Archive for the ‘Random Thoughts’ Category

Applying NIOSH Recommendations

NIOSH Death in the Line of Duty reports generally contain two types of recommendations, those that focus on specific contributory factors and others that address general good practice. As when examining contributory factors, it is important to read the NIOSH recommendations critically. Do you agree or disagree and why? What would you change and what additional recommendations would you make based on the information presented in the report?

Brief Review of the Incident

NIOSH Report F2008-06 examines a fire in a wood frame duplex that resulted in injury to Lieutenant Scott King and the death of Firefighter Brad Holmes of the Pine Township Engine Company. The fire occurred on February 29, 2008 in Grove City, Pennsylvania.

When the fire department arrived, the unit on Side D was substantially involved and a female occupant was reported trapped in the building. Initial operations focused on fire control and primary search of Exposure B. Rapid fire development trapped Lieutenant King and Firefighter Holmes while they were searching Floor 2 of Exposure B.

The following photographs are part of a series of 37 pictures taken during this incident and provided to NIOSH investigators during their investigation.

Additional detail on this incident is provided in Developing & Using Case Studies: Pennsylvania Duplex Fire Line of Duty Death (LODD) and Pennsylvania Duplex Fire: Firefighting & Firefighter Rescue Operations . In addition, readers should review NIOSH Report F2008-06.

Recommendations

NIOSH Report F2008-06 contains 11 recommendations. Several of these recommendations are well grounded in the contributory factors identified in the report. Others have a more indirect relationship to the factors influencing the injury to Lieutenant King and death of Firefighter Holmes.

Recommendation #1: Fire departments should be prepared to use alternative water supplies during cold temperatures in areas where hydrants are prone to freezing.

In preparation for potential issues, fire departments should develop standard operating procedures (SOPs) for temporary water sources to be dispatched like tankers, water shuttles, or portable drop tanks.

While this recommendation is valid and good practice, it has little to do with loss of water as a contributory and likely causal factor in the injury to Lieutenant King and death of Firefighter Holmes. Had Command been notified immediately of the frozen hydrant and implemented alternate water supply strategies, the outcome would have likely been the same if tank water had been used as it was in this incident to sustain initial operations.

However, it is critical for fire departments to have a plan to respond to respond to water supply problems. In this case, apparatus had substantial tank water which was used to support initial firefighting operations. In addition, there was sufficient hose available on first alarm companies to stretch to other hydrants (such as the one eventually used east of Garden Avenue on Craig Street). Use of a reverse lay to establish water supply allows the apparatus operator to continue the lay to the next hydrant (hose capacity permitting) or another apparatus to continue the lay and establish a relay. Depending on the distance to the next operational water source, this could be considerably more efficient and rapid than waiting for greater alarm resources to establish a tender shuttle.

Recommendation #2: Fire departments should ensure that search and rescue crews advance or are protected with a charged hoseline.

This recommendation is critical. However, the discussion fails to speak to the need for backup lines to protect the means of egress when crews are working above the fire. Recent incidents in Loudoun County, Virginia and Sacramento California, resulted in crews with a hoseline working above the fire without a backup line having their hose burn through, and means of egress cut off, necessitating emergency egress via second floor windows.

Recommendation #3: Fire departments should ensure fire fighters are trained in the tactics of a defensive search.

While training in search under marginal circumstances is important, this recommendation fails to speak to the need to understand fire behavior and applied fire dynamics as a foundation for maintaining situational awareness on the fireground. This applies to command personnel, company officers, and individual firefighters. While there are a number of points in the sequence of events that lead to Lieutenant King’s injury and Firefighter Holmes’s death, all are dependent on this. Failure to recognize the potential for extension and rapid fire progress, the influence of creating ventilation openings on Floor 2, and recognition of developing fire conditions were likely the most significant causal factor in this incident. Had this not been the case, the firefighters and officers involved would have had the opportunity to adjust their tactical operations or exit the building prior to the occurrence of the extreme fire behavior that trapped the search team.

NIOSH Report F2008-06 quotes Deputy Chief Vincent Dunn regarding flashover indicators:

There are two warning signs that may precede flashover: heat mixed with smoke and rollover. When heat mixes with smoke, it forces a fire fighter to crouch down on his hands and knees… As mentioned above, rollover presages flashover.

This statement is scientifically incorrect. Heat is simply energy in transit due to temperature difference. It is not a substance and cannot mix with anything else. Increasing temperature is an indicator of potential for flashover, but perception of a rapid increase in temperature is not certain to give adequate warning to take corrective action or escape from the hazardous situation. In addition, rollover does not always precede flashover (it is an important indicator, but only one of many).

The report also quotes Chief Dunn regarding defensive search tactics.

Three defensive search tactics are as follows:

1. At a door to a burning room that may flashover, fire fighters should check behind the door to the room and sweep the floor near the doorway. Fire fighters should not enter the room until a hose line is in position.
2. When there is a danger of flashover, fire fighters should not go beyond the “point of no return.” The point of no return is the maximum distance that a fully equipped fire fighter can crawl inside a superheated, smoke-filled room and still escape alive if a flashover occurs. The point of no return is approximately five feet inside a doorway or window.
3. When searching from a ladder tip placed at a window, look for signs of rollover if one of the panes has been broken. If rollover is present, do not go through the window. Instead, crouch below the heat and sweep the interior area below the windowsill with a tool. If a victim has collapsed there, you may be able to crouch below the heat enough to pull him to safety.

While these tactics have validity, making for search without without protection of a hoseline even to Chief Dunn’s “point of no return”� presents a significant risk. Further, I am uncertain that there is any scientific evidence supporting the concept of the point of no return as described by Chief Dunn. There are numerous examples of situations where firefighters thought they had time to complete a search, but were trapped by extremely rapid fire development. The risk of searching under marginal conditions requires firefighters to effectively read the fire and mitigate hazards in the fire environment through effective use of gas cooling and control of the ventilation profile (either tactical ventilation or anti-ventilation as appropriate) and establishing fire control in addition to primary search.

Recommendation #4: Fire departments should ensure that fire fighters conducting an interior search have a thermal imaging camera.

The thermal imaging camera is a tremendous technological innovation which can significantly speed search operations and provide visual indication of differences in thermal conditions. However, implementation of this recommendation would not necessarily have impacted on the outcome of this incident.

Recommendation #5: Fire departments should ensure ventilation is coordinated with interior fireground operations.

In the discussion of this recommendation, the NIOSH Report F2008-6 states “By eliminating smoke, heat, and gases from the fire it will help minimize flashover conditions”�

This statement is not always true. The influence of ventilation on fire development is dependent on burning regime (fuel or ventilation controlled) and the location of the inlet and exhaust openings. Heat release rate from a ventilation controlled fire will increase as ventilation is increased, potentially taking the fire to flashover (rather than the reverse as indicated by the statement in this NIOSH report). In addition, creation of an air track that channels the spread of hot gases and flames to additional fuel packages can result in fire extension and subsequent flashover. Both of these factors were likely to have been significant in this incident. Coordination of ventilation and search or ventilation and fire attack (as frequently stated in NIOSH reports related to incidents involving extreme fire behavior) requires knowledge of fire dynamics and the influence of ventilation in fire behavior.

Recommendation #6: Fire departments should ensure that Mayday protocols are developed and followed.

