Root-Cause Analysis and the Chain of Errors
- Principle One: a preoccupation with failure
- Principle Three: a sensitivity to operations
- Incident Command must maintain clear command and control of incident operations.
- Accountability of all incident personnel must be maintained at all times with a personnel accountability report conducted every 15-20 minutes of incident operations. A tactical command board with an aide (field incident technician) will help with this.
- A safety officer (competent and experienced for the hazards present) must be assigned to monitor incident operations and halt them if necessary.
- Responders must stay disciplined in completing assigned tasks. They must not wander or do things at an incident as they see fit. (A strong command presence and in-place accountability system will help to prevent this.)
- Company officers must constantly evaluate the building for the fire’s impact on its “gravity resistance system.” Remember: A building is only as sure as its connections. Load-supporting members may appear safe, but faulty connections (nails into 2 × 4 stringer) will still result in collapse.
- The Incident Commander must have a clear vision of how to manage an incident involving a Mayday and give clear orders following its resolution. Management of the incident must go on for the safety of those still working on the scene.
- This could have been prevented.
- We should have been together in teams of two to move the truck.
- I needed to wear my proper personal protective equipment while that close to the structure.
- We may not have needed to make entry with no lives at stake.
- In that situation, we all learned something from this event.
a. Sensation seeking (Jensen, 2005)b. Impulsivity (LeSage, Dyar, & Evans, 2011)c. Invulnerability (LeSage, Dyar, & Evans, 2011)d. “Can-do” attitude (Rosenkrance, et al., 1994)
Craig Nelson (left) works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.
Dane Carley (right) entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.
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