Firefighting, Fireground Safety

Near Miss Report: It was only supposed to be a drill

by Amanda McHenry

The National Fire Fighter Near-Miss Reporting System (www.firefighternearmiss.com) has 11 reports that mention “heat exhaustion.” You can widen your search by typing “exhaustion” in the text box. While the report mentions heat exhaustion as an outcome, there are larger issues that contribute to the heat exhaustion that are worth studying closely.

Our shift had put on a live fire training event for our new recruit class covering topics including fire behavior, ventilation, thermal imager orientation, and fire control. Near the conclusion of the afternoon round of burns, the captain of one of the participating engine companies wanted to provide a scenario for an on-duty firefighter who had been training regularly over the past several weeks in preparation for the engineers’ exam&The scenario was initiated and the recruits attempted to deploy the cross-lay&resulting in entanglement and a partial deployment& the engineer, for an undetermined reason, shut down the hose line to the interior observation crew, and& left the pump panel to turn on his own hydrant. At this time the fire conditions within the building were beginning to intensify. The interior observation crew&realized that the suppression crew was not making a timely ingress. They attempted to apply some water to the fire to keep it in-check for their own protection, only to then realize their hose line was no longer charged. They attempted to make contact with the engineer over the radio, but he did not respond and was seemingly overwhelmed with the scenario at this point. With rapidly deteriorating conditions within the building and a dry hose line, the interior observation crew& They were evaluated and treated on location for heat exhaustion.

There are several approaches that can be taken in analyzing this near-miss report. Customarily we would look for a single “root cause” for the event. However, if we apply Shappell and Weigmann’s Human Factors Analysis and Classification System (HFACS) to the incident, the following questions bring us to a conclusion that will identify a number of “layers” that contributed to the event.


  1. When you consider the actions of the engineer in training at this near miss errors or violations? (Use your department’s SOGs to make your determination).

  2. List three reasons why the engineer in training responded as described in this report.

  3. Are there any breakdowns in supervision?

  4. Do you believe there is only one root cause when it comes to accident investigation? Explain your answer to your colleagues.

  5. What is your department/training center policy on treating and transporting firefighters that suffer injuries or illness while at the training center?

Experience or witness a training event that didn’t go according to plan? Tell www.firefighternearmiss.com your account so others can learn without the debilitating first hand experience.

Note: The questions posed by the reviewers are designed to generate discussion and thought in the name of promoting firefighter safety. They are not intended to pass judgment on the actions and performance of individuals in the reports.