If the cliché version of insanity is doing the same thing over and over again and expecting different results, some could argue that many in the U.S. fire service should be running an asylum.
It has been 15 years since the National Institute for Occupational Safety and Health (NIOSH) began its Fire Fighter Fatality Investigation and Prevention Program (FFFIPP). Those familiar with the program are generally pleased with the investigations, which conclude with recommendations on how to prevent similar incidents in the future.
While the FFFIPP has surely done its part to reduce firefighter fatalities since 1998, perhaps the same can’t be said for some in the fire service who seem to ignore NIOSH findings, perpetuating the still-alarmingly high rate of firefighter fatalities. After all, firefighters in 2013 did not die in any new ways; they died from the same things that killed firefighters 15 years ago: poor incident command, lack of proper training, lack of risk vs. gain analysis … the list goes on.
“Frustrating” is the word Tim Merinar uses to describe it. A safety engineer, Merinar is a 25-year NIOSH veteran who started in the respirator certification program. He has coordinated the FFFIPP program for the last five years.
FFFIPP Beginnings
Interestingly, the first fire service fatality investigation by NIOSH was actually done in 1984 under its Fatality Assessment and Control Evaluation (FACE) Program. Ten incidents involving firefighters, beginning in 1984, were investigated prior to the start of the FFFIPP.
Later, the IAFF played a big role in lobbying to investigate firefighter fatalities. In 1994, IAFF General President Al Whitehead called for the investigations at the group’s convention in Detroit. Whitehead said he was too often asked at firefighter funerals if he could find out, “How did it happen?” or “What went wrong?” According to press reports at the time, he feared that locally controlled investigations would not be thorough enough or could lead to whitewashing of the incident to protect people.
IAFF efforts to persuade Congress and President Bill Clinton included a 1996 flight aboard Air Force One, where Clinton was reportedly lobbied by Whitehead and his executive assistant, Harold Schaitberger. In 1998, Congress funded the FFFIPP with a $2.5 million budget. The program was originally established to investigate every firefighter death and publish its results on the Internet.
Investigations began in 1998. By 1999, the NIOSH investigators saw enough of a pattern of recurrent behavior that the FFFIPP issued its first Alert Bulletin titled “Preventing Injuries and Deaths to Firefighters due to Structural Collapse.” Most industries would take that hard-earned information and make immediate efforts to change. But then the fire service isn’t like most industries. Culture and tradition infamously make change extra difficult for many fire service organizations. The end result: New firefighters continue to die in the same old ways. Using case studies for its 1999 Alert bulletin, NIOSH cited four fire incidents that had floor, roof or wall collapses and took the lives of five firefighters. Fourteen years later, that Alert, and others, seems to ring hollow. Among the first five fire scene fatalities reported in 2013, four were related to floor and roof collapses.
Evaluating the Program
In 2013, the IAFF remains pleased with the program and its investigations. “I think they do an excellent job reporting on fatality incidents,” says Pat Morrison, assistant to the general president for Occupational Health, Safety and Medicine. Morrison says FFFIPP investigation reviews are regularly done at IAFF Health and Safety Symposiums.
Morrison’s only criticism is not of the program itself, but its limitations. The program is not funded well enough to investigate most near misses or injury accidents. He also says it is not funded enough to more extensively investigate long-term firefighter exposures and their relationships to cancer. Unlike the NFPA and the USFA, the IAFF treats firefighter cancer fatalities as line-of-duty deaths (LODDs).
Phoenix Fire Chief (ret.) Alan Brunacini wrote the book Fire Command nearly 30 years ago and is perhaps the leading expert in fire service risk management. He believes the FFFIPP has done exemplary work in calling out causative factors in so many fireground deaths. If not enough good has come of NIOSH’s work, the fault lies solely with the fire service, Brunacini says: “That end of the system is fine. But they have no direct control over the leadership of the fire service. It’s an inside deal (in the fire service) that must be fixed at the strategic level of management.”
What to Investigate
The original mandate in 1998 was to investigate every firefighter fatality, but to not “point fingers or place blame,” Merinar explains. Merinar says those in the FFFIPP quickly learned they could not do quality investigations on all fatalities, and began to focus on those that had a wider impact for the fire service. “We cut back on the number and did a better job,” he says. Topics such as fire behavior and dynamics and organizational safety culture drew greater scrutiny from investigators. Further, the FFFIPP stopped investigating accidents involving firefighters driving privately owned vehicles. It also only works with departments where all parties involved agree to share information, although those that have refused to cooperate are probably fewer than five, Merinar notes.
The FFFIPP would like to get more involved in wildfire fatality investigations, which are now usually handled by state wildfire groups, the Bureau of Land Management (BLM) or the National Wildfire Coordinating Group (NWCG). Assistance was offered, but declined, for the Yarnell Hill Fire that resulted in the deaths of 19 firefighters in Arizona in June. The Yarnell Hill Fire Serious Accident Investigation Report has been criticized by some as being too benign, unwilling to hold any organization or person accountable. Additionally, the FFFIPP will not investigate aircraft accidents, which are usually associated with wildland fires, as they are investigated by the National Transportation Safety Board (NTSB).
