Fireground Safety

Culture Shock: A Line-of-Duty Death Reviewed

Fire apparatus on the roadway

 

By J. Travis Carricato

Photo above courtesy of Ashley Lopez

On November 13th, 2010, Firefighter Chance Hyatt Zoble of the Columbia (SC) Fire Department (CFD) was tragically killed while operating at a brush fire on a busy interstate just outside the City of Columbia. Since that tragic day nearly eight years ago, through investigations, instruction and reinforcement, the CFD has taken steps to drastically change nearly every single response consideration while operating on or near the roadway. Through this experience, each CFD member has been educated how to do things differently. Policies have been implemented, operational changes have been instituted and enforced; not out of fear of another incident, but out of respect and in memory of Firefighter Chance Zobel.

For the CFD, it took a young firefighter’s life to accept that a culture change was needed with regards to roadway safety. This change, for the most part, was embraced across the entire organization, as well as many of CFD’s local and regional response partners. I would hope that other departments elsewhere have also taken steps to increase their knowledge of the dangers and hazards while operating in the roadway based on the findings of this tragic line-of-duty death (LODD). What the CFD learned in the most unfortunate way is that most roadway hazards and dangers are recognizable and predictable. But this is true only if one dedicates the time to get educated on what many of our peers across the nation would consider preventable deaths and injuries if the right precautions are implemented and reinforced with training and accountability. This is certainly not meant to say all LODDs are preventable, as emergency personnel operate in a world of dynamic unknowns.

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True learning has occurred when there is a change of behavior. Whether it is how to effectively pull a hoseline or set up a safe working zone for emergency responders on an accident scene, true leaning has occurred when firefighters operate differently than before their training and education. With regards to roadway safety before Chance’s death, the Columbia Fire Department’s cultural acceptance, tolerance, and understanding of how to operate in or near the roadway was based on ignorance, recklessness, and a general unwillingness to change our operations. However, once members of the CFD were educated that there was a better way to operate, operational behavior changed. Glady, it changed for the better, or Chance’s passing would have been in vain.

It shouldn’t take another tragedy like that of 23-year-old firefighter Chance Hyatt Zoble to convince organizational leaders, fire officers, and firefighters to educate and train on how to recognize potential roadway hazards and prevent additional LODDs. I hope that other departments do not need to experience the loss of one of their own to recognize the need for a change of culture with regards to roadway operations. With all the published material on cultural change initiatives, fire departments should not have to experience a death or similar tragedy on the fireground to recognize the need for a culture change. Without directly addressing the need to change the culture inside the fire department, everything else will remain a symptom of a correctable mindset and its resultant behavior.

In April of 2015, the U.S. Fire Administration and International Association of Fire Chiefs developed “National Safety Culture Change Initiative: The Study of Behavioral Motivation on Reduction of Risk-Taking Behaviors in the Fire and Emergency Service.” The purpose was to address several of the firefighter life safety initiatives. Essentially, it states that every effort fire departments undertake to reduce injuries and firefighter LODDs will not and cannot be successful without first recognizing the need to change and address the cultural acceptance of overly-risky behavior.

In a high-profile incident involving Captain Pete Dern of the Fresno Fire Department who was critically injured when he fell through compromised roof decking penetrated by fire impingement, their post-incident analysis also emphasized the need for behavioral and cultural change. This incident sparked the Fresno Fire Department to step up and take a deep internal look at their operations. This investigation resulted in the “Courtland Incident” report compiled by an external “Serious Action Review Team” (SART), which can be reviewed HERE (PDF). The report suggests that department culture was a significant contributing factor in the critical injury of Fire Captain Pete Dern.

In February 2018, the Texas State Fire Marshal’s Office released the Firefighter Fatality Investigation of Firefighter Scott Deem of the San Antonio Fire Department, which urges their department to “Adopt ‘cultural change’ with a greater emphasis on firefighter accountability and Safety.” Consider the 10th inding from the report, which can be accessed HERE (PDF).

The path organizations frequently take is charted by the preparations individuals within make prior to the journey. These series of choices point toward the direction the group will take underway, inaccurately believing there is (or was) no other option. The current course some organizations are charting with regards to the lack of accountability, inconsistent discipline, and limited transparency will have consequences that will eventually directly impact the team. It is a hard choice the leadership team made, whether they realize it or not. When departments fall victim to the “treacherous terrain” or “austere environments,” it was in some cases the choices they made, long before the incident, that put them on their current path.

