How Sensory Overload Impacts First Responder Communications

SENSORY OVERLOAD AS A FACTOR IN CRISIS DECISION-MAKING AND
COMMUNICATIONS BY EMERGENCY FIRST RESPONDERS
by
Ronald P. Timmons
APPROVED BY SUPERVISORY COMMITTEE:
___________________________________________
Douglas J. Watson, Ph.D., Chair
___________________________________________
Kimberly A. Aaron, Ph.D.
___________________________________________
Donald R. Arbuckle, Ph.D.
___________________________________________
James W. Marquart, Ph.D.

Copyright 2009
Ronald P. Timmons
All Rights Reserved

“…our effectiveness is only as good as our ability to communicate.”
(Donald J. Burns in U.S. Fire Administration 1993, 54)
This dissertation is dedicated to the memory of Assistant Fire Chief Donald J. Burns,
New York City Fire Department.
At two of the most difficult fire department operations imaginable, there was one man
in the unique position to understand the interconnectedness of communications and
command. After facing the first World Trade Center attack in 1993, Chief Burns testified
that, “One of our biggest problems was communications” (U.S. Fire Administration
1993, 54). He returned on September 11, 2001 to command a portion of the FDNY
response to the terrorist attacks at the same skyscraper complex. Although radio
recordings prove police helicopter warnings of impending collapse of the second tower,
there is no indication that the message on the police radios made it to Chief Burns’ fire
command position at the base of the North Tower (Dwyer 2002; National Commission on
Terrorist Attacks 2004, 309). He died along with 403 other brave first responders in the
collapse of the buildings.
Befitting the man who served the citizens of New York for 39 years, many years past
retirement age, his funeral mass occurred at Saint Patrick’s Cathedral on October 9, 2001.
His wife and three children joined hundreds of uniformed firefighters lining Fifth Avenue
to salute the man, despite the unimaginable reality that his unrecovered remains were just
four miles away. The dignitaries used words such as “hero,” “patriot,” and “unparalleled
experience” to salute him at the funeral (Virasami 2001).
My experience with Chief Burns was happenstance, but indelibly memorable. I was
in need of a ride out the Long Island Expressway on a hot Friday afternoon in June 1987
and he was going in my direction. I was a rookie lieutenant from one of the smallest fire

iv
departments in the state and he was the chief in charge of the officers’ training program
for the largest fire department in the country. He was the boss and I was the student at his
training academy. Hierarchically removed from me by several ranks, it would have been
easy for him to say no to my request for a ride, but he did not. He was older and much
more experienced, but he was interested in what I had to say and impressed by my
educational and career aspirations. As much as I tried to turn the 90-minute conversation
back to him and his experiences, he was more interested in what I could tell him that he
did not know. He inspired me with his gentle, confident humility and encouraged me with
his vision of advancing our profession through formal education.
It is my fervent hope that this dissertation will inspire future generations of first
responders to address the perennially vexing problem of emergency communications, in
all its forms: technological, relational, and physiological. Chief Burns sparked that
interest in me, and now it is time for you to take it further…
Ronald P. Timmons

by
RONALD P. TIMMONS, B.S., M.P.A., M.A.
DISSERTATION
Presented to the Faculty of
The University of Texas at Dallas
in Partial Fulfillment
of the Requirements
for the Degree of
DOCTOR OF PHILOSOPHY IN
PUBLIC AFFAIRS
THE UNIVERSITY OF TEXAS AT DALLAS
May, 2009

ACKNOWLEDGEMENTS
I gratefully acknowledge the…
…loving support from my wife and daughter
…grounding and example from my beloved parents
…interest and encouragement from my brother and sister
…patience and insightful wisdom from Dr. Douglas Watson
…suggestions and generous service of the dissertation committee
…the dedicated firefighters of the Allen, Plano and McKinney Fire Departments
…assistance and inspiration from my devoted coworkers at the city of Plano, Texas
March, 2009
vi

Publication No. ___________________
Ronald P. Timmons, Ph.D.
The University of Texas at Dallas, 2009
Supervising Professor: Douglas J. Watson
The decision-making and communications processes of community first responders are
frequent concerns at intense crisis responses. Effective command is dependent on sound
decision-making; adequate communications processes are critical elements in successful
crisis decision-making. Homeland security initiatives have reemphasized this issue. Although
the assumption may be immediate and complete improvement of communications is solely
awaiting radio hardware upgrade, this study identifies nontechnical factors impeding
successful communications. Of particular interest were those situations whereby radio
messages were clear; however, the intended recipient was unable to receive the message or
make best use of it, despite evidence of cogent message delivery on recordings.
One hypothesis tested is whether sensory overload contributes to ineffective
communications. Also tested is a prediction that commanders at emergency scenes mishandle
radio messages even when the equipment is functioning properly. Case studies of actual
incidents and observation of realistic training exercises allowed isolation and analysis of
vii

common features of communications dysfunction. A series of phenomenological studies
observed first responders in the act of communicating as they typically would at emergency
scenes. This fieldwork at fire department training exercises allowed the researcher to collect
data associated with distractions and communications dysfunctions.
Validation of both hypotheses occurred. Messages requiring repeating, as well as those going
unanswered or otherwise missed were common. Most of the dysfunctional radio
communications occurred because of inattention to the radio due to distraction from talking
in person to others nearby, confusion over proper radio channel selection, garbled, excited, or
unintelligible messages from the sender, and background noise associated with chaotic
emergency scenes. In 38 percent of the cases, there was no apparent reason for the missed
message; physiological and psychological factors from analogous studies provide potential
explanation.
The significance of this research is in studying the specific moment of radio dysfunction and
correlation with underlying causes. In those instances where no apparent reason existed for
the communications dysfunction, physiological stress reactions are theorized as underlying
factors, along with a number of equipment and human factors. Readers receive practical
solutions for improvement of emergency communications, acknowledging that some
occurrences of missed messages are inevitable in the demanding emergency environment.
viii

TABLE OF CONTENTS
Acknowledgements............................................................................................................ vi
List of Figures................................................................................................................... xii
CHAPTER 1 INTRODUCTION .......................................................................................1
First Responder Communications Issues.................................................................4
CHAPTER 2 LITERATURE REVIEW ............................................................................7
Decision-making in the First Responder Environment............................................7
Military ....................................................................................................................9
Personal Influences................................................................................................10
The Role of Communications in Crisis Decision-Making.....................................13
Sensory Overload and Task Interruption...............................................................16
Inattentional Blindness...........................................................................................24
Literature Review Summary..................................................................................27
Hypotheses.............................................................................................................28
CHAPTER 3 METHODOLOGY ....................................................................................29
Research Design.....................................................................................................29
Data Collection ......................................................................................................33
Coding of Observable Behaviors...............................................................34
Data Organization and Analysis ................................................................34
CHAPTER 4 CASE STUDIES OF ACTUAL INCIDENTS ..........................................36
Syracuse, New York 1978 .....................................................................................37
Hackensack, New Jersey 1988...............................................................................38
North Hollywood, California 1997........................................................................39
Seattle, Washington 1998 ......................................................................................43
Prince William County, Virginia 2007..................................................................44
Charleston, South Carolina 2007...........................................................................46
ix

New York City, New York 2009...........................................................................52
Common Themes Among All Cases Studied ........................................................57
CHAPTER 5 CASE STUDIES OF TRAINING EXERCISES.......................................61
McKinney Fire Department Case Studies Venue Description ..............................61
Exercise Data .........................................................................................................66
McKinney Case Studies Day One..............................................................69
McKinney Case Studies Day Two.............................................................78
McKinney Exercises Analysis...............................................................................81
Plano Fire Department Case Studies Venue Description ......................................83
Plano Case Studies Day One......................................................................86
Reevaluation of the Simulation Environment – Testing Sub-Theories .................92
Plano Case Studies Day Two.....................................................................92
Plano Case Studies Day Three...................................................................99
Plano Exercises Analysis.........................................................................106
McKinney and Plano Exercises Compared..........................................................108
Influence of Talking While Wearing A Mask .........................................109
Simulation Environments.....................................................................................109
CHAPTER 6 IMPLICATIONS AND RECOMMENDATIONS..................................112
Research Summary ..............................................................................................112
Hypotheses Results..............................................................................................113
Why Messages Are Missed..................................................................................115
Sensory Overload.....................................................................................116
Physiological Hearing Deficit..................................................................117
Inattentional Deafness..............................................................................119
Solutions ..............................................................................................................120
Human Factors Engineering ....................................................................122
Training....................................................................................................124
Final Thought.......................................................................................................126
APPENDIX A..................................................................................................................127
APPENDIX B..................................................................................................................128
x

APPENDIX C..................................................................................................................129
BIBLIOGRAPHY............................................................................................................130
VITA
xi

LIST OF FIGURES
Number Page
1. Summary of Positive Scores From McKinney Day One...............................................77
2. Summary of Positive Scores From McKinney Day Two ..............................................81
3. Ranked McKinney Scores..............................................................................................81
4. Scores Compared To Pace .............................................................................................82
5. Summary of Positive Scores For Plano Day One..........................................................91
6. Summary of Positive Scores For Plano Day Two .........................................................98
7. Summary of Positive Scores For Plano Day Three .....................................................105
8. Collaboration Influence In Scoring..............................................................................106
9. Correlation of Collaboration With Scores ...................................................................107
10. Comparing Influence of Mask Usage on Communications Efficacy ........................109
11. Communications Deficits...........................................................................................116
xii

