Risk Management: It’s Not Just a Catchphrase

BY JENNIFER CHADWICK

The enemy has changed, and the enemy isn’t playing fair. Many of the rules that applied to firefighting 50 years ago are no longer valid today. Firefighters are now operating in environments that are trying to kill them faster and more aggressively than ever before. Lightweight construction components and the increased use of synthetic materials have changed the game for the fire service. It may appear that the fireground has become safer for firefighters because of a reduction in the overall number of firefighter fatalities over the past 30 years, but during this same time frame, there has been an alarming 67 percent increase in firefighter fatalities from traumatic injuries. The fireground has become increasingly dangerous to firefighters everywhere. We are duty-bound to understand why this is happening and to do whatever it takes to prevent the loss of another one of our own.

A line-of-duty death (LODD) is not something that any firefighter or any fire department expects, but it still happens. According to the United States Fire Administration (USFA) report Firefighter Fatalities in the United States, 81 firefighters were killed in the line of duty in 2012 and, on average, 100 firefighters per year over the past 10 years have lost their lives. Since 1977, the National Fire Protection Association (NFPA) has collected data from fire departments across the nation regarding fires and fire deaths. A report published by the NFPA states, “Since 1977, the number of U.S. firefighter deaths annually at structure fires has dropped almost two-thirds, a finding that often has been credited to improvements in protective clothing and equipment, fireground procedures, and training, but little attention has been paid to the drop in the number of structure fires themselves.” In fact, from 1977 to 2009, the annual number of structure fires has decreased by 53 percent. This would indicate that the decrease in firefighter fatalities might actually be the result of the reduction in the number of fires and not advances in all areas of the fire service.

shorter times to flashover than in the past, the fireground has become less forgiving and more dangerous to fire service members
(1) With considerably shorter times to flashover than in the past, the fireground has become less forgiving and more dangerous to fire service members. Firefighters must place an emphasis on the identification and recognition of warning signs that indicate a hostile fire event could take place. This could mean the difference between life and death. [Photos by Albert Pedroza, San Antonio (TX) Fire Department.]
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RISK MANAGEMENT

What resource can firefighters use to help combat the dangers they face in today’s modern fire environment? Risk management is a critical life-saving tool that, when used properly, will keep firefighters alive. This dynamic process involves the following:

  • Identifying actual and potential hazards or risks.
  • Deciding on a plan of action based on the level of risk to responders.
  • Implementing control measures to increase the safety of firefighters.
  • Constantly monitoring and reviewing conditions and adjusting the plan as needed to reduce the level of risk to responders.

An effective risk management plan could mean that defensive operations may be the only safe option at a structure fire because of the risk of collapse or that ventilation should be the first tactical priority to prevent flashover or that firefighters must back out of a structure because of rapidly deteriorating conditions. The ultimate goal of a properly executed risk management plan is to keep firefighters as safe as possible throughout the course of the incident.

The fire service has already recognized the importance of risk management in relation to firefighter fatalities. During the Firefighter Life Safety Summit that took place in 2004, 16 initiatives were developed with the goal of reducing the number of firefighter fatalities. Initiative number three specifically concentrates on risk management and calls for the need to “focus greater attention on the integration of risk management with incident management at all levels, including strategic, tactical, and planning responsibilities.”

What we must all realize is that risk carries a name. That name is the name of each and every firefighter operating at an incident. It is essential that all firefighters understand the difference between an acceptable and an unacceptable risk. It is fundamentally important that each of us understands that it is never acceptable to lose a firefighter trying to save lives or property that has already been lost. To do so is careless and intolerable. Firefighters have sworn to protect the lives of the citizens in their communities. They want to help people and save lives, but sometimes the lives they save need to be their own.

overall increase in firefighter deaths caused by traumatic injury
(2) There has been an overall increase in firefighter deaths caused by traumatic injury. To maintain the highest degree of safety for all firefighters operating on the fireground, always follow the principles of risk management: Risk a lot to save a lot, risk a little to save a little, risk nothing to save nothing.