This recommendation is important, but fails to address other individual level survival skills that must be integrated with these procedures. For example, in this incident, the Lieutenant and Firefighter might have been able to take refuge in one of the bedrooms, closing the door to provide a barrier to hot gases and flames. A ladder was initially placed to a window in the bedroom on Side B (in close proximity to the location where Firefighter Holmes was found). Ladders were subsequently placed to the bedroom windows on Side A. While it may have been difficult to accomplish this under conditions of extreme thermal insult, if developing conditions had been recognized soon enough (see my earlier observation on situational awareness), this may have bought critical seconds and allowed the trapped search team to escape or be rescued.

Recommendation #7: Fire departments should ensure that the Incident Commander receives pertinent information during the size-up (i.e., type of structure, number of occupants in the structure, etc.) from occupants on scene and that information is relayed to crews upon arrival.

Had the Incident Commander received more specific information from the occupants or law enforcement, this may have shifted focus in search operations as survivability in the original fire unit was doubtful. Despite this, the civilian casualty was later located outside the fire unit, behind the door in the front foyer that served both dwelling units.

Recommendation #8: Fire departments should ensure that fire fighters communicate interior conditions and progress reports to the Incident Commander.

This is a key element in maintaining situational awareness (on the part of the Incident Commander). However, it is equally important for Command to communicate with interior crews regarding conditions observed from the exterior or situations (such as water supply limitations) that will impact interior operations.

Recommendation #9: Fire departments should develop, implement, and enforce written standard operating procedures (SOPs) for fireground operations.

This recommendation focuses on general good practice, but is not tied to specific contributing factors related to the injuries and fatality that resulted in this incident. This type of recommendation should likely be included, but placed in a separate section so as not to dilute the focus on lessons learned.

Recommendation #10: Fire departments and municipalities should ensure that local citizens are provided with information on fire prevention and the need to report emergency situations as soon as possible to the proper authorities.

Recommendation #11: Building owners and occupants should install smoke detectors and ensure that they are operating properly.

If implemented prior to this incident, Recommendations #10 and #11 would likely have had a positive impact on its outcome, particularly with regards to the civilian casualty and the severity of conditions encountered by the firefighters.

However, these two recommendations do not go far enough. Citizens must also recognize the need for rapid egress and the value of closing doors to confine the fire and limit inlet of air required for continued fire development and increasing heat release rate.

Detailed Case Study

CFBT-US has developed a detailed case study based on this incident and the data contained in NIOSH Report F2008-06. Download the Grove City, Pennsylvania Residential (Duplex) Fire Case Study in PDF format.

Now What?

Over the last two weeks we have spent considerable time with a NIOSH Report F2008-06. NIOSH has completed 335 investigations during the first 8 years that this program has been in existence. 49 more investigations are pending. The information contained in these reports provides a vast reservoir of data that can be used to deepen understanding of your craft and improve decision-making and risk management skills.

Make a commitment to developing your expertise as a firefighter or fire officer in the new year and for the rest of your life. Look for the this logo (more information to follow)!

Have a safe and happy new year!

Ed Hartin, MS, EFO, MIFIreE, CFO

Exptertise

Knowledge and skill are critical to safe and effective performance during emergency operations and firefighters and officers who perform well on the fireground are respected by their peers. What does it take to develop a high level of expertise?

Believing that they are masters of their craft, some firefighters resist engaging in practice of basic skills such as door entry, nozzle technique, and hose handling (even when their demonstrated skill is far from proficiency). Others engage in this type of practice enthusiastically, serving as their own critic and identifying potential areas of improvement.

In the fire service, years of service is often perceived as a measure of experience. But is this really true? In The Making of an Expert, Ericsson, Prietula, and Cokely (2007) observe that “living in a cave does not make you a geologist. Not all practice makes perfect”�. Developing proficiency requires deliberate practice that focuses not on specific areas in need of improvement or development of new knowledge and skill.

Is Going to Fires Enough?

Can a firefighter or fire officer develop the knowledge and skills necessary for a high level of performance on the fireground predominantly from going to fires? Actual performance is important, but it is not sufficient.

Ericsson, Prietula, and Cokely (2007) use learning to play golf as an example of the need for deliberate practice. In the early stages of learning the game, players often begin by learning individual skills and then playing on the course. This generally leads to rapid development of a fundamental level of skill. However, additional time on the course will not necessarily lead to improved performance. Why?

You don’t improve because when you are playing a game, you get only a single chance to make a shot from any given location. You don’t get to figure out how you can correct mistakes. If you were allowed to take five to ten shots from the exact same location on the course, you would bet more feedback on your technique and start to adjust your playing style to improve your control.

Firefighting is similar, probationary firefighters spend considerable time practicing individual skills and learning to integrate them into the team context of company operations. However, after they leave the academy, how much time is spent in deliberate practice? Working on the fireground, you don’t get the opportunity for repetitive practice, and seldom have the opportunity to think about how to improve the effectiveness or efficiency of your work until after the fact. This often becomes even more difficult when individuals advance to the officer’s role.

Deliberate Practice

In his recent book Talent is Overrated: What Really Separates World-Class Performers from Everybody Else, Geoff Colvin (2008) explores the mystery of where great performance really comes from. This text provides a straightforward examination of current research on expertise the application of deliberate practice and examines how these concepts can be applied in a variety of contexts.

Colvin (2008) identifies that deliberate practice may involve activities specifically focused on performance improvement and practice that is integrated with actual work performance. He describes direct practice using three types of activity as models, music, chess, and sports.

• In the music model, you practice application of the skill and receive immediate feedback from a teacher or by reviewing a recording (audio or video) of your performance.
• The chess model involves examination of prior performance by others (i.e., studying the games of chess grand masters). In other domains such as business and the law, this model involves the use of case studies.
• Effective performance may include both physical and mental elements. The sports model involves conditioning. This is readily applicable to physical skills, but applies to cognitive demands as well. Conditioning in this case may involve developing a deeper level of knowledge or use of simulations to practice decision skills.

When applying the concept of deliberate practice to work activities it is important to identify your goals, what aspect of performance are you trying to improve. During work activity, pay attention to your performance. After the work feedback is critical. This may involve self-reflection, feedback from others, or preferably a combination of both.

Each of these approaches has direct applicability to the fire service. However, it is necessary to approach deliberate practice in an intentional manner by identifying areas of performance that can be improved and developing a plan that includes direct practice and integrates practice and work activity.

Coaching

We can’t necessarily improve our performance without help. Even highly accomplished performers have teachers, coaches, or mentors to help design practice programs, provide feedback on performance and help maintain the motivation and commitment necessary to continued improvement.

Teachers, coaches, and mentors are important to both individual and organizational performance. It is important to identify who will serve in this role as individual needs change and evolve as performance improves. What role do you serve; learner, coach, or (hopefully) both?

Time & Commitment

Developing expertise takes time and effort. World class performers in most any discipline generally need a minimum of 10,000 hours of intense training and practice before reaching that level. There are no shortcuts! It is difficult to develop and maintain the motivation and commitment to sustain this level of effort.

It is easy to look at our current performance level and think that we do quite well and take pride in our accomplishments. However, is this the best we can do? I would contend that good enough isn’t (good enough).

The greater the time invested in deliberate practice, the greater the improvement in performance. Be a student of your craft, seek out feedback, and work diligently to improve your performance.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Ericsson, A., Prietula, M., & Cokely, E. (2007, July-August). Harvard Business Review,, 85(7/8).

