A Study of Volunteer Firefighter Fatalities

WHAT IS KILLING FIREFIGHTERS? A STUDY OF VOLUNTEER FIREFIGHTER FATALITIES.

Robert C. Krause

A Dissertation

Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of

DOCTOR OF EDUCATION

August 2019

Committee:

Paul Johnson, Advisor

Molly Gardner Graduate Faculty Representative

Shirley Green

Judith Jackson May

Robert C. Krause

ABSTRACT

Paul Johnson, Advisor

Researchers at the University of Georgia, Kunadharaju, Smith, and DeJoy (2010), completed a study looking for patterns in firefighter fatalities and have identified four common factors which included under-resourcing, inadequate preparation for and anticipation of adverse events during operations, incomplete adoption of the incident command system or sub-optimal personnel readiness. The purpose of this study is to analyze 149 NIOSH volunteer firefighter fatality reports to determine if those fatalities could be linked to under-resourcing, inadequate preparation for adverse events during operations, incomplete adoption of the incident command system, or sub-optimal personnel readiness. Kunadharaju et al. (p. 1180, 2010) said in their article, Line-of-duty deaths among U.S. firefighters: An analysis of fatality investigations, “the underrepresentation of investigations involving volunteer firefighters deaths is a potentially significant issue, in that, the majority of firefighters in the U.S. are volunteers and the majority of line of duty deaths involve volunteer firefighters.”

This research is meant to determine if Kunadharaju et al. were correct in their identification of four major factors: under-resourcing, inadequate preparation for and anticipation of adverse events during operations, incomplete adoption of the incident command system and sub-optimal personnel readiness. The focus of this study is to determine if volunteer firefighters were experiencing deaths within the areas of under-resourcing, inadequate preparation for adverse events during operations, incomplete adoption of the incident command procedures and sub-optimal personnel readiness but also what additional factors were contributing to volunteer firefighter deaths not specifically addressed in the initial study. iii

To my family. I cannot fully express how much I love and respect each of them. My children inspire me and have made me very proud of the fine adults they have become. Finally, I would not be where I am today, personally or professionally, without the influences of my wife,

Diana. To her I will always be grateful.

ACKNOWLEDGMENTS

I wish to thank my dissertation committee for their guidance, patience and teachings.

This project would not have reached this point without their assistance. Dr. Paul Johnson,

Dr. Judy Jackson May, Dr. Patrick Pauken, and Dr. Chris Willis played significant roles in shaping my education and development as a scholar, thank v

TABLE OF CONTENTS

Page

CHAPTER I. INTRODUCTION TO THE STUDY ...... 1

The Setting of the Study ...... 1

Purpose of the Study ...... 3

Research Question ...... 4

Statement of the Problem ...... 4

Professional Significance of this Study ...... 5

Under-resourcing ...... 10

Inadequate preparation ...... 12

Incident command system...... 13

Sub-optimal personnel readiness ...... 14

Definition of Terms...... 20

Delimitations ...... 22

Organization of the Study ...... 22

CHAPTER II. LITERATURE REVIEW ...... 24

Incident Command ...... 24

Training Concerns ...... 36

Personnel Readiness...... 46

Leadership ...... 56

CHAPTER III. METHODOLOGY ...... 59

Research Question ...... 59

Rationale for Research Design...... 59 vi

Study Sample ...... 60

Data Source ...... 61

Data Collection ...... 62

Qualitative Data Analysis ...... 68

Establishing Trustworthiness ...... 68

Researcher Positionality...... 69

CHAPTER IV. DATA ANALYSIS ...... 71

Analytical Approach ...... 71

Demographics of the Study ...... 72

Age at Time of Death ...... 73

Confirmation of the Work by Kunadharaju et al ...... 75

New Factors Discovered by the Researcher ...... 79

Apparatus Crashes ...... 84

Fire Ground Operations ...... 87

Technical/Specialized Operations ...... 99

Road/Traffic Incidents ...... 100

Training Fatalities ...... 101

Wildland Firefighting...... 102

Non-firefighting Incidents/Station Maintenance ...... 103

Summary ...... 103

CHAPTER V. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS...... 105

Introduction ...... 105

Interpretation, Conclusions, and Recommendations from Data Findings ...... 106 vii

Apparatus Crashes ...... 107

Conclusions and Recommendations ...... 109

Fire Ground Operations ...... 109

Conclusions and Recommendations ...... 116

Technical/Specialized Operations ...... 118

Conclusions and Recommendations ...... 119

Road/Traffic Incidents ...... 120

Conclusions and Recommendations ...... 121

Training ...... 121

Conclusions and Recommendations ...... 122

Wildland Firefighting...... 123

Conclusions and Recommendations ...... 123

Non-firefighting Incidents/Station Maintenance ...... 124

Application of the Study ...... 124

Implications for Policy, Practice, and Leadership ...... 126

Suggestions for Future Research ...... 132

Conclusion ...... 133

REFERENCES ...... 136

APPENDIX A: MEMORIAM OF VOLUNTEER FIREFIGHTERS LOST IN 2018 ...... 158

APPENDIX B: CAREER VS VOLUNTEER FATALITY NUMBERS ...... 159

APPENDIX C: DEFINITION OF KEY TERMS ...... 160

APPENDIX D: COMPLETED CODING SHEET ...... 171

ER APPENDIX E: NIOSH REPORT AS EXEMPLAR ...... 172 viii

LIST OF FIGURES

Figure Page

1 Types of property in which firefighters were in at time of death ...... 17

2 Field note coding sheet ...... 67

3 Higher order reasons for firefighter fatalities ...... 80

LIST OF TABLES

Table Page

1 Type of activity at time of firefighters’ death ...... 16

2 Population density ...... 72

3 Coverage area ...... 72

4 Firefighter experience within the fire service ...... 72

5 Department membership size ...... 73

6 Age of firefighters at time of death ...... 73

7 Fatalities by state from 1998-2017 ...... 73

8 Frequency of fatalities by month ...... 75

9 Frequency of individual factors appearing in data ...... 76

10 Percentage of incidents that include a combination of factors 1, 2, 3, 4 ...... 77

11 Frequency of research factors and combinations of factors ...... 78

12 Prevalence of factors 3 and 4 in ALL fatal incidents 1998 – 2017...... 79

13 General incident type and number of firefighters killed ...... 84

14 Firefighter training level ...... 97

15 Firefighter fatalities related to technical and specialized operations ...... 99 1

CHAPTER I. INTRODUCTION

The Setting of the Study

A fire department responds to a fire every 23 seconds in the United States (National Fire

Protection Association Fire Statistic, 2015). Each year, fire kills more Americans than all other natural disasters combined (Hopewell Fire Dept., 2019). Most fire departments in the United

States are volunteer (National Fire Protection Association, 2019). Volunteer fire departments are those that are comprised of individuals who volunteer their time and efforts for the community in which they live for little to no financial gain and comprise 65% of firefighters in the United

States (National Fire Protection Association, 2019). Volunteer fire departments face many challenges in their efforts to protect their communities. Those challenges include, but are not limited to, low numbers of personnel to respond to fires and emergency calls, limited budgets to fund continuous training and quality equipment. Further, increasing calls for service, increased training demands upon department members and the rise in two-income households limit volunteer time. The most significant sources of increased time demands are increased volume of emergency calls and increased training hours to comply with training standards (National

Volunteer Fire Council, 2017). Departments are further challenged by the expectation of the public to be highly proficient in all forms of emergency response and rescue techniques such as hazardous materials and technical rescues (U.S. Fire Administration, 2007). The public views their local volunteer fire department as their first line of defense when crisis strikes (Firehouse

Forum, 2016).

The American fire service is separated into two service delivery models, volunteer firefighters and career firefighters. Volunteer firefighters contribute their time and energy to the defense of their communities for little or no financial gain. Career firefighters earn wages and 2 often receive benefits packages such as healthcare benefits and retirement pensions. Career departments are often located in urban settings. Volunteer departments are often found in smaller communities with population densities under 10,000 (National Volunteer Fire Council, 2017).

More than 50% of volunteers are in small, rural departments that protect a population of less than

2,500 (FireRescue, 2011). Training levels often differ between volunteer and career firefighters.

States often defer to local fire departments to set the training requirements for their departments

(National Fire Protection Association, 2019). An individual arriving on a local volunteer fire truck may be highly motivated to help those in need but is not always trained well enough to protect themselves, let alone those in the community. A structure fire in a small rural community is just as lethal as in large urban settings; so, training inequities between firefighters present a significant problem for both the firefighter and the public.

The volunteer firefighters in North America are the men and women that live in small communities, often with extended family history within the area. They typically have full-time and part-time positions at local businesses. They work as carpenters, plumbers, school teachers, mechanics, farmers, and shop keepers. They often have families that demand their time and attention when they are not working. Some families are comprised of multiple members being a part of the volunteer fire department. These volunteers donate their time and energy to respond to the alarm of a medical emergency, car accident, or building fire. The National Volunteer Fire

Council (NVFC) estimated in 2014, time donated by volunteer firefighters saves localities an estimated $139.8 billion per year (Dept of Homeland Security Report, 2016)

Training for both volunteer and career firefighters demands significant amounts of time.

