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USAF commanders have a variety of tools available to assist them in the day to day running of their units and organizations. Generally, things work out fairly well and the commander and first sergeant are able to stay on top of things. However, as personnel and behavioral issues seem to have become increasingly complex, as operations tempos intensify, as the family has become more and more prominent in military life, and as society has changed, military leaders need all of the help they can get in doing, what is at best, a difficult job.
This article intends to explain why a critical incident reporting system is needed in our Air Force organizations and explains how to use such a system. The article also provides an example of what the reporting system might took like. It is hoped that widespread adoption of the CIRS would assist military commanders and first sergeants in tracking significant events within their organizations and their responses to these events. The primary focus of CIRS is to increase the chances of a complete, competent, and caring response to selected events within US Air Force units.
The concept of risk is widely applied these days to a variety of fields, such as business and medicine, to characterize the probability of a negative outcome. The assessment of risk is the effort, as scientifically as possible, at quantifying the major aspects of risk. For example, how likely is it to happen? How many people could be affected? How severe might the effects be? Zero risk is obviously not the goal (for many reasons that would be impractical, as well as impossible). The idea is, with or without the benefits of empirical research, the systematic application of common sense and good judgment to identifying and managing potentially risky situations that crop up in our units.
By way of illustration, the following case material is presented. A young airman was the random victim of a predatory and murderous gang of criminals that fully intended to kill him. They almost succeeded but, for the most part, he recovered physically after several months. The airman was at risk for at least two things which seemed to go unrecognized by command. Firstly, and of greatest importance, was the risk of being reattacked. The OSI reported that this airman was, in fact, in continued danger from these same, unapprehended predators, who had made a point of making it known that they knew where he and his family lived. Secondly, the airman was at great risk for the development of Post-Traumatic Stress Disorder (PTSD).1 If the commander had obtained a mental health consultation he would have been told this. He would have also been told that the airman needed to be evaluated as soon as possible and treatment, if necessary, planned for. When the airman finally made it to mental health, some three months after the attack (way too late for preventive efforts), he had indeed developed PTSD and was deteriorating rapidly. This case illustrates, among other things, that risk assessment need not be performed by the commander. In many instances, the commander need only use his or her consultants properly. The OSI provided the risk assessment of continued danger, and still, applicable Air Force directives were not followed, at least not until a long period of time had elapsed and the IG, Congress, and others got involved. Since a mental health consultation was not obtained, the commander was not provided with the PTSD risk assessment, although this easily could have been done. It is probably safe to say that this case would be considered by most Air Force leaders a relatively easy risk management case. Yet something went terribly wrong and the airman and his family suffered much more than they should have.
This second case illustration is far less easy and truly tragic. A young dependent wife with a history of medical problems and two very young children was overcome with illness and died at their off-base home while her active duty husband was on a lengthy deployment. The children, totally dependent on their mother, died of starvation. Apparently, there was a costly mix-up in the squadron's visitation schedule to this family's home during the period of deployment.
The recounting of these two cases is solely for the purpose of illustrating why the CIRS is needed. Many details of each case have been deliberately omitted and some minor points have been altered to help in concealing identity. The point is that a system is needed and that this need has nothing to do with the degree of complication of the event. Even the easy ones can "slip through the cracks."
A second important reason to implement CIRS is because of the effect command response to critical incidents has on unit morale, both positive and negative. The commander who provides a complete, competent, and caring response to great events within his or her organization sends a powerful message to their people. And that message is "This organization respects and values its people" and leads to the attitude "I want to do everything I can for the good of our unit." On the other hand, incompetence, lack of caring, or negligence sends an equally powerful message - "This outfit doesn't care one bit about its people," resulting in the attitude "I don't want to work (fly, fight, train, fix airplanes, etc.) for them." The importance of "stories" within organizations cannot be underestimated. Some stories are so powerful that many years of work can be undone in a matter of weeks. Or, conversely, stories of great power can teach, motivate, spread enthusiasm, boost morale and so on. There are many examples of this but some seem more memorable than others. For example, when General Creech, the TAC Commander in the early-mid eighties, was trying to raise the status of supply personnel he "awarded," during a HQ TAC ceremony, the unserviceable chair of a supply sergeant to the three-star TAC logistics chief and told him it was his chair until supply was cleaned up!2 Or, when in the Korean Winter of 1990-91 (then) Lt Gen Fogleman, the Seventh Air Force Commander, directed anyone driving a GOV to stop and offer other USAF personnel a ride, proceeded to stop his staff car and offer people rides!3 These are two simple but very powerful stories that can have a dramatic impact on morale and, therefore, mission accomplishment. All good leaders realize that their people are watching every move they make and that those watching can't wait to tell others what they see. The smart commander knows that the grapevine is real, that it is extensive, and, perhaps most importantly, that it never shuts down. The truly wise commander sees opportunity in the grapevine. The opportunity to send his or her people a message - "I am competent, I am caring, I am trustworthy; and, I can and I will lead." If used properly, the CIRS will help ensure that this message is sent and received.
The final reason for using a CIRS involves the commitment and the sacred trust that is command, all of which spring forth from a core set of values, a body of profound knowledge, and a genuine desire to lead, a calling, if you will. Command is not for careerist ticket-punchers but for those who are eager and able to place the greater good before themselves. In other words, the honorable. They seem to live by the words of US Army psychologist Major (Dr) Katherine Platoni, "Every leader must persevere in developing the courage of conviction to stand up for and to abide by what is morally right. Situations, circumstances and consequences of any actions must never allow for compromise. Our lives, our humanity, are otherwise at stake."4 Indeed!