NIOSH FATALITY REPORTS

Since 1998, the National Institute for Occupational Safety and Health (NIOSH) has been charged with the investigation of firefighter fatalities in an attempt to prevent future injuries and deaths. The reports furnished by NIOSH are an incredible opportunity for us to reflect on our own departments, our own decision-making processes, and the way that we evaluate risks in every situation so we can determine whether we are on the path to an LODD of our own.

NIOSH invests considerable time and resources in the investigation of each fatality. We can learn a substantial amount of information from the data included in these reports. If we can learn from what has happened and focus our efforts on preventing similar events, then we are well on our way to limiting or decreasing firefighter fatalities.

Preparation and prevention are key components. We must be trained to recognize the cues and clues that indicate operations or conditions are dangerous, and we must be able to respond appropriately. This is not to say that all firefighter fatalities are preventable. Despite our best efforts, catastrophic events that may result in the death of a firefighter can and do occur.

The only component missing from the NIOSH LODD reports is the victim’s account of what happened. Without this information, we cannot truly understand the events that occurred on the fateful day. It does no good to be a “Monday morning quarterback.” Nothing will come out of this negativity. We cannot change the past or undo what has already been done. We must learn from these tragic events and figure out a way to prevent future firefighter fatalities.

Most firefighters understand the importance of risk management and know why it should be used on the fireground, yet failure to use it is still a major contributing factor in the death of firefighters, as demonstrated in many NIOSH LODD reports. An overwhelming number of contributing factors and NIOSH recommendations relate directly to risk management. Even more surprising and deeply unsettling is that many of the same contributing factors and recommendations appear over and over again, which could lead us to believe that we are not focusing on the lessons that need to be learned from these fatal events.

In an attempt to identify the scope of the risk management issue in relation to firefighter fatalities, NIOSH analyzed 36 structure fires that resulted in the death of a firefighter (nonmedical issue). These deadly fires occurred between June 18, 2007, and November 2, 2012. On June 18, 2007, the South Carolina Sofa Super Store fire took the lives of nine firefighters as conditions deteriorated inside the commercial furniture showroom and warehouse facility. These nine firefighters became disoriented and ran out of air. This was the second largest loss of firefighter lives at a structure fire since the terrorist attacks that took the lives of 343 firefighters on September 11, 2001. The NIOSH report included 43 recommendations to minimize the risk of a similar occurrence in another fire department. It serves as the beginning for this research because of the numerous risk management recommendations NIOSH provided.

The NFPA publishes consensus standards that cover all areas of fire safety and are nationally recognized by the fire service. Because of this, NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, was used to identify risk management categories for this study. It served as a guideline to place the applicable contributing factors and recommendations into the categories found in section A.8.3.2 of the standard. It states, “The management of risk levels involves all of the following factors:

  • Routine evaluation of risk in all situations
  • Well-defined strategic options
  • Standard operating procedures (SOPs)
  • Effective training
  • Full protective clothing ensemble and equipment
  • Effective incident management and communications
  • Safety procedures and safety officers
  • Backup crews for rapid intervention
  • Adequate resources
  • Rest and rehabilitation
  • Regular evaluation of changing conditions
  • Experience based on previous incidents and critiques.”

FIREFIGHTER LODD FACTS

Based on the information gathered from the 36 firefighter fatality reports, it is evident that risk management contributed substantially in the deaths of 57 firefighters. A total of 199 contributing factors were listed for 33 incidents. Two of the incidents, June 18, 2007, and August 3, 2007, did not have any contributing factors listed. More than 80 percent of the contributing factors can be placed into one of the risk management categories provided in NFPA 1500. Of the 12 categories listed in NFPA 1500, the top categories are the following:

  • Routine evaluation of risk in all situations (e.g., hazard recognition, ineffective/inadequate size-up, and building construction characteristics).
  • Effective incident management and communications (e.g., ineffective and/or inadequate communications, suboptimal incident command, and lack of personal accountability system).
  • Safety procedures and safety officers [e.g., crew integrity not maintained, and rapid intervention team (RIT)/rapid intervention crew (RIC) not established].
  • Effective training (e.g., training on collapse hazards and lack of comprehensive training on fire behavior).
  • Full personal protective equipment (PPE) [e.g., use of PPE and self-contained breathing apparatus (SCBA) issues].