Colvin, G. (2008). Talent is overrated: What really separates world-class performers from everybody else. New York: Penguin Group.

Relevance, Quality, & Impact

The National Institute for Occupational Safety and Health (NIOSH) conducted a public stakeholder meeting in Chicago, IL on 19 November 2008 to hear input and recommendations on the Firefighter Fatality Investigation and Prevention Program. Dr. Christine Branche, Acting Director of NIOSH opened the meeting by emphasizing that this program must be relevant, have high scientific quality, and impact on firefighter health and safety. Dr. Branche requested the participants to review and provide input on Draft strategic Plan for the NIOSH Firefighter Fatality Investigation and Prevention Program.

Tim Firefighter Fatality Investigation Program Project Officer Tim Merinar and Dr. Tom Hales who manages the Cardiovascular Disease and Medical elements of the program provided a program overview and outlined future directions that were identified on the basis of the 2006 stakeholder meeting and other program review efforts. One key area was an increased emphasis on fire dynamics. NIOSH has taken some steps in this direction through staff training and recruitment of investigators with a fire service background. However, much more remains to be done!

Strategic Plan

Paul Moore, Chief of the Fatality Investigations Team provided an overview of the Firefighter Fatality Investigation and Prevention Program Strategic Plan. This plan includes strategic goals (top level goals that state a specific desired change), intermediate goals (activities that NIOSH believes should be taken by stakeholders), activity/output goals (statements of NIOSH program activities), and performance measures (metrics indicating progress).

I was encouraged by a number of the goals identified in the strategic plan related to reducing deaths and injuries associated with structural firefighting.

Strategic Goal 2: Reduce deaths and injuries associated with structural firefighting operations by 2015.

Intermediate Goal 2.1: Fire Service agencies and labor organizations will develop safety interventions based on fatality investigation findings.

Intermediate Goal 2.2: Fire departments will modify training, policies and practices based on investigation findings

These goals are a good starting point. However, if investigation findings do not clearly identify causal and contributing factors, accomplishment will be difficult.

One of the intermediate goals in this section was a bit more problematic.

Intermediate Goal 2.3: Standards setting agencies will modify standards that apply to the design, maintenance, operation, and training regarding fire fighter personal protective technology based on investigation findings.

What could be wrong with this? It sounds perfectly reasonable. It is, but it does not go far enough. Standards setting agencies such as the National Fire Protection Association (NFPA) develop standards for many aspects of our work, including those related to professional qualifications which frequently determine the content of fire service training programs. I believe that this goal should be expanded beyond personal protective technology to include professional qualifications and operational practices.

Some of the activity/output goals identified in the strategic plan were similarly encouraging:

Activity/Output Goal C: Seek peer and stakeholder input to improve the quality of products and impact of the program.

Performance Measure C.1: 75% of fatality investigation reports will be reviewed by external experts prior to finalization and 100% of other publications will be reviewed by peer and/or stakeholder reviewers prior to finalization.

Performance Measure C.2: Expert consultation and/or equipment testing will be sought on all investigations suggestive of personal protective technology malfunctions or failures.

Performance Measure C.3: Stakeholder input will be sought at least every two years through a public meeting and/or docket.

I would encourage NIOSH to examine the process by which they select peer or stakeholder reviewers for specific types of incidents to ensure the greatest technical expertise is brought to bear. In addition, it would be useful to expand Performance Measure C.2 to include more than equipment. In depth fire behavior analysis and in some cases fire modeling would provide extremely useful information to development of effective intervention strategies. Ongoing feedback from the stakeholder community is critical. However, the turnout at this meeting was disappointing with few stakeholder presentations outside those made by national fire service organizations such as the International Association of Firefighters (IAFF), International Association of Fire Chiefs (IAFC), IAFC Health, Safety, & Survival Section, and NFPA.

The strategic plan also spoke to the need to increase the fire service expertise of the NIOSH staff involved in firefighter fatality investigations.

Activity/Output Goal D: Increase the fire service expertise of FFFIPP personnel.

Performance Measure D.1: Each fatality investigator will take at least one fire service training course or attend a fire service conference specifically for training purposes annually.

Performance Measure D.2: Any announcements seeking to fill investigator positions will require previous fire service expertise in addition to occupational safety and health training and experience.

These are positive steps, but it would be useful to provide a bit more direction with regards to what type of fire service expertise should be developed. For example, if the investigators will be examining incidents involving structural firefighting operations, developing competence in fire dynamics and the impact of tactical operations would be a high priority. In considering the experience of potential investigators, it is essential to examine both the breadth and depth of that experience, particularly in relation to understanding of fire dynamics and influence of tactical operations on fire behavior.

Feedback on the Firefighter Fatality Investigation and Prevention Program Strategic Plan can be submitted until 19 December 2008 via e-mail to niocindocket@cdc.gov (attachments should be formatted in Microsoft Word). I would encourage all of you to take the time to review this document and provide your input on this essential program.

Continuing Concerns

My feedback on the limitations of NIOSH death in the line of duty reports dealing with incidents where fire behavior and/or limited understanding of fire dynamics were causal or contributing factors in line-of-duty deaths was well received. In addition, my observations were supported by several of the other stakeholders, most strongly by Rich Duffy, Assistant to the General President of the IAFF.

While constrained by limited resources, the NIOSH staff is committed to serving the needs of the nation’s fire service and truly desires to provide quality information that is relevant, and most importantly has a positive impact on firefighter safety and health.

I will continue my efforts to ensure that this becomes a reality in fire behavior related incidents.

Ed Hartin, MS, EFO, MIFireE, CFO

This post is a continuation of my feedback to the National Institute for Occupational Safety and Health that will be presented at the public stakeholder meeting conducted in Chicago, IL on 19 November 2008. My recommendations are presented in the form of an analysis of NIOSH Report F2007-29. This incident resulted in the death of Captain Kevin Williams and Firefighter Austin Cheek of the Noonday Volunteer Fire Department.

This post continues with discussion the NIOSH reports examination of the influence of ventilation in this incident and provides specific recommendations for improvement of the NIOSH Firefighter Fatality Investigation and Prevention Program.

Tactical Ventilation

The NIOSH report makes a general recommendation that “fire departments should ensure that properventilation is done to improve interior conditions and is coordinated with interior attack”� [emphasis added]. However, the report is misleading and fails to address key issues related to tactical ventilation, its effective application, and its tremendous influence fire behavior.

NIOSH Report F2007-29 indicated that positive pressure ventilation was initiated prior to the second entry by the initial attack crew (a significant difference from the information provided in the Texas State Fire Marshal’s report). However, no mention is made of any action (or lack thereof) to create an adequate exhaust opening for effective horizontal positive pressure ventilation. While advising that ventilation needs to be proper, it would be helpful to provide more specific guidance. Lack of an adequate exhaust opening prior to pressurizing the building has been a major factor in a number of incidents in which application of positive pressure resulted in extreme fire behavior such as ventilation induced flashover or backdraft. Positive Pressure Attack for Ventilation and Firefighting (Garcia, Kauffmann, & Schelble, 2006), Fire Ventilation (Svensson, 2000), and Essentials of Firefighting (IFSTA, 2008) all emphasize the importance of creating an adequate exhaust opening prior to application of positive pressure.

The NIOSH report pointed out that smoke pushed out the inlet and overrode the effects of the blower, but attributed this to the presence of an attic floor that interfered with vertical ventilation rather than the lack of an adequate exhaust opening for the initial horizontal ventilation.