1
CHAPTER 1
INTRODUCTION
First responders are the police, fire, and emergency medical personnel who respond to
emergencies throughout our communities. Daily routine allows for management of incidents
in a habitual manner. Occasional intensive disasters, ranging up to the scope of the 9/11
terrorist attacks, Hurricane Katrina, the Columbine High School shooting, and the Oklahoma
City Federal Building bombing, are examples of calamitous incidents requiring the most
urgent of communications and decision-making capabilities by first responder incident
commanders.
Failure in this decision-making environment can result in dire consequences for crews
and citizens awaiting rescue. Commanders at emergencies do not have the luxury of
deliberation and debate. They often need to take instant action to achieve objectives within
very tight timelines. One study showed that fire department commanders face dynamic
conditions at emergency scenes, requiring new decisions to answer an average of five
situational changes within the typical incident (Klein 1999, 6). An interesting aspect of
emergency scene decision-making is the instant feedback provided to the decision-makers.
This allows a honing of decision-making skills and rapid development of experience in
critical situations, along with a tendency to apply heuristic decision-making as reflexive
coping mechanisms (Simon 1981, 66). People functioning as incident commanders at

2
community emergencies face a number of unique challenges. The rapidly changing
environment makes actions appropriate for one moment, yet inappropriate in new
circumstances just a short time later.
The command staff somehow has to reverse hierarchical practices used during daily para-
militaristic practices, as they seek to find creative, flexible decision solutions in infrequent
crises. Decision-making in hierarchical organizations can be problematic. Conflicting
interests of serving political or internal command structures make it difficult to provide
commanders in high-pressure situations the flexibility necessary to react to changing
circumstances (Roberts et al. 1994, 623). Mendonça (2007, 964) argued for the need to build
robust systems allowing flexibility and creativity for the proper handling of extreme events.
Analogies of jazz musicians using improvisation techniques built within the constraints of a
musical chord structure show the possibility of making procedures and rules constructed to
allow some degree of customization depending on the circumstances (Mendonça 2007, 964).
Comfort (1985, 158-159) highlighted the importance of concurrent information gathering
as the interaction of people and events generate geometric complexity in the decision-making
process at emergencies. All responders present at the incident need to make a scan of the
operational environment with relevant information fed to a centralized decision-making
authority. In one study, firefighters interviewed about their decision-making process denied
that it was a formal process of weighing several alternatives, but rather a reflexive reaction to
circumstances as they occur (Klein 1999, 16). Therefore, something significant is occurring
in the milliseconds between input of conditions stimuli and the resultant selection of an
appropriate response (Gladwell 2005, 11-15).

3
First responders rely heavily upon two-way radio equipment to communicate with one
another and to gather the information necessary to start the decision-making process before
arrival at the scene. “Inadequate fireground communication is repeatedly cited as a
contributing factor in many of the incidents reported through the United States,” according to
the U.S. Fire Administration (1999, 1-3). Chaotic communications at emergency scenes are a
frequent frustration with the assumption that only a technological improvement is necessary,
ignoring human factors (National Commission on Terrorist Attacks 2004, 280-285). The
weakest link in communications networks can be the human element. “There is a dearth of
available literature pertaining to the impact of human factors on effective fireground
communication” (U.S. Fire Administration 1999, 2). Even the most robust of radio systems
can be overwhelmed during routine incidents. Intense crisis situations can lead to almost
certain network collapse unless the users prioritize their messages. Radio traffic
management, within a fine line between too much information and not enough, needs
attention to assure that critical situational and safety information reaches incident
commanders (U.S. Fire Administration 1999, 10). The events and rapid flow of information
at emergency scenes can quickly overwhelm fireground commanders. The reduction in the
number of support personnel available in the form of chiefs’ drivers and aides may make this
concern more acute (U.S. Fire Administration 1998, 10).
This topic is ripe for further research to establish cause and effect relationships between
physiological and environmental influences in the emergency environment and the quality of
communications used by first responders. The commanders of emergency incidents measure
their successes by lives and property saved. Therein resides the difference between the
classic treatment of decision-making in the literature and the need for more research and

4
understanding of the unique challenges present in fast-paced emergency operations.
Demands for rapid decisions in compressed timeframes with limited information and
significant consequences for poor choices challenge emergency responders (Klein 1999, 9-
12; Garnett and Kouzmin 2007, 174.) Emergency commanders work in a critical decision-
making environment where the common doctrine of decision-making theory does not always
apply or it may need modification to meet the unique challenges. Decision theory literature
tends to focus on boardroom-style decision-making; slow, deliberate decision process is of
marginal value to emergency responders working in fast-paced, high stress, high stakes
environments (Klein 1999, 9, 18-19; Weick 2002, S12). Quality decisions by those
responsible for commanding emergencies are critical for the successful outcome of the
incident. Responders perform a number of critical tasks; the safety of those operating at the
scene, and the wellbeing of those affected by the incident, add to the pressure to find correct
decision solutions. One of the ironies and realities of all improvised decisions, such as those
made at emergency scenes, is the realization that a chosen tactic is not working only occurs
after it has already failed (Weick 2002, S12). Failure in the emergency services domain can
sometimes result in unnecessary death, destruction of property, and significant interruption of
commerce, which intensifies the need for sound decision-making practices.
First Responder Communications Issues
This research challenge is an outgrowth of the dissertation author’s interests and
experiences surrounding emergency scene decision making and communications processes.
Research shows human impediments to communications beyond the predominant technical
interoperability issues being address by homeland security professionals (Hutchins and

5
Timmons 2007). First responders face a work environment replete with stressful situations
and difficult choices in compressed timeframes. Since Gaines and Jermier (1983, 571-572)
claimed the literature conflicts in establishing the influences of stress and fear in decision-
making, this dissertation works to “de-conflict” the connection between environmental
influences and humans communicating and making decisions in crisis mode.
Upon arrival at an emergency scene, personnel quickly have to decide their initial tactics
from a range of choices. Years of adhering to customs and experience yield heuristic “rules
of thumb,” such as “lives first, property second.” However, within those two major
categories are dozens, or hundreds, of sub-options. Are there people in immediate danger
needing rapid rescue by the personnel already on the scene? Can the subjective assessment be
made that some victims are beyond hope of surviving their injuries, and the limited resources
available be redirected to the “savable?” The minimally injured “walking wounded” may also
be the most vociferous demanders of attention by the first responders, as they may
aggressively demand treatment, or want help to locate lost companions and family. Will the
decision-making first responders be able to transcend their daily orientation of helping people
in minor situations and go past those pleading for help, to seek those within minutes of losing
their lives from critical injury and immediate peril? The presence of multiple distraction factors
in the emergency operation environment can lead first responders not to hear critical information
on their radios due to noise at the scene and the sheer volume of radio traffic (Spahn 1989, 18;
U.S. Fire Administration 1999, 6). These are the realities of the first responder decision-
making and communications environment targeted by this research effort. There is a need to
study attention span and sensory overload as significant factors in communications efficacy.

6
This research is particularly timely since homeland security has received increased
interest and funding in this decade. Command and communications issues predate the terror
attacks of 9/11 and have been a factor for many years (Hawkins 2007, 1, 5-6; National
Commission on Terrorist Attacks 2004, 280-285; U.S. Fire Administration 1993, 14, 32, 38-
39, 51; U.S. Fire Administration 1999, 2-3, 9). Many of the same communications challenges
facing the responders to the World Trade Center in 2001 existed when they responded to the
same complex for the first terrorist attack in 1993 (U.S. Fire Administration 1993, 14, 32, 38-
39, 51). Some of the communications issues in high-rise buildings are technological, but
some part of the burden falls to the radio operators. There is a relatively low level of
consensus among emergency responders that they have a share of the responsibility in
communications failures. The tendency has been to blame the radio equipment, instead of
considering the human elements involved (Timmons 2007, 2).
This dissertation first examined the unique challenges present in the community
emergency environment and then outlined several underlying influences and biases in the
decision-making process used by command personnel at intense incidents. Communications
efficiency and the influence of distracting factors are the specific focus of this dissertation
since communications are such a critical component of the decision-making process. The
researcher presents new approaches in providing communications and decision support to
incident commanders and suggests implications and recommendations in the final section of
this dissertation. These suggested decision-support and communications improvement
opportunities customize the existing literature on generic decision-making, along with
information learned from analogous disciplines and perspectives.