Training in career departments often starts with the new employee attending a fire academy to learn the primary firefighting curriculum established by the National Fire Protection Association 3

(NFPA), Standard 1001 and averaging 270 hours of training (Mulherin & Weckman, 2015).

Volunteer firefighters as a group are trained locally within the department by fellow members and are not exposed to the 270 hours of training contained within the NFPA 1001 curriculum received by their career counterparts. New members may receive little more than an orientation to the physical layout of the firehouse before they respond on their first alarm. In Arkansas, an

18-year-old firefighter trainee with 6 months experience was killed when he contacted a downed

7200-volt powerline at a grass fire (NIOSH Report 99-46). The State of Arkansas at the time required 28 hours of training before engaging in fire ground activities. The victim at the time of his death, had not received the required training.

Fire departments, both volunteer and career, across the United States, for the most part, are structured in a para-military organizational manner. Each department has a chief, the individual who is responsible for all functions within the organization. Support staff for the chief may include an assistant chief, who is the immediate number two in charge of the department, and possibly several deputy chiefs who support the upper command staff and may have frontline operational responsibilities as well. The leadership team is then filled with captains, lieutenants, and firefighters who are expected to perform the tasks of firefighting and emergency medical care (Allan et al., 2014)

Purpose of the Study

The purpose of this study was to analyze 149 NIOSH volunteer firefighter fatality reports that resulted in the deaths of 176 firefighters to determine what factors contributed to the traumatic deaths of volunteer firefighters. Several the incidents resulted in multiple firefighter fatalities, giving the 176-fatality total. 4

Research Question

This study was guided by the following research question: What factors contributed to traumatic volunteer firefighter fatalities as revealed in the 1998-2017 NIOSH reports?

Statement of the Problem

Despite improvements in firefighter protective clothing, more aggressive fire prevention policies and procedures, and a national reduction in the number of structural fires, firefighter death rates remain consistently high the last decade (U.S. Fire Administration, 2017). Firefighter fatalities and injuries occur at a rate one and one-half times those of police officers ( Moore-

Merrell, L., McDonald, S., Zhou, A., Fisher, E., Moore, J., 2006). According to data from the

U.S Fire Administration, volunteer firefighters represent a more significant percentage of the overall firefighter deaths annually. Of the total estimated 1,056,200 firefighters across the country, 682,600 are volunteers, equating to about 65% of all firefighters (NFPA, 2019).

The fire ground commander (the individual running the incident and having overall responsibility for the incident outcome), at every incident to which they respond, need to evaluate numerous fire ground factors before implementing their tactical approach to suppressing hostile fires. This evaluation includes employing a risk-benefit analysis to determine if the fire will be fought offensively, which requires actively entering the structure to suppress the fire, or defensively, which requires positioning fire crews around the exterior of the building with hose lines. A risk-benefit analysis needs to be completed, rapidly considering the available resources, level of expertise of the fire crews and a determination of the likelihood of performing the fire ground operations safely and effectively. Fire ground operations are those activities performed by firefighters on the scene of a structure fire. They include but are not limited to, attacking the fire with hose lines, searching the building for trapped victims and ventilating smoke and toxic 5 products of combustion from the building.

Fire ground commanders need to decide if the available fire crews can safely extinguish the fire with the resources they have on hand and prevent the problem of under-resourcing a given task. For example, establishing a sustainable water supply requires several personnel. The question commanders need to answer is: do I have enough people here now to effectively suppress the fire and establish a water supply simultaneously? Strong, decisive leadership must occur in these initial moments of assessing the fire. A poor understanding of the dangers involved during fire ground operations can dramatically impact strategy and tactics. Poor leadership by fire commanders, even by those that clearly understand the dangers on the fire ground can have catastrophic consequences.

Professional Significance of this Study

Each year across the United States, fire departments and families mourn the loss of a loved one. Volunteer fire departments make up the largest percentage of firefighter fatalities as identified by the U.S. Fire Administration. Using the information that has been identified in a previous study that reviewed career fire departments, what changes, if any, can be made in those broad factors that have been identified to improve firefighter survival? Volunteer fire departments face many challenges, which include too few personnel to respond to fires, low run volumes which leads to inexperienced firefighters not fully understanding changing events on the fire ground. Moreover, fire ground commanders failing to or improperly using an incident command system contribute to uncoordinated emergency operations.

Volunteer fire departments often lack clear policies and procedures that address fire emergencies and critical incidents and is an often-cited contributing factor to a firefighter’s death. The review of 149 volunteer firefighter fatality reports was used to determine if those 6 fatalities can be attributed to under-resourcing, inadequate preparation for/anticipation of adverse events during operations, incomplete adoption of the incident command system or sub-optimal personnel readiness. Identifying these factors singularly or in combination led to a firefighter fatality that can focus where specific interventions can be applied.

Researchers at the University of Georgia, Kunadharaju, Smith, and DeJoy (2010), completed a study searching for patterns in firefighter fatalities and eventually identified four common factors: under-resourcing, inadequate preparation for or anticipation of adverse events during operations, incomplete adoption of the incident command system, and sub-optimal personnel readiness. Data for their study were collected from the National Institute of

Occupational Safety and Health (NIOSH) between 2004 and 2009 and focused only on career firefighters. The results of their study suggest that fire departments and individual firefighters that are not well prepared procedurally or sufficiently trained have a higher risk of injury or death.

During the same period, 2004 to 2009, structural fires across the United States decreased in number, yet the firefighter fatality rate remained steady. Despite the reporting of fewer structural fires, there has not been a corresponding decrease in firefighter fatalities. Improvements in firefighter protective clothing and more aggressive fire prevention procedures have only resulted in slight declines of firefighter fatalities.

The present study reviewed 149 volunteer firefighter fatality reports involving only traumatic death from 1998 until 2017 conducted by officials from the National Institute of

Occupational Safety and Health (NIOSH). These reports account for 176 deaths due to some incidents having multiple fatalities. Multiple firefighter fatalities can occur at a single incident because firefighters are trained to work in teams. Training of fire crews teaches them to work in 7 pairs so they are not alone and can assist each other in times of need. Therefore, when a catastrophic event takes place, such as a building collapse or an explosion, firefighters tend to be close to each other and, as a result, more than one is killed in a single incident.

To ensure that all available data were collected, the NIOSH reports were cross-referenced with fatality data from the U.S. Fire Administration (USFA). The USFA publishes annual data identifying firefighter fatalities but does not complete investigative reports of those deaths. A department that suffers a firefighter fatality notifies the USFA. Not all fatalities are investigated by NIOSH, so there are names registered at USFA that do not have a corresponding NIOSH report. It was determined based upon the cross reference of data bases; all available reports were identified. This cross-reference was done to ensure cases were not missed, and the data set was complete. The selected fatality reports include only those firefighters that perished as a result of a traumatic incident. Firefighters that perished due to a medical emergency, such as a cardiovascular event (heart attack, stroke) were excluded for this study.

Traumatic deaths refer to those deaths that directly result from an injury sustained in the course of a firefighter’s training, response to or from and participation in an emergency scene.

Medical emergencies such as heart attacks and strokes are a significant cause of firefighter deaths; however, they are not the focus of this research and remain as a potential research paper in the future. The data were analyzed to identify what factors contributed to traumatic volunteer firefighter fatalities, as revealed in the 1998-2017 NIOSH reports. Using Kunadharaju et al.(2010) as inspiration, this study analyzed the data from NIOSH reports looking for those factors identified in that study as well as additional contributory factors in the firefighters’ death.

NIOSH reports are official documents that are researched and then written by an investigative team of fire service professionals after they thoroughly investigate the fatality. A 8 report is constructed in the same manner across all other NIOSH firefighter reports. The report is assigned a number, and typically the number sequence is year-number of fatality for that year such as 2017-07. The report is broken down in the following manner: an executive summary, a list of contributing factors, and a set of key recommendations, which are bullet points offered by the investigators. The next section is the introduction, which recaps the executive summary. A profile of the geographic area, the involved fire department, and equipment follow the introduction. Next in the report is a section detailing the training and experience of the deceased firefighter. Often, a timeline is included that breaks down minute by minute descriptions of what was happening during the incident. Ancillary information such as weather and road conditions are contained in the report if they are germane to the discussion.

The report then transitions into a section of the investigation of the event. The cause of death that has been documented by the autopsy findings is next. The final section of the report are recommendations that are offered by the investigators are more detailed and supported by industry best practices. The final section contains a set of references used by the investigators.

It is the responsibility of fire department leadership, fire service policymakers, chief officers, company officers, and senior-level firefighters to more fully understand and improve conditions that lead to firefighter fatalities. Leaders within the firefighting community must seek out training and experiential opportunities to better prepare firefighters. Volunteers that enter community fire departments require training, development, and support of those in leadership positions within the department. It is incumbent upon all those that hold leadership positions within the fire department to adequately prepare those individuals that have willingly volunteered to place themselves in harm’s way.

According to Kunadharaju et al. efforts to protect firefighters have been shown marginally 9 effective and fall into two general factors: preparative measures and operational measures.

Preparative measures are those that prepare firefighters to work efficiently and safely, such as training. Operational measures include adherence by firefighters and officers to standardized safety best practices by senior officers responsible for the command and control in the development and utilization of standard operating procedures. Command and control refer to the exercise of authority and direction via a properly designated commander over a sign and attached forces in the accomplishment of the mission.