NIOSH also includes recommendations in each report for other departments to review in an attempt to try and prevent a similar tragedy. These recommendations are based on the events that took place at that particular incident. The number of recommendations NIOSH made in all 36 incidents totaled 398. Again, more than 80 percent of the recommendations fall into one of the 12 risk management categories listed in NFPA 1500. The top categories include the following:

  • Effective training (e.g., training to recognize all types of building construction, Mayday training programs, fireground survival training, and training on SCBA emergency procedures).
  • Routine evaluation of risk in all situations (e.g., ensuring a complete situational size-up is conducted at all fires, using risk management principles at all fires, and understanding the influence of ventilation of fire behavior).
  • Safety procedures and safety officers (e.g., having a designated incident safety officer and having a dedicated RIC/RIT, maintaining crew integrity).
  • SOPs (e.g., developing a Mayday doctrine, developing written guidelines for fireground operations, and developing guidelines on thermal imaging camera use).
  • Effective incident management and communications [e.g., fire departments using the incident command system (ICS) at all emergency incidents, the incident commander (IC) maintaining close accountability for personnel, and the IC establishing a stationary command post and maintaining the role as director of fireground operations].

One question we need to ask ourselves is, “Are we risking too much?” NFPA 1500 states: “Activities that present a significant risk to the safety of members shall be limited to situations where there is a potential to save endangered lives” and “No risk to the safety of members shall be acceptable when there is no possibility to save lives or property.” We may extend ourselves in a calculated manner if there is the potential to save lives or property, but there is absolutely no reason for firefighters to be killed when there is nothing to be saved. One important question the IC needs to ask on the fireground is, “What is more valuable-the building or my firefighters?” The answer should always be, “My firefighters.” You can rebuild a structure, but you cannot bring back a firefighter. It should not take the death of one of your own to figure this out.

Fifty-seven firefighters were lost in these 36 incidents. In comparison, five civilian fatalities occurred in four of the incidents. In the majority of the incidents, there was no civilian life safety issue. The breakdown of firefighter fatalities is as follows:

  • Occupants were reported to be inside the structure in just 10 of the 36 incidents by either the 911 caller or bystanders on scene. Seven of these 10 incidents actually had occupants inside. Twenty firefighter lives were lost as a result. Five civilians died in four of these fires.
  • In nine incidents, occupants told firefighters that everyone was out of the structure. Twelve firefighters were killed in these incidents. No victims were found inside during any of these fires.
  • In six incidents, there were no reports that anyone was inside, but a search was conducted. No occupants were discovered inside. Nine firefighters were lost at these fires.
  • In 11 incidents, there were no reports of occupants inside or of a search being conducted by fire companies. Sixteen firefighters were killed during these incidents. No victims were found inside any of the structures.

Just as each incident is different and carries its own set of risks and hazards, so, too, does each structure within which firefighters operate. It is important for firefighters to understand the strengths and weaknesses of each of these types of structures and how each will react when exposed to fire because of the potential for collapse. This knowledge directly affects responder safety during operations and may even dictate strategy and tactics. Of the 36 incidents studied, 18 of the structures involved Type V, or wood-frame, construction. Type V is used in most modern homes. It is also the most dangerous type of building in which a firefighter can operate. Of the remaining 18 incidents,

  • One incident occurred in a Type I, or fire-resistive, structure.
  • Two incidents took place in a Type II, or noncombustible, structure.
  • Ten incidents occurred in a Type III, or ordinary, structure.
  • Three incidents took place in a structure with mixed construction types.
  • Two incidents occurred in a silo.

When the first fire unit arrives on scene, the initial IC should conduct a size-up of the situation (to include an evaluation of the fire and smoke conditions) to assist in determining the strategy and tactics that will be used to bring the situation under control. In every incident that was analyzed, there was evidence of a fire on fire department arrival. Conditions ranged from light smoke showing to a structure that was fully involved. The amount of smoke visible on arrival is not always an accurate indicator of the potential severity of the fire and the potential life safety risk to responders. Experiments conducted by Underwriters Laboratories (UL) have shown that when a fire becomes ventilation-limited, smoke being forced out of openings in the home is greatly diminished or may even stop. Responders must remember this information when sizing up the incident.