7
CHAPTER 2
LITERATURE REVIEW
Decision-making in the First Responder Environment
Paradoxically, those involved in the dynamic environment of emergency services
traditionally have a systemic resistance to change (Comfort 1985, 163). Rapid, adaptive
learning, in “real-time” has to occur, yet those involved have classic attributes of traditional,
rules-bound bureaucrats. The same hierarchical orientation from daily para-militaristic
practices requires reversal by the command staff, as they seek creative, flexible decision
solutions in occasional crisis situations. A scan of the operational environment by all
responders present at the incident is valuable, with relevant information fed to a centralized
decision-making authority. Roberts and Rousseau (1989, 135) found it important for
researchers to consider the multiple levels of activity and the impact of expected and
unexpected events on people operating in high-reliability situations. Subsequent behaviors
redirected by unexpected events, make study and analysis of crisis decision-making very
complex.
Personnel in public safety agencies tend to function in rigid, linear organizations in which
inflexible rules convey organizational expectations and standardize the approach to situations
encountered. As much as the words “good discipline” may seem an oxymoron to some, they
may be desirable, if for instance they appeared on the performance appraisal of a police
sergeant, as in “maintains good discipline among subordinate personnel.” Bigley and Roberts

8
(2001, 1293) noted the conundrum generated when it becomes necessary to commingle the
tenets of hierarchical management, emphasizing rules, routine, and procedures, yet needing
to encourage procedural flexibility during occasional and intense decision environments.
The decision-making process starts before arrival, as responders build their knowledge of
what is occurring, in bits and pieces, while they monitor radio transmissions from dispatchers
and those already at the scene (Bigley and Roberts 2001, 1291). Emergency response
personnel use several terms to describe the notion of attaining pertinent information in the
operational environment. The need to establish “situational awareness,” “size-up,” and “big
picture” are terms used to acknowledge the tendency of those at the task-level to take a
myopic view of circumstances immediately affecting them, to the exclusion of considering
the overall scene.
An anecdote in decision-making literature sheds light on the conflicted association
between classical decision-making theory and the realm we are just starting to understand-
crisis decision-making. Howard Raiffa, noted scholar and author on decision-making,
received an offer in 1957 to leave his post on the faculty of Columbia University for a
position at Harvard. His relationship with his prevailing dean was such that he went to him
for advice. The dean’s alleged response was sarcastically that Raiffa should apply his own
principles of decision theory scoring, and to go where the result of the arithmetic formula
said he should. Raiffa’s response was purportedly, "No, this is a serious decision" (Bazerman
et al. 1998, 236).
Emergency responders are likely to think the same thing—that their decisions are too
serious for reduction to weighted scoring and sterile calculations. According to Bazerman et

9
al. (1998), Raiffa insisted the story was not accurate, but it amused him nonetheless. He saw
the story as proof that there is an inevitable tension between formal and informal decision-
making processes, and there is an acknowledged role for both in the arrival at the optimal
decision.
Military
Parallels in military culture exist, as similar situations have led the armed forces to pursue
adaptive behaviors. Development of situational awareness is a necessary ingredient in sound
crisis decision-making and effective communications are an important part of gaining the
necessary information to form situational awareness.
In the U.S. Navy, “having the bubble” is the phrase for maintaining a big picture view of
operations (Roberts and Rousseau 1989, 135; Bigley and Roberts 2001, 1292). Much like
counterparts in the military, our community first responders face overwhelming variables,
chaotic situations, critical decisions, and death of citizens and coworkers a potential
consequence of poor decisions.
Radios proved to be useful in the Vietnam War allowing commanders in the rear to
monitor battleground communications and attempt to piece together what was occurring at a
location they could not see. The communications at times included excited voices in which
net controllers had to exhort the senders to slow down and clearly articulate what it was they
were requesting. In one sequence of communications from the battle at la Drang Valley in
1965, a lieutenant colonel was pinned down and calling for support (Moore 1992, 246 – 248).
When he started yelling over the radio, “They're running! They're running!” his colonel
thought for a moment that he meant his own battalion was on the run, but the sender of the

10
message meant it was the enemy who were running as a result of the air strike (Moore 1992,
247). Such inappropriate assumptions of intent in phrases with double meanings occur in
both military and first responder settings. Message clarity is an important element in effective
emergency scene communications. Excited, emotionally aroused people can exhibit loud and
uncontrolled voices, making it very difficult to understand what they are saying (National
Institute for Occupational Safety 2003, 17).
Personal Influences
Want/Should
External command of the people working at emergency scenes is one aspect of the
overall decision-making arena for first responders, but there are also introspective
intrapersonal conflict considerations. Bazerman et al. (1998, 225-230) described our inner
conflict as we wrestle between what we know we should do for our own good, and that
which is more pleasing, easy, or desirable for a variety of reasons. Diet and exercise are good
examples of what we know to be good for us, yet the translation into action is missing for
many. While it seems likely that incident commanders can put aside concerns of personal
comfort or be truly altruistic in the necessity of the moment, it is important to consider that
decision-making in daily life does little to prepare incident commanders for a predominately
“should” environment. Increased focus on the safety of responders has presented additional
internal conflict between the “want” of personal safety and the “should” of rescuing people in
dangerous situations.

11
Groupthink, Stress, and Fear
Janus (1972, 9-10) established that people functioning in groups tend to form a collective
mindset and cultivate an atmosphere in which there is a strong bias for the status quo. Subtle
squelching of dissenters is common. Janus (1972, 143) juxtaposed the relative success of the
Cuban missile crisis in which President John Kennedy encouraged opposing viewpoints with
the Bay of Pigs incident where groupthink predominated. Janus cited the latter as an example
of the deleterious effect of groupthink. Schafer and Crichlow (1996, 429) noted that group
influences are presumed to be at their highest point in crises, yet the data show a lack of
documented influence under such circumstances. Since crises are the category of interest for
this research effort, and the influences delineated in their study are pertinent to first
responder operations, the findings in the Schafer and Crichlow study are applicable since
they suggest negligible groupthink influence at emergency operations. There is a need for
further study before connecting significant inferences to the emergency environment.
Occasionally, in military and community emergencies, a cascade of poor decisions makes
it difficult to bring the chaotic situation under control, as was the case in the example of the
Bay of Pigs cited by Janus. Major failures in emergency circumstances can be a product of
multiple, successive failures. Schafer and Crichlow (1996, 418-420) examined 19 different
wars throughout history to measure the influence of the following ten attributes of
groupthink: group insulation, impartial leadership, methodical procedures, group
homogeneity, time constraint, recent failure, personal stress, invulnerability illusion, closed-
mindedness, and uniformity pressures. Schafer and Crichlow were not able to validate a
significant influence to wartime decision-making from these factors, despite assumptions
they are contributing factors in crisis decision-making dysfunction. The authors admit to a
need for further study and a greater sample size beyond their cold-war era study. Bravado

12
and peer pressure play some role in influencing the decision-making process of first
responders, as customs and traditions meld with presumed deleterious elements of
groupthink. There is a need for further study to establish connectedness to the emergency
environment before making significant inferences.
A tendency to scramble and hastily recover from an initial poor decision may negatively
influence subsequent decisions. Caldwell and O’Reilly (1982, 124, 134) referred to a level of
“self-justification,” in which decision-makers may get filtered information portraying
conditions being better than they really are, in an effort to mask failing courses of action and
to highlight positive cues. Another term generated from Caldwell and O’Reilly’s research is
“impression management,” which identifies the phenomenon of justifying increasingly
failing approaches in an attempt to prove the soundness of the initial premise. Watergate and
the Vietnam War are prime examples of self-justification and impression management
(Gouran 1976, 183-185; Caldwell and O’Reilly 1982, 124-125; McDermott et al. 2002, 145).
Another influence imposed upon first responders is a state of “expressive suppression,”
which involves the conscious inhibition of emotional expressions while emotionally aroused.
First responders force themselves to “stay calm” and to control their emotions as they try to
work through the formidable challenges present in the emergency theater of operations. One
study showed that people who suppress natural emotional responses experienced elevated
blood pressure, increased stress levels, disrupted communications, a reduction in rapport
building, and inhibited relationship formation (Butler et al. 2003, 48-67). Emotions play a
significant role in the operations at emergency scenes. It is not possible for the responders to
isolate themselves entirely from the effects of emotion, despite expectations of peak
efficiency. Kahneman (2003, 706) observed that it is not possible to separate emotions from

13
the decision-making process and that emotion is triggered by the dynamic conditions at the
scene. Kahneman (2003, 706) noted that the long-term environment is not where life is lived
and he cautioned decision theorists that broad, long-term views may be prescriptively sterile.
As Bazerman outlined in his subchapter on harm, omission bias, and status quo (2006,
54-55), there is a tendency to select options having even a slight possibility of doing no harm,
even when probability suggests that it may be wise to sacrifice the few in order to save a
larger group at risk. A false sense of heroics and false optimism for a miraculous outcome
can lead to overly conservative tactical strategies, even when the odds are stacked against
successfully saving everyone. The “do no harm” alternative (Bazerman et al. 2001, 1-10)
carries a strong bias, since it presumably requires the least amount of explanation, has a long
history of use in everyday situations, and is consistent with change-averse organizations,
which is a typical feature of public safety agencies.
The Role of Communications in Crisis Decision-Making
In studying common features of disaster management behaviors, Karl Weick noted the
importance of communications (Weick 1990, 589). Effective communications allow complex
systems to become more understandable. Discovery of new pieces of information allow one
to make sense of one’s experience thus allowing the situation to become linear, predictable,
and controllable. Weick argued that the situation is more complex than simply telling people
to talk more, noting the disorganization and chaos that can evolve when too many people are
talking at once. In recalling the atmosphere inside the control room at the Three Mile Island
nuclear power plant during tense moments surrounding the release of radioactive steam
during a serious accident in 1979, Weick noted there were too many people in the control