Kunadharaju et al. wrote that investigating fatalities involving volunteer firefighters presents some distinct logistical challenges, but the very same organizations may have the greatest need for external evaluation and general technical assistance. The challenges investigating volunteer firefighter fatalities include that not all volunteer firefighter fatalities are reported to the National Institute of Occupational Safety and Health (NIOSH), meaning data of every single firefighter fatality are not available, which could lead to a yet undiscovered fatality trend.

Firefighting is considered a high-reliability organization (HRO). HROs are those in which disasters are a continual threat but are constantly avoided via effective sensemaking (Weick,

Sutcliffe, & Obsteld, 2005). Sense-making is defined by Gary Klein (2006) as the ability or attempt to make sense of an ambiguous situation. More exactly, sense-making is the process of creating situational awareness and understanding in situations of high complexity or uncertainty in order to make decisions. It is a motivated, continuous effort to understand connections (which can be among people, places, and events) in order to anticipate their trajectories and act effectively (Klein, 2006). With proper training and education, fire ground commanders, at all levels, firefighters, lieutenants, captains, and certainly chiefs can use sense-making to better 10 guide their recognition of hazardous conditions and react to them in a timely manner.

Baran and Scott (2010) wrote that leadership within this context (HRO) must involve interactions that facilitate the appraisal of hazards, risks, potential benefits, resources, and solutions with information that is often insufficient and equivocal. Fire grounds are rapidly changing environments with shifting risk profiles. Training in HROs must be channeled to prepare decision-makers to make sense of what they are seeing and capable of responding to high-risk stimulus effectively.

Under-resourcing

Under-resourcing is not having enough people readily available at the scene of an emergency to perform all the tasks necessary for effective and safe fire ground operations. This problem is ever increasing in the volunteer ranks. The U.S. Fire Administration (2007) wrote that several factors were affecting volunteer participation rates; they include, economic impacts, individuals that had volunteered in the past are now having to work longer hours and employers are less tolerant of allowing workers to leave. Training requirements of hundreds of hours require large blocks of time and effort. Sociological changes have also impacted volunteer services, young people are seeking education and employment away from home, and interest in volunteerism is fading (U.S. Department of Homeland Security, 2016). Fire crews across the country routinely respond to structure fires, the National Fire Protection Association (NFPA) reported 1,345,000 fires in the United States in 2015. In that same year, 501,500 were structure fires causing 2,685 civilian deaths, 13,000 civilian injuries, and $10.3 billion in property damage

(NFPA, 2015). To illuminate the seriousness of fires in the United States, the NFPA reported in

2015, a fire department responded to a fire every 23 seconds. One home structure fire was reported every 86 seconds, one civilian fire death occurred every 2 hours and 40 seconds, and 11 one civilian fire injury was reported every 34 minutes.

Comparatively, the NFPA published a report on April 23, 2013, that said on average seven people died each day in reported U.S. home fires. Upon arrival at a "working fire," a building that is actively on fire, several simultaneous activities are required to safely and effectively extinguish the fire before it spreads throughout the structure. Fire crews will be assigned tasks such as attack, which is stretching a hose line, entering the structure, searching for and locating the fire and then extinguishing it (Fornell, 1991). Pulling, stretching, and advancing a hose line filled with water is difficult and time-consuming depending upon the structural configuration of the building and the proficiency of the crew.

Having to move a hose line filled with water significant distances through a structure can push crews to their physical limits. Depending on the size of the fire, more than one hose line may be required to successfully extinguish the fire (McGrail, 2007). Each hose line requires at least two firefighters to move successfully into a burning building. Often, firefighters are advancing into a structure filled with smoke conditions that severely limits or completely obstructs their visibility and internal room temperatures that can exceed 1800° at the ceiling

(Fornell, 1991).

During the attack on the fire, a Truck company—a specific firefighting crew—will be assigned the responsibility of providing ventilation (Coleman, 2001). This specific task requires a fire crew to assess the smoke conditions within the structure and then determine the best path to remove the smoke. Techniques implemented include positive pressure-ventilation fans, opening windows, cutting a hole in the roof, or a combination of all the above. Another very high priority task that must be completed during the initial fire ground operation is a quick and thorough search of the structure to ensure there are no trapped civilians within the building 12

(Norman, 1998). Search and rescue operations are labor-intensive, high risk, and are often conducted with minimal information regarding the whereabouts of potential victims within the structure (Smith, 2002). The ambiguity and time compression that is placed upon the crews can lead to elevated stress levels. It is crucial that fire ground leaders understand the complexity involved in fighting a structural fire and rescuing trapped occupants. Strong leadership involving command and control is imperative when conducting operations in this hostile environment

(Coleman, 1997).

Additional staffing is required to conduct overhaul operations, the process by which firefighters open ceilings and walls looking for small pockets of fire that may have traveled to another section of the structure. This overhaul procedure can vary from being minimal, for example, in a small bedroom where the fire did not travel to multiple rooms throughout the structure. This same procedure can be quite extensive if there are multiple rooms, attic, or large storage areas involved in the fire, and require intensive labor during the overhaul process

(Norman, 1998). The intensity of firefighting operations upon responding personnel is significantly elevated, considering firefighters don 60 or more pounds of protective clothing.

Inadequate preparation

Inadequate preparation for/anticipation of adverse events during operations means fire crews are not prepared to recognize and react to sudden changes on the fire ground (Kolomay &

Hoff, 2003). This is the area that offers the most ambiguity to firefighters. Well-trained and experienced firefighters can recognize subtle changes in fire conditions that may include rapid fire spread throughout the structure, building instability, or sudden explosive conditions

(Coleman, 2001). Recent research indicates that important elements of expert performance are tied to experience and that practice is more significant than was earlier believed possible (Chi, 13

Glaser, & Farr, 1988; Ericsson & Smith, 1991). Continuous, meaningful, and practical training that includes rigorous practice must be undertaken to better prepare emergency responders.

While similarities exist in structural fires, there are always outliers, conditions that create sudden changes within the structure causing rapid fire to spread throughout the building.

Firefighters directly caught in flash-over conditions, where everything within the fire area ignites and temperatures exceed 1500°, will not survive (Armstrong et al., 2004). The need to recognize and react to dynamic changes on the fire ground cannot be understated. Fire ground commanders must recognize both overt and subtle changes that do occur on the fire ground (Coleman, 2001).

These clues can be used to determine if the strategic and tactical approach is effective or ineffective. Fire ground commanders must also anticipate sudden and dramatic changes that put firefighters at risk and always have a "what if" plan. This failure to prepare for adverse events can lead to situations in which firefighters cannot recover from an unfolding series of catastrophic events (Smith, 2002).

Incident command system

The incident command system is a formalized approach to managing structural fires and other major incidents. Faggiano, McNall and Gillespie (2012) define the incident command system, as a comprehensive, national approach to incident management that is applicable at all jurisdictional levels across functional disciplines. It is designed to create a standardized methodology that departments use in mitigating critical incidents. The incident command system originally developed in California to assist the forest service in firefighting operations has been modified and adapted for use in structural firefighting. The federal government has also made modifications in the system and developed what is widely used as the national incident management system, is used for large-scale emergency operations such as hurricanes that have 14 made landfall.

The incident command system used by most fire departments has several working components, however without a solid understanding or experience in using the incident command system problems can arise (Coleman, 1997). Prior to the use of the incident command system, firefighters “freelanced” on the fire ground. This meant that they worked independently of each other seeking out tasks that needed to be completed without coordination amongst other members.

The incident command system has created a much more coordinated approach to firefighting operations and has increased accountability of firefighters on the fire ground

(Coleman, 2001). Problems arise when fire ground commanders (leaders) fail to fully implement the various components of the incident command system. This leads to a situation where firefighters without clear directions may initiate tasks on their own, called freelancing.

Freelancing leads to an uncoordinated fire attack, poor rescue operations, and most importantly a lack of accountability of personnel (Kolomay & Hoff, 2003). Fire ground commanders must always know the whereabouts of all firefighters on the fire ground , this is what is meant by accountability. The incident command system requires training repetition so that it is well understood and used effectively by fire ground leadership. Misuse, or incomplete adoption of the incident command system can lead to a breakdown in firefighting operations and a significant increased risk to firefighters.

Sub-optimal personnel readiness

The remaining factor outlined by Kunadharaju et al. (2010), is sub-optimal personnel readiness indicates that fire crews are not fully prepared to operate on the fire ground. This sub- optimal readiness can be attributed to a lack of training, lack of experience, substandard or 15 absence of policies and procedures, and low levels of physical fitness. It is well documented that a significant number of firefighter fatalities are a result of sudden cardiac arrest brought on by events on the fire ground (NFPA, 2017). The U.S. Fire Administration in 2014 reported that

64.8% of all fire ground deaths, 59 firefighters, were attributed to cardiac arrest. Physical fitness programs are stressed widely throughout the fire service; however, compliance is not required.

Taking into consideration some firefighters will not be physically fit is an unfortunate reality.

Numerous programs have been established to improve firefighter health and fitness; an internet search provided approximately 13,000,000,000 references on December 4, 2018.

Firefighting is an acquired skill. Much like being a concert musician. Firefighters that are well trained and routinely practice their craft will demonstrate the best performance when called to serve. Skill development improves from both technical training and hands-on experience.

