Investigating a major accident or injury can be a heart-wrenching process. One step that can help hold a department together after such an incident is to conduct a full and transparent investigation. The investigation must be highly refined so everyone believes a fair evaluation has taken place. Additionally, a department culture that involves highly punitive action for every adverse action that occurs generates mistrust between leadership and workers, hiding mistakes and blaming others. Laying out an investigation model that will ensure people are being assessed fairly will improve morale and produce a document worth periodically revisiting to prevent recurrence. Report No. 08-487 from www.firefighternearmiss.com will assist in illustrating those first crucial steps to a fair investigation.
Event Summary
A firefighter acting as a driver/operator is performing a morning apparatus check on an aerial truck. During the aerial test, the aerial is taken out of the bed and fully extended between 19,900-volt power lines. There is an arc, the truck is electrified, and a firefighter checking the compartments is enveloped in the flash.
Comments
At first glance, the actions of the driver/operator appear to be the single cause of this incident. Summarily disciplining or terminating this driver/operator may make the department feel as if swift and firm action had been taken. That drastic an action should not take place, however, without first looking at the role of the chain of command in placing the driver/operator’s hands on the control levers.
Why would a driver/operator extend a metal ladder between high-tension lines? The answer lies in one of two categories: an intentional act or an error. If you conclude that the act was intentional, termination will likely result. Terminating an employee is drastic and tragic. Even when a termination is warranted, all parties are harmed: The employee leaves the organization without a salary or benefits, the organization loses one of its investments, and the crew loses the experienced knowledge of the staff member.
A different option that may avoid termination: conducting a top-to-bottom incident review. This will likely reveal institutional flaws that contributed to the event. Whether you call it an “incident 360,” “accident hearing board” or “investigation,” gathering facts and evaluating factors that come to light will result in a better road map for preventing repeat events.
Preparation
The preparation phase of the incident review starts with an injury assessment. Was anyone injured? If so, were they properly treated/transported to the appropriate medical facility? If not, why?
The next step is to assemble a fact-finding investigation team. The team should include:
- A chair who should be advised to review the incident and make recommendations for improvement.
- The fire department safety officer or appointee.
- Two members from the individual’s peer group (i.e., same rank).
- A member from the training division or the department training officer.
- A member from the labor relations group (if one exists).
- A member from a neighboring department.
Prevention & Closing
The complete elimination of incidents from this industry is a physical impossibility. One way to mitigate the risk is to investigate injuries and incidents in a transparent manner with the goal of learning and sharing the information openly. Learning lessons from others before encountering a similar situation is one of the missions of the National Fire Fighter Near-Miss Reporting System. It should be your mission, too.
Until next time, be vigilant and stay focused.