14
room talking at the same time. Each was attempting to contribute their hunches to what was
occurring and what tactics should be employed (Weick 1990, 589).
The literature reveals a contrast between classical decision-making theory, such as the
rational-comprehensive model in which exhaustive examination of all factors is made before
decision selection (Morçöl 2006, 5), and the “Thin Slicing” theory introduced by Gladwell
(2005, 23). Gladwell (2005, 23) defined thin slicing as “the ability of our unconscious to find
patterns in situations and behavior based on very narrow slices of experience.” Klein (1999,
4) noted that fire department commanders make about 80 percent of their decisions in less
than one minute. In the course of normal operations, emergency responders use recognition-
primed decisions (RPD), employing the first workable solution in the interest of time and
expediency (Klein 1999, 30).
Since rational-comprehensive models are impractical in the emergency environment
(Klein 1999, 9-12; Soelberg 1967, 26), another view is necessary to bring clarity to
emergency command situations. Lindblom (1959, 80-83) challenged those facing complex
problems to acknowledge the limits of intellectual capacities and to narrow analysis to the
most critical, non-exhaustive components. Lindblom (1959, 80-83) contended that any
attempt to take every possible factor into consideration leads to the likely outcome of narrow
definitions and a resultant limited scope. Former Secretary of State and retired U.S. Army
General Collin Powell waited for 40 percent certainty on data before considering an intuitive
solution to a problem. To overcome what some may call analysis paralysis, Powell viewed
any more than 70 percent certainty to be more information than necessary to make a sound
decision, wasting valuable resources on data acquisition (Klein 2003, 171).

15
Herbert Simon’s bounded rationality theory holds that actors in intensive decision-
making situations use a form of “rational choice that takes into account the cognitive
limitations of the decision-maker—limitations of both knowledge and computational
capacity” (Simon 1997, 291). Simon contended that people use heuristics to make decisions
instead of attempting to optimize the decision with extensive data acquisition and analysis.
Heuristics are a reflex reaction when deliberation costs are high and the actor has a base of
experience to draw upon to arrive at a rapid and usually sound decision (Simon 1981, 66).
Render et al. (2006, 68) outlined the several steps in decision-making; they essentially are
to gather information, process it, and apply the best choice. Render et al. (2006, 68)
articulated an idealistic notion of decision-making in stating that any decision based on logic,
after scrutiny of available data and alternatives, applied in a careful, systematic manner is a
good one, regardless of the outcome. Emergency responders attempt to apply all of these
steps, in milliseconds, when corporate managers can take weeks to reach decisions with far
lower consequences. Emergency responders would likely take little comfort from Render’s
sound decision disclaimer, regardless of how perfect the logic was, especially if the result of
decisions involved loss of life. Testing of counterfactual alternate endings is not possible in
the emergency environment.
For a variety of reasons, some academics and practitioners may make incorrect
assumptions about how emergency first responders make decisions (Klein 1999, 7-13). Some
portion of the body of literature tends to address boardroom style decision-making, in which
students are encouraged to gather facts, extrapolate decision formula, and choose the best
option derived from multiple options, although contemporary approaches have begun to
recognize the impracticality of doing so (Morçöl 2006, 5). Even the most ardent quantitative

16
decision-making academic may ponder the applicability of this process for the incident
command personnel if personally impacted by a disaster.
Sensory Overload and Task Interruption
Framing and Heuristics
The term decision framing refers to the situation whereby acts, outcomes, and
contingencies attributed to each choice in a decision sequence shape the decision-maker’s
perceptions. Framing is influenced by both the circumstances prevailing within the decision,
and the habits, customs, and norms possessed by that particular decision-maker (Tversky and
Kahneman 1981, 453). Therefore, there are two variables present in any major decision: the
person and the circumstances.
Bazerman (2006, 43) argued that people make decisions from their own neutral reference
point, making the location of the reference point, i.e. positively or negatively framed, an
influence on the amount of risk assumed. The decision-maker may select a different course
of action, if he had greater awareness of a slightly different decision frame or ease in which
to access and consider other alternatives. The communications process is a key factor in
alternatives awareness. Decision frame also gives the decision-maker a comfort zone of
operation, in which the single option chosen early in the process becomes more and more
fortified, shaping the point of reference, and increasing risk propensity (McDermott et al.
2002, 145).
Subtle perceptions of risk and reward, as well as the tendency of the individual to take
risk, can produce widely differing outcomes when two or more people view the same
circumstances. Tversky and Kahneman (1981, 454-458) established that seemingly

17
inconsequential shifts in circumstances, or perceptions thereof, could produce wide variation
in choices made to address a dilemma and give those frame elements weighted values within
prospect theory. Prospect theory assumes decisions have two major phases: 1) editing and
framing, and 2) evaluation, during which choice selection occurs (McDermott et al. 2002,
135). Prospect theory requires time to gather and evaluate data before reaching the decision.
The communications process is integral in gathering data for first responder consideration.
First responders must compress the timeframe of the decision process and yet arrive at sound
judgments.
The presence of uncertainly leads to psychological shortcuts in daily life to get through
the number of overwhelming choices one faces navigating through a typical day. Heuristics
are short cuts or “rules of thumb” used to transfer familiar experiences into new situations
with presumed similarities. First responders bring heuristic orientations with them to the
workplace and rely heavily upon them to seek positive outcomes. Use of heuristics occurs
especially in situations of uncertainty, where available options are imprecisely specified
(Kahneman et al. 1982, 710-712; McDermott et al. 2002, 136). People prefer heuristics under
unfamiliar or critical circumstances because they are cerebrally economical, demanding
fewer cognitive resources to reconcile the dilemma presenting itself. Bazerman et al. (1998,
236-238) acknowledged the presence and significance of “gut feelings” but also advocated
for an umpire to assure that the logical mind has an opportunity to seek any disproving
evidence through the objective examination of fact. A gut feeling can serve as a re-opener
when something does not seem quite right about a pending decision; gut feelings are an
unproven, and admittedly unscientific phenomena, but their anecdotal occurrence rate
suggests the need for greater study and quantification.

18
Tversky and Kahneman (1974, 1124) recognized the usefulness of heuristic principles in
helping people maneuver through complex tasks and in predicting the outcome of decisions
based on similar experiences, but they articulated a number of instances in which heuristics
can lead to severe systemic failures. Over-reliance on heuristics can lead to cognitive biases,
which degrade decision quality and preclude the consideration of better alternatives. Tversky
and Kahneman (1974, 1124-1131) called attention to three areas of heuristic and cognitive
bias concerns:
1. Representativeness, in which one facet of the decision is influenced by the other. In
this filtering situation, preceding actions taint the final decision. Another way of looking at
representativeness heuristic is gambler’s dilemma, in which the gambler expects a certain
outcome to be “due” despite equal odds of any of the possible outcomes occurring next.
2. Instance and scenario availability, during which people recall personal experience with
a circumstance and disproportionately assume recurrence of factors despite nuanced
differences and often-disparate time and conditions from the base experience triggering the
recollection.
3. Adjustment from an anchor refers to situations in which bias influences people in
picking a starting point presuming an outcome and/or tends to stay close to an expected
outcome and rearrange the circumstances to fulfill preconceived expectations.
Rensink et al. (1997, 372) suggested that perception of a change occurs most effectively
when the object is given focused attention. When there is a lot of changing stimuli observed,
it is unreasonable to expect all unusual events to receive equal attention. Distraction conflict
theory investigates the influence of distractions on decision performance. Speier et al. (2003,

19
773-774) used distraction conflict theory as the basis for building their interruption/decision-
making model. Their findings included:
1. Capacity interference results when the amount of incoming cues is greater than the
processing ability of the decision-maker.
2. Interference occurs when the decision-maker must attend to two or more inputs
requiring the same physiological mechanisms.
3. As people attend to multiple demands for attention, they may be unable to access the
necessary amount of additional cognitive processing capabilities needed for successful
problem resolution.
4. Memory loss and confusion are likely byproducts of such circumstances.
While processing critical information, decision-makers tend to minimize their
expenditure of scarce cognitive resources, which results in a lack of scrutiny of both relevant
and irrelevant new information (Speier et al. 2003, 775). For example, cell phone use while
driving has opened a debate about the influence a seemingly minor task (talking on the
phone) has with a relatively critical task (operating a vehicle). Bazerman (2006, 171-172)
attributed the association of traffic accidents and cell phone usage to be a result of
inattentional blindness, a phenomenon in which the majority of those viewing extreme
features of an event do not perceive critical elements. Bazerman (2006, 172) also gave the
example of spouses frequently accusing the other of not retaining something just told to them
by their partner. One study (O’Conaill and Frolich 1995, 262-263) showed that managers
spend 10 minutes out of every hour at work responding to interruptions. In 41 percent of the
cases studied, managers do not return to the original task after interruption (O’Conaill and