Some fire departments, due to their low numbers of calls for service do not have the opportunity to develop extensive practical experience in fighting fires. Depending upon experience alone is not enough however, and technical training must also be utilized to fill the lack of experience void.

Technical training combined with practical application that leads to experience is the best tool to prepare firefighters and bring them to their optimal readiness. Meeting the objective of delivering high quality training that is cost effective and targeted to the needs of the fire department can prove to be expensive and time consuming. Departments across the country are searching for quality training methods, extensive research on skill acquisition with college students and more representative samples, such as military recruits, show that performance on a wide range of tasks improves as a function of many hours of practice, (Ericsson, Krampe &

Tesch-Romer, 1993). It is the understanding that proficiency is acquired over time and rigorous 16 practice that proves most challenging for fire service leaders.

Organizational deficiencies that must be considered are the lack of, or minimal, policies and procedures maintained and practiced by fire departments. Policies and procedures provide firefighters with an understanding of the minimal expectations and a standardized approach to a variety of firefighting and emergency situations (Richman, 2008). Standardized policies and procedures are a necessary tool in establishing the groundwork from which firefighters develop their skill set (Norman, 1998). The lack of established policies and procedures would be comparable to asking an orchestra to play a symphony without providing them with the sheet music.

Where, when, and the type of activity firefighters are doing at the time of their deaths is not an issue that warrants merely a cursory review. Identifying and highlighting factors attributed to why firefighters are dying should aid policy makers and senior fire officials in the decision- making processes that impact those that fight fires. Developing and implementing policies and procedures that provide for and guide fire crews, in my opinion, is mandatory. Senior fire officials and policy makers can have a profound impact on firefighter safety through the development and enforcement of sound policies and procedures.

Table 1: Type of activity at time of firefighters’ death.

Type of Activity % Fire Attack 42 Ventilation 4 Water Supply 7 Support Functions 7 Search and Rescue 11 Scene Safety 3 Pump Operations 2 Incident Command 5 Other 11 Unknown 8 Total 100 17

Types of Property Where Firefighters Died 1998 - 2017 25

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Residential Commercial Figure 1: Types of property in which firefighters were in at time of death.

Zeller (1940) an expert in risk management (as cited by Graham, 2018), suggested that man has changed little in recorded history. And because humans do not change, the types of errors they commit remains constant. The errors that he will make can be predicted by the errors he has made, according to Zeller. Commercial deaths in 2007 spiked due to nine firefighters lost at one time in a South Carolina furniture store (see Figure 1). Commercial deaths in 2013 increased due to ten firefighters lost at one time in a Texas fertilizer plant (see Figure 1).

The FDNY 9-11 loss of 343 members was not included above as it skewed the search and rescue data.

The possibility certainly exists that, based on information discovered in these reports, any one or a combination of previous factors could be the result of the firefighter’s death. It must also be considered that none of the previously identified factors contributed to the firefighter’s death, and that something new, yet undiscovered, will be identified. 18

In terms of leadership, the in-depth review of the NIOSH fatality reports and their analysis by fire service leadership can provide much needed insight and guidance to fire commanders that will assist in decision-making and better prepare them to anticipate potentially fatal fire ground developments. Equally important to this research is that information collected can lead policy makers to a better understanding of the needs of their community. Policy makers are in positions to influence budgets and legislation that can aid local fire departments. Increases in training budgets will provide greater opportunities for fire officials to better train their members, which will translate into better protection for the community.

Kunadharaju et al. wrote investigating fatalities involving volunteer firefighters presents some obvious logistical challenges, but the very same organizations may have the greatest need for external evaluation and general technical assistance. The logistical challenges investigating volunteer firefighter fatalities includes that not all volunteer firefighter fatalities are reported to the National Institute of Occupational Safety and Health (NIOSH), meaning data of every single firefighter fatality is not available, which may lead to a yet undiscovered fatality trend.

Improvements to firefighter safety can come from many places. Attitudinal changes among firefighters regarding the use of standard operating procedures. Fire service leadership providing clear guidelines for firefighters with respect to strategic and tactical approaches to fire ground emergencies. State and local legislative officials understanding the risks involved to the fire crews protecting their communities and allocating the necessary funding to ensure firefighter safety.

The intent of this study is to identify, develop and implement control measures that can limit the risk to firefighters based upon the data found within the fatality reports. Leaders within the firefighting community must seek out training and experiential opportunities to better prepare 19 their firefighters. Volunteers that enter their community fire departments need the training, development and support of those in leadership positions within the department. Is incumbent upon all those that hold leadership positions within the fire department to fully prepare those individuals that have willingly volunteered to place themselves in harm’s way. Untrained and unprepared fire crews are at great risk of being killed in the line-of-duty.

Many sports teams across the country set time aside each week to watch video of the upcoming opponent. Watching the videos provides players with knowledge of the opposition’s abilities, formations and trends. This study provides to the reader similar information, only this time the opposition waiting in the middle of the night is unforgiving and lethal if not taken seriously. Firefighters that prepare themselves to better understand fire behavior, building construction as well as sound strategy and tactics will become better prepared to extinguish the fires quickly and effectively, ultimately protecting their own lives, as well as those of their coworkers.

Thousands of communities throughout the United States depend upon a small group of dedicated community members to provide protection for both their lives and property. Learning from prior incidents that resulted in a firefighter fatality should be a powerful incentive to all firefighters, career and volunteer, policy makers, local governmental officials and senior fire administrators. Certainly, the public should know how and why those among them who have volunteered to protect them, and their loved ones have perished. 20

Definition of Terms

The fire service is full of terms and phrases not commonly found in the local lexicon. To address the vastness of applicable terms, an appendix has been added to provide more information and fill-in gaps in understanding. See Appendix C. The following terms have been used with regularity throughout the paper.

Attack line – the hose that delivers water from a fire pump to the fire. Attack hoses range in size from 1 inch to 2 ½ inches.

Battalion chief – usually the first level of fire chief. These chiefs are often in charge of running calls and supervising multiple stations for districts with in a city. A battalion chief is usually the officer in charge of a single alarm working fire.

Company officer – usually a lieutenant or captain in charge of a team of firefighters, both on scene and at the station. The company officer is responsible for firefighting strategy, safety of personnel, and the over-all activities of the firefighters on their apparatus.

Hazardous materials – Materials for substances that pose an unreasonable risk of damage or injury to persons, property, or the environment if not properly control during handling, Storage, manufacture, processing, packaging, use and disposal, or transportation.

Fire ground operations - are those activities performed by firefighters on the scene of a structure fire. They include but are not limited to, attacking the fire with hose lines, searching the building for trapped victims and ventilating smoke and toxic products of combustion from the building.

Freelancing – dangerous practice of acting independently of command instructions.

Incident Management System (IMS) – the combination of facilities, equipment, personnel, procedures, in communications under a standard organizational structure for use in incident mitigation. Also known as incident command system (ICS). 21

Incident Command System (ICS) – the first standard system for organizing emergency incidents.

Incident type – used as a term for cataloging similar incidents

National Fire Protection Association (NFPA) – the association that develops and maintains nationally recognized minimum consensus standards on many areas of fire safety.

National Institute for Occupational Safety and Health (NIOSH) – a federal agency responsible for research and development on occupational safety and health issues.

Personal protective equipment (PPE) – gear worn by firefighters that includes helmet, gloves, hood, coat, pants, SCBA, and boots. The personal protective equipment provides a thermal barrier for firefighters against intense heat.

Personal alert safety system (PASS) – device worn by a firefighter that sounds alarm if the firefighter is motionless for period.

Rapid intervention team (RIT) – a minimum of two full adequate personnel on site, is a ready state, for immediate rescue of injured or track firefighters.

Safety officer – the position within ICS responsible for identifying and evaluating hazardous or unsafe conditions at the scene of the incident.

Self-contained breathing apparatus (SCBA) – respirator with independent air supply used by firefighters to enter toxic and otherwise dangerous atmospheres.

Standard operating procedures (SOPs) – written rules, policies, regulations, and procedures enforced to create structure for the normal operations of the most fire departments. 22

Delimitations

This study’s population were the volunteer firefighters who have died traumatic deaths in

United States from 1998 to 2017. The purposely selected sample from those volunteer firefighters will be 149 firefighter fatality reports conducted by the National Institute of

Occupational Safety and Health (NIOSH). My research question establishes the boundaries of what this study will be looking to answer. The sample of fire firefighters in this study have all died as a result of their injuries sustained on the fire ground.

The firefighters studied here are distributed all over the United States, from various community sizes and geographical locations and have occurred over a 19-year period. Selection of a NIOSH report to study was based upon all currently available volunteer firefighter fatality reports published by the Center for Disease Control (CDC) from 1998 to 2017 that corresponded to traumatic deaths. NIOSH reports related to medical emergencies, such as cardiac arrest or stroke were not included within the confines of this study; however, future research in the volunteer population should be pursued.

