Photo by Tony Greco.
By Eric G. Bachman
Popularized by television police dramas, most people recognize the acronym “CSI” as a law enforcement reference for “Crime Scene Investigation.” In the fire service, however, it represents “Case Study Intelligence.” Law enforcement CSI examines all facets and forensics of a crime to enhance investigators’ intelligence to identify evidence and determine a chain of events. Fire Service CSI (FS-CSI) is a similar practice that all fire department staff should embrace—regardless of position or tenure—to improve their intelligence and safety for future incidents. It is imperative that fire service students take advantage of learning opportunities to improve personal and organizational readiness for future incidents. One beneficial practice is looking at case study results from others’ past experiences.
Formal Case Studies
For the purposes of this article, the term “case study” includes formal and informal resources.
Formal case studies are most correlated in the fire service to line-of-duty death (LODD) reports published by the National Institute of Occupational Safety and Health (NIOSH) and technical reports developed by the United State Fire Administration (USFA). Both entities are often referenced in training programs to support practical improvement of fire department pre- and post-dispatch operations. Tremendous efforts are concentrated by these agencies to determine the contributing factors to tragic events. It is important to review these documents for comparative analysis against local conditions to prevent similar events. Often, a LODD was not the result of a singular act, omission, or factor but rather from multiple deficiencies or a series of seemingly unrelated actions over time that merges at the incident. Most case study reports provide a list of lessons learned that may be shared in the reader’s locale.
I teach an annual “Pre-Incident Planning” class at our county fire training center. An awareness level program, one segment of the class includes case study overviews on how preincident preparedness, or lack thereof, contributed to tragic outcomes. After reviewing one report during a recent class, a student commented on the age of one case study, saying that it was an “old” one. It certainly seemed old to the student because the incident occurred before the student could walk or talk. My response was a comment lamented by many fire service instructors and leaders that reinforce we have not invented new ways to die; we are killing ourselves the same way now as we did then.
As a witness to a LODD that took the life of my best friend, fire service students of all ages and experience levels must be reminded of the timelessness of LODD case study reports. All LODD reports and close-call examinations are relevant, especially if the root causes are recurring. Most LODD and close-call reports establish a list of lessons learned. In some cases, it is quite a list. When I discuss the proverbial lessons learned, I replace the term “lesson learned” with “failures.” We can only consider lessons learned when the subsequent result is a change to preclude a reoccurrence. Changing policies, procedures, training, and culture (to name a few) to prevent similar results is a positive step in learning the lesson(s). However, when subsequent reports are published with the same recurring lessons identified as a contributing factor; the lessons have not been learned. It is failure. Think back to when you were a child, and a parent told you to not touch the stove burner because it was hot. You may have touched it once, but after that one time, you learned your lesson and never did again (on purpose anyway). Many case studies and LODD reports show that lessons learned are virtual facsimiles of another incident; the only difference is the date and location.
Some staff may see no benefit reviewing case study information with differing dispositions. Career staff may not immediately see a correlation from a report involving volunteer firefighters, and vise-versa. A fire department that protects an urban area may not recognize a relationship to a fire department in a rural setting. That same reluctance precludes reviewing an incident that occurred in a certain venue such as a high-rise when, locally, the fire department does not protect a structure more than two-stories tall.
Reviewing case studies that may seem irrelevant will surprisingly yield many commonalities to local situations. Although physical fire department dispositions vary, fundamentally, they are no different. I learned a long time ago that the only differences between fire departments are the names and addresses; their purposes and focus are likely the same. Chances are your fire departments mission mirrors mine—to protect lives and property.
A Team Approach
All fire departments share several influences. I don’t know of any fire department that does not want more funding. I don’t know of any fire department that is overstaffed. And I don’t know any fire department that has time to spare. There is always something to do and never enough money, personnel, or time to do it. Fire departments strive to balance administrative and response obligations and, being experienced in most disciplines, they are tasked with doing more with less. Striving for that balance often defines the organizations priorities. Public fire education, preincident preparedness, and other nonemergent activities, although important, are often at the bottom of the priorities list or they are underfunded.
So with all of the external and internal influences, how does a fire department include a review of case studies as part of improving its intelligence? Granted, some reports are lengthy and will take time to review, but there is time if you make time. A method to improve FS-CSI is to assign certain staff members, regardless of position or tenure, a case study to review, overview, and identify the similarities to local conditions. A member may also present an overview of a report as part of a training session or meeting. The briefing can be as detailed as the case study warrants. Each case study briefing should note the minimum criteria established. At a minimum, case study information should the following:
- An overview of the building: “What was the building’s size or arrangement?”
- The fire scenario: “When and where did it start, and how did it spread?”
- The general fire department operations conducted: “What strategies and tactics were employed?”
- The result: “What happened?”
