Applying the Outdoor Accident Matrix to Fire Ground Operations (Part 2)
By: Mark vonAppen
Palo Alto Fire Department/ Nobody Gets Left Behind Training
"Be prepared and be honest."
-John Wooden
Potentially Unsafe Acts As a group, fire fighters are thrill seekers- this is why we engage in activities in our personal lives that continually stimulate our need for excitement. Skiing, mountain biking, sky- diving, and free diving are a few of the activities that involve risk that some of my fire fighter brothers and sisters take part in. Thrill seeking is part of what drew us to become fire fighters- we feel more alive as we perform some of the more dangerous aspects of our job because we are in a heightened state of arousal. Gonzales writes, “As we grow older, especially in an environment that is contrived to be (or seem) safe, there is less novelty. More and more of the world becomes interpreted and categorized and falls into the background. Time seems to speed up. As people age, the years seem to fly by, partly because there isn’t a lot that’s new. 
It’s also why we go to new places, why we seek out novelty and excitement. When you go to the wilderness or an exotic land, what you’re implicitly saying is, ‘Surprise me.’ Seeking novelty and surprise, doing what you’re not used to doing, is a prescription for triggering that ancient perceptual richness that helps us to live more fully.“
The drive for excitement and the accompanying emotional pay off is also what leads us at times to exceed an acceptable level of threat and assume undue risk. When we are rewarded with a rush of emotions- feeling good, after successfully completing a dangerous task on the fire ground, we book mark the experience as positive. We continually seek the emotional reward brought on by previous successes and might miss important cues about the constantly changing environment. The sentiment that the fire ground is something contrived, almost too familiar is an extremely dangerous place. Fire is an indifferent force that will punish inattention and arrogance. We must be at once bold and humble.
Peter Leschak, the author of “Ghosts of the Fire Ground” says this about the fire ground and his attitude toward it. “There is a core of mystery and faith that has guided not only my career but also, my life. To me, the fire ground is a sacred locale, a place of power that is rich not only in tradition and history, but also in sources of emotion, and meditations that I can only describe in terms of reverence and awe.”
Inadequate Protection
In Texas, a line of duty death report (LODD) from 2003 where a Lieutenant was struck and killed by a car while providing aid to a person involved in a motor vehicle accident contained the following information:
“(Fire fighter) was not wearing any personal protective equipment (PPE) at the time of the incident. He was wearing a red fire department tee shirt, blue pants, a red baseball cap, and leather boots. (Fire fighter) was not wearing any reflective equipment when the incident occurred. He was not carrying a flashlight. A safety vest with reflective tape was found in his personal vehicle parked at the scene.”
The lack of personal protective equipment was not the direct cause of death for this fire fighter, getting struck by a car was- but lack of PPE was certainly a contributing factor. The accident occurred at night, in foggy conditions. Wearing PPE with the required reflective trim may have prevented this LODD.
The United States Fire Administration (USFA) has been working to enhance the operational safety of emergency responders on the highways.
Inadequate Instruction
The scope of preparing recruit fire fighters is enormous, as is the scope of the fire service. The fire service has become the all-risk entity in which we are the ones people call for help when there is no one left to call. In an effort to meet the all-risk model, during recruit training fire departments are forced to pack overwhelming volumes of information into a short time period. Recruit fire fighters are subjected to weeks of specialized training to meet the changing face of threats in the world today.
The broad- spectrum approach to fire ground preparation by some fire departments is turning out fire fighters that are not particularly skilled in the areas that are critical to basic personal fire ground safety and overall incident mitigation. New fire fighters often receive exotic, specialized training at the expense of simple but vital foundation skills such as hose lays, forcible entry, and survival training. A large number of recruits show up for their first day of duty and are lacking in very important basics. The end result is a recruit who has received a lot of training that looks good on paper but has little practical application.
These fundamental skills, this foundation, if not engrained early on, may be forever lost. Basic skills must be reinforced through explanation, demonstration, correction and repetition. John Wooden, the legendary basketball coach from UCLA asked, “If you don’t have time to do it right, when will you have time to do it over?”
Inadequate Supervision
A pair of LODDs from California in which a Captain and an Engineer were killed during a flashover event contained the following information. “There was a failed attempt to pass command by the first- in Company Officer. There was no clear announcement by (the Battalion Chief) that he was assuming command. Companies engaged in independent action.”
This LODD report in no uncertain terms says that for the critical early stages of this fire, there was no command and control. Companies acted in a manner that they deemed appropriate based upon their interpretation of the environment- but did not coordinate their actions, resulting in the death of 2 fire fighters. Strong supervision, utilizing common fire ground terminology is key to safe operations.
A NIOSH LODD report from Layton City, Utah contained the subsequent recommendation, “Ensure the Incident Commander be clearly identified as the only individual responsible for the overall coordination and direction of an incident.” Similarly, NIOSH reports often cite lack of a unified command and lack of common fire ground terminology as a link in the error chain.
Unsafe Speed
In Nevada, an engine and a ladder company were responding to a report of smoke in an apartment complex. The route of travel to the incident included a section of freeway. The exit ramp from the freeway to the surface street near the reported fire had a posted speed limit of 25 mph. As the engine traveled through a right-hand curve on the exit ramp at 45 mph, the engineer lost control of the vehicle. The apparatus fell onto its left side and slid approximately 50 yards into impact absorption barriers. The ladder company responding with the Engine was less than a minute behind the engine and provided immediate treatment to the injured fire fighters in the engine.
The engineer was the only member of the four-person crew that was wearing a seat belt. The fire fighter seated behind the officer fell onto the fire fighter riding behind the engineer. The fire fighter seated behind the engineer was held in place by his partially donned SCBA. These fire fighters received minor injuries.
