of how others are perceiving the same situation, this is referred to as ‘crew awareness’.
“The ideas of distributed cognition, shared mental models, and common frame of reference play a role in understanding how groups can be aware of a situation and thus act upon it,” the US National Research Council says.
Typically, there are three stages of situational awareness which are information gathering, understanding information, and anticipation, affirms the UK National Fire Chief Council (NFCC)[iii]. “As personnel carry out their tasks, they may gain new information about hazards or risks. Each person has a responsibility to complete their own risk assessment, and to provide this to the incident commander as appropriate. This new information may affect the incident plan and the safety of people, property or the environment. Therefore, it is important that personnel are aware of their responsibilities for identifying hazards and assessing risk, to support accurate situational awareness.”
Why it is Important
The US National Wildfire Coordinating Group (NWCG) affirms that good situation awareness is the cornerstone of good decision making[iv]. “Leaders can increase their decision space by attaining and maintaining good situation awareness. Decision space is simply the amount of time that a decision maker has for considering options before reaching a required decision point,” the US NWCG says.
It is important for one to know how many problems one faces and how serious they are. The loss or lack of situational awareness is a causal factor in, for example, several construction accidents. Often there is so much ‘going on’ in the working environment, or one can become so absorbed in one’s thoughts, to the point that one may fail to spot those things that could pose a serious threat to health and safety, according to the UK HSE[v]. “Situational awareness is important to everyone –everyone should be aware of their surroundings and the potential hazards they face. It is important that each individual is looking out for his or her own safety as well as looking out for their workmates. Even the most experienced people can lack situational awareness – especially when doing tasks that have become routine.”
In the military domain, situation awareness has received considerable attention because it is linked to effective combat decision making in the tactical environment, according to the US National Research Council[vi]. “It is appropriate to note that ‘good situation awareness’ in a tactical environment is regarded as critical to successful combat performance. This is the case both for low-tempo planning activities, which tend to be dominated by relatively slow-paced and reflective proactive decisions, and high-tempo ‘battle drill’ activities, which tend to be dominated by relatively fast-paced reactive decisions.”
Causes of Loss of Situation Awareness
The loss of situation awareness is associated to the limitation of working memory.
“Working memory is limited to up to seven items, depending on genetics and environmental factors such as stress, fatigue and health. If working memory becomes overloaded, items will simply be forgotten,” states the Royal College of Obstetricians and Gynaecologists (RCOG)[vii].
As there may be many more variables to contend with at any one time, the fundamentally fallible nature of situational awareness becomes apparent, according to the RCOG[viii]. “The construct of situational awareness, the limitations of human memory and the complexity of any given situation mean that, inevitably, situational awareness will be suboptimal at any one time. Put simply, we cannot remain aware of everything which is going on around us.”
Distractions and cognitive overload are considered causes of loss of situation awareness. Having two competing tasks can be a problem. It is easy to see how having two complex patients would push one over the threshold of working memory and allow distractions to creep in, says the RCOG[ix].
Recommendations for Situation Awareness
To target distractions as a cause of loss of situation awareness, observes the RCOG[x], several hospitals have adopted visual barriers to prevent interruptions during safety-critical tasks, for example by displaying ‘Do not interrupt the drug round’ messages during medication administration.
Interruptions to safety critical tasks may be reduced by visual prompts. Image credit: Nursing Times.
A safety trigger should also be created to make sure that the system does not rely on the team realising they have lost situational awareness; instead, there should be a fixed, forced trigger for a consultant to be contacted, according to the RCOG[xi]. “Calling out a second theatre team could be trigger to the response of informing the on-call consultant to come and adopt a helicopter view whilst other team members are concentrating on tasks.
When personnel are performing a technical task, they need to concentrate. Situational awareness will be lost if the task is being performed without due attention. When about to undertake something technical, personnel should actively delegate the job of maintaining a ‘helicopter view’ to someone else, according to the RCOG[xii]. “This could be another doctor or another midwife, either onsite or offsite. Staff should learn to recognise when situational awareness is being lost, and the times when people are more prone to this (stressed, fatigued), and practice responding to these in simulations.”
All members of the team need to be cognisant of the key principles of maintaining situation awareness to ensure the safe management of complex situations. Regular simulation should happen which incorporates a ‘safe space’ to practise and reflect on personal and team behaviours. Furthermore, team members should use checklists for common emergencies and drill their use, states the RCOG[xiii].
