Learn the Value of Accountability Through Near Misses

We’ve been discussing Accountability on the blog this month.  Accountability measures are often the focus of departments’ near-miss reports.  Sometimes they save lives, and sometimes their absence leads to the near-miss.  Either way, conducting near-miss reports can be extremely informative.  Below you’ll find summaries of two near-miss reports the commission received in 2011.  Check them out!

Near Miss – 1

Incident

On Friday, June 17, 2011 a garage fire was called in.  When the department arrived on the scene it was a two story residence.  It quickly became a two alarm fire.  A crew went to the second floor.  Two rooms were cleared.  In the third room, the crew encountered thick dark smoke.  The crew decided they needed to leave but became disoriented.  The crew called a Mayday.  They were able to find a window and make their way to the roof where the RIT team was able to help them from the structure.

Summary

Date of Incident:  June 17, 2011

Time: 2130

Weather Conditions:  Hot 95 degrees, the day’s high had been 102 with winds from the south, sustained at 23, gusts to 41 MPH, humidity 40%.

Size up: Large (5,100 sq. ft.) two-story single family residence, wood construction, brick veneer, composition shingle roof, fire through the roof of the attached three car garage (south side of residence).

Exposures:  There were residential homes north and south with 15-ft. side-yard setbacks.  Firebrands were landing on other structures to the north of the fire.

Initial actions: First crew was assigned the interior of the home on first floor with a 2.5” line to the door between the living space and the garage.  The second interior crew was assigned to the second floor to do a primary search.

Of course it is human nature to minimize personal exposure when things go wrong.   Most often that is exactly the worst thing you can do.  To seek the root cause, discover, and to understand and learn is to protect you from future failure. It is also imperative to communicate those lessons to fire service personnel in hopes the information helps to prevent future casualties.  The event we recently experienced resulted in injury to two firefighters.  In actuality, it is very clear we were moments from losing two firefighters to a flashover in a residential property.

It would have been easy to do a quick post incident analysis; admit that was a close call and move on.  Instead we wanted to dig deeper and analyze not only what went wrong, but what went right.  To that end, we wanted to reinforce the actions of personnel, methods and procedures which allowed us to overcome a potentially lethal scenario.  Of equal importance, we needed to know what factors, actions and dynamics that colluded to expose our personnel to grave danger.  We felt it was essential we analyze the incident to discover these points.  We needed to reveal the issues with a goal not to point fingers, assign individual blame or guilt.

A committee was assigned to analyze and evaluate this near miss.  The personnel who were assigned to the task were not present at the fire.  Each rank of the department from Battalion Chief to rookie firefighter served on the panel.  The charge given was to look at all factors, not just the incident.  The areas the committee evaluated included but were not limited to:  personal accounts, bystander video, weather conditions, fire behavior, training, SOP’s, communications, tactics, departmental culture, RIT, Mayday, command, company level and actions of personnel.

The final report provides enhanced details, but generally we found that:

Prior to the incident, drills focusing on mayday and self-evacuation were invaluable.  The two members recounted they realized they were in trouble and action must take place immediately.  They called a Mayday before it was too late.  The challenges of the drills conducted in a maze and live fire scenarios performed at various training fields in the area proved to be invaluable.

As the Mayday was called, radio traffic ceased leaving just essential traffic centered on dealing with the Mayday.  Over time we have been able to provide all personnel on the fireground with portable radios.  With that came the benefit that personnel all know what is being communicated, but also the potential drawback of too much radio clutter.   Prior to our event, Officers had listened to radio recordings of a fire where multiple firefighters were lost at another department.  The significance was that Command seemed to be overwhelmed with answering non-priority communications, while you could tell he was attempting to account for his personnel.

At the incident, personnel had accomplished, or were in the process of implementing RIT and rescue procedures in advance, and just in case of such a scenario.  RIT was in place but additional ground ladders were being placed as the Mayday was called.  A ladder was set just as the firefighters began their bailout of a window.

The effects of the heavy winds (to 41 MPH) created challenging conditions as the fire grew rapidly in intensity. 

The building construction seemed to have a factor in the progress of the fire.  The interior crew also recounted how a Mylar- like window film treatment inhibited their ability to break and clear glass for their escape.

Crews were assigned to enter and search the residence, but failed to use a hose line to cover them.  The area of the residence where they found themselves trapped and disoriented had initially been cool and with limited smoke.  Their thermal imager was with them, but not powered on.  Once the fire breached the wall, the room was immediately untenable.  Their tag line had also not been deployed.