20
Frolich 1995, 262-263; Speier et al. 2003, 772). It is not just the actual time of the
interruption to consider. The decision-maker must cognitively re-immerse in the train of
thought prevailing before the interruption during a recovery period (Speier et al. 1999, 339).
Incident commanders experience a constant stream of interruptions and redirection of their
attention through contacts with people over two-way radios and in person. Physiological
influences detrimental to cogent information processing and articulation of optimal
communications may be a major factor in the quality of decisions made by first responder
commanders.
People in all fields of endeavors find value in taking a break when faced with a situation
in which they are stuck in finding the solution to an issue at hand. After relaxing or attending
to other matters and then returning to the work, the solution often spontaneously emerges
into consciousness (Speier et al. 2003, 790; Lyubomirsky and Nolen-Hoeksema 1995, 187).
Such “time-outs” are valuable to our decision-making abilities, yet time is a luxury not
usually available to first responders. Speier et al. (2003, 790-791) recommended taking a
break and “quiet time” as antidotes to debilitating information overload and constant
interruption. Those recommendations work in some venues, but the incident commander of
an emergency response, dealing with time-critical matters, has minimal time for fact-finding
and debate.
Like many aspects of decision theory, the absolutes elude us when it comes to
interruptions, however. Speier et al. (1999, 340-348) tested a theory whereby the assumption
is that some level of interruption is welcome and valued in the decision-making process.
After observing subjects as they perform in a problem-solving environment, Speier et al.
(1999, 344-353) found that interruptions used to gather more information input and time for

21
collaboration helped to improve the quality of decisions made on “simple tasks.” Task
complexity is increased by making later decisions dependent on imbedded decisions made
earlier in the sequence. As Speier et al. (1999, 346-350) predicted, the quality of the decision
degrades upon interruption during complex tasks, yet the quality improves after interruption
when working on simplistic, monothematic issues. Improvements in the human-machine
interface hold potential for improved decision-making in critical situations, since incident
commanders use an increasing array of technologically complex communications and
information management equipment while operating at emergencies (Speier et al. 1999, 351-
353).
The presence of stress has some positive outcomes in-group performance when low-to-
moderate levels of stress were present (Selye 1936, 32; Kerr and Tindale 2004, 630-640). So
it is likely that some level of managed stress at incidents can sharpen the decision-makers’
attention toward better processes, and therefore better decisions. Statistics show some
increased danger in public safety occupations; in addition, the perceptions of danger by first
responders is as significant as the actual risk (Jermier et al. 1989, 28). While it may be an
overstatement to label safety concerns as preoccupations or obsessions, there is a potential
connection to distraction and risk-aversion due to the state of mind of those needing
maximum faculties to make difficult decisions. First responders work in stressful situations
and make difficult decisions in rapid timeframes. An assumption may be that such stress
influences and degrades the quality of decisions made. Gaines and Jermier (1983, 571-572)
called the literature “conflicting” on the influences of stress, burnout, exhaustion, danger, and
fear. Counterintuitive subtleties, such as organizational structure and promotional
opportunity based on perceptions of fitness for command, appear to be at least as significant

22
in generation of stress, as is impending physical danger. However, Gaines and Jermier (1983,
571-572) admitted that the relationships are intricate and in need of additional study.
Entropy
In A Mathematical Theory of Communication (2001), Claude E. Shannon’s seminal piece
established entropy theory, and shaped the computer and communications systems in wide
use today. Shannon (1951, 50) defined entropy as “a statistical parameter which measures, in
a certain sense, how much information is produced on the average for each letter of a text in
the language.”
The study of patterns of letters in the English language, with pages of mathematical
proofs, establishes the probability of conveying the essence of a message without
transmission of the entire message (Shannon 2001, 1-19; Posner and Rodemich 1971, 2079-
2125). In further documentation, Shannon (1949, 700-701) reported a 50 percent redundancy
in the English language with accurate communications resulting in one study in which
removal of the vowels from passages, without essential loss of the message, occurs. The
missing letter concept advanced further another step, when Shannon calculated the
probability of predicting the next letter of a text when spelling of a word is initiated (Shannon
1951, 50). The average person can relate to those occurrences whereby someone is able to
finish the sentence of another, based on the context up to that point. Certain letters have a
greater propensity to follow others when forming words and the filling-in of missing words is
relative to familiarity with clichés, idioms, lingo, and the context in which something is
stated. Computer users have begun to discover the power of computer portholes, such as
Google, which has an automatic suggestion feature to fill in the missing word consistent with
Shannon’s theory.

23
The concept of entropy helps to explain some of the dysfunction experienced at
emergency scenes as incomplete communications are conducted and statements among first
responders jump around from topic to topic. The phenomenon of entropy also holds promise
for compression and prioritization of critical information at incident scenes. New
technologies could be aimed at abbreviated delivery of critical information among first
responders, based on the likely content of frequent messages, i.e. “send more help,” “mass
care for casualties needed,” “evacuate the area,” “building structure unsafe,” and “hazardous
substance present.”
In situations whereby a high degree of noise prevents a satisfactory message
accomplishment rate, Shannon (2001, 22) made the case for message redundancy as the
answer for greater accuracy. Message redundancy has several meanings in this context; from
a technical systems approach, it may mean multiple communications via parallel, redundant
paths, to assure a critical message makes it to the destination. Redundancy can also mean
several persons passing similar observations or key messages to a single collection point for
additional validation and the resultant improvement in the quality of information upon which
to base critical decisions (Surowiecki 2004, 4-6). Information overload, in the emergency
environment, makes it impractical to bombard incident commanders with more and
redundant information. The challenge posed to the human factors community is to devise
technological improvement in the human-machine interface, to allow critical information to
flow, without overwhelming the incident commander with sensory overload.

24
Inattentional Blindness
In a well-known study written by Simons and Chabris (1999, 1066-1073), test subjects
were instructed to focus their attention on people playing a basketball bouncing game. The
video features the introduction of a gorilla into the video frame, or more exactly a person in a
gorilla suit, who walked across the screen in front of basketball players. The person in the
gorilla suit did not just flash across the screen but rather stopped in the middle of the players,
as the action continued around the gorilla-suited person. The person in the gorilla suit
actually turned and faced the camera, thumped his chest, and resumed walking at a leisurely
pace across the field of vision. Half of the people who observed this demonstration did not
see the person in the gorilla suit at all because they focused intently on counting the number
of the passes between members of the different basketball teams.
The Simons and Chabris (1999, 1063-1064) experiment was an update of an earlier study
in which a woman with an umbrella walked across the test subjects’ screen. The study,
conducted by Becklen and Cervone (1983, 601-608), showed a similar inattention bias to
those who observed the incident because they focused their attention so sharply on the area
of interest. In the Simons and Chabris study, one team of the three basketball players wore all
white; the other team of three wore all black. Since the gorilla suit was all black, they were
able to test and control for the influences the colors and inattention had on whether subjects
noticed the gorilla walking across the frame. In a counter-intuitive result, the study
demonstrated that those who were studying the black-suited players were more likely to
notice the similarly colored black-suited gorilla walk across the screen, instead of those who
were concentrating on the players dressed in all white. This differed from the expected
outcome since we may anticipate they would notice something contrasting from the white-

25
suited players. However, the researchers concluded the observers focused so intently on those
similar to the object of their attention that they were not able to see the opposite effect.
The “Gorilla” study, “required observers to attend to one event while ignoring another
that was happening in the same region of space” (Simons and Chabris 1999, 1072). Simons
and Chabris called this a phenomenon of “directed ignoring” which could inhibit perception
of not just the event the individual is attempting to ignore, but of all unintended events that
may occur in the space studied. The subjects involved in this experiment were more likely to
notice an unexpected event that shares the same basic visual features, which in this case was
color. This would be the opposite of the phenomenon expected in which an item that differs
in basic features from the rest of the display might be easier to notice and identify. With
approximately half of the observers overall failing to notice the highly contrasting but
unexpected event that moved across the screen, Simons and Chabris were able to
demonstrate “a robust phenomenon of sustained inattentional blindness for dynamic events”
(Simons and Chabris 1999, 1069).
The next question pondered by the dissertation author is whether the previous studies
involving visual perceptions and sensory input also apply to strictly auditory worlds. This is
pertinent since so much of the emergency communications process is strictly auditory.
Neumann et al. (1986, 186-187) addressed whether there is a direct correlation between
visual and auditory sensory input. Neumann et al. cautioned that there are certain
fundamental differences between the information processing used in vision as opposed to
audition. They suggested that there should be models developed to recognize the selective
processes within the different senses individually and not treat them all as the same, because
there are fundamental differences in the critical process of deselecting information in the

26
studied space. It is important for the subject to reject, block, or at least manage in some
manner the amount of received sensory input. In the visual world, this is somewhat different
from strictly auditory input. In filtering out input received through auditory channels, it is
necessary to make some distinction between the “signal,” that is, the desirable input from the
unwanted “noise” that the individual is attempting to sort out. This notion of signal-to-noise
separation is an important feature of auditory sensory input. Neumann et al. (1986, 185-188)
left it to future researchers to make fine distinctions, inferring it is more difficult in the
auditory world to make such isolations. There are fewer layers and less depth present in the
sense of hearing to assess situations and to make the appropriate distinctions among the
images seen by participants.
The Neumann et al. (1986, 186) challenge to the research world to do more
individualized studies in auditory perception was followed up in the 1998 book Inattentional
Blindness by Mack and Rock (1998, 215-223), in which they indicated that there is a
connection between the inattention phenomenon in the visual world as well as in the auditory
world. They indicated that inattention phenomenon cuts across all sensory input settings.
Mack and Rock (1998, 215-223, 246) established that auditory deafness is analogous to
inattentional blindness. Nearly everything that could apply to inattentional blindness
translates directly into auditory deafness. They conducted a series of studies in which
individuals had input given to them over headphones while there were multiple things
occurring. Replication of the very same version of the shadowing task used in the gorilla suit
and umbrella exercises proved to apply in the strictly audible world, too. Mack and Rock
found inattention and an inability to respond to those incidents that were above an auditory
threshold. The inattention phenomenon is not unique to vision, therefore, and migrates across