Organization of the Study

Chapter one introduces the very real and sad reality of regular people who, for one reason or another, volunteer to protect their communities from the danger and ravages of fire and in traumatic fashion, die as a result of their participation in the fire service. Chapter two discusses previous relevant research and literature that informs the reader of what the fire service is, how is works and specific components of the organization. The chapter includes discussion about fire command, recruiting of volunteer members, training, policy making, stress inoculation and performance improvement. Chapter three outlines the data used for this study, how they were selected, where it came from and how the data was analyzed. Chapter four reports in detail with 23 the help of graphs and tables, the information garnered from the research and answers the research question. Chapter five puts forth the conclusions drawn from the research, offers recommendations for action and practice and finally suggestions for further study in the area of firefighter safety and fatality reduction. 24

CHAPTER II. LITERATURE REVIEW

Firefighter fatalities across the United States continue at an alarming rate. The firefighter population is comprised of both career firefighters, those that receive compensation in a regular paycheck and benefits, and those that serve their communities as volunteer firefighters. A review of the nationally available firefighter fatality data indicates that far more volunteer firefighters are killed annually than their career counterparts (U.S. Fire Administration, 2017) . Traumatic occupational fatalities represent a public health problem of significant proportion (Higgins,

Casini, Bost, Johnson, and Rautiainen, 2001). The present study examines the factors contributing to volunteer firefighter deaths and provides insight on how to lower the fatality rate.

To that end, the reports will be examined to determine what factors that have been identified, as well as the fatality factors offered by Kunadharaju et al. (2010). The study conducted by Kunadharaju et al. examined if incidents investigated by NIOSH were representative of all firefighter line-of-duty deaths (2010). They in fact are not fully representative of all firefighter deaths. Involvement in a NIOSH investigation is voluntary on the part of a fire department. Therefore, it is reasonable to believe some firefighter deaths have not been fully investigated by NIOSH, thus no reports have been generated from that agency. Local agencies do investigate the circumstances of the firefighter’s death, but that does not result in the generation of a nationally available report.

Incident Command

We will begin the journey with a review of the incident command system. The Incident

Command System (ICS) is a framework, a tool, used to organize a structured response to a given problem. The ICS was developed in the late 1960s and early 1970s in California out of 25 frustration in managing large-scale forest fires. California fire departments at that time, like many others around the country, each spoke their own language in terms of fire suppression operations. Fire suppression vehicles in one community may be called pumpers, while in the neighboring community they were called engines. Terminology used in fire suppression activities varied from community to community. Neighboring fire departments were unable to communicate to each other via their radio systems, because they had different frequencies.

Organizing and coordinating fire suppression efforts between departments during a large-scale forest fire became nearly impossible.

Following several uncoordinated fire suppression efforts, a group of senior chiefs in

California met to discuss how improvements in the command and control at the large events could be better orchestrated. From these meetings, the framework of the incident command system was born. Using military planning techniques as a guide, fire chiefs worked to model their command system in a similar fashion as a field commander may deploy his/her troops on the battlefield. Please make no mistake, the geography on which forest fires are fought is certainly a battlefield; history is filled with the names of firefighters that have died in the line of duty. Even with the development and advancement of the ICS, in 2013 the Yarnell Hill fire in

Yarnell, Arizona, ignited by lighting, killed 19 City of Prescott firefighters who were over run by a wall of intense heat and flame. Funding was sought and eventually received from the state of

California, then arising from the efforts of these concerned fire officials, an incident command system was born called FIRESCOPE. This acronym stood for Firefighting Resources of

Southern California Organized for Potential Emergencies.

The incident command system (ICS) has evolved over the past several years and is now universally accepted as the tool to use at emergency incidents. The National Incident 26

Management System (NIMS) was mandated for use by all agencies and organizations involved in disaster response in 2004 (Jensen & Yoon, 2011). However, as pointed out by Jensen, (2008) not all emergency managers felt the NIMS was a suitable tool for all emergency situations and was not fully implemented as designed. In 2004, the Department of Homeland Security mandated the use of the National Incident Management System (NIMS) by agencies that deal with disaster response and mitigation.

The effectiveness and completeness of the mass adoption of NIMS is still in debate

(Jensen, 2010). It is important to distinguish NIMS and the Incident Command System (ICS) as different management systems. Chief Alan Brunacini of the Phoenix Fire Department during the

1970s and 1980s developed an alternative fire ground management system to FIRESCOPE. This alternate incident management system, according to Coleman (pg. 8, 1997) was “laid back and less formal” than the original FIRESCOPE. Brunacini’s design was scaled down to fit smaller scale incidents such as structural fires. Named the Fire Ground Command System, this management tool was widely adopted and used in firefighting throughout the 1980s and 1990s

(Angle et al., 2001). Jensen (2011) wrote the NIMS usefulness on a day-to-day basis was perceived to be low, and the systems perceived usefulness for disaster situation was only moderate. The incident command system (ICS) is focused for use as an “on-scene” management tool. The term “ICS” is the official designation for an approach used by many public safety professionals, including firefighters and police, to assemble and control the temporary systems they deploy to manage personnel and equipment at a wide range of emergencies, such as fires, multi-casualty accidents (air, rail, water roadway), natural disasters, hazardous materials spills, and so forth. In 2011, Jensen and Yoon concluded that ICS was a modular organization with integrated communications, common terminology and manageable spans of control. 27

Bigely and Roberts (2001) pointed out many departments still do not routinely follow the organizational plan in the ICS. Jensen (2011) reported that in the state of North Dakota, NIMS and ICS are not popular management tools within much of the volunteer fire services. She also points out that lack of popularity does not necessarily equate to lack of implementation. Decker

(2011) described the strategy to implement the ICS as yielding mixed results among first responders and allied disciplines in Ohio. Decker (2011) suggested that the adoption of ICS by the fire service is understandable, but other agencies such as law enforcement and public works are slow to embrace the system.

Think of the incident command system as a guide for management success. Like any guide, or check list there are specific points that need to be followed that guide the user to an intended objective. The incident command system needs attention and development by the incident commander, combining the proper components, including strict accountability of personnel to ensure a successfully run incident.

The incident command system can be a format for mitigating a larger scale emergency.

Yet in Ohio, according to Decker (2011) ICS entry level training is beneficial for departments.

Decker (2011) indicates it is the more advanced ICS training modules that do not appear beneficial to volunteer organizations. When the fire ground command system is used appropriately and in its entirety, critical fire ground incidents can be safely managed. Deputy

Chief Skip Coleman, of the Toledo Fire Department in Toledo, Ohio, wrote in 1997, the incident management system (IMS) is a standard method of operating at all incidents to which a fire department responds. The firefighting text, Fundamentals of Firefighter Skills 3rd Edition

(2014) said ICS, provides a standard, professional, organized approach to managing emergency incidents (Armstrong et. al., 2004). As a fundamental concept to aid commanders in incident 28 management, some form of a structured, proceduralized incident management system must be used to guide responders in incident mitigation,

To better illustrate the need for the standardized incident management system, such as the fire ground command system, consider the following: a small volunteer fire department in rural

North America is dispatched to a residential structure fire. It is 3 o’clock in the morning and initial reports indicate the house is occupied. Almost simultaneously as being dispatched, the responding department requests mutual assistance from the neighboring fire department twelve miles away. The first department arrives to find a home with moderate smoke conditions and fire showing from the kitchen area of the house. A terrified mother in the front of the house said her teenage son was right behind her as they escaped the burning home, but now is missing.

Three firefighters from the first arriving engine company begin to put in place both a rescue and fire suppression effort. The next arriving fire company will not arrive for 10 minutes.

The officer on the first engine, using the radio to communicate, provides a size-up of the problem, “Dispatch, we have a 2-story, wood frame house with fire and smoke showing from side charlie, (back of the house) with a report of a person that may still be inside the building.

Engine 312 (the first arriving crew) you are attack. I need the next arriving crew to conduct a search.” To those fire crews that are familiar with and have practiced the incident command system a clear picture of conditions on the fire ground, along with what tasks need to be completed has been broadcast.

Terms such as “attack” and “search” mean very specific things as they relate to actions and behaviors by responders and the use of those terms prevents an incident commander from having to ramble on over the radio with directions explaining what she wants in terms of actions from fire crews. Attack means to directly engage the fire and begin suppression efforts. Search 29 means to conduct a search inside the building for any possible victims trapped in the fire building and remove them to safety. Secondly, the use of the ICS, better known as the incident command system (ICS) eliminates confusion.

The use of common terminology allows for faster understanding of what their assignment may be and reduces radio traffic. The Federal Emergency Management Agency (FEMA) in their

2008 training manual on ICS, standardizes the use of common terminology as using common terminology helps to define organizational functions, incident facilities, resource descriptions and position titles. Fundamentals of Firefighter Skills 3rd Edition (Allan et. al., 2014) states on page 122 , “The ICS promotes the use of common terminology both within an organization and among all agencies involved emergency incidents. Common terminology means that each word has a single definition, and no two words used in managing an emergency incident have the same definition. Everyone uses the same terms to communicate the same thoughts, so everyone understands what is meant.”