- The identified lessons learned: “What were the contributing factors?”
- A query of how it applies locally: “How can we improve our operations?”
Develop a standard form to capture the information. After a scheduled briefing, post it on a bulletin board or by the restroom urinal/toilets so it is readily seen. Maintain a FS-CSI manual that includes past reviews for new personnel to study or for other staff to refresh their memories.
Assigning other staff to engage in FS-CSI research gets them involved and alleviates the task time for one individual. Likely, it will result in a learning experience that may heighten individual awareness to universal fire service issues and perhaps be used as a motivational tool to improve personal and or organizational readiness.
Informal Case Studies
A case study does not necessarily constitute a situation that ended tragically, nor does it have be a document labeled as such; it can be a source that identifies some condition or circumstance that can be applied to operational, organizational, or personnel improvement. An informal case study is any resource that describes an incident, identifies challenges, and reveals response deficiencies or need for improvement. It is a source that correlates circumstances which can be applied locally as a catalyst for change or reaffirms continued, ignored, or ill-advised practices. Informal FS-CSI can come from any source that you can take away beneficial information from such as a newspaper article about challenges faced by a fire department at an incident, a topical Web site article that can be related to an incident influencing factor (like building construction materials), and discussions on Web-based forums. Although not labeled as a classical case study, these sources can provide incident-improving data.
Articles in fire service periodicals can be FS-CSI especially, when improving or influencing operational ideas, practices, and concepts that are presented and embraced for local application. For example, an article in a fire service periodical that highlights a large-loss fire at a food processing facility might point to the roof being covered by a photovoltaic system, hampering firefighting efforts and contributing to the high dollar loss. This article sparked local interest in learning about such systems and the need to identify local installations.
Although not labeled as a case study, it served as one because it changed the local fire department behavior and considerations for future operations. Of course, you should evaluate informational sources for credibility and not as a biased, complaint-based rant. Review of these article and reports are necessary to analyze close-call incidents and correlate the situational circumstances to local conditions.
A benefit to FS-CSI is its low- or no-cost availability. Most formal case study reports are available electronically and can be easily reviewed and downloaded. As mentioned earlier, the USFA (www.usfa.fema.gov/operations/ops_safety.html) offers many technical reports and other operations and safety resources that can be ordered and sent to you free of charge. The NIOSH reports can be found at www.cdc.gov/niosh/fire . Seek out other fire service related sites such as the Texas State Fire Marshal’s Office (TSFMO) (www.tdi.texas.gov/fire/fmloddinvesti.html), which provides access to firefighter fatality reports conducted by the TSFMO and provides lesson learned. And, hopefully, you visit www.FirefigherCloseCalls.com to access its important relative operations and safety data. There are several other fact-finding fire service Web sites that contain FS-CSI applicable information such as www.nationalnearmiss.org.
Do not limit your source search of case study reports to common fire service links. Other resources such as the Chemical Safety Board (CSB) publish case study reports on the results of root cause investigations of chemical accidents at fixed industrial facilities. You can also download or order reports from the CSB Web site (www.csb.gov) or order them a free DVD series of report investigations. Keep an open mind when reviewing case study reports; sometimes, the reports are focused and related to the mission of the investigating authority. The CSB reports primarily focus on chemical process issues, so the resulting list of lessons learned or recommendations are more process safety oriented. Nonetheless, these reports provide valuable hazard analysis that can be correlated to applicable local processes.
History is an important aspect of study. The saying “history repeats itself” is certainly true in the fire service, and is reinforced by common factors among many tragic case studies. Reviewing formal and informal case studies can also reveal adverse circumstances on current or emerging threats for which you should prepare, embrace, and counter. FS-CSI should be a part of any fire department’s intelligence to improve culture. LODD reports represent tremendous sacrifices that you cannot forget, overlook, or not study. Reviewing contributing factors to an incident that went bad is important to develop, practice, and initiate corrective actions before they adversely affect you. Information access and availability using today’s technology is ever-present. Understandably, time is a limited commodity. Creative time management from all staffing levels will heighten your awareness, be a catalyst for improved operations and safety, and identify lessons that you can truly learn.
ERIC G. BACHMAN, CFPS, is a 33-year veteran of the fire service and a former chief of the Eden Volunteer Fire/Rescue Department in Lancaster County, Pennsylvania. He is the hazardous materials administrator for the County of Lancaster Emergency Management Agency and serves on the Local Emergency Planning Committee of Lancaster County. He is registered with the National Board on Fire Service Professional Qualifications as a fire officer IV, fire instructor III, hazardous materials technician, and hazardous materials incident commander. He has an associate degree in fire science and earned professional certification in emergency management through the state of Pennsylvania. He is also a volunteer firefighter with the West Hempfield (PA) Fire & Rescue Company.