The wind conditions reported during on-scene operations are another factor that was considered while reviewing the NIOSH LODD reports because of the potential impact on fire conditions. The National Institute of Standards and Technology (NIST) research has determined that wind speeds as low as 10 miles per hour (mph) are adequate to create wind-driven fire conditions if the flow path is not controlled. Of the 36 incidents,

  • Fourteen involved wind speeds of 10 mph or greater.
  • Another four involved winds that were less than 10 mph but had wind gusts above that number.
  • Twelve incidents had wind speeds of less than 10 mph.
  • No wind conditions were reported in four of the incidents.
  • In two of the incidents (those in which firefighters fell from the exterior of the structure), wind did not play a part in the fatality.

Wind can have an immense impact on the outcome of an incident, and firefighters must be aware of how much more deadly it can be when operating in today’s fire environment. Fires burn hotter and faster than ever before, and wind can be a catalyst in the rapid development of untenable conditions. It is extremely important that firefighters understand the impact wind can have on fire behavior. They must be ready to adjust the strategy and tactics used to match environmental conditions.

According to the USFA 2012 Firefighter Fatalities in the United States report, “the term ’cause of injury’ refers to the action, lack of action, or circumstances that directly resulted in the fatal injury. A fatal injury is usually the result of a chain of events, the first of which is recorded as the cause.” The causes of injuries in the 36 incidents include the following:

  • Lost or disoriented: Five involved a firefighter who became lost or disoriented within the structure.
  • Collapse: Nine incidents resulted in firefighter fatalities from structural collapse.
  • Caught or trapped: This classification covers firefighters who were trapped in structure fires and were unable to escape because of rapid fire progression and the by-products of smoke, heat, toxic gases, and flame. There were 15 incidents that met this criterion.
  • Fall: This was the cause of injury in five incidents.
  • Out of air: One incident involved a firefighter who ran out of air while still inside the involved structure.
  • Contact with: This cause of injury was involved in one incident in which a firefighter came in contact with an overhead power line.

WHY IS THIS HAPPENING?

The information provided from the 36 incidents spanning over five years provides an eye-opening look at the fire service in relation to firefighter fatalities. Risk management is one of the most important tools firefighters can use to help reduce the level of risk to responders operating at a fire. You must consider all fireground factors and their associated risks prior to committing crews to interior operations. All firefighters should be familiar with the concept of risk management. So why is it that the lack of risk management seems to have been an enormous factor in the deaths of 57 firefighters that occurred between June 18, 2007, and November 2, 2012?

As stated in the NIOSH reports, “Occupational fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the fatality.” The contributing factors, along with the recommendations listed in each report, provide insight into the events that unfolded during the course of that incident and can be broken down into individual and organizational factors. Three individual factors that may have impacted the risk management process include the body’s reaction to stress, “helmet fire,” and lack of fireground experience.

THE BODY’S STRESS RESPONSE

Stress is something all firefighters experience; it comes with the job. It can be described as “a state that results from an individual’s perception or reaction to an event or a threat.” The event or threat itself is not considered stress but can produce it and, as such, is referred to as a “stressor.” Stressful events occur frequently at the scene of a fire as we attempt to bring order to chaos or when firefighters find themselves in a life-threatening situation. The key to firefighter survival is the ability to manage the stress.

The “fight-or-flight response,” also termed the “acute stress response,” helps an individual respond to a stressful or dangerous situation. The intensity of the reaction depends on the individual’s perception of the stressor. When a person is placed under stress, the sympathetic nervous system (SNS) will automatically activate and release hormones into the body. These hormones primarily include epinephrine (adrenaline) and norepinephrine (noradrenaline). As they are released, the body prepares itself for action. This includes an almost immediate increase in heart rate among many other things. Activation of the SNS can raise the heart rate from 70 beats per minute (bpm) to more than 200 bpm in less than a second. The increase in heart rate is critical for the hormones to reach their target location within the body for the intended physiological effect to occur. This will continue as long as the individual perceives the stress or threat. The hormones and the increase in heart rate can also affect how the body functions.