No NIOSH report was conducted on the events of September 11, 2001, in New York City that killed 343 firefighters, as it was an act of terrorism.
In Charleston, S.C., where nine firefighters were killed in a 2007 commercial fire, FFFIPP offers to investigate were initially rejected as the city set up its own investigative committee, Merinar explains. The city eventually agreed to the FFFIPP investigation, and NIOSH investigators worked well with the experts assembled by the city. Both groups worked in a collaborative fashion and issued extensive reports that essentially reached the same major conclusions.
Educating Departments about FFFIPP
Merinar says educating fire departments about the FFFIPP can often take considerable time after investigators arrive on scene. He notes that both career and volunteer departments “think we are OSHA” and fear being fined or otherwise held liable for the fatality incident.
The FFFIPP has a staff of eight investigators, four of whom have fire service backgrounds. Most are headquartered out of Morgantown, W.Va., while medical investigative staff is located in Cincinnati. NIOSH estimates that it has investigated approximately 40% of firefighter deaths since the program’s inception. Program objectives are clear:
- Better identify and define the characteristics of LODDs among firefighters
- Recommend ways to prevent death and injuries
- Disseminate prevention strategies to the fire service
Identifying LODD Trends
The leading cause of firefighter fatalities while on duty is usually sudden cardiac death, according to NFPA data. After changes in federal law in 2003, deaths that occur up to 24 hours after working are considered LODDs by the USFA, but not the NFPA. The general downward trend of cardiac and medical deaths has continued since awareness of fitness and medical concerns has increased, Merinar says. He credited programs such as the joint IAFF and IAFC Wellness-Fitness Initiative for reducing deaths and getting unfit firefighters off the fireground.
But another troubling fatality trend continues: A 2010 NFPA study concluded that although the number of fires continues to decline, traumatic deaths of firefighters operating inside structures returned to the same approximate rate as in the late 1990s. In other words, we’re having fewer fires, but killing more firefighters per 100,000 fires. The 2010 study revealed that on-scene traumatic deaths in recent years have increased. A greater number of firefighters are dying due to structural collapse and fire progression. Deaths due to firefighters being lost inside the building continue on the same trajectory.
Merinar says initial feedback from the FFFIPP findings was, “These reports all say the same thing.” Which was true, but the fire service was not paying attention. He adds that newer construction materials have only made the problem worse. NIOSH has seen several recurrent themes in the structural fireground fatalities:
- Lack of training/ineffective training and inexperience: Training is one of the first areas cut at budget time, but is all the more crucial in a period where the number of structure fires is greatly reduced. With fewer fires, officers are often promoted with inadequate experience. Merinar cites a firefighter recently being killed in her first significant fire after graduating from the department’s academy.
- Incident command failures: Strong command is not in place because the department does not have a policy and training in place, or it simply disregards its own standard operating procedures, perhaps because it is in such a rush to put the fire out. Merinar uses the example of a large department operating under a weakened bowstring truss roof.
- Poor risk vs. gain analysis: This should be completed before firefighters are ever committed to offensive attack or high-hazard areas. In most fatality cases, this step was bypassed, Merinar says.
- Poor fireground communications: It often takes the form of inadequate reporting back to command, allowing ICs to lose sight of changing conditions. It also leads to the highly dangerous problem of mixed operational modes, Merinar says.
Problems to Address
Merinar also points to the dangerous culture that for years has pushed firefighters to put out the fire first and ask safety questions later. In an era when the number of fires is reduced, many firefighters don’t want to miss their chance to extinguish a fire, Merinar says. “They should ask themselves, ‘Are you here to serve the community or are you here to serve yourself?’”
Further, Merinar believes cultural influences and peer pressure unintentionally place too many firefighters at risk. He acknowledges that firefighters have to be willing to take some level of calculated risk, but adds, “On the other hand, do you want the big risk-taker leading a charge into that abandoned building? No.”
We operate in a culture that still passively allows risk-taking in the form of aggressive interior attacks in abandoned buildings and structures that have been weakened by fire or other deterioration. Brunacini also sees culture as big killer. Pointing to the continuing loss of firefighter lives in structure or floor collapses, he reminds, “One of the things nobody has much effect on is gravity. We still can’t change that.”
When the wrong people are promoted to leadership positions, things get worse. Big risk-takers have no business in the fire service, let alone as officers or chief officers, Brunacini says: “That’s like having a Kamikaze pilot running an airline.”
As if the routine level of risk acceptance wasn’t enough of an issue, Brunacini says the fire service’s continuing use of the rescue mode as “alibi” deserves greater scrutiny. He describes the illogical philosophy of bundling a firefighter in the most modern turnout gear and SCBA to survive “the worst thermal and toxic insults”–and then thinking a person being rescued could possibly survive after being down more than a brief period. The vast majority of times when the need for rescue is cited, it is unfounded, Brunacini notes. “Was anybody ever inside?” he asks rhetorically.
Morrison stresses that training should focus more on behavioral leadership that can drive poor choices in risk decision-making. He notes how behavioral leadership could vary in the same department, even between different shifts and different stations.