Every fire officer, volunteer or career, is expected to function as an initial incident commander, as well as a company-level supervisor within the ICS (Brown et al., 2010). Fire officers, those individuals tasked with leadership responsibilities must understand and use an incident management system, such as the fire ground command system. The ICS assists leaders in managing their resources in an efficient manor. Equally important are leaders that fully embrace the ICS and use it to guide their decision-making process, add a layer of operational safety to the emergency incident. The ICS requires accountability, company officers without question must maintain accountability of their fire crews. To enhance the accountability issue, the effective leadership span of control must be addressed. Company officers should maintain a span of control between 3 and 5 people. 30

Returning to the above structure fire, the initial company officer is expected to take command of the incident and develop an initial strategic approach to managing the emergency. A strong initial incident commander is necessary to “set-the-table” for the next phase of the emergency operation, the tactical approach. After assuming command and clearly stating it on the radio so the remaining responders know who to look to for direction, orders should focus on scene mitigation. The incident commander can, if he or she doesn’t maintain a strong internal locus of control, become quickly overwhelmed. Pabst et al., (2013) identified in their research that acute stress has rapid and time dependent effect on decision making. Ross (2007) discussed police officers in high-risk decision-making scenarios were good at screening out “visual noise,” and irrelevant peripheral distractions because of their training and practice. The ICS provides structure that allows for command and accountability, logistics, finance, planning, command & control and demobilization when used at larger scale incidents.

In general, the ICS is constructed around five major functions: command, planning, operations, logistics and finance/administration (Bigely & Roberts, 2001). Emergency scenes can be very hectic, and responders can become quickly stressed under the enormous pressure of command. Self-discipline and self-control are paramount. Stressors will be incoming to the incident commander fast and furious. The inexperienced and/or poorly trained commander can quickly become overtaxed and an ineffective leader. The breakdown of the initial incident commander can result in a disorganized and ineffective fire suppression effort.

The researcher has witnessed first-hand the results of an incident commander that failed to fulfill the responsibilities of the first arriving commander and resulted in a botched and ineffective rescue effort of a trapped victim in an upstairs hallway of a room that was on fire

(Bakewell Street, Toledo, Ohio, 2017). Bigley and Roberts (2001) indicated training that 31 included lectures and simulations appeared most useful. The following statement is contained in

NIOSH report F2014-03, “Among the most important duties of the first officer on the scene is conducting an initial size-up of the incident.” This information lays the foundation for the entire operation.

The incident commander, using the ICS, can begin to breakdown the incident into scalable components making them easier to manage. For example, the initial arriving officer in the above fire is presented with several serious, time compressed challenges. The raging fire consuming the house, the threat to the trapped occupants, the potential for the fire to extend to the houses next door, night-time conditions which inhibit visibility and a limited number of initial firefighters that can be used in the rescue and suppression effort are just a few. A scattered approach to mitigate this emergency will create even more problems. Fire ground leaders have at their disposal a framework which to guide their decision-making processes. Commanders must understand that they are responsible for three umbrella concepts, life safety of civilians and their firefighters, incident stabilization, and property conservation.

After “setting-the-table” by completing a size-up of the emergency scene, that includes a

360-degree evaluation of the scene if possible, commanders need to evaluate what tasks need to be accomplished, in what order, how quickly, and by whom. No problem, right? According to

Bearman (2013) the incident commander will develop an initial plan, which may be to defend assets, attack the fire, to wait or to move elsewhere. The initial actions at this early time are critical, a working knowledge and practical experience using the ICS is important. Incoming fire crews need to be given direction as to what the incident commander’s overall strategy is and what he wants them to do to accomplish these goals. 32

His or her responsibilities as the incident commander are to assemble a command structure, (IC, safety officer, staging officer, etc.) depending on the needs of the incident. The flexibility of a modern ICS allows for smaller incident, such as a car fire, to be managed without filling all the extended ICS positions (Kastros, 2011). Just as easily, larger incidents such as a grain silo fire that involves multiple agencies, across many disciplines to work together smoothly. The ICS provides for command & accountability, logistics, finance, planning, command & control and demobilization when used at larger scale incidents. In general, the ICS is constructed around five major functions: command, planning, operations, logistics and finance/administration. (Bigely & Roberts, 2001) It should come as no surprise to anyone in the emergency services sector that the ICS is pivotal in managing natural disasters such as the

California wildfires in 2016.

A glaring example of the failure to implement the ICS and its catastrophic result was in the state of Louisiana in 2005 during hurricane Katrina. According to a special report of the U.S.

Senate Committee on Homeland Security and Governmental Affairs, “Perhaps the most significant reason for the failure to establish a unified command in Louisiana was the lack of

NIMS (National Incident Management System) and NRP (National Response Plan) training.”

(HSGAC, 2006, p. 562) The desperate attempt to train staff members, including the governor and her chief of staff, on NRP and ICS four days after the federal Emergency Response Team (ERT) arrived in Baton Rouge, perhaps defines why it was impossible to establish a working unified command in the state (Hayes, 2012).

The incident commander (IC) must communicate with responders the strategic objectives and turn them into tactical operations. For example, The IC arrives on scene to find a semi-truck and passenger car involved in a collision. Four people are injured, including two small children. 33

The IC needs to assess the needs of the situation, are the vehicles on fire, are people trapped within the vehicles, how badly are they injured, are any of them already deceased, what medical assets are required?

Within moments the IC must begin developing his/her strategy, get people safely out of the vehicles, treat their injuries and get them transported to the hospital. It is important for the IC to “communicate” with the incoming responders and begin assigning tasks to arriving crews. The communication of accurate and timely representational information is critical to the early stages of system development (Bigely & Roberts, 2001). It is not recommended to begin assigning tasks to crews that have not arrived on location because assignments could be mixed up and the order in which crews arrive may not be in sync with the task priorities that were assigned.

The final major priority under the canopy of command is for the IC to establish command and assign incoming resources to perform the specific tasks that have been identified during the initial size-up. This is moving from developing the strategy into tactics. Typically, in a case such as this, paramedic teams will be assigned to triage and treatment of the injured. Fire crews may be assigned to fire suppression and extrication efforts. A medical helicopter may be needed for expedient transport of a critically injured patient.

The IC must understand the capabilities of the incoming responders and task them with operations they can perform (Hewitt, 2007). Misalignment of needs and resources causes delays and poor outcomes. The need exists for the fire and rescue services to maintain a well-organized, strong system of on-scene command to handle these potential situations (Kidd & Czajkowski,

1991). The 2006 Fire Fighter Fatality Investigation and Prevention program conducted by

Peterson, Witt, Morton, Olmsted, et al, (2006) clearly pointed to the need to establish a formalized incident command system. A focus group within the study indicated that “a lot of 34 freelancing” seems to be occurring on the fire ground. Freelancing is a result of arriving fire crews choosing their own activities, separate and apart from what the incident commander has put in place. Freelancing is a dangerous activity which puts firefighters at risk for injury or death.

The role of the incident commander is critical to the successful outcome of whatever type of emergency scene, be it a structural fire, a vehicle accident, a hazardous materials spill, a water rescue or any one of a myriad of other potential scenarios. Faggiano, McNall and Gillespie,

(2012) wrote good tactical leaders understand that managing a scene is crucial to success.

Experiences have shown that incidents don’t lack emergency providers to do the tasks, they lack having someone in charge. Scene commanders must issue clear, specific orders to responding units, while this maybe difficult in and of it-self, the pressure to communicate clearly will be compounded by the stress of operating in some of the most tragic and horrific situations imaginable.

It is imperative that commanders demonstrate to responding personnel that they are in charge and have a clear idea to stabilize and mitigate the crisis (Faggiano et al., 2012). Incident commanders will be required to function under stress and make decisions that have long term consequences. Failure to recognize the need for and prepare for this stressful environment can lead to functional collapse. The ill prepared IC will become over-whelmed with the volume of information flowing into them and become incapable of making decisions under pressure. A lack of incident command, lack of accountability, inadequate communications and lack of standard operating guidelines – or failure to follow them – can lead to firefighter line-of-duty deaths and injuries and chaos on the fire ground (Kastros, 2011). Faggiano, et al., (2012) wrote, “Take advantage of opportunities to assume the IC/leadership position. Use minor incidents such as non-injury vehicular accidents to demonstrate to your crew the dynamics you’ll expect on a 35 critical scene.” Decision making under pressure is the capacity to make sound and rapid decisions under pressure, particularly when time pressures and limited information exists

(Sweeney, Matthews & Lester, 2011).

As an example of information overflow try the following exercise, take a deck of cards and place a card face up on the table, after two-seconds another, two-seconds another and so on until thirty cards are on table, then quickly cover all the cards in one move. Now after covering the cards, orally recall all thirty cards that were on the table. The researcher would imagine, for most of us it would be difficult. Trying to recall, conceptualize and process multiple stimuli can be extremely difficult, especially when time compression is added. Now, using the same sequence as above, only lay three cards down. How’d the recall of those three work out?

The suggestion here is that an incident commander should assess the situation presented to them, identify what they feel are the three most important tasks that must be managed quickly and then focus resources in that direction. The next step is then to reshuffle “the deck of problems,” reassess the situation and select the next priority three critical issues and begin addressing them to continue the mitigation of the problem. Using this method, incident commanders can parse out major items that need immediate attention and not become overwhelmed trying to resolve the entire problem all in one bite.

Consider the incident commander that is well trained and rehearsed in using the incident command system, when challenged with the following, an over-turned gasoline tanker on a busy roadway. A scenario such as this will require multiple and simultaneous activities that need to be accomplished very quickly to avert a potential disaster. However, even the most accomplished incident commander will be limited in what can be done if too few emergency responders arrive in a timely manner. This is the problem of under-resourcing. Volunteer fire departments 36 throughout the country are reeling from the effects too few available trained personnel are having upon their communities.