Demographics
Much of this section is self-explanatory, but very important nonetheless. The information should be as complete as it possibly can be.
First and foremost, it is necessary to identify exactly what requires the implementation of the CIRS. It need not be an earth-shaking event and may, in fact, be somewhat routine, such as a DUI. It also need not necessarily be an incident, but simply certain knowledge that, when carefully evaluated, should lead those in authority to pay particular attention or demonstrate concern. Once identified, rigorous and timely follow-through is crucial, until the matter is closed or the situation is resolved. This would require daily review of all open CIRS within a given unit by the commander personally. This is, realistically, the best insurance against the proverbial "ball being dropped."
Although identification is the obvious first step in utilizing a reporting system, it is of little use if the necessary follow-up is not performed. Management, simply stated, is doing whatever needs to be done to increase the likelihood, in so far as is possible, of a favorable outcome. This is much easier said than done because management activities frequently involve an inordinate amount of work, can be exhausting, and may be unpleasant or uncomfortable.
This section of the CIRS should, at minimum, answer the basic questions of reportage: Who, what, when, and where. It forms the foundation for the course of action, if any, to be taken. It should be multi-source and involve interview data, pertinent documents such as police reports, and any related history that may be considered significant.
A commander should actively seek, and expect, expert advice from his or her consultants. This section should begin with asking the question "Should I speak to any of the experts available to me about this situation?" And if so, "What are my questions?" Many people in positions of authority appear guided by the "three ironclad rules:"5
Those who live by these "rules" are asking for trouble. Some of the most frequently needed types of evaluations are legal, medical, psychological, and family advocacy. One might also consider consulting with their own commander in certain situations. It is important to fully document the consultation; what was asked of whom, when it was asked, and what their opinion was.
Recording all referrals in detail is considered essential. This should include how the referral was made (e.g., phone call, and if so, by whom and to whom?, etc); to whom the referral was made (i.e., an agency? an individual within an agency? who?); and if follow-up was required (and if so, when and by whom?).
It is a serious mistake to neglect researching this topic. Much of the guidance we are expected to follow has the force of law or is based on public law (The Boxer Amendment, for example, became Public Law, then DOD Directive, then a separate regulation for each service and now determines how commanders and mental health officers arrange for and conduct psychological evaluations).6 There is existing guidance, usually partial, however, on many, if not most, situations that may arise. Some examples include: Threats against the president; endangered airmen; illicit drug use; alcohol abuse; commander directed mental health evaluations; child abuse; marital violence; and so on. Less clear situations, such as helping the family members of the deployed, require special vigilance, rigorous application, dedication, and creativity on the part of supervisors, first sergeants, and commanders.
Does the situation or event require notifications? Certainly all required notifications should be made promptly, and would usually involve the MAJCOM, Wing, Family Advocacy Officer, etc. However, in some instances notifications may not be required but may simply be considered astute. There are some situations in which the risk of adverse outcome is so great or the consequences so severe that only a fool would not notify appropriate others. One example of this that comes immediately to mind is when a situation involves the risk of death or serious injury to a child. It is imperative to involve others in such circumstances. The benefits of this are at least two-fold; first, augmentation of your own efforts by concerned and professional others and, secondly, if something does happen and you did not ethically involve others you may find yourself being fixed with the blame, fairly or unfairly.
There is, for good reason, wide latitude in the use of this final information category. No form can possibly capture the complexities and multiple factors inherent in a large number of the potential situations faced by commanders. However, an attempt must be made to determine, and then record, if indeed there are any unique or other relevant circumstances that command should know about. An example may be the medical history of the young dependent wife who died in her home while her husband was deployed.
Military command is one of the greatest challenges there are. We live in a time of increasing accountability and of growing complexity of issues faced by commanders. Risk assessment is becoming a more and more fundamental aspect of leadership. We need to recognize this and evolve and adapt the tools with which we accomplish our mission. And not just the hardware. The CIRS is an attempt at developing such a tool, a tool for today's potentially risky command environment. We are obligated to use all reasonable and available means to accomplish our mission. The CIRS, properly used, will help ensure this happens.
1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, DC: Author, 1994), 424-29.
2. Tom Peters and Nancy Austin, A Passion for Excellence (New York: Warner Books, 1985), 323.
3. Mark Holden, "Standards and Accountability - One Without the Other?" Military Psychology Bulletin, (in press).
4. Katherine T. Plutoni, "The Quest for Ethical Leadership in Military Medicine," Military Medicine 159, no. 2 (February 1994): 169-171.
5. William C. Byham with Jeff Cox, Zapp! 7he Lightning of empowerment (New York: Fawcett Columbine, 1988), 34.
6. DOD Directive 6490.1, 14 Sep 93; AFI 44-109; AR 8-240; & NAVMED P-5105.
| Name | Rank | SSN | DOB | ||
| Marital status | Tour status | Dependents | |||
| Other: | |||||
| Critical incident or situation: | |||||
| Consultations: | |||||
| Referrals: | |||||
| Applicable directives and instructions: | |||||
| Notifications: | |||||
| Special circumstances: | |||||
| Follow-up: | |||||
| Name of person(s) completing this CIERS form: | |||||
| Date initiated: | Date completed: | ||||
| Signature | Signature | ||||
Disclaimer
The conclusions and opinions expressed in this document are those of the author cultivated in the freedom of expression, academic environment of Air University. They do not reflect the official position of the US Government, Department of Defense, the United States Air Force or the Air University.
This article has undergone security and policy content review and has been approved for public release IAW AFI 35-101.
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