Near-Miss Report: Door Blocks Egress

According to the NFPA, fire departments in the United States respond to approximately 12,000 fires in industrial and manufacturing properties each year. This number is relatively small considering that fire departments responded to 524,000 structure fires in 2006. Using these numbers as a reference, manufacturing/industrial fires represent just 2 percent of the total fire problem. The infrequency of these fires, coupled with the fluid movement of personnel in most fire departments, means most firefighters will likely only respond to a fire at this type of occupancy once in a career; thus, experience is limited. Without a well-developed knowledge of fire behavior, human behavior in fire situations and at least a passable knowledge of the building’s layout and operations, the potential for this once-in-a-career opportunity to become a career-ending experience is high. Following is an excerpt from Near-Miss Report No. 08-167, which describes a working structure fire in a manufacturing occupancy.

Event Description
“At 1422 hrs, our department was dispatched to a reported commercial structure fire. A full first-alarm assignment was dispatched and arrived on scene in less than 3 minutes. The first-in company performed an initial size-up and declared a working structure fire. The commercial occupancy was a metal-fabricating business in a 40′ by 75′ 1 ½-story metal building located in a commercial park in our district.

“Knowing that several dogs were trapped inside the occupancy, firefighters used a forklift to ram and pierce the 14′ overhead door. Firefighters arriving on the scene after this saw very heavy black smoke and fire issuing from the now-open overhead door. The first-in firefighters, a mix of the rescue and engine crews, pushed in through the overhead door to reach the seat of the fire in the middle of the fabrication area.

“Approximately 20 seconds into the advance into the business, the overhead door failed from a combination of the fire and the damage caused by the forklift prior to our arrival. The overhead door collapsed from its tracks, crashing down just behind the firefighters, and then fell into a position that blocked their egress. The second- and third-due companies were able to quickly remove the door from the opening and the attack was continued.”

Lessons Learned
“The actions prior to our arrival have to be taken into account, and a good size-up must be performed. In this case, the size-up of the door was hidden by the amount of fire byproduct and the fire issuing through the opening. The quick actions of the incident commander and the other companies on scene were credited with quickly removing the door from the egress area. Lesson learned: Always expect the unexpected!”

Comments
Some people say that recognition-primed decision making (RPD) is the default decision-making tool that firefighters use in time-compressed situations. RPD can be defined as looking at a situation where time is critical and selecting a course of action based on past experience or knowledge. Typically, a firefighter who applies RPD takes action quickly because he or she is able to recall a previous experience with the same variables and project a similar outcome.

In this month’s near miss, firefighters used an expedient and ingenious method to force entry and rescue the dogs. The crew accomplished their immediate goal of getting in to rescue the dogs, but didn’t account for others using their entry point. In a situation like this, ask yourself these two questions:

  • Are later-arriving crews going to understand what you did?
  • Does your entry include a clear, unobstructed exit? Crews can get tunneled in when faced with time constraints that are incident-driven or self-imposed. The key here is to ensure all hazards are secure.


Preparation

  • Constantly remind all members of your crew to be vigilant. Remind them the IC only has one brain and one set of eyes and ears. Practices reinforced in the station will pay big dividends on the street.
  • Foster an environment where everyone in your crew knows they can speak up if they see something that doesn’t look right.
  • Maintain the “big picture.” You don’t necessarily need to have the 60,000′ view every time, but make sure you do know what is 20 feet above you in the ceiling of a commercial occupancy–overhead door hardware, steel bar joists and storage (aka, firefighter killer, firefighter killer and firefighter killer). But how do you know that when you can’t see 3 feet above your head? Familiarize yourself with buildings in your response area before fire breaks out and smoke obscures your view.
  • While preplanning, visualize the structure with smoke pouring out. Imagine the possible color, velocity and density. By conditioning yourself to see the building on fire, when the time comes, it won’t be such a surprise.
  • Review and scan near-miss reports. They are survivor stories submitted to enhance your RPD.


Prevention

  • One member of the team should be assigned to maintain a broader view of the situation. A periodic “step back” or analysis of the surrounding environment can weave the web that catches oversights and problems before they become critical.
  • Make sure everyone involved in the situation has the same vision of the outcome you do.
  • Assume nothing. If you’re arriving on a scene where crews are already engaged, look at every element as a potential hazard. Ensure forced doors are propped open, look up and check with command to make sure you’re in tune with what’s happening around you and your role in mitigating the situation.
  • Respectfully challenge situations you don’t understand. I don’t mean you should tell ICs they’re wrong, but if you don’t understand something when you check in or operate on the incident scene, ask for clarification.
  • Clear all openings. Any parts left in the breach will only serve as entrapment hazards.


Conclusion
The “back-to-basics” battle cry sweeping the fire service must be more than just lip service if it’s going to be effective. “Remember the basics” may be an even more appropriate reminder as we pull up to the scene. Part of that memory should include a millisecond review of previous performances of the crew under stress. That review may become your greatest predictor of a successful outcome.

 

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The National Fire Fighter Near-Miss Reporting System is a voluntary, confidential, non-punitive and secure reporting system with the goal of improving firefighter safety. The system is funded by grants from the Department of Homeland Security’s Assistance to Firefighters Grant Program and Fireman’s Fund Insurance Company. The project is supported by FirefighterCloseCalls.com in mutual dedication to firefighter safety and survival.

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