This month’s near-miss report focuses on three issues: fireground tactics, communication and accountability. The featured report is from the scene of an attic fire being fought by two departments. After a vent hole is cut, the fire takes a turn for the worse, trapping firefighters inside. As you read report No. 07-841, a number of observations made by the reporting firefighter should trigger “watch-outs” to consider the next time you’re in a similar situation.
Event Description
“We arrived on scene with our engine and multiple personnel. An additional department was already on scene and actively fighting an attic fire. An unknown number of men from two different departments were in the attic.
“As I walked to the rear of the structure, I observed a ladder leaning against the lower rear flat roof. The roof was not visible due to heavy smoke. I asked a ground firefighter how many firefighters were on the flat roof. He did not know. I asked how many minutes they had been out of contact. He did not know.
“I climbed the ladder to investigate the status of our men. The attic ignited after a ventilation hole was cut in the front of the house. I reached the top of the ladder to find a man stumbling out of the rear of the attic; his air tank was empty. He was able to communicate that he could not see the ladder and could not clear the smoke for clean air.
“While assisting him to the ladder, the flat roof became soft and started melting under our feet. Shortly after removing the personnel from the roof, it caved in as the flames consumed the home.
“The man assigned to the bottom of the ladder had left. He was from a different department and was unaware of the firefighter stranded on the roof.”
Lessons Learned
“Incident command and a task assignment board with accountability tags would have improved operational safety. Several firefighters were working independently of each other and without knowledge of other firefighters’ positions. The decision to leave the foot of the ladder, the decision to stay in the attic after the tank bell sounded and the decision to cut a ventilation hole without knowing the position of the interior firefighters all contributed to this near miss.”
Comments
The fire in this month’s report presents a number of ambiguous clues that create discrepancies. For example, fire conditions are apparently tenable inside, but deteriorating conditions are apparent outside. The number of personnel in the attic is unknown. A ventilation hole is cut, but under whose direction?
Firefighting with mutual- or automatic-aid departments requires military precision and common operating procedures and radio talk groups (including common terminology). There must also be a firm commitment from the chiefs down to the jump-seat firefighters to train on common firefighting strategies and uniform tactics. As Chief Alan Brunacini has stated time and again, “Common practices applied in a consistent fashion avoid uncommon outcomes.”
The fact that firefighters were working independently of each other suggests that the command structure was passive rather than active. Passive command promotes freelancing. Independent operations lead to multi-tracked paths to objectives that work against each other to achieve the same goal (extinguishing the fire). The more efficient and preferred path is an organized, unified approach toward the common goal. A focused action plan, coupled with good communication and rigid accountability, can help departments extinguish fires with the highest degree of professionalism.
Preparation
- Review your department’s standard operating procedures (SOPs). Are they clear, concise and complete in their objectives?
- Conduct a climate assessment of your incident scenes. Include all crewmembers. Listen (without being defensive) to what they say about the organization of the incident scene, their sense of confidence in command and their perception of both their own well-being and firefighting basics (e.g., good strategy, well-executed tactics and achievable tasks).
- Facilitate and foster the development of regional SOPs so mutual aid and automatic aid are seamless. Don’t hold onto “your way” of doing things unless it can be backed up by solid firefighting strategy, tactics and incident management principles.
- Organize periodic drills and casual meetings with the companies of neighboring departments. Work a community meal into the meetings when practical.
- Develop a formal after-action critique process to evaluate the good, bad and ugly of the incident. Improvement can’t be made without the close evaluation of actions.
- Insist on open, frank and respectful communication. You’ll understand people better if they’re speaking directly.
- Adopt an accountability plan that is applicable and agreeable to all departments in the region.
Prevention
- Ensure companies arriving after command is established are either operating according to SOPs, or check into the command post prior to engaging in operations.
- Assign an incident safety officer to every incident. The eyes and ears of a dedicated safety officer provide incident commanders with a global, objective perspective of the incident scene.
- Read the smoke. (Take a reading smoke class if you’ve never been taught how to do this.)
- Require personnel accountability reports (PAR) so you can keep track of everyone all the time.
- De-stigmatize “mayday.” No firefighter should be afraid to call for help.
- Operate in teams of at least two, even at the command post.
Conclusion
This is just one of the more than 1,750 reports that have been filed with the National Fire Fighter Near-Miss Reporting System. The Safety Pyramid–originated by H.W. Heinrich, an American industrial safety pioneer from the 1930s–shows that for every serious injury, there are 300 near misses. Heinrich also states that to take care of our own, we must focus on near misses and prevent them from becoming hits. By concentrating on reporting, collecting data and exchanging information at the near-miss level of the injury pyramid, we should logically see a reduction in near-miss events, which should, in turn, reduce serious injuries and fatalities. It is a low-intensity, high-impact effort worth pursuing to help push through the plateau of fatalities we have experienced in the fire service over the last 15—20 years.