In his book, Deep Survival: Who Lives, Who Dies, and Why? Laurence Gonzales (who has covered stories for National Geographic and published several books on the topic of survival) states, “The hormones released by the body interfere with the working of the prefrontal cortex of the brain. That is where perceptions are processed and decisions are made. You see less, hear less, miss more cues from the environment, and can make mistakes. Under extreme stress, the visual field actually narrows. Stress causes people to focus almost exclusively on the thing that they consider the most important, and it may be the wrong thing.” The body’s reaction to a life-threatening situation (e.g., being trapped following a collapse or running out of air inside a structure that is on fire) can result in sensory distortions and a decrease in cognitive processing. The impact of the “stress” hormones on the body can affect the physiological system, the perceptual system, and the cognitive system. When it comes to managing risk, the two systems with which we are concerned are the perceptual and cognitive systems.

The perceptual system refers to our ability to process input from the five senses- vision, hearing, smell, taste, and touch. The two that responders use most on the fireground are the sense of vision and the sense of hearing. As the heart rate climbs to 145 bpm, perceptual narrowing begins to occur as the brain focuses solely on the sense providing it with the most information. In most cases, this is the sense of vision. Visual exclusion, also known as “tunnel vision,” occurs as the field of vision narrows to focus on what is causing the individual stress. When the heart rate exceeds 175 bpm, peripheral vision and depth perception can be lost. Firefighters will lose the ability to see the “big picture,” which is so very valuable when it comes to risk management and subsequent decision making. Auditory exclusion may also occur when the heart rate is above 175 bpm. Hearing may be diminished, or an individual may lose the ability to hear altogether. Critical transmissions on the radio to evacuate the structure can be missed, or the shout from a victim inside a burning building may go unheard. If we are not getting all of the visual and auditory information that our brains need-our cues and clues-then decisions will be flawed, which can have disastrous consequences.

Changes in the modern fire environment have caused significantly dangerous alterations in fire dynamics and fire behavior
(3) Changes in the modern fire environment have caused significantly dangerous alterations in fire dynamics and fire behavior. It is imperative to conduct a thorough size-up of the tactical area prior to the commencement of operations. Evaluate all fireground factors to determine the amount of firefighter involvement it will take to bring the situation under control.

The cognitive system refers to the mind and the ability to process information, which enables firefighters to perform the risk management function. The ability to think clearly, assess risks and hazards, and make decisions is critical on the fireground when lives are on the line. When the heart rate climbs to 175 bpm, cognitive processing can begin to deteriorate. The brain is concentrating almost exclusively on one stimulus and can shut out or blunt any other stimuli. This is done in an attempt to prevent the brain from being overstimulated or overwhelmed. Information processing times slow down and the decision-making process may be delayed. Access to long-term memory may be blocked, which can be problematic because many of the decisions that firefighters make are based on past experiences. Also, the brain can actually begin to “shut down,” and a firefighter may simply “give up.”

When it comes to the ability to perform on the fireground and to recognize and respond to risks and hazards, there is an ideal range for the heart rate to be within. The rate to perform optimally is between 115 to 145 bpm. This range is a guideline, not a rule, and varies based on the individual. Many factors can affect a firefighter’s performance at the scene of a structure fire. Experience, or lack thereof, is perhaps the most important factor. Other factors include the environment itself; lack of sleep; and an individual’s confidence in his level of skill or knowledge, which can be tied to experience, an individual’s level of physical fitness, or the perception of limited time and resources needed to accomplish a task.

It is important to note that an increased heart rate caused by physical activity does not have the same effect on the body. Physical work performed on the fireground can raise an individual’s heart rate without any significant changes in the perceptual or cognitive systems because the sympathetic nervous system has not been triggered. But if a firefighter is suddenly placed in a dangerous situation, such as when conditions deteriorate quickly (e.g., sudden collapse or flashover, for example), the SNS will activate and the heart rate can jump immediately into a range that can impair functioning. The heart rates given above are guidelines, not absolutes, for the way in which the body reacts when placed in stressful situations. We must learn how to keep our heart rates in the “ideal zone” for optimal performance on the fireground.

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