BY QUINN MacLEOD
Over the years, I have read, seen, and been involved in fireground operations that were littered with errors. With the help of www.firefighterclosecalls.com, www.firefighternearmiss.com, and other such Web sites, we can read about these from the safety of hindsight and hopefully learn something from others’ unfortunate situations. Incidents and training exercises can be the breeding grounds for errors. Fortunately, many of us, including me, have escaped witnessing a line-of-duty death (LODD), but we have seen fellow firefighters taken to the hospital in our own rescue units. When we examine the situation retrospectively, the number of errors present created a chain of events that should have been foreseen. Of course, there are many underlying problems pointing to the decisions made on those days, but that’s another discussion.
“Error” has many definitions, but my favorites include a wandering or deviation from the right course or standard; something done wrong and left uncorrected; and a misconception resulting from incorrect information.
As referenced above, errors are present on virtually every incident. Some are very minor and can go undetected—casual blunders that lurk around harmlessly, sometimes for years or even decades. These concealed errors, however, can gang up with other mistakes for an ambush, compounding a negative outcome. Larger errors will drag an incident to a grinding halt, requiring an immediate change of strategy and tactics, and may even involve the search for a downed firefighter.
THE SWISS CHEESE MODEL OF HUMAN ERROR
Among the numerous ways of flushing out errors, the Swiss Cheese Model has become quite popular. It has been effective in determining human error across many lines of high-risk occupations, such as aviation; nuclear power plant management; and, more recently, firefighting. Created in 1990 by James Reason, a professor of psychology in Manchester, England, the model has been modified to meet the needs of different occupations; but because we are dealing with human factors, the underlying premise is consistent.
The Swiss Cheese Model is such a useful tool because it can be used not only in an accident investigation but also to help identify potential errors before they occur. Dr. Reason brings to light that all levels of an organization can and usually do contribute to the error. Like Swiss cheese, these holes in the organization line up perfectly to allow the accident to occur (Figure 1).
Figure 1 |
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| Source: Adapted from “The Human Factors Analysis and classification System–HFACS,” DOT/FAA/AM-00/7, February 2000. |
Traditionally, we have focused our investigative efforts around the person or persons who committed the active failure that caused an accident of some sort. Although this approach has always been convenient, it is basically a blaming mechanism and fails to expose the bigger root causes.
Within the Swiss Cheese Model, Dr. Reason identifies those active failures as the final unsafe act. Unsafe acts fall into two categories: errors and violations. Errors are skill-, decisional-, and perception-based, such as forgetting or not knowing how to perform a skill, choosing the wrong tactic, and having low situational awareness. Violations are just that—a person knowingly operates outside of acceptable policies and procedures. Some violations may be routine, such as a deviation within the framework of a standard operating procedure. Others may be exceptional violations, such as freelancing.
Dr. Reason identifies three areas of latent failure. As the name suggests, latent failures, unlike their active counterparts, may lie dormant or undetected for hours, days, weeks, or even longer, until one day they adversely affect the unsuspecting person or crew.1
The first latent failure, Preconditions for Unsafe Acts, involves how an individual’s or crew’s condition affects performance. This includes mental fatigue and poor communication and coordination practices. (1) Not surprisingly, if fatigued firefighters fail to communicate and coordinate their activities with others, poor decisions are made and errors often result.
As with other high-risk occupations, leadership is crucial. Within the Swiss Cheese Model, an entire slice is devoted to leadership, labeled Unsafe Supervision. Keep in mind that supervision is present in many levels on the fireground, from the incident commander (IC) down to the two firefighters who are paired up as a team. The company officer position is the most crucial because this is where the majority of the pivotal decisions are made.
Unsafe supervision falls into four categories:
- Inadequate supervision. A lack of guidance, leadership, and motivation.
- Planned inappropriate operations. The task, tactic, or tempo of the operation puts individuals at unacceptable risk.
- Failure to correct known problems.Failure to correct problems with individuals, equipment, training, or other related safety areas that are “known” to the supervisor but are allowed to continue unobstructed.
- Supervisory violations. Rules and regulations are willfully disregarded by supervisors.
Dr. Reason rounds out the model by including the organization itself, Organizational Influences, which can impact performance at all levels. When budgets are tight or funding is cut, seemingly nonessential programs are omitted or severely scaled back. Although the training division as a whole may not be cut, more costly exercises or funds for traveling to a class or seminar can be the first to go. Failing to increase staffing to account for increased call volume and replacement or upgrades to equipment and apparatus would also fall into this slice.
The list is endless. How significant of a latent failure would fire prevention division cutbacks be? One only has to look at any number of significant firefighting disasters for examples, such as the 2007 Charleston (SC) Sofa Super Store fire. Being fiscally responsible while providing for firefighter safety is a balancing act with no easy answers.