27
all sensory input. Mack and Rock (1998, 223-225) did tactical studies using puffs of air
blown onto subjects’ arms at certain times to determine if they would recognize a distraction
while they focused intently on a task. Regardless of whether the input was tactical, visual, or
auditory, Mack and Rock (1998, 74-103) found similar inattention when individuals focused
intensely and exclusively on a single task.
Literature Review Summary
In summary, this review of decision-making literature reveals:
1. Communications are a critical element in successful decision-making
2. People in stressful situations experience communications deficits
3. There are a variety of circumstances and stimuli attributable to a state of
debilitating sensory overload
4. There is a relationship between stress reactions and communications difficulties
The literature suggests that humans in stressful situations are likely to exhibit verbal
communications deficits due to the nature of and influences present in such circumstances.
Communications deficits are measurable in terms of inadequate and ineffective
communications turns, especially in situations whereby radio calls go unanswered by the
intended recipient, or need repeating. There is an unmet need to study the micro factors
present in the emergency command environment causing communications inefficiencies.

28
Hypotheses
An informed review of the literature forms the basis for the issues addressed in the
empirical work contained in this dissertation.
Hypothesis #1: Sensory overload leads to ineffective communication, as measured by
missed messages, by first responder commanders under emergency conditions.
Hypothesis #2: Commanders at emergency scenes mishandle communications even when
utilizing functioning, state-of-the-art equipment and the messages prove to be clear and
concise.

CHAPTER 3
METHODOLOGY
This chapter explains the data collection methodology, analysis process, and the approach
used to test the hypotheses. Chapter Four presents a series of case studies from actual
incidents to establish common features of communications lapses. The final product of this
dissertation is a test of the hypotheses and a presentation of the findings and the implications
they have for training and formatting of first responder incident command communications.
Research Design
The study presented in this dissertation’s Chapter Five employed a phenomenological
case study technique to determine the non-technological influences affecting efficient first
responder radio communications at emergency scenes. The subjects for the field study were
fire department response personnel functioning as incident commanders at the scene of
simulated emergencies. Observation of personnel at training exercises and emergency
simulations served as the basis for this study. Of particular interest were simulations of
emergency scenes where large complements of personnel were operating, and the potential
for simulated injury or death was present. Participants included personnel from fire
departments in McKinney and Plano, Texas with assistance from the Allen, Texas Fire
Department. The University of Texas at Dallas Institutional Review Board granted approval
29

30
to observe first responders at the scene of training exercises and to document the occurrence
of interruptions and distractions when dysfunctional radio communications occurred.
The researcher used a degree of sensitivity and discretion to put the subjects at ease and
to assure cooperative access to their operational environments. A statement of research
purpose was included in the pre-exercise briefings along with a request for written
permission to videotape the participants. The researcher realized that it might have been
necessary to discontinue the documentation of any single incident that was particularly
emotional or sensitive out of courtesy and respect for those involved.
Video and audio recording of the command post environment, synchronized with radio
traffic recordings, formed the raw data for the study. This allowed for the documentation of
the multiple influences causing the sensory overload and the resultant degradation of fluid
verbal communication. A combination of live observation, subject interviews, and review of
the audio/visual recordings provided the documented observations germane to the study. The
first observation step was to listen and document missed radio messages and to note the
distractions and influences at that specific instant. The researcher scored an unacknowledged
or repeated message as an ineffective, or negative, communications turn. The use of a coding
scheme (Appendix A) allowed for the conversion of qualitative data into quantitative data.
The second step in the series of outdoor exercises was a post-incident interview with the
subjects, where data gathered provided balance and explanation for any factors not
observable by the researcher. Joint review of the videotape provided an opportunity to refresh
memories and present factors not perceived as they occurred. The interview style was a semi-
structured format using an outline of interview questions (Appendix B), allowing for a free-

31
flowing explanation of circumstances experienced by the subject. Standardization was less
critical at this step, since the purpose of the interview was to add richness to the observation
data. Each interview lasted between 30-45 minutes at the subject’s normal place of work.
Follow-up interviews with the commanders from the indoor simulation exercises were not
necessary due to the immediate access the researcher had with them in the laboratory
environment provided by the simulator.
This research builds upon data derived from an earlier study, whereby 428 radio
communication turns at a multi-jurisdictional fire training exercise were assessed using a
coding scheme (Timmons, 2006). The previous study established that the incident
commanders missed or did not respond to a significant number of radio calls from
operational personnel; 11.9 percent of all the radio calls at the exercise were
unacknowledged, which compared closely to actual incident recordings reviewed. Thirty-
three out of the overall fifty-one unacknowledged radio messages in that earlier study were
people trying to call the incident commanders. Incident recordings show the messages in the
earlier study were cogent, yet at incident debriefings, it was common to hear assumptions
that the radio was not working, rather than cognitive inability to receive and process multi-
sensory stimuli. The first study only examined radio recordings, which demonstrated the
presence of inattention; actual field observation in this study determines what the distracting
influences are. The precise moment of inattention is the focus of this new research, so that
the researcher can establish the type of distraction and its impact on the ability to process the
information from documented radio transmissions.
Documentation of deficiencies provides insight into specific causes of communications
failures commonly identified after disasters. The specific area of concern is radio

32
communications used by first responders in the course of their operations at emergency
scenes. Discovery of sets of negative influences in sufficient quantities and from common
sources draws cause and effect relationships, suggesting better training and compensating
strategies.
The case selection strategy used for this multi-case phenomenological study involves
simulated emergency situations routinely assigned to first responder personnel. The
interaction between the responders at an incident and the distraction factor it introduces is the
focus of these observation exercises. The researcher made a conscious effort to avoid
distraction during the observation data collection to avoid being handicapped in objective
data collection. The researcher stayed focused on the sensory influences occurring in the
communications interface between responders and commanders. In doing so, this reduced the
possibility that the same influences negatively affecting the subjects would also similarly
affect the researcher.
The subjects of the study were the response personnel, especially the command officers
from fire departments in Plano and McKinney, Texas. This study allowed for the observation
of multiple parties from two different fire departments for stronger scientific validation.
Training exercises attempted to create realistic emergency circumstances, testing and honing
skills used at actual emergencies. The study’s venues were the fire training facilities in Allen
and McKinney, Texas. Training exercises provided an environment conducive to observe
pertinent influences without an undue Hawthorne effect (Bracht and Glass 1968; Cook 1962;
Jones 1992). The participants were present primarily to solve a tactical scenario, allowing the
researcher an opportunity for separate and discreet observation of the decision-making and
communications processes.

33
Actual emergency scenes offer the opportunity to test the truest of circumstances and
influences. One drawback of this method is that access and opportunity are limited since the
case cannot be staged or scheduled, and because intense incidents are sporadic and
unpredictable (Klein 1999, 10). Because of these limitations, this project focused exclusively
on training exercises. Improvements in miniature camera technology may allow future
researchers to keep subjects “wired-up” with video and audio observation capability until the
occasional incident of interest occurs. Miniaturized biomonitoring may allow measurement
and analysis of pertinent biological factors.
Data Collection
The data collected in this study are the communications behavioral choices made by
incident commanders in emergency command situations. The research observer chronicled
the sensory influences present in the emergency environment and their impact upon the
incident commander. Comparison of observation data with any radio communications
underway at the same instant helped to determine the influence the distracting stimuli had on
the quality of the prevailing radio communications.
Data derived from the interviews provided the opportunity to compare and contrast what
the objective observer saw with what the subjects perceived was happening. This method
helped to triangulate the data (Creswell 2007, 208; Berg 2007, 5-8; Patton 2002, 248) and
give it greater quantification strength. This study observed and analyzed multiple sequences
of command decision-making and communications to establish the frequency of errors and
the trends and causes therein; the simultaneous recounting by the actors involved provided
additional perspective. The study also gave the opportunity to examine the benefit of two-

34
person command crews, as a contrast to the typical solo command operations, with the hope
of yielding valuable insights.
Coding of Observable Behaviors
Coding of the observations (Appendix A) allowed for documentation of the type of
apparent distraction leading to the missed turns of communications. The observer first noted
the existence of one of the following markers of a dysfunctional radio communications turn:
• Unacknowledged message
• Clearly delivered message needing to be repeated
• Inappropriate translation of message intent (i.e., “What color is the
sky? Answer: “three”)
At the instant when the researcher noted one of the above-named radio communications
dysfunctions, he documented the presence of influences in the incident commanders’
operational environment. The researcher observed the incident commanders as they
conducted their duties with the distractions codes list acting as a menu of specific distracters.
This allowed for the association of influences indiscernible from the incident recording
review or by either party of the communication since they are typically isolated spatially,
thus their use of the radio.
Data Organization and Analysis
As advocated by Weiss (1995, 21), the quantity of cases observed was driven by analysis
of the early results. Once returns became redundant or peripheral, there was a discontinuance

35
of additional data collection. Yin (2002, 21-22) suggested that cases can be events or entities;
in this instance, the cases are both, since the event, i.e. the emergency, is a necessary
ingredient, yet it is the actions of the actors at the emergency that are the subject of this
study. The post-incident interviews followed Creswell’s (2007, 159) suggestion to develop
generalized “meaning units” or theme categories derived from significant statements
collected from the subjects. Use of this technique promoted uniformity of the data and
assured high accuracy and validity. Collection of the raw data was through a process of
coding the behaviors and responses observed in the test environment derived from the
observations. Analysis of the coded results disclosed any discernable patterns and cause-and-
effect relationships (Creswell 2007, 152).