In such cases, organizations should not pass blame of these ramifications on “unavoidable conditions.” The implicit outcomes of an agency’s own actions are easily identified by those outside the organization. Sadly, the internal realization typically only occurs after a serious incident or loss of life, because when something goes tragically wrong, someone unknown to the department will come in to educate the organization on how they could have done better to recognize and prevent said tragedy. This is the tragic realization the Columbia Fire Department had after the death of firefighter Zoble.

What makes changing the fire service culture even harder is that most firefighters are pre-programmed to know what to do on the fireground before they arrive, sometimes without regard to presented conditions. Unfortunately, after a serious injury or LODD, reports often disclose the usual and predictable contributing factors and tasks are ill-timed, uncoordinated, or not properly communicated.

A research paper conducted by the International Association of Fire Fighters, “CONTRIBUTING FACTORS TO FIREFIGHTER LINE-OF-DUTY DEATH IN THE UNITED STATES,” concludes: “Ninety-seven and one-half percent of all firefighter LODD occurring between the years of 2000-2005 are attributable to an identifiable cluster of contributing factors. Approximately half of all firefighter LODD that occurred between these years are attributable to a cluster of three factors that are under the direct control of the individual firefighter and chief officers. The information revealed in this study imposes a considerable burden on decision makers and fire service leaders as well as firefighters themselves. It offers substantial guidance for shaping local fire department policy decisions and operational priorities.”

Failing to observe conditions and lack of teamwork are major contributing factors (See table 1). From the incident commander, to the firefighter, lack of teamwork can be better explained as freelancing. Either everyone is supporting the incident commander’s incident action plan, or they are freelancing, namely when a firefighter works independently, commits to tasks, and acts without the express knowledge or consent of an officer or incident commander (see “San Antonio LODD Recommendation 43).

During a recent webinar, Loveland-Symmes (OH) Deputy Chief Billy Goldfeder, one of the presenters, boldly stated: “Without discipline, the fireground is a playground with the firefighters doing whatever they want.” It takes courageous leaders with intestinal fortitude who are willing to expose questionable ideology. When you step up and lead, inevitably you will step on a few toes in the process. Not only can this be uncomfortable, but it can also damage friendships that have been forged by fire over decades of dedicated service. But true leaders will never ignore duty and responsibility over relationships, especially if lives truly are on the line.

At any incident, the number-one priority is life safety.

  • By simply doing their jobs, first responders face the possibility of injury or death.
  • However, this danger should be controllable because present and potential hazards are usually recognizable and predictable.

In one of his recent weekly featured videos, “Preventing the Mayday,” Gordon Graham, risk management expert, stated, “Now more than ever, all fireground commanders and all on scene personnel need to anticipate changing conditions and be proactive to prevent the Mayday before it happens.” However, this can only happen as long as firefighters aren’t outpacing their smarts and situational awareness, like I was early in my career. Doing so can lead to more severe consequences when bad things happen on the emergency scene. I had a seasoned company officer once tell me, “Slow down! Look at what you’re looking at!” He was telling me to slow down and observe what I was actually seeing on the fireground so that I could operate more effectively and safely.

Where Is the Fire? Where Is It Going? And How Long Until It Gets There?

An easy comparison is to think of the conditions from a kitchen fire versus a well-involved fire in a split-level home extending into the attic. Failing to observe and recognize the difference and adjusting operations accordingly can have dire consequences simply because the conditions have changed.

Using an everyday example, driving speed is often a contributing factor in roadway fatalities simply because the driver outpaced his capabilities based on the conditions. According to the National Highway Traffic Safety Administration, the consequences of speeding are far-ranging:

  • Greater potential for loss of vehicle control;
  • Reduced effectiveness of occupant protection equipment;
  • Increased stopping distance after the driver perceives a danger;
  • Increased degree of crash severity, leading to more severe injuries;
  • Economic implications of a speed-related crash; and
  • Increased fuel consumption/cost.

Now correlate the same results of excessive speed on the roadway to that on the fireground. Just like the reckless driver, a firefighter outpacing his situational awareness has very similar results.

