Applying the Outdoor Accident Matrix to Fire Ground Operations (Part 1)
By: Mark vonAppen
Palo Alto Fire Department/ Nobody Gets Left Behind Training
“Fire is an indifferent force that will punish inattention and arrogance.”
Fire fighters of yesterday were not required to perform the wide variety of skills that fire fighters of today are expected to be experts in. Fires in the 21st Century develop much more rapidly and are far more dangerous than fires of just 20 years ago. The fire ground has changed, and we must adapt with it. A United States Fire Administration study contained the following conclusion. “Approximately half of all line of duty deaths (LODDs) from 2000- 2005 are attributable to factors that are under the direct control of the individual firefighter or Chief Officers.” Knowing that a great number of fire ground tragedies are under the direct control of fire fighting personnel at the scene means that we need to apply different concepts to suppression operations in order to meet our number one incident priority, life safety. Better stated, the number one incident priority is responder life safety.A collective theme in near- miss reports is a lack of fundamental fire fighting skills. Commonly cited as a reason for the lack of these skills is the overall decrease in the number of fire emergencies that fire fighters respond to annually. While it is true that the number of fires has decreased of late, the total number of injuries and deaths has remained relatively static. Statistically, injuries and deaths are up when compared to the number of fires to which we respond. Fires in the past were of greater number, thus the larger possibility to perform on the job training. The fires were still a risky undertaking but fire fighters of 30 years ago went to a few more fires than we do today making it a more high- frequency, high- risk skill. 
“Potential causes for accidents in outdoor pursuits” is a matrix designed and copyrighted by Dan Meyer in 1979. The matrix identifies how accidents occur based upon three categories- potential unsafe conditions, potential unsafe acts, and potential errors in judgment. All three categories identify contributing factors that lead up to an accident. The concept of the matrix is to improve outdoor safety in hiking, camping, and climbing by examining accidents in these leisure activities so that those who read it may gain insight as to what befell others who preceded them and thus, not make the same mistake(s). Many of the causes identified in the “Accident Matrix” can carry over to fire ground operations and can affect our safety and performance in a positive way if we are mindful of these factors and apply them to suppression operations.
POTENTIAL CAUSES OF ACCIDENTS IN OUT DOOR PURSUITS
A matrix designed by Dan Meyer (1979) and edited by Jed Williamson (1989-2008) ©
Potentially Unsafe Conditions Due To:
• Falling Objects (Rocks, etc)
• Inadequate Area Security (Physical, Political, Cultural)
• Weather
• Equipment/Clothing
• Swift/Cold Water
• Animals/Plants
Potentially Unsafe Acts Due To
• Inadequate Protection
• Inadequate Instruction
• Inadequate Supervision
• Unsafe Speed (Fast/Slow)
• Inadequate or Improper Food/Drink / Medications
• Poor Position
Potential Errors in Judgment Due To:
• Desire to Please Others
• Attempting to Adhere to a Schedule
• Misperception
• New or Unexpected Situation (Includes Fear and Panic)
• Fatigue
• Distraction
• Miscommunication
• Disregarding Instincts
• Physical/Psychological Profile
• Unauthorized/Improper Participants and/or Procedure
Potentially Unsafe Situations
In the fire service, every incident to which we respond has its own unique and potentially ominous set of circumstances. In Laurence Gonzales novel, “Deep Survival” he writes of common factors that exist among survivors involved in various disasters throughout history. He writes, “There are things (on the fire ground) that you can control, so you had better be controlling those things at all times.” Certainly, we cannot control everything that happens on the fire ground because sometimes- bad things do just happen. There are times despite our best efforts that unfortunate incidents will occur.
Many recognized risk management experts attempt to apply the simple risk management model to fire operations stating that accidents are predictable and thus, preventable. The concept is to anticipate where an incident is headed based upon the current situation, forecasting conditions and basing actions upon model projections. This risk management model is a useful starting point but has limitations. Problems arise when reality does not match the plan. Predictable is not always preventable- predictable means that things are proceeding as expected. Forces of nature- specifically fire, can sometimes progress with a swiftness that our minds cannot comprehend. We would be naïve to reduce our battle ground to such a simple concept- if it were that uncomplicated nobody would ever get injured or killed. The fire ground is such a complex and dynamic system with so many variables that not every possible occurrence can be scripted. Additionally, the fire ground does not adjust the level of complexity to match the level of skill possessed by fire fighters at the scene. From the recruit to the veteran, all fire fighters face the same level of risk. John Dryden said, “No one can possibly know what is about to happen; it is happening each time for the first time and the last time.” The inherent dangers of the fire environment cannot be calculated away. Risks can however, be mitigated if we approach incidents with informed caution rather than blind commitment to duty. By doing so, we stand a greater chance of survival.
We cannot know exactly how everyone on an emergency scene will perform because each person has a different interpretation of their surroundings and what their role is in the system. Standard Operating Guidelines (SOGs) can assist in this area- but SOGs are reliant on perceptions and interpretations by individuals to be implemented as intended. Accidents often happen because everyone has a unique perspective on the environment and each makes different decisions based on their perception. John F. Kennedy said, “There is always some son of a bitch who doesn’t get the word.”
We must perceive the environment correctly in order to ensure we make the right move. If actions are not communicated and coordinated in the intricate system that is the fire ground- accidents are the inevitable and regrettable results.
Falling Objects
One of the first reasons for accidents identified in the matrix is falling objects. In the matrix, this would typically apply to rocks or logs falling on hikers or climbers as they enjoy their chosen activity. Falling objects have injured their share of fire fighters over the years. In August 2010, six fire fighters were injured, four critically, in a building fire and collapse on Detroit’s east side. The fire was reported to be suspicious.
