BY SHANE M. RUTLEDGE
Over the past 100 years, many modern improvements have contributed to the safety of firefighters-the National Incident Management System, the Incident Command System, advances in our personal protective equipment, and a countless number of safety improvements in our response apparatus. Yet with all these advancements, each year there are approximately 100 firefighter fatalities and 81,070 line-of-duty injuries, according to the U.S. Fire Administration.1 Pick up any magazine or read any fire-related manual, and the associated facts will show that we are not dying from new causes; they are the same causes that have happened in the past. We must ask ourselves, “Why is it that we allow this to continue when we know the exact cause of each event? Why isn’t safety the primary value within our occupation?”
Consider the double-fatality training event that happened on January 25, 2009. Members of a Texas fire department were familiarizing themselves with a newly purchased aerial ladder platform apparatus when, suddenly, two members were thrown from the platform-both falling 83 feet to their deaths. Were these members practicing safety during their training session? Was a safety officer assigned as they were performing the unfamiliar operations? What was the fire department’s safety culture during this tragic event? The intent here is to not lay blame but rather to prevent future mishaps. Below is the description and an analysis of the incident, some additional facts, and the recommendations on how departments can prevent similar safety violations within their organization.
DOUBLE FATALITY DURING TRAINING
The National Institute for Occupational Safety and Health (NIOSH) conducted a line-of-duty death investigation, summarized in report F2009-06, “Two Fire Fighters Die after Falling from Elevated Aerial Platform.”2 The report is also discussed in the William C. Peters article, “Aerial Training Accident Results in Firefighter Deaths” (Fire Engineering, October 2009, http://bit.ly/1ejnLx3).3 According to the NIOSH report, four firefighters were standing in the aerial platform, which was raised to the roof of an eight-story dormitory building at a local college. The platform became stuck on the concrete parapet at the top of the building. During attempts to free the platform, the top edge of the parapet gave way; the aerial rebounded from the top of the building and then began to whip violently back and forth. Two of the four firefighters were ejected from the platform by the motion. They fell 83 feet to the ground and died from their injuries.
Prior to the incident, the department had received an eight-hour in-service training class from the manufacturer. Investigations show that during this training, the manufacturer did not emphasize the use of ladder belts while operating within the platform. In fact, ladder belts were not even supplied with the apparatus. The department knew of this and had the belts on order, yet it still allowed the training to continue. The day before, the apparatus was allowed to respond to a working structure fire at which the aerial was used as a master stream during defensive operations. In all cases, the apparatus was allowed to be in service when it was not fully equipped to safely respond.
Records show that both victims and the platform operator received in-service training from the manufacturer, including practical exercises. When interviewed by NIOSH investigators, the operator stated that the day of the incident was the third time he had operated the aerial platform controls. However, the report shows that the crew members operating within the platform on the day of the incident were still unfamiliar with the operation of the controls. If the manufacturer or fire department staff had mandated and instilled a safety culture that required the use of fall protection (i.e., ladder belts), the two victims might not have fallen to their deaths. Taking it one step further, if only one member of the department had retrieved ladder belts from the department’s reserve apparatus, maybe the victims would be here today. Instead, they subconsciously acted like many do, “It’ll never happen to me.”
INCIDENT ANALYSIS AND DISCUSSION
In addition to the above facts, two prominent National Fire Protection Association (NFPA) documents, NFPA 1901, Standard for Automotive Fire Apparatus (which only requires that the safety belts be on the apparatus), and NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, required the use of fall protection. Were these documents simply overlooked, or were the required safety implements considered to be of little value? Other than the fact that the ladder belts were not provided, it is hard to understand why we would choose to risk our safety when very prominent documents like these have been researched and developed to protect us. These committee members do not create these documents as a way to justify their jobs; they create them from factual recommendations from NIOSH reports and because the firefighting profession comes with serious, extraordinary life safety risks.
WHY DO WE ALLOW THIS?
This brings me to my original question, “Why do we allow this to continue when we know the exact cause of each occurrence?” The NIOSH investigation teams do a phenomenal job laying out their findings and recommendations in each of the fatalities they investigate. What they don’t do, and can’t do, is solve the problem. The solution is up to the organization and perhaps, more importantly, up to each individual. Fire service administrators (FSA) need to be problem preventors and not just create policies to protect against liability.
If we want the fire service to become a safer occupation, we must have a major shift in the organizational culture within the workplace. “Saying that we want safe workplaces and actually having them are two different phenomena,” Randy Okray and Thomas Lubnau, in Crew Resource Management for the Fire Service,4 elaborate on the fact that we cannot just attempt to persuade employees to be safe, but we must also give them the proper tools they need to practice and enforce safe measures.
Senior members on the job must be role models of safe practices. Ask yourself, “Would you be more safety conscious if your superiors had practiced safety in everything they did?” Of course you would! Your parents taught you as a child to look both ways before you crossed the street, and today you know that it is the safe thing to do. Therefore, if these unlucky members who fell from the aerial ladder had been following members who wore fall protection (i.e., safety conscious leaders), then perhaps we would not be discussing this case.