CHAPTER 4
CASE STUDIES OF ACTUAL INCIDENTS
This section reviews several significant emergency incidents in which use of radios
played a key role in the outcomes. Two incidents of major concern to the fire service
community occurred during the spring of 2007. In one instance, a firefighter died while
fighting a structure fire in April 2007 in Prince William County, Virginia. The second
incident was a major furniture store fire in June 2007 in Charleston, South Carolina. Both of
these incidents raised significant concerns because the mayday distress calls placed over the
radios during the incidents were associated with the firefighters’ deaths. These two fire
incidents had common factors with an incident predating them by nineteen years, in which a
building collapsed during a fatal fire at a car dealership in Hackensack, New Jersey in 1988.
Case studies of precursory fires in Syracuse and Seattle are included here to provide
additional insights into recurring communications dysfunctions. Next, the researcher presents
the case of a dramatic 1997 bank robbery and shootout in North Hollywood, California
showing the challenge of communicating during an intense police incident. The final case
study in this chapter is from a highly publicized successful emergency plane landing in the
Hudson River in New York City in February 2009. Radio transmissions during the
emergency landing hold important lessons in crisis communications.
36

37
Syracuse, New York 1978
The earliest documented case of radio communications contributing to a firefighter
fatality occurred in Syracuse, New York in 1978. Four firefighters died at a fire in an
apartment building (Varone 2003, 142; Demers 1978, 24-25). According to official radio
recordings, there was a weak radio transmission made around the sixteen-minute mark
stating, “Help me.” An investigative report indicated the radio signal was very weak on the
tape recording and there was no indication that anyone on the fireground heard it. A district
chief and deputy chief were present at the incident prior to the call for help; they had been
issuing orders for several minutes prior to the distress message.
About one minute after the original distress call, a second transmission was recorded, this
time someone stating, “Help, help, help,” followed by static. None of the fire personnel at the
scene or at the dispatch office heard any of these radio transmissions. An observer at the
incident heard a radio message on a scanner stating, “Help, help, help, third floor attic.” The
bystander immediately reported the information to a fire department command officer at the
scene. It was later determined that the four firefighters died on the third floor (Varone 2003,
142; Demers 1978, 24-25).
Recovery of the first firefighter’s body occurred 20 minutes after the original unnoticed
distress call. The remaining comrades were not located for another 54 minutes following a
search of the gutted interior and calls to local hospitals to see if they were among several
firefighters sent for treatment (Demers 1978, 15, 24-25). There was only one portable radio
issued among the four victims; it was later recovered in the debris and found to be in working
condition after drying out and being outfitted with a new battery (Demers 1978, 24-25).

38
Hackensack, New Jersey 1988
One of the most prominent early instances of miscommunications at fire scenes involved
the fire at a Ford dealership in Hackensack, New Jersey on July 1, 1988. Five firefighters
died while engaged in interior fire suppression efforts following the collapse of the building
(Klem 1988, 1). Investigators studying the fire command operations found a number of
issues with the radio communications at the incident. “Apparently due to the initial confusion
that existed on the fire ground after the collapse and the sounding of tones for the recall over
the only emergency fire ground radio frequency, the initial calls for help from the firefighters
were not acknowledged” (Klem 1988, 14).
A detailed investigative report based on radio recordings from the incident concluded
there were numerous radio messages that were unanswered, messages delivered but not
acknowledged, and there were several requests for messages to be repeated (Demers 1988,
8). Tape recordings of radio messages clearly showed the trapped firefighters articulated their
specific location several times. There was no acknowledgement for the messages over the
radio, nor were those working at the incident aware of the distress calls, as revealed during
post-incident interviews (Demers 1988, 10-15). The incident commanders did not
acknowledge one-half of the radio messages transmitted at the Hackensack fire.
Unacknowledged messages created an obvious safety hazard for the personnel at the scene,
and contributed to further overload of the radio system since the message needed to be
repeated (Varone 1996, 98). One investigator concluded, “There was a great deal of talking
on the radio but a severe lack of communication” (Demers 1988, 14). As was the case in the
Syracuse incident that preceded it, people remote from the fire scene monitored the desperate

39
messages on scanners and they called to report them, yet the incident command personnel at
the scene were unaware of such messages (Varone 2003, 141).
On the twentieth anniversary of the Hackensack fire last year, the retired fire chief, now
age 84, in command of the incident that day reflected upon the criticism involving the tactics
and communications used at the fire. The retired fire chief stated that he had asked for budget
dollars to improve the department’s radio system at least a year before the fire, but the city’s
administration denied the funding request. The Hackensack Fire Department was using hand-
me-down radios from the police department on the day of the fire; the chief’s radio was
inoperative and he had to borrow one at the scene before he could do anything (Bonamo
2008). The rationalization involving equipment failure being the major contributing factor
belies the significant command and control issues outlined in the Demers report (1988, 14).
The incident commander blamed the equipment, but people detached from the scene were
able to monitor the messages.
North Hollywood, California 1997
On February 28, 1997, a bank robbery turned into an armed standoff with the Los
Angeles police officers seriously mismatched by robbers with automatic weapons, extensive
body armor, and armor piercing ballistics. At the conclusion of the 44 minute incident, over
1000 rounds had been fired, ten police officers and six bystanders were wounded, and the
two perpetrators were dead (CNN 1997).
The incident began as a radio report from a unit in the area of a robbery in progress with
shots fired. Bystanders reported to the patrol unit that heavily armed men, wearing all black
outfits and ski masks and carrying assault rifles, had entered the bank. Immediately after

40
arrival, the excited radio communications began with the officer broadcasting, “Shots fired,
shots fired, officers need help!” As numerous units acknowledged the call for help and
radioed that they were responding, there were multiple overlapping layers of radio
transmissions, making it difficult for the dispatcher to track the messages. The conflicting
radio broadcasts of the physical descriptions of the suspects ranged from white, black, and
Hispanic, with numbers ranging from two to eight. At the conclusion of the incident, it was
determined that there were two white males involved. The dispatcher remained controlled
and helpful in reaction to a constant barrage of requests and situational updates. There were
isolated instances of the dispatchers raising their voices in anxiety level in reaction to
particularly emotionally charged messages from the field units. There were several
occurrences of officers screaming on the radio that they were injured, pinned down, and
requested assistance. At one point, the dispatcher asked if any units knew how many officers
were down. The response from an excited voice was, “more than one, more than one!”
In reviewing the incident recordings, it was obvious in several instances that units were
overlapping each other’s radio transmissions, not awaiting acknowledgement for messages,
and covering the more critical messages with less critical ones. In one interval, the suspects
had exited the bank and were shooting at officers in the area; other officers were attempting
to broadcast a warning of their movement. At that instant, an unintelligible voice started
screaming something over the radio, with a siren running in the background, similar to radio
transmissions expected during a vehicle chase. It was just barely discernible that the officer
was saying something about an injured civilian, perhaps while transporting someone to
medical treatment. The dispatcher asked the officer to roll up the car windows so the radio
message could be heard over the siren; the message was not repeated and the radio channel

41
resumed other critical information on the movement of the active shooters. There were some
instances of messages requiring repeating, but given the intensity of the event and the
number of people attempting to transmit at the same time there were surprisingly few
repeated messages, owing to the communications skill of the dispatchers and first responders
(Rigg 1997).
Review of the recordings reveals that there were three broad categories of use for the
single incident radio channel: 1) tactical consideration of where the suspects were and
strategies to engage them, 2) maintaining radio contact with the injured officers awaiting
rescue, and 3) requests for additional personnel, specialty units, and supplies such as
ammunition and radio batteries. Each of these differing yet simultaneous uses of the radio
channel created contention and inefficiencies, especially when wounded officers needed
reassurance help was on the way.
Following the incident, there was some criticism of the incident command structure used
at the scene. The dispatcher asked multiple times where the command post location would be
and where to send the additional inbound resources. The original locations attempted for
placement of the command post proved to be too close to the incident, considering the
weapons in use. Tactical commanders eventually did identify who was in command, assert
control on the radio channel, and issued orders on the rules of engagement. Even one hour
after the shooting stopped, police command officers struggled to track the number of
personnel at the scene and to determine if all elements of the incident were secure (Edwards
2002). Before a specific incident commander was established over the radio, the police
helicopter served as temporary incident commanders issued commands based on what they
were able to observe from above the incident. Interestingly, they passed along officer safety

42
updates to the units on the ground, while the ground units warned the helicopter crew as the
suspects fired their automatic weapons skyward towards them. The pilot’s voice was slightly
more controlled and less emotional than the field units due to the helicopter’s remote position
and they were able to lend valuable insights and perspective, reminiscent of the helpful,
accurate updates provided by the helicopters and fireboat during 9/11 in New York City
(Firehouse Magazine 2005).
Of the 300 officers who eventually responded to the incident, all of them survived,
including the ten officers who suffered a variety of ballistics wounds. Many involved still
carry emotional scars from the incident even those whose connection to the action was only
over the radio. Several of the officers who worked at the North Hollywood shootout
subsequently received therapeutic counseling for depression and substance abuse, and three
of the officers involved later committed suicide. One of the officers with lingering impact
from that day attributed some portion of his trauma to hearing his wounded comrades
screaming for help over the radios (Edwards 2002).
A reporter covering the story noted that one of the detectives who responded to the
incident and worked to assist an injured partner “was still gripping her police radio so tightly
that her knuckles were white,” even one-half hour after the shooting had stopped. The
detective praised her wounded partner’s presence of mind to broadcast his location so his
rescue could be arranged, showing the value of having a radio at such intense incidents
(Shuster and Rainey 1997). It was because of her monitoring the radio while working another
assignment that she became aware of the shootout and she responded to the citywide request
for officers to assist.

