Break the Failure Chain with Competent Leaders

WE ARRIVED ON THE SCENE, and heavy fire was showing out the rear of the apartment building. Occupants were outside the building in their nightclothes and were repeatedly stating that everyone was out of the building.

After this fire, the following conversation took place among the training captain and the firefighters at the back step of the rig.

Captain: “Great job fellas … all that live training we did paid off!”

Firefighter 1 (tired and grinning from ear to ear): “Yeah, I was wondering how many times you were going to make us do that during training the past few months!”

Mutual-aid member: “What is live training?”

Firefighter 1: “You know, we would roll up on the ladder truck, get off with the right tools, get the ground ladder to the roof, start the saw, select the spot to cut, and then we ….”

Firefighter 2 (who had vented at the fire): “We did that at our firehouse, at the training center, and at several buildings in our first-due area. Guess it was good we did all that practice; it sure paid off tonight.”

Captain: “More importantly, it may have saved some lives tonight! Well, we have to practice it until we get it right; we have to get it right every time we roll out. My life, your lives, and those of the firefighters and civilians inside depend on how much and how effectively we have practiced. Just like in sports: If you want to win, you have to practice a lot. The key is to practice first at slow speed, then at half speed, and then at full speed, over and over again!

“If you remember, we first practiced at slow speed, making sure we had everything right-the right tools, straps on the saws so they were easy to carry up the ladder, and so forth. Then we moved up to half speed, and then finally full speed. Remember when we went full speed the first time? I forgot to bring the thermal imaging camera out of the cab of the rig. That was the reason we did it again and again until we all got it right, including me!”

Firefighter 2: “Lieutenant, we had the roof cut and the ceiling pushed down and had good fire and smoke coming out of the hole even before the engine had water on the fire. Damn, we’re good!”

Captain: “Most important, we’re all safe; this fire could have been much worse. There was a recent fire case history that was very much like ours today.”

Firefighter 3: “What happened, Captain?”

Captain: “There was fire in one apartment, kind of like we had tonight, that had extended into the attic. A firefighter went into exposure 2 and opened the ceiling to look for fire. There it was. The attic flashed over, extended down into the exposure 2 apartment, and lit it up! The firefighter jumped out the window as the FAST was trying to put up the ladder-it happened that quickly! Sometimes, speedy roof ventilation is critical!

“You guys did a great job tonight, but never, ever forget this: The members inside doing the search and the engine company taking a beating from the heat are depending on the roof team to get it open and lift the heat and smoke off them. It’s a matter of life and death-firefighters’ lives. Okay, let’s get picked up and back to quarters. Great job guys, great job!”

Firefighter: “Great job because of you, captain!”

Captain: “It was the training, not me!”


Lieutenant (yells out): “Aw, shut up, we finally got the roof cut-what are you bellyachin’ about?”

The firefighter sits down on the apparatus’ running board, buries his face in his hands, and cries uncontrollably. Several other firefighters surrounding him comfort him. The lieutenant walks away alone, bitter.

The chaplain comes over and prays with the group of firefighters. Physical and emotional comfort is hard to come by. Their world had come down around them.

Suddenly, all the firefighters jump to attention, place their helmets over their hearts, and form a cordon between the building and the waiting coroner’s vehicle. A member was carried out in one of those ugly black bags-he was burned beyond recognition in the flashover that started in the attic.

When the attic lit up, it pushed the ceiling down; he was caught in the fast-moving fire in the apartment (exposure 2), got entangled in flexible ductwork and electrical and cable TV wiring, and burned to death. The FAST was there, but by the time it got the line charged, the screaming from inside the apartment had stopped.

The suffering did not end there. Someone had to notify the member’s wife and kids. Can you imagine that painful walk up the sidewalk to his home? The funeral was terrible. The minister told the firefighter’s children, “Never forget that your Daddy was a hero.” Somehow, that just did not seem to be enough to make up for the empty seat at the dinner table every night. It sure was not enough to fill the empty seat at the hockey game, the Cub Scout meeting, or the graduation.

The Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health reports tore the company apart. We’re still waiting to see if any of the company leaders will serve jail terms-a partial down payment for the firefighter’s death. The media were relentless. The newspaper headlines read, “Family escapes, firefighter killed, others badly injured.”