In another example, situational awareness (SA) is the leading contributing factor selected by reporters to the Fire Fighter Near-Miss Reporting System.5 It is also one of the factors in crew resource management. It describes the need to recognize that situations in the emergency service are especially dynamic and require responders’ full attention.5 Before we go further in-depth on SA, let’s look at the Near-Miss Reporting System’s definition of SA: “An individual or group’s attentiveness to the event; a relationship between perception of individual and reality of situation.”5 In other findings, you may see that SA is a skill. Although we can look at all kinds of analyses behind the loss of SA, I want to focus on how we as an organization can prevent it.
Lubnau and Okray offer many strategies for maintaining SA. However, perhaps the best description comes from the prominent risk management leader Gordon Graham. Graham says that the best advice he can give is to “slowww dowwwn.”6 In risk management, we break risk into four categories; the most important risks are those that combine high risk and low frequency. In the case of the aerial ladder fatalities, this was a high-risk/low-frequency training event in which the crew had a loss of SA and a lack of adequate training. Had the members been adequately trained, then their SA would have enabled them to properly prevent the mishap. In the case of risk management, if the members had simply slowed down and assessed the lack of aerial ladder response to the movement of the controls (thus exhibiting situational awareness), they would have noticed that the platform was stuck on the parapet.
Many departments implement standard operating procedures (SOPs) for training that mandate the use of an incident safety officer (ISO). In some training situations, such as those involving live fire, standards requiring the use of an ISO have been implemented. Would it be too inconvenient (even without an SOP or standard in place that mandates it) to assign an ISO in this situation? No! Assigning an ISO requires one single person to maintain SA to ensure that the operation is safe. This responsibility, although overwhelming to some, is the answer to ensuring a safe operation, since it makes the ISO consider all actions.
In addition, even if an SOP is in place, administrators cannot expect that its existence will ensure that it is followed. We need to confirm that all SOPs are followed as written, not just assume that they’re being followed. As an example, when we create a public education course to help prevent cooking fires within our community, we don’t just educate the public and forget about it. We create a follow-on measurement tool that evaluates the success of the program and implements revisions where necessary. In the case of the aerial ladder fatalities, an SOP that requires the appointment of an ISO might have positively influenced the use of fall protection. In fact, NIOSH recommends that departments develop and follow an SOP for the safe use of aerial apparatus. NIOSH cannot ensure that the SOP is being followed.
LESSONS LEARNED AND RECOMMENDATIONS
The lesson of this tragic incident is as follows: Safety must be a part of our culture, not just that we must wear fall protection at all times when we are on an aerial device. Wearing it, however, is the easy part. Below are some recommended procedures for fire service administrators to implement that will assist in preventing these incidents within their organizations.
- Create a culture of safety, and make it the primary value within your organization. Don’t just speak it; demonstrate it with everything you do.
- Assign a qualified ISO at all training sessions that involve risk. Don’t just require that one be assigned; enforce the assignment, and verify that it is happening by implementing an annual spot check.
- Ensure that SOPs are written, and require that all members review them before an apparatus is placed in service. Don’t just write an SOP and expect it to be acted on-verify that it is carried out with a rigorous apparatus training program that includes 100-percent member participation and signatures.
- Maintain SA by practicing risk management and slowing down.
Risk during training is a common part of firefighting; having a strong culture of safety is, unfortunately, not so common. When NIOSH offers recommendations, it is important that we learn and honor those who passed away by preventing others from dying from the same oversight. As fire service administrators, we must ensure the implementation of the solutions for those recommendations. Consequently, the true measure of any organization is the value of its safety program and the value that its members place on it. Is safety your organization’s primary value?
1. U.S. Fire Administration. Statistical Reports: Firefighter Casualties. February 22, 2011. http://www.usfa.fema.gov/statistics/reports/firefighter_casualties.shtm“>http://www.usfa.fema.gov/statistics/reports/firefighter_casualties.shtm. Accessed November 1, 2013.
2. National Institute for Occupational Safety and Health. “Two Fire Fighters Die after Falling from Elevated Aerial Platform.” July 13, 2009. http://www.cdc.gov/niosh/fire/reports/face200906.html. Accessed October 31, 2013.
3. Peters, William C. “Aerial Training Accident Results in Firefighter Deaths.” Fire Engineering, October 2009, 67-77. http://www.fireengineering.com/articles/print/volume-162/issue-10/features/aerial-training-accident.html.
4. Okray, Randy and Thomas Lubnau II. Crew Resource Management for the Fire Service. Tulsa, Oklahoma: Fire Engineering, 2004.
5. International Association of Firefighters. Frontline Safety Student Manual. (Washington, DC: IAFF, 2009.) 85.
6. Graham, Gordon. YouTube.com.( n.d.) “High Risk/Low Frequency Events in the Fire Service.” http://www.youtube.com/watch?v=Og9Usv82CdU. Accessed November 1, 2013.
SHANE M. RUTLEDGE is an eight-year veteran of and an engineer/paramedic for Denton (TX) Fire/Rescue, where he is assigned to the technical rescue team. He is also an 11-year veteran of the Air Force Reserve Fire Protection, serving as an assistant chief of training. He has an A.A.S. degree in fire science and is certified as a fire officer IV, instructor III, and hazmat technician/incident commander. He has numerous certifications in the rescue disciplines.
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