From the Detroit Free Press, “Four Detroit firefighters who were injured when a burning building collapsed remained hospitalized as the ATF joined an investigation into the suspicious blaze. A prayer vigil for the victims was held at the scene of the fire Sunday night.
Two of the firefighters remained in critical condition Saturday, a fifth firefighter was treated and released from a hospital after Friday's fire.”
We all know apparatus and hose line placement are extremely important- the rule of thumb for collapse zone safety is, one and a half the height of the building. Read the situation and adapt to reality. Be vigilant of construction features that contribute to collapse- respect building construction.
Inadequate Security
Emergency medical service (EMS) responses are perceived as high frequency, low risk endeavors. If one examines close call reporting across the nation it can be noted that first responders from time to time are the victims of violence at EMS responses. The accident matrix lists inadequate security as a cause for accidents in the outdoors due to physical, political, or cultural reasons.
Uncooperative patients are most often the cause of unsafe scene conditions on EMS runs. A headline from a Los Angeles newspaper in May 2010 read “LA fire fighter attacked; stabbed on the job.” The LA fire fighter paramedic had been attacked on an EMS response and stabbed 3 times. In July 2010, four EMTs were attacked on an EMS call in New Jersey by a patient who had taken PCP. The EMTs suffered minor injuries ranging from bruises to bites. In August 2010 a report from firefighterclosecalls.com read, “An elderly man who apparently thought someone was breaking into his home fired two shots at Chicago Fire department personnel who were checking on his well being early Wednesday in the Woodlawn neighborhood on the South Side.”
A lot of focus has been placed on situation awareness in the fire service of late, if a situation does not appear or “feel” secure for any reason, trust your instincts and call for law enforcement to secure the scene prior to committing.
Weather
The first of the 10 Standard Fire Orders reads, “Keep informed on fire weather conditions and forecasts.” Weather is a prominent contributing factor in accidents in both the fire service and in outdoor endeavors. As fire fighters we must be aware of weather conditions as they pertain to wild land fires. We must also be aware of weather conditions when fighting structure fires as well- a number of fire fighters have been seriously injured or killed over the years due to wind driven events inside of structures.
The National Institute for Standards and Testing (NIST) recently performed studies in conjunction with the Fire Department of New York (FDNY) and the Chicago Fire Department regarding wind driven fires in structures. The study shows that fire behavior in a structure can be extremely unpredictable in areas subject to high winds.
A NIOSH report from Texas involving the deaths of 2 career fire fighters reads, “Shortly after midnight on Sunday, April 12, 2009, a 30-year old male career probationary fire fighter and a 50-year old male career captain were killed when they were trapped by rapid fire progression in a wind-driven residential structure fire. The victims were members of the first arriving company and initiated fast attack offensive interior operations through the front entrance. Less than six minutes after arriving on-scene, the victims became disoriented as high winds pushed the rapidly growing fire through the den and living room areas where interior crews were operating. Seven other fire fighters were driven from the structure but the two victims were unable to escape. Rescue operations were immediately initiated but were suspended as conditions deteriorated. The victims were located and removed from the structure approximately 40 minutes after they arrived on location.”
Equipment/ Clothing
Bunker gear has been the subject of much debate since it became the standard for even some of the most steadfast holdouts in 1995. Much of the nation had already switched to bunker gear from the older, traditional ¾ boots and long coats when FDNY made the conversion in mid 90’s. The change was not without criticism.
Critics charge that while the bunker gear has allowed firefighters to go deeper into fires and remain inside longer, the added weight, stress and increased body temperature are taking a toll on the hearts of the fire fighters. A report from 2001 regarding the conversion to bunker gear by FDNY contained the following, ”Fire Commissioner Thomas Von Essen defended the use of heavy protective bunker gear after a 42-year-old member of the Bravest became the third firefighter to die of a heart attack in three months. ‘There are definitely negatives to bunker gear," Von Essen told The Post. "You get tired sooner because of the weight of the gear, [and] exhaustion comes on more quickly, but the tradeoff is the unbelievable protection you get.’"
Heart attack is the number one cause of death for fire fighters. An increase in body temperature places an additional strain on the heart to pump greater volumes of blood to the skin to promote heat loss to the environment. So, although bunker gear offers greater protection it places firefighters at greater risk of succumbing to heat illness.
Bunker gear masks heat to the point that fire fighters can operate in extreme temperatures for minutes without feeling it. Bunker gear can give a false sense of security, allowing fire fighters sometimes to go farther in than is safe. Is it better to push deeper into fires and stay in longer? If we push our safety gear to its performance limits are the people we are attempting to save viable? If true risk management is applied the answer overwhelmingly would be no. This is not an argument against bunker gear, far from it. A 70% decrease in burns at FDNY in the first year of issuance of bunker gear speaks volumes about the merits of full encapsulation. Rather, it is a call to be smarter in our approach to how far we are willing to thrust ourselves into structure fires. Our job is to mitigate hazard- a large part of that is limiting our exposure to risk.
Mark vonAppen has been a fire fighter for the City of Palo Alto since 1998. He is currently assigned to the Palo Alto Fire Department Training Division and is a fire fighter on the Ladder Company. He is a committee member for California State Fire Training and has contributed to the development of Fire Fighter Survival and Rapid Intervention curriculums. Mark is an Academy instructor for the Santa Clara County Joint Fire Academy, Recruit Instructor for Palo Alto Fire, and a member of the ‘Nobody Gets Left Behind’ training group. He has been involved in training and public speaking for 6 years. Mark is also lead instructor for ‘Read and React: Calling the Mayday’ which was featured in the California State Training Officers Symposium Fresno in 2009/ 2010 and is offered at the TAK Response Conference in September 2010.
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