Now the lawyers are involved. A chain of errors came together for only a few seconds one awful morning, but it will haunt the firefighters every day. Many have left the company; still others are in counseling. The incident is not talked about much. There was one attempted suicide that not too many members know about.


The failure chain came together that morning with devastating consequences. The first-in truck was the new ladder truck, the “do-everything truck.” It had a 100-foot aerial; a 1,500-gpm pump, a generator, large-diameter hose, preconnects-all the best. But fire trucks don’t put out fires-well-trained, well-drilled, highly motivated firefighters do. When your leadership doesn’t train the company members in these critical fireground skills, bad things happen when the failure chain comes together.

Here is what happened at this fire: Heavy fire was showing from several windows in a one-story apartment building with a peaked roof. The search team went in; the hoseline followed to the front door. The outside vent man saw the stretched line and took the window. The roof team was delayed getting to the roof, because it had to go back and get the proper tools. They looked like the Keystone Cops trying to put up the ladder. The butt man did not even know he was responsible for placing the butt in the right place for the raise.

Once the team was on the roof, the first saw would not start. The second saw finally made it to the roof. The team started to make the cut when members realized the saw had the wrong blade for the material. There was a lot of yelling down below as the roof team looked down from the roof. One firefighter outside was yelling about someone still inside. One search team member made it out. As he removed his gear, it looked like it was glowing. The roof team began to cut the roof vent when fire blew out all of the windows at once. The remaining search team member was caught in the flashover. The engine company was also caught; however, the members survived, but two were badly burned. Of the two-firefighter search team that went into exposure 2, one made it out and one didn’t.


Although some of this story is fiction, the bulk of it is based on actual incidents, slightly rearranged. Outcomes have been dramatized to make critical points. What did you get out of this article? If the time you invested in reading this article does not make you change anything-your attitude, company training, planning, training techniques-it was a waste of time. Do something, change something, be better prepared, be better trained, do more live training.

A fire company’s effectiveness and safety depend on the company officer’s ability to train its members. The fire company’s effectiveness is based on written standard operating procedures (SOPs) that have been developed and practiced over time to provide a road map for new and experienced members. It is the company officer’s responsibility to ensure that company members can correctly and consistently execute the SOPs on the training ground so members can do the same on the fireground.

The company officer must repeatedly train members in the perishable basic skills essential to properly executing the critical fireground functions-water supply, stretching the line, advancing the line and delivering water, search and rescue, forcible entry, and horizontal and vertical ventilation.

Developing speed in performing evolutions is essential. Members must frequently train at slow, half, and full speed (realistic speed conditions at an actual incident). At slow speed, the focus is on ensuring all evolution elements are included and done properly. Once this is accomplished, the focus can shift to improving company speed in performing the evolution, moving up to half and then to full speed.

The officer must know the tactics to apply in specific fireground situations based on the incident conmander’s strategic goals. For example, the company officer and his members must know where and how to stretch the initial attack line when command directs a line to the seat of the fire.

. . .

Providing good leadership is the primary issue affecting volunteer fire departments today. Good leadership by skilled, trained, experienced, competent, and open-minded leaders will ensure success and safety on the fireground. Bad leadership by poorly trained, closed-minded, heavy-handed, and “suspension-happy” leaders will continue to result in horror stories like the one described above.

Someone once said, “If your only tool is a hammer, everything is a nail.” Great firefighters are developed by well-trained, skilled, and competent leaders who deliver good coaching; frequent, effective training; and productive mentoring. Anything else breeds contempt, poor morale, and dangerous fire scenes.

To ensure fireground safety and success, continue to take advantage of every training opportunity, provide high-quality training for your officers and members, and continue to focus on maintaining the critical skills described above. Although members may learn these skills at the regional training center, it is the company officer’s duty to hone and maintain them so officers and members can execute them properly on game day. The stakes are much higher than just a mark in the win or loss column: It is a matter of life and death-ours.

JERRY KNAPP is a training officer at the Rockland County Fire Training Center in Pomona, New York; a 33-year veteran firefighter/EMT with the West Haverstraw (NY) Fire Department; a battalion chief on the Rockland hazmat team; and the plans and operations officer for the Directorate of Emergency Services at the U.S. Military Academy at West Point. He has an associate’s degree in fire science, is a frequent contributor to Fire Engineering, and is an FDIC H.O.T. Engine Company instructor.

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