  • Greater potential for loss of control
    • Failure to observe conditions and adjust strategy and tactics accordingly
  • Reduced effectiveness of PPE 
    • Greater exposure to danger and recognizable hostile fire events
  • Increased reaction time to adjust after the firefighter perceives a danger
    • Remaining over-committed in marginal or rapidly deteriorating conditions
  • Increased degree of incident severity, leading to more severe injuries
    • Failure to observe and operate within acceptable risk-benefit models
  • Economic implications of a LODD or significant line-of-duty injury
    • Worker’s compensation, lost time, medical leave, and overtime costs
  • Increased financial consumption
    • Mental health impact of a firefighter LODD or significant injury to fellow personnel

Incessant and obsessive training with incorrect tactics and inappropriate strategies and failure to address cavalier and reckless behavior will not change the outcome of preventable fireground injuries and deaths. This is because it is a poor assumption that improper tactics and inappropriate strategies can be overcome by any company or crew if they are simply dedicated and committed enough to training, regardless the risk they personally chose to take on the fireground. This is simply the ego of the fire service failing to embrace science, education, and nationally recognized best practices, while also choosing to ignore LODD reports and firefighter close calls. This “ego trip” will continue to have irreparable effects and disastrous consequences if we don’t alter course.

Just like many departments across the nation, the CFD is comprised of an extremely dedicated group of career and volunteer members whom I consider both professional firefighters because of their dedication and approach to the job, not because they happen to get compensated. Career or volunteer, it is our sworn and solemn duty to ensure that those who have been entrusted to us are brought home safely. We can no longer turn a blind eye when it comes to nationally recognized best practices and recommendations, such as those listed in the LODD report of 23-year-old firefighter Chance Hyatt Zoble.

Therefore, it is my hope, desire, and prayer that fire service leaders everywhere review these detailed reports and begin truly understanding the culture change that our profession needs to make at all levels for the overall health, safety and well-being of every firefighter. This in turn will allow us to better serve the citizens we have sworn to protect. No fire organization should ever wait for their own tragedy to change a known deviant cultural course. By becoming students of the cultural change needed in the fire service, together we can strive to ensure that “Everyone Goes Home.”

J. TRAVIS CARRICATO has been a member of the fire service for over 25 years. Currently, he is an Operations Division Chief with the Columbia (SC) Fire Department. He served as a member of SC-TF1 for over nine years, rising to the position of Task Force Leader. Carricato is also the founding owner of E-Med Training Services, LLC, which specializes in Emergency Response training for the industrial sector. An accomplished speaker and instructor, he has delivered training programs nationally as well as internationally in Russia, Saudi Arabia, China, and Kuwait.

REFERENCES

1. Chance Hyatt Zoble NIOSH Report: https://www.cdc.gov/niosh/fire/reports/face201036.html

2. “National Safety Culture Change Initiative” The Study of Behavioral Motivation on Reduction of Risk-Taking Behaviors in the Fire and Emergency Service.

3.  “The Courtland Incident” Multi – Agency Serious Accident Review Team S.A.R.T. Investigation Report Fresno Fire Department; https://assets.documentcloud.org/documents/2694283/Sart.pdf

4.  FIREFIGHTER FATALITY INVESTIGATION Firefighter Scott Deem San Antonio Fire Department Investigation FFF FY 17-02 San Antonio, Texas • May 18, 2017; https://www.tdi.texas.gov/reports/fire/documents/fffsadeem.pdf

5. “Structural Firefighter Line of Duty Deaths The Facts, the Lessons & the Future,” Webinar: http://info.lexipol.com/firefighter-lodds

6. CONTRIBUTING FACTORS TO FIREFIGHTER LINE-OF-DUTY INJURY IN METROPOLITAN FIRE DEPARTMENTS IN THE UNITED STATES: https://www.researchgate.net/publication/237280119_CONTRIBUTING_FACTORS_TO_FIREFIGHTER_LINE-OF-DUTY_INJURY_IN_METROPOLITAN_FIRE_DEPARTMENTS_IN_THE_UNITED_STATES [accessed Apr 21 2018].

7. Weekly Webinar; Gordon Graham, “Preventing the Mayday”

8. TEEX Risk Management; Industrial Emergencies for Municipal-Based Responders

9. National Highway Traffic Safety Administration