Posts Tagged ‘near miss’

Lessons Learned: The Way Forward

Monday, October 27th, 2008

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.

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

Entrapment Investigation & Lessons Learned

Monday, October 20th, 2008

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:


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

That was close!

Thursday, October 16th, 2008

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 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