On February 1, 2014, a 28-year-old volunteer firefighter with 15 years of experience was killed when a cell phone tower fell, striking and killing him. He was apart of the mutual aid fire department responding to this incident. The volunteer department, Company 13, that was dispatched first due and where the initial incident commander served, had 1 station with 4 uniformed members, serving a population of approximately 3,500 within an area of about 35 square miles. While this example of under-resourcing may seem extreme, similar staffing concerns plague departments across the country.

Training Concerns

The New York Times published an article in August 2014 entitled, “The Disappearing

Volunteer Firefighter,” in-which authors Andrew Brown and Ian Urbina wrote the allure has diminished because fund-raising now takes up roughly half the time most volunteers spend on duty. It’s also harder to fit volunteer work into their personal lives. The rise in two-income households often means there is no stay-at-home parent to run things so the other can dash off for an emergency. The time and training needed to become a certified firefighter have also increased.

Federal standards enacted to save firefighters’ lives have unintentionally created a barrier for the volunteer service: It now takes hundreds of hours to be certified, and new firefighters often must cover the cost of training. In Loami, Illinois, a village of about 800 people, 10 miles southwest of Springfield, Fire Chief Troy Johnson is quoted in the State Journal Register

(www.sj-r.com) in February 2017 “It’s hard getting anyone interested in serving the community.

Nobody wants to do anything for free and everybody is too busy.” Chief Johnson also said that 37 after receiving a call for mutual aid from a neighboring department to fight a brush fire, only one of Loami’s approximately 15 volunteer firefighters responded. Johnson continued, “In a rural fire department where most people work during the day, you’re lucky if you get maybe two people who show up on a call.” Chief Johnson is not alone in his dilemma. The Illinois Fire

Chief’s Association, seeing the decline in volunteer firefighters began offering seminars meant to assist departments in Illinois to recruit and retain volunteers.

Since the lower numbers of arriving firefighters are an identified problem, the need to ensure those that do arrive are properly prepared with good equipment and training must be prioritized by policymakers and department leadership (Neddel, 2009). Sub-optimal personnel readiness could suggest that equipment and training are less than optimal for those arriving fire crews. The research here focuses on the training of those firefighters that did show-up when called upon.

A national standard firefighter curriculum does exist. However, numerous states do not mandate minimum training requirements for volunteer firefighters. Several well-known textbooks are published that clearly outline and introduce new personnel to firefighting principles and practices. The NFPA has written standards detailing best practices for firefighter training. NFPA 1720, Standard for the Operation and Deployment of Fire Suppression

Operations, Emergency Medical Operations and Special Operations to the Public by Volunteer

Fire Departments identify best practices and policies for volunteers in the fire service. With respect to training, the 2001 edition of NFPA 1720 says, Section (5.3) the fire department shall have a training program and policy that ensures that personnel are trained, and competency is maintained to effectively, efficiently and safely execute all responsibilities consistent with the department’s organization and deployment. In addition, NFPA 1001, Standard for Firefighter 38

Professional Qualifications (2002), is directed at both career and volunteer firefighters and identifies the minimum job performance requirements for firefighters whose duties are primarily structural in nature.

With the understanding that compliance with NFPA standards is voluntary, these standards, developed by subject matter experts in the fire service establish what can be considered best practices within the fire service industry. The state of Iowa adopted what is called the Minimum Training Standard, as adopted in the Iowa administrative code (section 661, chapter 251), which states on or after July 1, 2010 any member of the fire department shall have completed the training requirements identified in the job performance requirements for firefighter 1, classification in NFPA 1001.

It is noted, a firefighter is not required to be certified to meet this requirement. Training to meet this requirement may be provided by the fire service training bureau, a community college, the regional fire training facility, or a local fire department, or any combination thereof.

Iowa is not alone in their desire to establish minimum training standards. A 2002 report from the state of Oregon contained, “Rural, all- volunteer departments are unlikely to be able to provide adequate training to meet even the most basic safety and competency standards without state assistance.”

A 2006 study of 3000 sampled fire departments with a response percentage of 54.9 percent pointed to some interesting data with respect to training (Peterson, Witt, Morton,

Olmsted, 2008). Departmental training is being provided by internal trainers (84.9 percent), officers within the department not assigned to the training section (82.8%) and state fire training programs (77.4%) (Peterson et al., 2008). These numbers, while positive, do illustrate not all fire departments have internal trainers and highlights their reliance on external trainers to augment 39 departmental training needs. Departmental officials need to seek out highly skilled trainers that will provide a high level of education and training.

An emerging field of training methodology is Reality Based Training (RBT). Being introduced within the law enforcement community and our military, RBT places students in scenarios that require execution of a set of skills under stress, to successfully navigate the training session (Murphy, 2012). RBT has a place in the fire service and should be used routinely to prepare firefighters for predictable events on the fire ground. RBT can and should evoke a stress response from the student.

Kathleen Vonk of the Ann Arbor police department conducted research on heart rate acceleration and its impact on performance. Vonk also pointed to experiential levels when compared to actual time spent doing the street work. Vonk uses the example of two police officers having eight years of experience, but when compared side-by-side one officer spent eight years on the street and the other after one year on the street went to staff and spent the remaining seven years patrolling a desk. The abilities to perform under stressful environments greatly differed (Vonk 2001).

Glombowski (2018) wrote in a widely distributed departmental email that a group of recent trainees were trained to the “basic, bare minimum”. Certainly, we can do better than sending out new recruits with only being trained to the bare minimum. The uncertainty of firefighting demands new recruits are trained to a level that prepares them to recognize what is occurring and advance, then close with the enemy to extinguish the fire in the safest possible manner. This training needs to incorporate reality-based training in which problems arise and firefighters are taught to recognize and respond to those sudden changes while under stress. 40

In the movie We were Soldiers, (2002) the main character, Lt. Col Hal Moore is conducting training, During the training sequence Col. Moore notices that simulated combat training is running very smoothly, almost flawless. He immediately recognizes that the real experience will be much different and injects himself into the training scenario…”bang he’s dead…what da gonna do?...too late, your dead…on to the next, what ya gonna do…? Soldiers learn to function under stress in order to survive, firefighters should too.

New training that is directed toward a dangerous activity, fire suppression, an individual must be taught how to manage their stress and response with techniques in arousal/anxiety control (Hall, 2010). New firefighters can suddenly find themselves in a very hot, dangerous, and disorienting environment. Their ability to control their anxiety can be drastically improved if they were exposed to training that included stress inoculation during their initial training phases.

Asken (2010) wrote that stress inoculation can be introduced by using reality-based training that stresses fire fighters. This training develops a firefighter’s capabilities to function under stress, maintain control and complete their assigned tasks. Deliberate training works to develop memory markers for firefighters to use during later incidents.

In 2008, Bruce Siddle wrote about how important precision skills were for firefighters and EMS personnel, such as EMTs and paramedics. Emergency responders who are unable to manage acute stress are susceptible to the loss of fine motor skills, visual narrowing, auditory occlusion and mission failure. Reality based training that includes stress inoculation works to condition firefighters and EMS personnel to function in high stress environments. Stress inoculation training can also include environmental factors.

US Army MSG. Paul R. Howe (2011) wrote that understanding how you and your equipment will function in a wide range of climates that include freezing cold, high heat and 41 humidity, rain and sun. Howe (2011) indicated that training in all those conditions, in addition to daylight and nighttime were essential to becoming skilled in working with your equipment.

Specialized rescue teams such as water rescue, hazardous materials and confined space teams should regularly train in similar conditions as outlined by Howe, if they expect to develop expertise in those areas.

In 2004, Carlstedt put forth a theory he called Theory of Critical Moments. This notion described critical moments that were pivotal to successful resolution in a given scenario.

Carlstedt indicated he identified specific traits in those that would succeed and those that would, in his words “choke.” While these traits are complicated to understand and especially difficult to measure, Carlstedt believes specific practice within stress inoculation training can maximize an individual’s own response traits to better perform at critical moments.

Discussion of training methodologies and stress inoculation are interesting and important to those that understand them and appreciate the advantages of using them. Training discussion for some may be boring and to the uninvolved and ill-informed policy maker, legislating from behind a desk, they may have minimal understanding of what the expected outcome should be.

Even worse is the policy maker that is more concentrated upon cost containment than hypothetical training methodologies. Fire service leaders need to bridge this information chasm between community policy makers and themselves.

Policy Issues

Preparing firefighters cannot solely focus on the mechanics of skill performance, such as advancing a hose line, climbing a ladder or chopping a hole in the roof. Training should flow from a crawl, walk, run perspective, deliberate practice if you will. Deliberate practice (Clear,

2017) refers to a special type of practice that is purposeful and systematic. While regular practice 42 might include mindless repetitions, deliberate practice requires focused attention and is conducted with the specific goal of improving performance.

Firefighters function within stressful environments. Failing to prepare them mentally for what is to come is shortsighted and disingenuous. Human cognition research suggests “new information is always interpreted in light of what is already understood” (Spillane et al., 2002, p.