CHARLESTON SOFA SUPER STORE FIRE
The Charleston Sofa Super Store fire’s chain of errors highlights every element of the Swiss Cheese Model. The information in Figure 2 is taken from the City of Charleston Post Incident Assessment and Review Team’s Firefighter Fatality Investigative Report, dated May 15, 2008.2 The details are a sobering reminder of just how tragic events can become when many errors eventually come together to create the perfect storm.
All types of postfire analysis (e.g., debriefings, after-action reviews) are critical to identify what went right, what can be improved, and what errors were present. Finding the root cause of the errors and then applying corrective action runs the gamut from minor to monumental. Unfortunately, because error is so heavily tied to the human element, we will probably never be able to eliminate each one.
Errors are present at almost every emergency and nonemergency incident. The bottom line is that even the most experienced firefighter/officer is not immune to errors. The Swiss Cheese Model is an excellent tool for flushing out errors where most reside—in the human element.
Now that we have a better understanding of what errors look like, let’s look at a number of solutions for managing errors in the future.
ERROR MANAGEMENT
Learning from past mistakes is valuable, but it provides little benefit if that knowledge does not lead to corrective action. Although anyone can use the Swiss Cheese Model to prevent fireground deaths and injuries, just how much success can any one individual achieve? A fire department board, department chief, and division chief can effect change in a number of areas by setting the groundwork for fire companies to conduct safer operations, but it is unrealistic to think that every positive change will create an error-free fireground. Thorough fire department strategic planning, with constructive input from the line, is an important step toward reducing potential problem areas, but holes will still exist. The emphasis here is to identify the shortcomings and mitigate their effects.
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(1) Open communication, trust, teamwork, and recognition of members’ strong and weak points all must start back at the station. Individual firefighters and crews can actually break the error chain and create their own safer fireground. [Photo by Rick Lynsky, Montebello (CA) Fire Department.] |
Individual firefighters and crews can actually break the error chain and create their own safer fireground. Before looking at how to reduce errors on the fireground, consider building the foundation back at the station, which will support what happens on the fireground. A high level of communication and trust must exist between the company officer and crew. The company officer will need the eyes and ears of all the crew members, and the members will need to feel that they can give open and honest feedback. The company officer can create this culture, but it must be consistent. In challenging and stressful situations, such as on the fireground, individuals will default to what is familiar to them. Open communication, trust, teamwork, and recognition of members’ strong and weak points all must start back at the station.
Structural Watch Out Situations. Once the crew is functioning as a team, it needs an easy way to identify errors. The Structural Watch Out Situations below will aid the crew in recognizing a present or developing error (i.e., hazardous situation) that may endanger the crew or others. When these situations begin appearing at the incident, you need to change strategy and tactics or simply reevaluate the level of risk needed to get the job done safely. All crew members must be able to recognize the risks early on and to know that, although a couple of watch outs may not be a problem, the presence of several could start the error chain. Situational awareness should be constantly increasing, since low situational awareness is an error in itself.
It is impractical to think that the average firefighter or IC will physically reference these 20 Watch Out Situations while engaged in an incident. Therefore, the preferred method of integrating this information is to incorporate them into the daily routine—for example, by introducing errors into a training scenario.
Alternatively, incorporate the Watch Outs into postincident debriefings and after-action reviews to help when discussing the reasons events unfolded as they did. Finally, post the Watch Out Situations in the day room so members will read them frequently; this can promote important casual discussions that sometimes prove to be the best way to retain information.
Note that the Structural Watch Outs list below is not all-inclusive and should be modified to fit each jurisdiction.
1. 360-degree view of fire and size-up not performed.
2. Uninformed on strategy, tactics, fire conditions, and hazards.
3. Instructions and assignments not clear.
4. Incident is progressing poorly.
5. Transitioning from offensive to defensive, or vice versa.
6. The structure has been evacuated by the public and is confirmed.
7. Water supply is unreliable.
8. Searching without a hoseline or tag line.
9. Working above or below the fire.
10. Attempting to attack the fire from a ground ladder.
11. Interior building configuration makes escape to safe areas difficult.
12. On entering the structure, heavy smoke conditions and/or high heat are encountered.
13. Unable to quickly locate the seat of the fire.
14. Unfamiliar with the building and/or its contents.
15. The building has had numerous alterations.
16. Operating on the roof with only one means of egress.
17. 15 minutes have elapsed and the interior firefight continues.
18. Environmental conditions are extreme.
19. The incident scene is dark.
20. Mentally and/or physically tired.
Now that we’ve identified some developing errors, what can you do about them? First, communicate the situation to command. If errors are present, most likely command is suffering from low situational awareness. Obviously, if it’s a life-threatening situation, you need to take immediate action. If the incident is beyond rescue mode, there is nothing wrong with ceasing operations while taking control measures. If rescues are ongoing, just knowing that errors are present will help to avert disaster—for the firefighter and for the person to be rescued.
