Posts Tagged ‘firefighter fatality’

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

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

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

In 2007, twenty firefighters in North America lost their lives due to extreme fire behavior while engaged in interior structural firefighting operations. The United States Fire Administration Report 2007 Firefighter Fatalities in the United States and the NFPA Report Firefighter Fatalities in the United States-2007 provide analysis of firefighter fatalities that occurred during this year. Neither report specifically addressed the issue of firefighter fatalities as a result of extreme fire behavior. In fact the NFPA report classified a significant number of these fatalities as being the result of structural collapse (despite the fact that collapse occurred some time after rapid fire development trapped the firefighters involved).

Thus far in 2008, eight more firefighters have died due to extreme fire behavior while working inside burning buildings. This is the tip of the iceberg! Since January 2008, there have been several incidents in which rapid fire progress trapped multiple firefighters. In each of these incidents the firefighters escaped with serious injuries.

• May 25, 2008 – Four firefighters trapped on the second floor by a flashover, Loudon County, Virginia
• October 7, 2008 – Four firefighters trapped on the second floor by a flashover, Sacramento, California

In What’s Changed Over the Last 30 Years, Fahy, LaBlanc, and Molis state that the rate of traumatic fatalities while engaged in offensive firefighting operations inside burning building has been increasing.

In many cases, extreme fire behavior is a causal or contributing factor. It is critical that firefighters understand compartment fire behavior and can apply that knowledge to maintain situational awareness and make effective decisions on the fireground. Fire behavior training for most firefighters and fire officers is limited to a few hours during recruit academy and possibly brief mention during tactical training. This is not adequate!

At the 2008 International Association of Fire Chiefs Conference in Denver, Colorado, Chief Fire Officer Charlie Hendry of Kent Fire Rescue Service and President of the United Kingdom (UK) Chief Fire Officers Association discussed a number of significant incidents that impacted his nation’s fire service. One of these incidents was a backdraft in townhouse apartment in rural Wales that killed Firefighters Kevin Lane and Stephen Griffin. This incident and the subsequent investigation by the British Fire Brigades Union and the Health and Safety Executive identified major training deficiencies, resulting in changes in fire behavior training across the UK. For a brief overview of the incident and discussion of its impact on the UK fire service, see Blaina: A Perpetual Legacy.

Where is the recognition that the American fire service faces the same problem on an even larger scale?

What can we do, individually and collectively to address this issue? I will be writing about this topic for the next couple of weeks. Add a comment to this post with your ideas!

Ed Hartin, MS, EFO, MIFireE, CFO