The PPV fan and vertical ventilation had little effect due to an attic floor being installed. At 0231 Chief #2 had horizontally vented the window on the D side near the A/D corner.

In this incident, ventilation was being performed while the interior attack crew was already inside working. When the ventilation was completed, minimal smoke was pushed out of the vented hole but dark smoke pushed out of the front door, in spite of the fact that a PPV fan was set up at the front door. Note: The dark smoke pushing out the door indicated that the conditions were worsening and the vertical ventilation was not impacting the fire.

In addition, the report fails to note that the opening made on Side D near the AD Corner placed the attack team between the fire and an exhaust opening. As with lack of an adequate exhaust opening, this has been demonstrated to have the potential for disastrous consequences (see NIOSH Death in the Line of Duty F2004-02).

Floor Plan Illustrating the Position of Captain Williams and Firefighter Cheek

Texas State Fire Marshal’s Office Firefighter Fatality Investigation Report FY 07-02

Extreme Fire Behavior

Command ordered companies to abandon the building at 0234 hours using three air horn blasts as an audible signal. The NIOSH report indicated that heavy fire “continued to roll out the front door”� but it is unclear how soon this occurred after smoke conditions at the doorway changed.

NIOSH Report F2007-29 does not clearly identify that extreme fire behavior was a causal or even contributory factor in the deaths of Captain Williams and Firefighter Cheek. It simply states that they died as a result of smoke inhalation and thermal burns.

NIOSH Recommendations

NIOSH made six recommendations based on analysis of the incident in which Captain Williams and Firefighter Cheek lost their lives. Several of these recommendations focused on factors that may have contributed to these two LODD. These included radio communications equipment and procedures, accountability, rapid intervention, and the importance of mutual aid training. Two recommendations were more directly related to causal factors: The importance of ongoing risk assessment and use of proper and coordinated ventilation. However, these broad recommendations miss the mark in providing useful guidance in minimizing the risk of similar occurrences.

Ensure that the IC conducts a risk-versus-gain analysis prior to committing to interior operations and continue the assessment throughout the operation.

This statement is necessary but not sufficient. Size-up and risk assessment is not only the responsibility of the incident commander. All personnel on the fireground must engage in this process within the scope of their role and assignment. Understanding practical fire dynamics is critical to firefighters’ and fire officers’ ability to recognize what is happening and predict likely fire behavior and the influence of tactical operations. To effectively address this issue, NIOSH death in the line of duty reports must be explicit and detailed with regards to key fire behavior indicators observed, subsequent fire behavior phenomena, and the influence of the action or inaction of responders on fire development.

Fire departments should ensure that proper ventilation is coordinated with interior attack.

NIOSH Report 2007-29 focused on the ineffectiveness of the vertical ventilation, but failed to recognize the impact of the sequence of action (i.e. pressurization of the building and creation of exhaust openings), inadequacy of initial exhaust openings, and eventual location of exhaust openings in relation to the operating position of Captain Williams and Firefighter Cheek.

As with situational awareness, effective tactical operations are grounded in training, education, and experience. The incident commander and crews tasked with carrying out tactical ventilation must understand how these tactics influence the fire environment and fire behavior. As with size-up and risk assessment, this is dependent on an understanding of practical fire dynamics.

Other than indicating that ventilation must be coordinated with interior attack, the NIOSH report did not speak to fire control operations conducted during this incident. From the building floor plan and information presented in both the reports by NIOSH and the Texas State Fire Marshal, it appears that the fire was shielded and direct attack was not possible from the position of the first attack team nor the position reached by Captain Williams and Firefighter Cheek. The Fire Marshal’s report indicated that the initial attack team “penciled”� the ceiling to control flames overhead and experienced disruption of the hot gas layer and an increase in temperature at floor level.

Just as ventilation must be appropriate and coordinated with interior fire attack, fire control must also be appropriate and coordinated with tactical ventilation. Cooling the hot gas layer is an appropriate tactic to create a buffer zone and increase the safety of the attack team as they access a shielded fire. However, penciling (use of an intermittent application of a straight stream) the ceiling is an ineffective method of cooling the hot gas layer and results in excessive steam production. In addition, cooling the hot gas layer is not an extinguishment technique; it must be integrated with other fire control methods such as a direct attack on the seat of the fire.

NIOSH death in the line of duty reports must explicitly address the effect of tactical operations, particularly where effectiveness or ineffectiveness was a contributing or causal factor in the LODD.

The Way Forward

While this assessment has been quite critical of NIOSH’s investigation of traumatic fatalities involving extreme fire behavior, it is important to emphasize that with all its faults, the Firefighter Fatality Investigation and Prevention program is a tremendous asset to the fire service.

The following recommendations are made to further strengthen and improve the quality of this program and the utility of recommendations made to reduce the risk of firefighter line of duty deaths as a result of extreme fire behavior during structural firefighting operations:

• Emphasize the criticality of understanding fire behavior, causal factors in extreme fire behavior, and the influence of tactical operations such as fire control and ventilation.
• Increase attention to building, smoke, air track, heat, and flame indicators when investigating incidents which may have involved extreme fire behavior as a causal or contributing factor in LODD.
• Examine training in greater detail, with specific emphasis on fire behavior, situational assessment, realistic live fire training, and crew resource management.
• Provide fire behavior training to all NIOSH investigators to improve their understanding of fire development, extreme fire behavior phenomena, and the impact of tactical operations.
• Include a fire behavior specialist on the investigation team when investigating incidents that may have involved extreme fire behavior as a causal or contributing factor.
• Initiate investigations quickly to avoid degradation of the quality of information obtained from the individuals involved in the incident and other witnesses.

Ed Hartin, MS, EFO, MIFireE, CFO

References

National Institute for Occupational Safety and Health (NIOSH). (2008). Death in the line-of-duty… Report 2007-29. Retrieved November 14, 2008 from NIOSH http://www.cdc.gov/NIOSH/FIRE/reports/face200729.html.

Texas State Fire Marshal’s Office (2008). Firefighter fatality investigation FY 07-02. Retrieved November 14, 2008 from http://www.tdi.state.tx.us/reports/fire/documents/fmloddnoonday.pdf

Svensson, S. (2000). Fire ventilation. Karlstad, Sweden: Swedish Rescue Services Agency

Garcia, K., Kauffmann, R., & Schelble, R. (2006). Positive pressure attack for ventilation & firefighting. Tulsa, OK: Pen Well

International Fire Service Training Association. (2008) Essentials of Firefighting (5th ed). Stillwater, OK: Fire Protection Publications.

Public Stakeholder Meeting

On 19 November 2008, National Institute for Occupational Safety and Health (NIOSH) will conduct a public stakeholder meeting to gather input on the Firefighter Fatality Investigation and Prevention Program. This meeting has a similar focus to one held on 22 March 2006 in Washington DC. At the 2006 stakeholder meeting, NIOSH received Input from a diverse range of fire service stakeholders. Feedback was extremely supportive of the program, but provided input on potential improvements to this extremely important program. In 2006, I gave a brief presentation that focused on several key issues:

• The upward trend in the rate of firefighter fatalities due to trauma during offensive, interior firefighting operations.
• Failure of NIOSH to adequately address fire behavior and limited understanding of fire dynamics as a causal or contributing factor in these fatalities.