Training Items for Situation Awareness
Training is key to embed situation awareness in teams working in safety critical industries. One technique which should be covered in training for situation awareness is the so-called SLAM technique.
According to the UK HSE[xiv], SLAM consists of four steps: Stop, Look, Assess, and Manage. With ‘stop’ one engages one’s mind before one’s hands, one looks at the task in hand. One then has to ‘look’ at the workplace and find the hazards to him/her and the teammates, these should be reported immediately to the supervisor. Following this one has to ‘assess’ the effects that the hazards have on him/her personally, the people one works with, equipment, procedures, pressures and the environment; one should ask oneself if they have the knowledge, training, and tools to do the task safely and do this with their supervisor. At the ‘manage’ step, if one feels unsafe one should stop working and tell this to the supervisor and workmates, one should tell the supervisor what actions they think are necessary to make the situation safe.
An example of a SLAM checklist. Image credit: SafetyCulture.
The NWCG underlines the importance for leaders to optimize their decision space by using time efficiently[xv]. “Seeking advance information in new situations or utilizing standard operating procedures for routine tasks are examples of techniques that make good use of available time. In the wildland fire environment, decisions have serious consequences and often can have life-or-death implications for others. With so much on the line, we have a responsibility to understand the decision-making process - the components, the flow, the effect of time - and to develop the skills and confidence that enables us to make the best decision possible with the information and time available.”
In order for leaders to be effective decision makers they need to receive dedicated training that is applicable to each of the three main stages of situation awareness:
1. Information Gathering
2. Understanding Information
For the information gathering stage, leaders should know the typical sources of information available to them when gathering information as this will assist them to obtain and maintain situational awareness, according to NFCC[xvi]. “To accurately perceive a situation an incident commander should gather and understand information to enable them to anticipate how an incident may develop and what the impact of an intervention may be on its development. Providing risk-critical information is essential to ensure safe operations. Command decision-making can be significantly affected if there is a lack of risk information or where information has not been passed on. Fire control personnel will often be required to receive and communicate risk-critical information. Where risk-critical information is included on the initial turnout details it should be easy to identify. One of the tasks of the incident commander is to apply suitable control measures. To be able to do this they must be able to gather all available information about an incident. This is likely to include information from the pre-planning stage, such as risk information, available in electronic or written format.”
For the understanding information stage, leaders should be able to interpret the information they have gathered, together with their knowledge and past experience, into a coherent picture to understand the ongoing situation, observes the NFCC[xvii]. “Effective situational awareness ensures that the interpretation reflects the actual situation. Incident commanders should be aware of the factors likely to adversely affect their situational awareness. These may include: stress; fatigue; biases that affect decision-making, memory recall and interactions with others; poor communication, for example unstructured briefs and debriefs; excessive spans of control; distractions during critical tasks; assumptions that are not confirmed as accurate; poor information management, for example, failing to record or validate information.”
For the anticipation stage, leaders should be able to anticipate how a situation will develop and change based on their understanding, they should be able to predict the impact of their actions on incident development and outcomes, concludes the NFCC[xviii].
[i] National Research Council. 1998. Modeling Human and Organizational Behavior: Application to Military Simulations. Washington, DC: The National Academies Press. https://doi.org/10.17226/6173
[ii] Health & Safety Executive, Leadership and worker involvement toolkit, Knowing what is going on around you (situational awareness), https://www.hse.gov.uk/construction/lwit/assets/downloads/situational-awareness.pdf
[iii] National Fire Chief Council, National Operational Guidance, Control measure - Situational awareness, https://www.ukfrs.com/guidance/search/situational-awareness
[iv] National Wildfire Coordinating Group, Leading in the Wildland Fire Service https://www.nwcg.gov/sites/default/files/publications/pms494-2.pdf
[v] Health & Safety Executive
[vi] National Research Council
[vii] Royal College of Obstetricians and Gynaecologists (RCOG), Each Baby Counts: 2015 Full Report. London: RCOG, 2017, https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/each-baby-counts-2015-full-report.pdf
[xiv] Health & Safety Executive
[xv] National Wildfire Coordinating Group
[xvi] National Fire Chief Council