Near-Miss Report No. 08-105 highlights an incident that occurred during an emergency response. The incident conjures up images straight out of slapstick Hollywood comedies. However, there are no special-effects people to guide the driver, no track to keep the rig on the road and no director yelling “Cut!” to stop the mayhem.
Event Description
“I was the driver/operator of our department’s 2 1?2-ton brush truck responding to a natural-cover fire. Our truck had been used in training and had also received maintenance within the past week. Although I was running emergency, the truck was going approximately 5 miles under the speed limit due to vehicle’s limitations. My speed was approximately 55 mph on a two-lane highway. The truck’s hood is held in place by three latches: two hook-style external latches and one standard internal latch on the front. Apparently, either during training or maintenance, these latches were unhooked. I did not notice this during a walkaround prior to my response.
“While driving on a downhill slope of the highway, the hood suddenly began vibrating violently with the wind. I was unable to pull off the road immediately because there was a stalled car and occupants on the shoulder ahead. However, I did let off the accelerator. The hood then came up and hit the cab, damaging the hood and lightbar and completely obstructing my forward vision. I kept the truck as straight as I could while I passed moving vehicles on my left and the stalled vehicle on my right. I was lucky that I did not sideswipe or hit any of the vehicles. I had to judge my direction by sticking my head out the window. I was able to pull the vehicle off the road and re-latch the external hooks.
“Later investigation revealed that the internal hook was working normally. My guess is the violent movement of the hood somehow made the internal latch release. Obviously that would have been a moot point if the external latches were in place.”
Lessons Learned
“We’ve learned the importance of a pre-response checklist, especially in the volunteer environment. We also learned that we must ensure that apparatus are completely checked after maintenance and training prior to being returned in-service.
“Following this incident, it has been made clear that the external hooks on the ‘deuce-and-a-half’ are an important point of the pre-response walk around. We have made it clear that the external hooks are to be double-checked post-training, post-maintenance and whenever the vehicle is sitting in the bay in-service.”
Comments
We can only imagine what was going through this lieutenant’s head as the hood flew up and smashed into the windshield. He notes that the vehicle had been worked on and used in training in previous days. This point is a cue to be more highly attentive to vehicle latching mechanisms once all hands have finished with their work.
The lieutenant also states that he did not notice the latches were not latched during his walkaround prior to response. Even on our most “routine” responses, a touch of haste can lead to overlooking what would normally appear to be an obvious trap. These links in the error chain eventually result in the near miss described here. The control and ingenuity he exercises after the hood flies up and blocks his view are a credit to his self-control.
Prevention
- Create a safety checklist for your vehicle-maintenance program that includes a visual scan for any tools or rags left in the engine compartment, and that reminds the maintenance technician to double-check all caps, covers and latches.
- Add the same requirement to your periodic maintenance forms.
- Know your vehicle. Ensure that all drivers are aware of the reason and purpose of all mechanisms.
- Include a vehicle-inspection reminder about latches and securing locking mechanisms in your department’s safety message at least quarterly.
- Ensure that driver trainers emphasize the need to use all vehicle and equipment mounting latches, especially if it appears to be a redundant system.
- Remind all members to notify the vehicle driver when they’re going to take equipment off of the rig or conduct a motor-familiarization drill.
- Place the rig out of service if you cannot get the OEM (original equipment manufacturer)-specified locking devices to work properly.
Preparation
- Teach drivers to touch and visually inspect all apparatus latching mechanisms as they conduct their vehicle inspections.
- Conduct a visual scan of the latching points on the apparatus prior to entering the vehicle for any travel. Make it a habit for yourself as well as the officer and firefighter. Pay close attention to your instincts, and don’t scan too fast.
- As you ease the rig into traffic, note any unusual vibrations, movement or unrecognized sounds. Acceleration can be a good tool for assessing how well latches and handles are secured.
- Once on the road, listen to the rig carefully when you hit a bump. Check your mirrors frequently to ensure nothing has come loose.
- Ensure you are in the proper frame of mind when conducting a vehicle inspection. While vital to developing good practices, repetitious processes (norms) can degrade over time due to complacency, fatigue, distraction and haste.
- Include a component in your driver training program that covers reacting to unexpected occurrences (e.g., debris falling off of lead vehicles, animals darting into traffic).
Conclusion
The value of near-miss reporting is becoming clearer every month. This young lieutenant from the heartland provides a well-prepared, graphically descriptive account of a hair-raising near miss. His effort arms the rest of us with new knowledge to avoid having to learn the same lesson the hard way.