The issues that I raised at the 2006 stakeholder meeting continue to be a significant concern. In 2007, extreme fire behavior was a causal or contributing factor in 17 firefighter line of duty deaths (LODD) in the United States. Where these incidents were investigated by NIOSH, the investigations, subsequent reports, and recommendations did not substantively address the fire behavior phenomena involved nor did they provide recommendations focused on improving firefighters and fire officers understanding of practical fire dynamics.

Ongoing Challenges

In the 20 months since the 2006 stakeholder meeting, NIOSH has implemented a number of stakeholder recommendations. However, Death in the line of duty reports continue to lack sufficient focus on fire behavior and human factors issues contributing to traumatic fatalities during offensive, interior firefighting operations.

Where these reports could provide substantive recommendations for training and operations that would improve firefighter safety, they continue to provide general statements reflecting good practice. While the recommendations contained in NIOSH Death in the line of duty reports, are correct and critically important to safe and effective fireground operations, they frequently provide inadequate guidance and clarity.

In incidents involving extreme fire behavior, investigators frequently fail to adequately address the fire behavior phenomena involved and the implications of the action or inaction of responders. In addition, while training is addressed in terms of national consensus standards or standard state fire training curriculum, there is no investigation as to how the level of training in practical fire dynamics, fire control, and ventilation strategies and tactics may have impacted on decision making.

Presentation of these issues in general terms does not provide sufficient clarity to guide program improvement. Examination of a recent death in the line of duty report will be used to illustrate the limitations of these important investigations and reports in incidents where extreme fire behavior is involved in LODD.

Death in the line of duty… F2007-29

There are many important lessons to be learned from this incident and the limited information presented in this report. However, this analysis of Report F2007-29 focuses on fire behavior and related tactical decision-making. This analysis is completed with all due respect to the individuals and agencies involved in an effort to identify systems issues related to the identification and implementation of lessons learned from firefighter fatalities.

On August 3, 2007 Captain Kevin Williams and Firefighter Austin Cheek of the Noonday Volunteer Fire Department lost their lives while fighting a residential fire. Neither this information nor any reference to the report on Firefighter Fatality Investigation FY 07-02 released by the Texas State Fire Marshal’s Office was included in NIOSH Death in the line of duty report F2007-29. This is critical to locating additional information regarding the incident. Even more importantly, it is important to remember that firefighter LODD involve our brother and sister firefighters, not simply “Victim #1″� and “Victim #2”.

Reading the Fire

This incident involved a 2700 ft², wood frame, single family dwelling. The fire was reported at 0136 and the first unit arrived on scene at 0150. The crew of the first arriving engine deployed a 1-3/4″� (45 mm) hoseline and positive pressure fan to the door on Side A. NIOSH Report F2007-29 reported that the attack team made entry at 0151 but backed out a few minutes later due to flames overhead just inside the front door and that positive pressure was initiated at 0156 prior to the attack team re-entering the building.

However, the Texas State Fire Marshal’s Report FY 07-02 indicated the following:

Flint-Gresham Engine 1 arrived on scene at 01:50:21 positioning short of Side A� and reported, “On location, flames visible.”�

Firefighters Joshua Rawlings and Ben Barnard of the Flint-Gresham VFD pulled rack line 2, a 200� long 1.3/4” (45 mm) � line, to the front door on Side A.� Flint-Gresham VFD Firefighter Robles conducted a quick survey of the north side and then positioned the vent fan at the front door to initiate Positive Pressure Ventilation (PPV). Robles stated that the PPV was set and operating prior to entry by the first attack team. Robles stated that he started to survey the south side and noted heavy black smoke from the top half of a broken window. He stated that he reported this to the IC.

Flint-Gresham Firefighters Barnard (nozzle) and Rawlings (backup) entered through the open front door and advanced 8-10 feet on a left hand search. This attack team noted flames rolling across the ceiling moving from their left to their right as if from the attic. Rawlings stated that flames were coming out of the hallway at the ceiling area and around the corner at a lower level. Barnard reported the hottest area at the hallway. The interior attack team then backed out to the front doorway and discussed their tactics. After a brief conversation, Rawlings took the nozzle with Barnard backing him and they re-entered. They entered approximately 10 feet and encountered flames rolling from their left to their right. They used a “penciling technique”� aimed at the ceiling to cool the thermal layer. Rawlings reported in interview that there was an increase in heat and decrease in visibility as the thermal layer was disrupted and heat began to drop down on top of them.

There is an inconsistency between the NIOSH and Texas State Fire Marshal’s reports regarding the timing of the positive pressure ventilation. The NIOSH report indicates that positive pressure was applied between the first and second entries by the attack team. However, in the Fire Marshal’s report, Firefighter Robles is quoted as stating that positive pressure was applied before entry. This seems to be a minor point, but if effective, positive pressure ventilation would have significantly changed the fire behavior indicators observed from the exterior and inside the building. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

The NIOSH report did not identify the fire behavior indicators initially observed by Firefighter Robles or the attack team, nor did they draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation.

NIOSH Report F2007-29 did not speak to the fact that none of the first arriving personnel verified the size and adequacy of the existing ventilation opening, the potential implications of inadequate exhaust opening size, and the need to verify that the positive pressure ventilation was effective prior to entry. In addition, the initial attack crew observed flames moving toward the point of entry, which would not be likely if the positive pressure ventilation was effective. However, no mention was made in the NIOSH report regarding conditions inside building and the observations of the attack team.

Window size is not specified, but it is likely that the opening was significantly less than the area of the inlet being pressurized by the fan. Inadequate exhaust opening area leads to excessive turbulence, mixing of hot smoke (fuel) and air, and can lead to extreme fire behavior such as vent induced flashover or backdraft. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

In reading this case study, it would be useful for the reader to be able to make a connection between key fire behavior indicators, the decisions made by on-scene personnel, and subsequent fire behavior. The NIOSH report did not identify the indicators initially observed by interior or exterior crews, nor did it draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation, all of which were likely factors influencing the outcome of this incident.

NIOSH Report F2007-29 indicated that the attack team exited the building at 0213 due to low air and reported that the fire was knocked down, identified the location of a few hot spots, and that smoke conditions were light. The report follows to indicate that one of the chief officers did a walk around two minutes later and observed smoke in all the windows and smoke coming from the B/C and C/D corners of the structure. However the Texas State Fire Marshal’s Report 07-02 stated:

Firefighters Rawlings and Barnard penciled the rolling flames in the thermal layer until Rawlings’s low air alarm sounded. The Incident Commander, Captain Williams and Firefighter Cheek met Firefighters Rawlings and Barnard at the front door and a briefing occurred. Firefighters Rawlings and Barnard reported to Asst. Chief Baldauf they had the hot spots out. Rawlings stated in a later interview that they told Williams and Cheek they knocked down the fire and only overhaul was needed.

At 02:13, Captain Williams and Firefighter Cheek entered the structure as attack team 2, using the same line previously utilized by Firefighters Rawlings and Barnard.

Exterior crews from Noonday and Bullard started horizontal ventilation by breaking a window out on Side C (north side). Noonday Chief Gary Aarant performed a walk around, then reported heavy smoke from the B/C,and C/D� corners and at 02:15:51 asked if vertical ventilation had been started. Command then gave the order to begin vertical ventilation.