43
The radio also became pertinent in another one of the many subplots to this story. Two
injured officers made their way into a dentist’s office and received first aid treatment for their
wounds. Maintaining radio contact and assuring one another that more help was on the way
allowed them to stay in their protected position and overcome their instinct to go help a
wounded partner in the street below (Shuster and Rainey 1997).
Seattle, Washington 1998
A fire at a lumber company in Seattle in September 1998 resulted in the death of one fire
lieutenant and injury to two other firefighters. The Seattle fire department arrived two
minutes after a telephone report of a fire at a lumber facility at 9:23 p.m. Firefighters made
entry in the building and began extinguishing efforts. One of the fire crews became lost and
disoriented in the heat and smoke with the command officer trying several times to call for
help on his portable radio. As the lieutenant ran low on air, he handed the portable radio to a
firefighter; that same firefighter attempted radio contact with incident commanders with
negative results. The firefighter was able to hear the dispatcher sending additional fire units
so he was sure the radio was working. The National Fire Protection Association (NFPA)
investigation of the incident indicated one of the factors contributing to the death of the fire
lieutenant was an inadvertent use of the wrong radio channel by the two disoriented
firefighters. They may have selected a setting on their portable radio intended for scene use
only; the message would not have gone through a repeater system allowing monitoring and
recording at the dispatch office. Citizens in the area monitoring on their scanning radios
heard the distress calls, but the incident commander and the dispatch office did not (Isner
1990b, 20-21). The NFPA report suggested the possibility that the firefighters were not using
their radios appropriately, or that their message was lost in the flow of loosely monitored

44
incident command radio traffic by the incident commanders. The report was also critical of
the system of accountability used to track and control the operation of firefighters in the
hazardous environment (Isner 1990b, 18-19).
The firefighter with the radio somehow made it out of the building and to medical
treatment with only a vague recollection of what had occurred. It eventually became apparent
that the lieutenant he had been with was still missing. Following an extensive search, his
body was located under about two feet of debris inside the building (Isner 1990a, 31–34).
Prince William County, Virginia 2007
A fire occurred in Prince William County, Virginia on April 16, 2007 in a single-family
residence on a very windy day. The wind was a major contributing factor in the rapid spread
of the fire, just as firefighters began entry into the structure. As it turned out, the occupants
had escaped prior to the fire department’s arrival and no one was awaiting rescue within the
building. The only fatality was a firefighter conducting suppression and rescue operations
inside the house (Prince William County 2008, 4-5).
Reports from this incident indicate that the fire department did a number of things
correctly. A command structure was in place. The incident commander was operating from a
stationary position of tactical advantage across the street and from within a vehicle where the
ambient noise could be controlled. The incident commander was apparently operating alone
during the early critical stages of this incident. The command officer of the firefighter who
eventually perished, as well as the firefighter in peril, transmitted separate mayday radio calls
per the department’s policy. However, no one at the scene recalled hearing a mayday
message.

45
Review of recordings after the incident show the mayday radio message transmitted
clearly, as well as urgent follow-up messages. However, the incident commander did not hear
the mayday call; but he heard something he did not understand and requested the repeat of
the last message. When there was no reply to his request for a repeat of the last message, the
incident commander moved to other tactical messages with other units operating at the scene,
unaware of a mayday message. The fire-dispatch center operator was aware of the mayday
message; the dispatcher initially attempted to assist the incident commander in hearing and
reacting to the message, but the dispatcher did not persist in making sure the incident
commander was aware that a mayday message existed. There are other procedures in place
requiring the broadcast of an emergency announcement over the radio channels from the
dispatch center when a mayday is declared, but the dispatcher did not interrupt the steady
flow of tactical messages on the radio channel (Prince William County 2008, 64-66).
Prudent practice dictates establishment of radio contact with a firefighter declaring a
mayday emergency. In this instance, the firefighter was in peril several minutes until he made
his final anguished request for water, which proved to be his final transmission. Review of
the recording showed two ways to interpret his request for water. It is clear now that it was
the extreme heat he was experiencing and he was referring to the life-threatening situation he
was experiencing when pleading for water. It is also common for firefighters to radio
requests for more water, for tactical application to extinguish the fire, while still in tenable
conditions within their turnout gear. The typically muffled voice of the firefighter trying to
speak while wearing a self-contained breathing apparatus mask may have contributed to the
misinterpretation of message intent. The distressed firefighter was indicating a life-

46
threatening situation. The twenty-four year old firefighter was later found deceased within
the structure (Prince William County 2008, 16-18).
The investigator’s report of the incident is critical of the radio discipline used at the
incident (Prince William County 2008, 68, 121). After declaration of the mayday, radio units
at the scene continued to make radio transmissions unrelated to the mayday event, as well as
items of non-emergent nature. The report recommended the way to overcome this in the
future is to designate individual radio channels for specific tasks. However, a person must be
dedicated at the command post to monitor each of these radio channels, assuring continuity
of critical communications on all channels (Prince William County 121, 2008).
Charleston, South Carolina 2007
Nine firefighters died while fighting a fire at the Sofa Super Store in Charleston, South
Carolina on June 18, 2007. The city of Charleston commissioned a panel of nationwide
experts to examine the handling of the fire. The investigation reports indicated a number of
radio communication failures. In most instances, it was not equipment failure, but rather the
practices that were in use by the individuals operating at the scene. The committee generated
a number of recommendations and observations about the operations during the incident
(City of Charleston 2007).
As in several other incidents, radio communications were ineffective at the Charleston
furniture store fire. Recordings show a typical tangle of incomplete, indiscernible, and
disconnected communications segments. A number of firefighters were calling for help
within the building, yet the incident commanders at the scene did not hear the distress
messages. In fact, no one at the scene recalled hearing the radio messages that contained calls

47
for help (City of Charleston 2007, 22). During the fire, firefighters transmitted 16 different
distress messages from inside the building. They were emotionally charged radio messages,
including firefighters praying and asking comrades to send sentiments to their loved ones
with the assumption that they would not survive the incident. No one involved at the incident
scene heard any of these distress messages (City of Charleston 2007, 70).
An off-duty fire department employee gave the first indication of firefighters awaiting
rescue inside the raging fire. He was able to monitor the radio communications on his car
radio as he was responding. Upon arrival at the scene, he made the incident commanders
aware that there were firefighters calling for help within the building. His notification was
the first indication anyone in charge at the incident had that there were firefighters in peril.
Confusion followed as to how many were missing, where they were, and whether they had
already been rescued (City of Charleston 2007, 74).
There were a number of complicating matters at this incident combining to form a
paralyzed and ineffective communications situation.
• Many fire departments use standardized alarm levels, i.e. second alarm, third
alarm, to streamline the calling for additional resources and to minimize
contention for airtime. The practice at Charleston involved requesting and station
radio dispatching of each unit individually, one by one, over the same radio
channel used for tactical level conversations at the fire scene (City of Charleston
2007, 111).

48
• During the incident, a civilian inside the building called 911 indicating he could
not escape and was awaiting rescue. This created additional urgent radio traffic on
top of that typically expected at a routine incident.
• This was a rapidly developing fire with plenty of fuel load in a very large non-
standard building, which placed additional responsibilities on the fire department.
The experience base of the typical fire department is in much smaller structures,
such as single-family residences.
• Inaccurate assumptions of radio message content and intent occurred between the
commanders. In one particularly poignant radio exchange, the fire chief called his
assistant chief at another side of the building and a message was transmitted;
however, each thought the message meant something else, so ineffective
communication was occurring. The fire chief said that he wanted to know how
things were looking inside of the store. The assistant chief replied, “I am trying to
get back to it now.” The fire chief heard the message but inaccurately interpreted
it as, “we’re getting to it now,” which he assumed to mean that they were starting
to make progress on the fire and that no extension of the fire into the remainder of
the showroom was anticipated. It was in that area where a majority of firefighters
eventually died (City of Charleston 2007, 105).
• The report is highly critical of the incident command principles used by the
Charleston fire department at the incident. The National Fire Protection
Association 1500 firefighter safety standard indicated the incident commander has

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