Morrison adds that the fire service continues to “normalize deviance” from safe policy and practice, allowing behaviors and actions that are known to be unsafe. “Why are we not holding officers accountable?” he asks. “We do a lousy job mentoring our officers.”
Another complicated issue: personal protective equipment (PPE). Merinar explains that while the marked improvement of PPE has saved lives, it also raises the question of whether it allows firefighters to go too deeply into buildings, increasing their level of risk. In years past, uncovered ears told firefighters to get out. Merinar still subscribes to Vincent Dunn’s theory, first espoused in the 1980s, that the best protected firefighter still has to be near the door of the room to survive a flashover. Although the level of protection is better for firefighters, the danger level is inversely proportional to the greater amount of plastics and other modern materials in homes. “These fires behave and burn differently,” Merinar says. “The fuel level has greatly increased.” But firefighters continue to employ the traditional method of crawling in under thick smoke to find the seat of the fire. “That is very fuel-rich smoke–fuel that is just waiting for an opportunity to burn,” Merinar says.
Merinar notes that adding together increased fuel load, newer buildings that collapse sooner and fewer fires with less experienced firefighters makes for a deadly combination.
Research Debunks Myths
Recently completed research by the National Institute of Standards and Technology (NIST) and UL provides the science that justifies safer offensive strategies for firefighters in the future. This research, among other things, shows that common ventilation and interior attack practices may actually worsen fire conditions. Merinar supports new recommendations developed by the IAFC and the International Society of Fire Service Instructors that provide for safer, more efficient fire attack. The new guidelines were released late last year.
Morrison agrees that the recent NIST/UL research provides a great platform for building a safer worker environment for the fire service. He says responding firefighters should have a much better understanding of what risks they are dealing with. “Let’s really understand the consequences of what we’re about to do,” he says. “We have to make damn sure we understand the environment.”
Final Thoughts
Merinar says he and his NIOSH coworkers get satisfaction in helping to determine what actions or inactions caused an incident, but are often disheartened to see that “it really could have been prevented.” Frequently, there are multiple scene problems that snowball or otherwise set off cascading failures at fatality incidents.
It is frustrating, too, for NIOSH investigators to see, in the final analysis, what the firefighter was trying to save. Merinar cites an incident that claimed the life of one firefighter and injured five others. The firefighters were attacking a heavily involved, abandoned crack house. “You realize somebody died for no good reason,” Merinar says.
Brunacini often sadly mentions a firefighter who died in Phoenix in 2001, Bret Tarver, as he speaks of the fire service’s shortcomings in protecting its personnel. “Your goal as fire chief should be to do everything you can to keep NIOSH out of your town,” he says.
sidebar-Firefighter Fatality Trends Since 2000
The decline in annual firefighter deaths ended following a horrific 2013 that claimed 62 firefighters in just the first six months. This includes 19 Prescott, Ariz., firefighters who were killed during the Yarnell Hill Fire, and multiple firefighter fatality incidents in three Texas communities: West (5), Houston (4) and Bryan (2).
Preliminary USFA data listed 101 firefighter fatalities in 2013. That number is subject to change when the final report is released this summer. Since 2008 the fatality total has been less than 100 annually. But the four-year decline in deaths is over. Particularly alarming is the number of fire scene traumatic fatalities in 2013. A review of preliminary reports indicates 38 possible traumatic fire scene fatalities in the first half of the year alone. Even annual totals have not been that high in more than 13 years.
Each year a significant number of the reported firefighter fatalities occur at fire scenes and while responding to or returning from emergency incidents. Both incident groups have seen a reduced number of deaths in the last seven years. But the sub-category that has made the least improvement is fire scene traumatic injuries. This reflects the recurrent problems cited by the FFFIPP, including incident command failures, poor risk/gain analysis, poor fireground communications and lack of training and experience.
USFA data collection changed in 2000, two years after the FFFIPP began operations. For comparison, the fatality data was grouped from the years 2000—2005 and 2006—2012.
Fire scene traumatic fatalities averaged 21.5 per year from 2000 to 2005 and 20 per year from 2006 to 2012, for a mere 7% decrease. Fire scene cardiac/medical deaths averaged 13.8 per year from 2000 to 2005 and 9.3 per year from 2006 to 2012, for a 33% decrease. The great majority of cardiac/medical deaths were cardiac arrests.
Fatalities while responding to or returning from incidents were also categorized as collision/traumatic deaths or cardiac/medical deaths. There was an average of 14.8 collision/traumatic fatalities per year from 2000 to 2005 and 11.1 fatalities per year from 2006 to 2012, for a 25% decrease. There was an average of 8 cardiac/medical fatalities in this category from 2000 to 2005 and average of 6.7 fatalities from 2006 to 2012 for a 16% decrease. The great majority of deaths in these categories were from vehicle collisions and cardiac arrests.
Overall annual firefighter fatalities averaged 110.6 from 2000 to 2005 and 98.8 from 2006 to 2012 for an 11% decrease. Deaths resulting from the terrorist acts of September 11, 2001, are excluded.