Understanding what occurred in this incident requires more than the cursory information provided in the NIOSH report. Developing the understanding of critical fire behavior indicators is essential to situational awareness. Discussion of fire behavior indicators and their significance in NIOSH reports would provide an excellent learning opportunity. For example, in this incident, the difference between “smoke” as described in the NIOSH report and “heavy smoke” as reported in the Texas State Fire Marshal’s report is likely a significant difference in assessment of conditions from the exterior of the building (particularly if this is a change in conditions).

NIOSH Report F2007-29 made brief mention of smoke discharge from the point of entry which was being used as the inlet for application of positive pressure. “At 0236 hours, heavier and darker smoke began pushing out of the entire front door opening and overriding the PPV fan”. However, the report does not speak to the significance of this indicator of impending extreme fire behavior.

The Texas State Fire Marshal’s Report 07-02 included a series of photographs provided by the Bullard Fire Department which provided a dramatic illustration of these key smoke and air track indicators. Inclusion of these photographs in the NIOSH report would have aided the reader in recognizing this key indicator of ineffective tactical ventilation and imminent potential for extreme fire behavior.

Photo of Conditions on Side A at 0210

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0217

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0223

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

NIOSH Report F2007-29 addresses the need for the incident commander to conduct a risk versus gain analysis prior to and during interior operations. However, the report does not address the foundational skill of being able to read fire and predict likely fire behavior as a part of that process. In addition, reading the fire and dynamic risk assessment are not solely the responsibility of the incident commander. Everyone on the fireground must be involved in this process within the scope of their role and work assignment. For example, the initial and subsequent attack teams were in a position to observe critical indicators that were not visible from the exterior.

While there is no way to tell, it is likely that if Captain Williams and Firefighter Cheek recognized the imminent probability of extreme fire behavior or the significance of changing conditions they would have withdrawn the short distance from their operating position to the exterior of the building. Likewise, if the incident commander or others operating on the exterior recognized deteriorating conditions earlier in the incident it is likely that they would have taken action sooner to withdraw the crew working on the interior.

Understanding practical fire dynamics, recognition of key indicators and predicting likely fire behavior is a critical element in situational awareness and dynamic risk assessment. Fire behavior and fire dynamics receive limited focus in most standard fire training curricula. It is important that NIOSH examine this issue when extreme fire behavior is a causal or contributing factor in LODD.

My next post will continue with the analysis of NIOSH Report F2007-29 and will make specific recommendations for program improvement.

Ed Hartin, MS, EFO, MIFireE, CFO

Fire Ventilation by Stefan Svensson was originally written to support ventilation training delivered by the Swedish Rescue Services Agency (R�ddnings Verket). However, the English translation of this text is an excellent resource for any firefighter or fire officer.

Stefan does an excellent job of integrating practical fireground experience and the underlying science of thermodynamics and fluid dynamics that are essential to really understanding ventilation. Many of the concepts presented in this text will be familiar to firefighters anywhere in the world. Topics include:

1. Fire Ventilation
2. Fire Behavior
3. Fire Gases
4. The Spread of Fire Gases
5. Working with Fire Ventilation
6. Creating Openings
7. Safety When Working at high Altitudes
8. Openings in Different Roof Structures
9. Tactics
10. Examples of Firefighting Situations

The chapters on fire ventilation, fire behavior, and fire gases, were a necessary introduction to the topic, but other texts provide a more comprehensive examination of these important subjects. The chapters that I found most useful were The Spread of Fire Gases and Working with Fire Ventilation. Stefan’s explanation of influences on smoke movement, influence of inlet and outlet opening size, and other factors that impact the effectiveness and efficiency of ventilation operations is excellent. The narrative is simple and straightforward and shaded boxes highlight mathematical formula and calculations necessary for those who want to engage with this topic at a deeper level.
For individuals without an engineering background, the mathematical explanations of the underlying principles and engineering applications may seem a bit daunting. More detailed explanation and worked examples would provide better support of this content. However, this is a minor issue which does not significantly compromise the utility of this text to a wide range of audiences.
Fire Ventilation is available for on-line purchase from the Swedish Rescue Services Agency for 120 SEK (around $16.00) plus shipping. The agency will invoice for payment Swedish Kroner after your purchase (which necessitates using a bank that can produce a check in foreign currency).

NIOSH Public Meeting

On November 19, 2008, the National Institute for Occupational Safety and Health will be conducting a public stakeholder meeting regarding the Firefighter Fatality Investigation and Prevention Program. This meeting will be held at 1000 hours at the Crown Plaza Hotel at Chicago’s O’Hare Airport. My next post will provide a preview of my presentation at this meeting and written testimony submitted for inclusion in the public docket. Take a minute to review NIOSH Report F2007-29 before Thursday’s post.

Ed Hartin, MS, EFO, MIFireE, CFO

Quantitative Analysis

Quantitative analysis of firefighter injuries and fatalities uses statistics to describe what has occurred and identify patterns and trends. Annual reports and longitudinal (multi-year) quantitative studies provide one way to examine firefighter safety performance.

• Firefighter Fatalities in the United States 2007, National Fire Protection Association (NFPA)
• U.S. Fire Service Fatalities in Structure Fires, 1977-2000, NFPA
• Firefighter Fatalities in the US in 2007, United States Fire Administration (USFA)
• Firefighter Fatality Retrospective Study, USFA

Examination of firefighter fatalities and injuries over time requires consistency of method when comparing data from year to year. However, dividing fatalities and injuries into a small number of causes or injury or death provides a coarse grained picture of the problem. This is useful, but not sufficient.

Reporting system limitations in dealing with multiple causal and contributing factors also limits firefighter injury and fatality statistical analysis and reporting. Quantitative analysis is extremely useful in identifying trends and pointing to issues needing further examination. Identification of the increasing rate of firefighter fatalities inside buildings during structural firefighting is one example. However data and system limitations may preclude a fine grained quantitative analysis of this issue.

Qualitative Analysis

Qualitative analysis of firefighter injuries and fatalities often involves examination of individual incidents, describing in detail what happened in that specific case and identifying causal and contributing factors. The limited information provided by annual reports and longitudinal analysis of firefighter injuries and fatalities can be enhanced by examining individual cases.

The NIOSH Firefighter Fatality Investigation and Prevention Program investigates many firefighter fatalities as a result of trauma (see the NIOSH Decision Matrix). However, they do not generally investigate non-fatal incidents and do not investigate near miss events. In addition to not examining all traumatic fatalities there is often a considerable delay in beginning the investigative process. This delay may result in the building involved being demolished and loss of important detail in witness interviews.

My last two posts looked at the US Forest Service approach to Investigating Wildland Fire Entrapments and Peer Review Process to identify lessons learned. Application of these methods in structural firefighting would provide an excellent method for improving our understanding of applied fire dynamics, tactical operations, and decision-making as well as other hazards such as structural collapse, and firefighter disorientation.

The Way Forward

Fire service organizations should examine all events that involve structural fire entrapment, collapse entrapment, and disorientation. There are no commonly accepted definitions for these types of events. However, the US Forest Service definition for wildland fire entrapment could serve as a starting point for defining entrapment and disorientation in the structural environment.

• Structural Fire Entrapment: a fire behavior related event involving compromise of normal (planned) means of egress; or thermal exposure resulted in, or had significant potential for death, injury, or damage to personal protective equipment.
• Collapse Entrapment: A structural failure related event involving compromise of normal (planned) means of egress, or impact resulting from structural failure (load bearing or non-load bearing) that resulted in, or had significant potential for death, injury, or damage to personal protective equipment.
• Disorientation Entrapment: Loss of spatial orientation while operating in a hazardous atmosphere that resulted in, or had significant potential for death or injury.