The choice of hand tools selected by the interior search crew was not the most appropriate for their assignment.

Since this event several actions have taken place:

The final report from the panel has been disseminated to all personnel in the interest of applying lessons learned.

The Captain, who was trapped with the firefighter, has created a website in order to share his experience with other fire personnel.  His website includes the final document, radio traffic, bystander video and his personal thoughts.  He has since developed a program which he has delivered to all of our personnel recounting the incident. He provides honest analysis of the lessons learned.  He has also been a guest lecturer at many departments throughout North Texas to allow his experience to benefit others.  

We have evaluated the tactics utilized during this incident. We are training to reinforce the use of hose lines, tag lines, hand tools and thermal imaging when conducting interior search operations.  Training also includes additional concentration on building construction and weather influences relative to fire behavior.

Turnout gear is only a relatively thin barrier between a hostile and lethal environment and the firefighter inside.  In sterile laboratory settings, structural gear is tested to provide about 17.5 seconds of personal protection in a flashover situation - before the firefighter receives a second-degree burn.  Actual fireground conditions can vary widely.  Our personnel have all examined the thermal insult the bunker gear and SCBA withstood.  This visual drives home the need for proper use, inspection and care of PPE and SCBA. This incident underscores how essential it is to perform daily inspections and advanced testing of gear. 

Upon conclusion of our evaluation, we found the panel conducted the analysis in a professional and thoughtful manner.  We knew from inception it ran the risk of being perceived by personnel as being an exercise in blame and fault finding.  In the end, the process actually worked to build trust as it was seen as thorough, honest and non-punitive.  This event will serve to remind us we are engaged in a deadly serious profession.  We don’t want the lessons learned here to have been in vain, or be soon forgotten.

Near Miss – 2

Incident

On September 5, 2011 a residential structure fire was called in.  The fire was reported to be in the attached garage.  There was heavy smoke coming from the D side of the building.  The winds were 25 – 30 mph.  Crews made an initial attack.  Heat was high in the garage.  A relief valve from an acetylene bottle began to vent and burn, fire became visible, and there was a rollover of flames across the ceiling and behind the crew. 

Summary

On September 5, 2011, Fire Rescue experienced a firefighter near-miss incident. This incident resulted in two firefighters receiving first- and second-degree burns to their arms, neck, and ears. While the injuries were minor when you consider what could have happened; nonetheless they were still injuries with lessons to be learned. Three areas for improvement resulted from our internal investigation into this near-miss incident.

These are as follows:

1. Equipment Checks: These must be consistent across the job and must occur immediately at the start of each shift. This includes personal protective equipment as well as equipment assigned to the apparatus.

2. Training: COMMAND training must be continued for all officers. Additionally, training must be completed and consistent for all full-time, part-time, PRN part-time, and volunteer-time personnel.

3. Personal Protective Equipment (PPE) Specifications: Work with the Safety Committee on the development of specifications for all types of PPE. Do not just rely on a tag or brochure that states an item meets a particular National Fire Protection Association (NFPA) standard. These are minimum standards only. Not all items are alike even if they meet the minimum standard.

By following our own recommendations we believe that we can continue to reduce the number and severity of an injury in this fire department.

In Near Miss-1, the department’s Mayday drills and other Accountability measures were paramount in keeping people safe in this event.  In Near Miss- 2, Accountability factors like lack of training, differences in PPE equipment, and incomplete uniforms/gear were all factors in this incident.  Reading near-misses like these, whether the Accountability policies saved lives or didn’t, can enforce the value of this type of Accountability training and policy-making.

Submit Your Near-Miss Reports

In an effort to maximize the benefits of near-miss reporting, the commission encourages all departments to submit near-miss reports to us.  We would like to share these reports with the community, and would be happy to do so anonymously, if preferred. The names involved are not important, but the safety issues we all face are.

The departments whose summaries are included here are to be commended for taking the initiative in doing their analyses and in sharing their experience with the Texas fire service community.  If you would like to send in your near-miss report, contact our Injury Reporting staff.  And thank you!

Learn From Even More Near-Miss Reports

Search the National Firefighter Near-Miss Reporting System, using the keyword “Accountability” to learn how Accountability systems affected, or were affected by, near-misses.  Also, visit Firefighter Close Calls, for more near-misses.

Has your department conducted a near-miss investigation?  If so, how did Accountability, or relevant Accountability factors, play into the event?