The Captain tumbled over the center hump in the front of the cab and landed on the engineer. The engineer sustained a broken nose and facial injuries. The 39-year-old Captain suffered a spinal cord injury and was left paralyzed from the neck down. The engineer was charged with driving too fast for conditions. A law enforcement report on the incident estimated the speed of the apparatus prior to the crash at 45 mph. The reported apartment fire to which the units were responding proved to be a false alarm.
All apparatus occupants must wear their seat belts at all times when the vehicle is in motion. In this incident three of the four occupants were not wearing seat belts at the time of the collision. All three of these occupants received injuries because of their failure to wear seat belts and the engineer, who was wearing a seat belt, was injured when the unbelted Captain fell on top of him when the apparatus turned over. The Captain received life-altering injuries as a result of his failure to be properly belted in.
Operate the apparatus at a safe and cautious speed at all times. The police investigation determined that the apparatus entered the curve on the exit ramp at a minimum of 20 mph above the posted speed limit. Keep in mind that these posted speed limits are determined based on the safe speed of a passenger vehicle operating on a dry road surface. Even the posted speed limit may be too fast for a fire apparatus.
Part 3 of this article will appear in the next TAK Response newsletter.
About the author:
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.
Related Article: Applying the Outdoor Accident Matrix to Fire Ground Operations (Part I)
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.
Related Article: Post-Blast Response to Explosions
Post-blast (or post-detonation) response takes place after an explosion has occurred. An explosives event has the potential to overwhelm first responders because of the large number of victims and fatalities and the extensive property destruction.
Related Article: Team Situation Awareness: An All Hands Approach to Safer Fire Ground Operations
Have you ever watched a really efficient fire company in action? Have you ever wondered how a crew can move almost effortlessly through an evolution with little apparent communication and few breaks in the routine? A group of 2 to 5 people acting as one, accomplishing all assigned tasks at maximum efficiency. Well-scripted and choreographed fire ground operations do not happen by accident. Strong fire ground performance is the combination of communication (both verbal and non verbal), dedication, mentoring, and training all of which culminate in a shared understanding of what each of the crew members responsibilities are, how they interrelate, and anticipating future actions. This is also known as Team Situation Awareness (TSA).
Related Article: What the Fourth of July means to America's Firefighters
Allow me to comment briefly to you, my fellow brothers and sisters, on what I believe to be the importance of July 4th to the American fire service. As firefighters, community leaders, and as the recipients of a sacred inheritance due to the incredible efforts and toil of the world's bravest and brightest men and women, we few lucky sons and daughters of liberty preparing to celebrate the most important social moment of all time—July 4th—should reflect on what this holiday truly means.
Related Article: ICS for House Fires
We should expect the command of fires to improve over the years. There are countless workshops, videos, books, certification tracts, etc, relating to command. That being said, we seem to struggle. Command officers from the same department often have completely different (and sometimes opposing) styles, opinions, and philosophies on fire command.
Related Article: The Training Dynamic of Today's First Responders
No one will argue against a trained and competent force of first responders. It is virtually the only “product” that emergency services provides and a solid program of training and education is a priceless commodity. I recently retired from the fire service after a 34 year career and have made a few observations about the type, method and intensity of training programs, especially in today’s climate of smaller government and reduced services.
Related Article: Avoid Getting Sidetracked; Always Do a 360 with a Thermal Imager
I was recently sitting in on Dave Dodson's class on the art of reading smoke and I noticed something. There were no Police Officers in the class. This on it’s own is not remarkable. After all, this was a smoke reading class. As I reflected on every fire department class I had ever attended in my 12 years of service a trend emerged.
Related Article: You Must Always Evaluate the Fire's Potential
One of the most imperative responsibilities of the company officer in a wildland incident is to quickly and constantly evaluate the potential of the fire. This critical function is the foundation upon which crew safety and tactical success is built. Although this appears to be a relatively simple concept, the complex interaction of wildland fire behavior variables, yielding incident specific fire behavior, cannot be underestimated.
Related Article: Situational Awareness
Although the upcoming 2010 wildland fire season is still months away it is never too soon to begin preparing, especially mentally. As you all know well preseason intellectual preparation could easily be consumed with repetitive review and recital of the litany of checklists and acronyms related to firefighter safety. Repetition is an important part of training, both mental and physical, however repition alone does not replace the basic skill of solid situational awareness.
Related Article: Survivability Profiling: Are the Victims Savable?
This is it—the one we all think about, the one we train for every day but hope never happens: Your department is called out in the early morning for a structure fire. While you are responding, the dispatcher gives you additional information, “Multiple calls with trapped occupants.”
Related Article: Have A Good Shift!
Every day we say to each other, “have a good shift”, let’s see if we can back that statement up so everyone goes home safe. It seems that the emphasis in training is on “Back to the Basics” and “Firefighter Survival”. This is appropriate considering that each year we lose 100 or more Firefighters. These are; fathers, mothers, husbands, wives, brothers, sisters and someone’s child or friend.
Related Article: 'Once More Unto the Breach'
Firefighter Line of Duty Deaths (LODDs) fell below 100 for the first time in 15 years in 2009. This is a tremendous milestone in our industry. Focusing on fire fighter safety has been a big priority over the last decade or so, and we have made some tangible progress of late. The ability to point to a drop in fatalities from 118 in 2008 to 93 in 2009 is no doubt a significant advancement.
2010 NEWS
Click the community links below to read the latest in first responder news
TACTICAL LAW ENFORCEMENT
FIREFIGHTING
EMS/MEDICAL
DISASTER
HOMELAND SECURITY
SPECIAL OPERATIONS
SAR
EMERGENCY NURSING
WILDLAND FIREFIGHTING
NEWSLETTER ARCHIVES