If an incident is built on a good size-up, solid communications, acceptable fire control practices, and ongoing efforts at raising everyone’s situational awareness, error control will naturally follow. But, unfortunately, a time will come when, despite good intent, poor decisions will be made. (Watch Out 4).
Error control.Errors usually start with your selection of strategy and tactics, so it makes sense that you can largely control errors by modifying strategy and tactics. An exception, of course, is an incident that is in rescue mode; then Lookouts, Communications, Escape Routes, and Safety Zones (LCES) play a critical role. Task selection is another area in which to minimize errors. Although the items listed below are not true stand-alone strategy and tactics, these items represent opportunities to control errors.
- Aggressively locate the building/homeowner to verify that the structure is unoccupied. Keep the property owner at the incident command post as a source of information.
- Reperform the 360-degree walkaround of the building and overall incident. Closely examine structural stability.
- Verify that all building exits are unlocked, marked (e.g., illuminated with glow sticks), and known to all personnel.
- Ladder the roof on all sides, and illuminate the ladder tips.
- Assign an additional person to assist the IC; this person monitors radio traffic exclusively.
- Control areas where structural integrity has been compromised.
- Establish a collapse zone if an exterior attack is undertaken, and ensure that the zone is controlled!
- Consider using heavy equipment for overhaul.
LCES. LCES is an integral mechanism for error control at wildland fires and can also be used for structural fire incidents. In fact, LCES can be adapted to control errors at any type of emergency and nonemergency incident or event. For LCES to be truly effective, members must train on its components at every opportunity. The outline below minimally details how you can use LCES.
Lookouts are situated to notice the minor, major, and cumulative changes of a specific area. A member assigned as a lookout
- ideally should not be involved in tactics; exercise caution if this person is engaged in collateral duties—e.g., acting as a safety officer, as this can overburden the individual;
- must know the plan, the fire’s location and behavior, the building’s construction type, and the exit locations;
- must possess good communication skills; and
- must have a portable radio and, if possible, a thermal imaging camera.
Effective communication is critical to ensure a safe and successful operation.
- All on-scene personnel are obligated to voice their concerns. The foundation for this should have been built back at the station, so a level of trust should already exist. This encourages members to raise concerns when an error is developing or present.
- Use effective two-way communication, listening and speaking. Employ active listening techniques and strong speaking skills.
- Conduct overall incident and crew briefings.
- Elevate situational awareness through strong communications.
An escape route is a preplanned and understood route to reach a safe area.
- Control the primary means of ingress. Support firefighters (hose backup) maintain and improve this avenue by moving furniture, blocking open doors, illuminating with glow sticks, obtaining situational awareness of possible secondary means of egress, and so forth.
- The company officer or his designee shall be responsible for finding a secondary means of egress. Coordinate this with the lookout, other crews, and the safety officer.
A safety zone is a location where the threatened firefighter can find adequate refuge from the fire and building conditions.
- An escape route must lead to an area outside of the immediately dangerous to life and health (IDLH) atmosphere and the collapse zone.
- Communicate the safety zone and escape routes to all personnel.
The error control techniques discussed above are not all-inclusive. One final control worth mentioning is that of limiting personnel exposure time to the hazards. You can facilitate keeping nonessential personnel out of the IDLH atmosphere and collapse zone using basic principles of staging and “on-deck” practices. If you don’t need five companies to vent the roof, don’t put them up there. Stage them at the bottom of the ladder until needed.
Errors are present at virtually every emergency and nonemergency incident. The true professional firefighter, whether career or volunteer, will actively seek to expose errors and then manage them.
The Swiss Cheese Model is only one way of flushing out the error chain. Building the error-resilient crew begins back at the station, which supports the open communication and trust needed on the fireground. The Structural Watch Out Situations identify potential and developing hazardous situations. LCES is a proven error-control mechanism and is easy to integrate into every situation. What matters most is that you recognize errors and establish controls at every incident to mitigate their adverse effects.
Endnotes
1. Shappell, Scott A., Douglas A. Wiegmann. “The Human Factors Analysis and classification System–HFACS,” DOT/FAA/AM-00/7. United States Department of Transportation, Federal Aviation Administration, Office of Aviation Medicine, February 2000.
2. City of Charleston Post Incident Assessment and Review Team, “Firefighter Fatality Investigative Report: Sofa Super Store, 1807 Savannah Highway, Charleston, South Carolina,” Phase II Report, May 15, 2008, http://www.charlestoncity.info/shared/docs/0/sofa super store report may 15 2008 final.pdf.
QUINN MacLEOD, owner and lead instructor of Integrated Fire Solutions, has been in the fire service since 1985, which includes 20 years on the line with the Parker (CO) Fire District. He is NWCG qualified as a wildfire division supervisor and has an associate degree in fire science along with numerous state and national certifications, including fire officer and fire instructor.