Note that like the US Forest Service definition of wildland fire entrapment; these events are inclusive of fatalities, injuries, and near miss events.

Investigating a near miss or accident involving a serious injury or fatality may present significant challenges to an individual agency in terms of resources and expertise. Individuals and organizations also filter information through cultural norms which define “the way we do things”. Use of a multi-agency team reduces these potential challenges. However, as in emergency response, it is important to define the process and develop effective working relationships prior to facing a serious injury or fatality investigation.

Who should be involved? Adapting from the US Forest Service Investigating Wildland Fire Entrapments individuals with the following skill sets should be involved in structural fire, collapse, or disorientation entrapment events.

• Command Officer
• Safety Officer
• Fire Behavior Specialist
• Structural Specialist (collapse entrapment)
• Fire Investigator
• Personal Protective Equipment Specialist (may be an external resource)
• Photographer/Videographer

There are a number of considerations in determining the makeup of the investigative team. Depending on the nature of the investigation, some of these skill sets may not be as critical or a single individual may fill more than one role (e.g., fire investigator and photographer). Unlike the wildland community, there is considerably less clarity to specialization in structural fire behavior. In some cases this may be a fire investigator with specific training in fire dynamics and fire modeling, in others it may be a compartment fire behavior instructor. This will depend on the nature of the incident and available resources. In addition, the technical complexity of assessing personal protective equipment performance (particularly self-contained breathing apparatus) may require specialized external expertise.

As in wildland incidents, there is also great value in peer review of structural incidents. Like the more formal investigation, peer review is a team based process, but the team is comprised of a small group of experienced firefighters and fire officers who are known to be insightful, fair, just, and honest.

A Call to Action

There is not a simple cookbook approach to developing processes for entrapment investigation and peer review. The first step is to identify how your organization can effectively identify and communicate lessons learned. While serious accidents and injuries present a significant challenge, near miss events occur much more frequently and provide an opportunity for individual and organizational learning as well as an opportunity to develop the entrapment investigation and peer review processes. The following two actions provide the opportunity to improve firefighter safety while operating offensively at structure fires:

• Members submit near miss reports to the National Firefighter Near Miss Program
• Agencies use a team based, multi-agency approach to investigate structure fire, collapse, and disorientation entrapments (inclusive of near miss events).
• Agencies widely share their lessons learned with other fire service agencies and organizations

Please post your thoughts on this process and how we can best develop and communicate lessons learned from entrapment events occurring during structure fires.

Ed Hartin, MS, EFO, MIFireE, CFO

In May 2006 US Forest Service Fire and Aviation Management published a briefing paper on Peer Review Process. Later that year, a peer review team used the process to investigate a near miss incident in the Shoshone National Forest and issued a report titled Little Venus Fire Shelter Deployment. This report provides an interesting look at the peer review process and potential benefits of a similar approach to identifying and communicating lessons learned in the structural fire service.

The stated purpose of the peer review process is:

..to reduce errors by correcting or reinforcing upstream behaviors and other factors. Peer reviews provide a means to learn from a variety of situations including close calls, significant events, and other routine performance evaluations. The objective is to create a culture that expects and values peer reviews as an important means to discover subtle indictors of potential future errors and as a catalyst for positive change.

Peer Review and Accident Investigation

Peer review is not limited to investigating accidents and near miss events; it examines organizational performance in a variety of circumstances. However, a peer review and formal accident investigation may run concurrently. As stated in the US Forest Service Peer Review Process Briefing Paper, “this approach helps to segregate human error from intentional disregard of rules and gives the opportunity to identify positive behaviors and decisions even when bad outcomes occur.”

It is important to emphasize that peer review goes well beyond the context of accident and near miss investigation. This process applies to a broader range of significant events.

Key Process Elements

Like entrapment investigation, peer review is a team based process, but the team is comprised of “a small group of operators known for their ability to perform the particular mission in the particular environment, and also known to be insightful, fair, just, and honest”�. This approach is consistent with the focus of peer review on developing lessons learned.

Key questions addressed in peer review examine individual observations and perceptions and include:

• Action Plan and Leaders Intent
• Situational awareness
• Actions Taken and Not Taken
• Personal Lessons Learned

In many respects the peer review process gathers the same types of information as the National Firefighter Near Miss Program. However, there is a significant difference. In peer review, team members are encouraged to “continue questioning in areas where the reviewers feel disconnect, discomfort, confusion, or curiosity”.

Communicating Lessons Learned

The peer review team develops a report that provides a look from outside the element of the organization involved in the accident, near miss or significant event. This written report identifies the story of the event, reasons the situation developed as it did, and lessons learned. The Peer Review-Purpose and Process Briefing Paper outlines a number of potential benefits:

• Provides feedback on performance and potential areas of improvement
• Assists supervisors in employee development
• Helps guide training strategies, organizational policy, and operating guidelines
• Develops data higher level lessons learned analysis
• Promotes long-term positive shifts in organizational culture

Peer review reports such as the Little Venus Fire Shelter Deployment take a middle ground between a comprehensive organizational assessment seen in some agency reports (see reports from Loudon County Fire and Emergency Management and Prince William County Department of Fire and Rescue) and more limited information provided in National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty reports.

Obstacles

Peer review requires a bit of organizational and individual courage and commitment. One element of the deliberate practice required to develop expertise in any field is feedback on results and engaging with that feedback to refine and improve performance. Individuals and organizations must have the courage to ask for feedback and accept performance related feedback, which may be uncomfortable or difficult when things do not go well.

A more fundamental and underlying challenge lies with our underlying assumptions about the nature of fire, firefighting, and the business that we are in. Future posts will address at these important issues.

Ed Hartin, MS, EFO, MIFireE, CFO

Structural firefighting agencies can draw some valuable lessons from the wildland firefighting community. Fire behavior training in many structural agencies often begins and ends in recruit academy. For wildland firefighters, fire behavior training involves an extensive, multi-level curriculum (S-190, S290, S-390, S-490 and so on). The wildland community is also more substantively engaged in analysis of fatalities, accidents, and near miss events with the intention of impacting policy, procedure, and performance. This is not to say that they have a perfect safety record, far from it. However, this ongoing effort to identify and implement best practice based on lessons learned is worthy of emulation.

The US Forest Service Technology & Development Program produced a document titled Investigating Wildland Fire Entrapments which outlines the process that should be used and documentation required for entrapment related incidents. Entrapments are:

A situation where personnel are unexpectedly caught in a fire behavior related, life-threatening position where planned escape routes and safety zones are absent, inadequate, or have been compromised…These situations may or may not result in injury. They include”near misses”�.

The concept of entrapment applies equally in the structural firefighting environment. I read news accounts of extreme fire behavior related events (e.g., flashover, backdraft) from around the United States on a weekly basis. Flashover, backdraft, or other extreme fire behavior often results in a near miss or minor injury and less frequently in serious injury or fatality. Some (actually very few) of these incidents are documented in the National Firefighter Near Miss Program. As discussed in my last post, the near miss program uses self-reported data. This is extremely useful in determining the individual’s perception of the event and what lessons they took away from the experience. However, the individual reporting the event may or may not have the training or education to recognize what actually happened, determine multiple causal factors, and provide a reasonably objective analysis.

Formal Investigation

If a significant injury occurs, some level of investigation is likely to take place (even if it is limited to a cursory examination of circumstances and conditions by the individual’s supervisor). Traumatic fatalities result in more significant and in many cases multiple investigations by the agency involved, law enforcement agencies, Occupational Safety and Health Administration (state or federal), and potentially the National Institute for Occupational Safety and Health (NIOSH). The purpose of these various investigations is different and not all focus on identifying lessons learned and opportunities for improving organizational performance. However, some reports by the agencies involved, state fire service agencies, and NIOSH take positive steps in this direction. For example:

• Prince William County (Virginia) Department of Fire & Rescue
  Line of Duty Death (LODD) Report for Technician I Kyle Robert Wilson
• Texas State Fire Marshal’s LODD Investigation Program
• New Jersey Division of Fire and Life Safety Firefighter Fatality and Serious Injury Report Series
• NIOSH Fire Fighter Fatality Investigation and Prevention Program

Limitations

Near miss events and events involving extreme fire behavior resulting in minor injuries or damage to equipment frequently are not or are inadequately investigated to identify causal factors and lessons learned. Investigation of serious injuries and fatalities in many cases do not adequately address fire behavior and interrelated human factors that may be directly or indirectly related to the cause of the incident. This results in lost opportunities for individual and organizational learning.

Two interrelated challenges make investigating extreme fire behavior events or structural fire entrapments difficult. First is the lack of a formal process or framework for this specific type of investigation and second is potential for investigators lack of specific technical expertise in the area of fire behavior.

A Solution

The US Forest Service uses a team approach to investigating entrapment incidents. The team may include (but is not limited to):

• Fire Operations Specialist (Operations Section Chief level)
• Fire Safety Officer
• Fire Behavior Analyst, with experience in the incident fuel type
• Fire Weather Meteorologist
• Fire Equipment Specialists who develop the personal protective equipment (including fire shelters) used on wildland fires
• Technical Photographer
• Fire Information Officer

This team is established and begins the investigation as soon as possible after the occurrence of the event to ensure that critical information and evidence is not lost. The investigative process and documentation focuses on accurately describing what happened, when it happened, causal and contributing factors, and recommendations to reduce the risk of future occurrence.

What might this look like in the structural firefighting environment?

Communicating Lessons Learned

Lessons learned must be integrated into appropriate training curriculum to ensure that the lessons are built into organizational culture.

Some agencies have taken steps in this direction. Following the line-of-duty death of Technician Kyle Wilson, Prince William County Department of Fire & Rescue conducted an in-depth investigation which integrated use of computational fluid dynamics (CFD) modeling to describe likely fire conditions and the influence of wind on fire behavior. Following the conclusion of this investigation, the report and related presentations have been distributed widely.

Investigating Wildland Fire Entrapments identifies timeliness as being essential in dissemination of the lessons learned. This presents a significant challenge when faced with a complex event involving a major injury or fatality. However, it is likely that timeliness in communicating lessons learned can be improved without compromising the thoroughness and quality of the investigation.

My next post will examine the US Forest Service’s less formal Peer Review Process which may be used following near miss events or significant events regardless of outcome (possibly concurrently with a formal investigation). Like the entrapment investigation procedure, there are likely some lessons here for the structural firefighting community!

Ed Hartin, MS, EFO, MIFireE, CFO

What is the difference between a fairy tale and a firehouse tale?

Fairy tales generally begin with once upon a time, while firehouse tales begin with you wouldn’t believe what happened last shift and no, this really happened. This post begins with a firehouse tale.

A crew of firefighters advances a 1 1/2″ (45 mm) hoseline up a stairwell in a large wood frame house. The second floor is well involved, and the smoke level is down close to the floor. The young firefighter with the nozzle indicates that it is too hot to advance onto the fire floor. The officer moves up close to the nozzle and evaluates conditions, finding that the firefighter is correct. The officer calls the incident commander and asks for ventilation to raise the smoke level and relieve some of the heat that is preventing advancement onto the fire floor and an attack on the fire. Moments later, the officer is enveloped in fire and feels himself flying backward through the air. This ends when he slams into a hard surface. Everything is black, and he is unable to see. It is not hot, and eventually, he sees a glimmer of sunlight. Attempting to remove his breathing apparatus facepiece, he experiences discomfort in both shoulders, but is able to pull the facepiece off, discovering that the darkness was caused by blackening of the exterior of his facepiece lens. The building is still well involved, the hoseline extended through the front door, but the crew of firefighters that was with the officer are nowhere to be seen. The officer pulls his facepiece back on and crawls back in along the hoseline, finding the firefighters frantically trying to make the fire floor, thinking that their officer had been blown down the hallway instead of up and over their heads, balling down the stairwell behind them and rolling out into the street. The officer withdraws his crew as other crews extend hoselines to the second floor, and extinguish the fire.

In this incident, the officer with the hoseline was unaware that significant indicators of a potential backdraft in an enclosed section of the second floor were visible from the rear of the structure (where the incident commander and the crew performing horizontal ventilation were located). The effects of the backdraft were serous but could have been much worse. The officer received minor burns, injured both shoulders, and severely damaged his facepiece and turnout coat. What made this incident worse was that it occurred during live fire training with a group of recruit firefighters.

I know that this firehouse tale really did happen as I was the officer in the story. This incident occurred in the late 1970s while I was working for the Massachusetts Firefighting Academy as a part-time instructor. Unfortunately, while academy staff investigated this incident, the outcome of this investigation did not impact substantively on training practices, and at the time, the academy staff did not widely communicate lessons learned.

How many of you have had a close encounter with extreme fire behavior? One where you said that was close or you suffered a minor injury? What did you learn and how did you share this information?

Often, as in this backdraft incident, those involved learn a valuable lesson, but do not share the information beyond the firefighters and officers they work with. Many things have changed since the 1970s. One is the existence of National Fire Protection Association 1403 Standard on Live Fire Training Evolutions. While not perfect (but that is another topic for discussion), it identifies systems of work that increase the safety of participants engaged in live fire training. Another, more recent change was the development of the National Firefighter Near Miss Reporting System. This system leverages the advantage of the World Wide Web to provide the ability to report near miss incidents and widely share our lessons learned. If you have been involved in or witnessed a near miss incident or have been told of the event, you can anonymously submit a report and share what you have learned.

The data submitted to the Near Miss Reporting System does not go into a vacuum. Following review, and removal of information which would identify the agency involved, reports are posted in a searchable database on the firefighternearmiss.com website.

This program is a tremendous resource! Visit the site and search on flashover (38 reports), backdraft (9 reports), rapid fire progress (4 reports), or smoke explosion (33 reports). Remember, this database contains self-reported information. This does not make it less useful. In many ways it is more useful than distilled and analyzed information presented in other types of reports (particularly when the individual was involved in or witnessed the event). However, there may be technical inaccuracies (particularly with regards to extreme fire behavior phenomena) and the lessons learned by the individual who submitted the report may or may not be what you want to take away. Read the reports, think about the factors that influenced the occurrence of the event, how it could have been prevented, trapped or mitigated, and draw your own conclusions.

If you are involved in, witness, or are told about a near miss event, report it. The more information in the database, the greater the potential to identify patterns of causal factors and develop strategies for improving firefighter safety.

Ed Hartin, MS, EFO, MIFireE, CFO