394). Policy makers, politicians and senior fire administration and associated emergency service leaders need to consider training methodologies that incrementally stress new firefighters to better prepare them for the conditions that lay ahead when they arrive in the fire stations and head out on their first alarm. Policy makers and politicians could control the flow of financial support necessary for training. Training programs should be uniform for all new firefighters; having a documented, clear training protocol is the only way to ensure all new members receive the same type and quality of initial training, (Swanick, 2012).

Policymaking can be hard work. But hard work dedicated to developing meaningful safety policies can have generational effects. Well developed and thoughtful polices can save lives. Firefighters that are kept alive because of well developed policies that are enforced within the organization affects families, fathers and mothers with children and grandchildren. Good policies that are well thought out, implemented and enforced by supervisory personnel and then updated regularly can affect generations.

Getting departmental policy changes in-place is a process. A critical factor in policy implementation is mobilization. Mobilization is more than likely the most critical step in policy implementation. Huberman and Miles (1984) found that mobilization typically lasted 14 to 17 months. Leaders who hope to bring about a lasting change should pay careful attention to each 43 step of mobilization: policy adopting, planning and gathering of resources. Failures in the mobilization process for policy implementation almost always doom a project.

To aid in the adoption of new departmental policies leaders should ensure they can answer yes to the following questions.

1. Do we have a good reason for adopting this new policy? For example, will a policy

requiring the use of seat belts in moving fire apparatus save lives?

2. Is this new policy appropriate for our fire department?

3. Does this policy we are considering have support from key stakeholders? Such as the

volunteer fire fighter’s association as an example.

Fire service leaders should expand their consideration of selecting and retaining new members in the fire service that can perform well within the organization (Neddel, 2009). A leader’s long-term success isn’t derived from sheer force of personality or breadth and depth of skill (Mayo & Nohira, 2005) The provision of high-quality training and routine assessment of the firefighter has long-range consequences. There should be a moral and ethical consideration when deciding to keep a prospective firefighter in an organization. Retaining a firefighter that consistently performs below standards in both training and fire ground operations is potentially a danger to themselves and those firefighters they work with.

Carried even further, doesn’t fire service leadership bare a responsibility to remove a poor performing individual from the dangerous environment? What measure of consolation can be offered to the spouse and family of a fallen firefighter that fire service leaders knew, based upon previous performance, more than likely should not have continued within the organization because of their substandard performance? Just like not every person is capable of being a physician, lawyer, NFL star or college professor, not everyone is capable of being a firefighter. 44

Policies don’t just appear; they require thought and reflection to ensure applicability to the perceived problem. Charles Jones (1984) wrote that policy implementation required three activities—organization, interpretation and application—to successful implementation of any policy objective. Several different models and theories of policy development are available; they include group theory, institutional theory, rational choice theory, elite theory, political systems theory and the policy process model (Anderson, 2006).

Not all these policy development theories are applicable in the context of firefighter safety. A brief description of each methodology is reasonable and the potential application to firefighter safety as it relates to policy development and implementation is appropriate. Keeping focus this study centers upon a volunteer firefighter population and the ramifications of its findings can have broad-spectrum application throughout the firefighting community.

Group theory views policy making through the lens of many parties having power to affect policy development (Anderson, 1997). Firefighters may lobby for additional funding, training education and modern equipment to the local legislators and elected officials while at the same time working to appeal to the local community they serve on the need to improve safety conditions for their community firefighters. Appealing to multiple groups (stakeholders) could bring power and influence from a broad section of potential supporters (Latham, 1965).

Institutional theory addresses a formal and legal process for policy development that can be very rigid with defined structure and processes. Volunteer firefighter organizations around the country can wield significant political power within their regions, influencing politicians and their policy decisions. As an example, the National Volunteer Fire Council (NVFC) (nvfc.org) is a membership association that represents volunteer firefighters around the country. The NVFC accomplishes its mission and provides meaningful support to fire and EMS organizations 45 through a wide range of services and programs by representing the interests of the volunteer fire, emergency medical, and rescue services at the U.S. Congress, federal agencies, and national standards-setting committees (nvfc.org, 2018).

From an elevated prospective, elite theory public policy can be regarded as reflecting the values and preferences of the governing elite. This argument of elite theory is policy is not the result of those “doing the work” or those “in need” of a policy change, but rather policy is a result of preferences of the ruling elite that come into being by politicians and political agencies

(Anyebe, 2018). Firefighters as a group do not typically walk among the political and ruling elite, and as a result, have little impact on firefighting safety policy initiatives that serve the firefighting community on a broad scale.

The political systems theory developed by David Easton, offers potential in policy development that may be advantageous to the firefighting community. This policy theory runs on the idea of input (from groups or individuals) and output (policy makers, legislators). Input comes from stakeholders (ie. firefighters) in the form of demands, from interested parties looking for enhanced firefighter safety as an example, such as labor organizations, volunteer firefighter associations, community groups and education and safety organizations lobbying for specific policy initiatives. The outcome results from the combinations of shared values and available resources and decided upon by politicians.

Policy development can be a complex process and as such policy decisions need to be well designed, thought out and involve pertinent stakeholders. It is important to understand that in the context of the fire service, policy decisions made by community leaders impact more than just fiscal concerns. Community safety, regional insurance ratings, and quality of life issues for 46 the population are a few of the issues that must be addressed. Poor policy implementation within the fire service can have long term negative effects for a community.

Personnel Readiness

Sub-optimal personnel readiness indicates that firefighters are not fully prepared to operate on the fire ground when sudden and unpredictable changes occur. As an example, a firefighter suddenly has a self-contained breathing apparatus (SCBA) emergency and is struggling to breathe, a firefighter falls through a floor into the basement, or a firefighter becomes disoriented within a smoke-filled structure and gets trapped. How does the firefighter respond to these sudden and emergent situations? Have they been trained on how to anticipate certain situations that present serious dangers? How does the outcome of a distressed firefighter differ depending on the firefighter’s training and experience? Does fear and panic result? What can be done to blunt the fear factor that ultimately lends itself to firefighter survival?

The 2016 Annual report from Firefighter Near Miss (www.firefighternearmiss.com), an web site launched in 2005, in cooperation with the International Association of Fire Chiefs

(IAFC) with funding from the Federal Emergency Management Agency (FEMA). This site is designed to provide a public, anonymous reporting system for firefighters to share incidents in which actions during fire operations, including active fire grounds and training evolutions in which circumstances where firefighters were confronted with serious injury or death, yet through a lucky break in the chain of events dodged such a terrible fate. This program provides for a non- punitive place for firefighters to share their experiences with others in the hope that their near- death experiences can be used as tools for others to learn from and therefore not repeat the same mistakes. This firefighter site is modeled after the aviation industry’s Aviation Safety Reporting

System (ASRS) that was developed as early as 1976 (Hagen, 2013). 47

Some interesting data are contained within the report. In forty-five (45%) percent of the reports submitted to the site were from fire departments other than full-time career departments.

Those departments were comprised of volunteer (5%), combination, volunteer and paid members

(22%), other (8%) and not specified (10%). Among many eye-opening data points contained within the 2016 report are the following, firefighters were permitted to select what they felt were contributing factors to their near miss event.

The overwhelming contributing factors were, human error (1st), situational awareness

(2nd), decision-making (3rd) and individual actions (4th) (Firefighter Near Miss Report, 2016).

Further, the report states that of all the incidents reported, unintentional human error comprised

42 percent of the incidents, a willful disregard for best practices, operating guidelines or procedures comprised 13 percent of the total reported unsafe acts. The remaining 45 percent did not specifically indicate if the action was unintentional or not (Firefighter Near Miss Report,

2016).

Almost half of the near-miss incidents were related to unintentional human error, this fact should be alarming to any fire service leader. More alarming should be the fact that of the near miss incidents, 13 percent were attributed to intentional and willful disregard for best practices, operating guidelines or procedures. Firefighting is a risk industry, but willful and intentional disregard for best practices puts fellow firefighters and civilian lives in danger when it is unnecessary. This overt disregard for safety must be swiftly addressed by fire service leaders so the negative behavior is not emulated by others within the organization.

Hendricks and Campbell (2016) wrote in The Kansas City Star, firefighters often died because their commanders made poor decisions and strategic errors that put them in excessive danger. Captain Kevin Kalmus of Austin, Texas (as cited by Hendricks & Campbell, 2016) 48 stated “We allow the same events to occur year after year that lead to firefighter fatalities.” More from Hendricks and Campbell (2016), their investigation into firefighter fatalities chronicled in almost every case they reviewed, they determined that firefighters may have lived, had better smarter decisions been made at the fire scene and they found that similar tactical errors repeatedly are uncovered in fatality investigations.

Failing to acknowledge fear and performance issues while under stress is a serious fault within high-risk occupations such as firefighting. Training time should be spent with firefighters that prepares them to function and react when things go wrong, and they find themselves in potentially life-threating situations. For this training to be meaningful and beneficial to the firefighter, fire command officers and instructors must understand what physiologically happens to individuals under extreme stress. Lieberman (2005) conducted a series of evaluations on military personnel with differing experience levels that included officer and enlisted personnel.

The officers were selected from elite groups such as Army Rangers, the enlisted were assessed for their ability to function as Rangers or Navy SEALS. Lieberman (2005) found in both groups, during stressful combat-like training, every aspect of cognitive function assessed was severely degraded compared with baseline, pre-stress performance. Relatively simple cognitive functions such as reaction time and vigilance were significantly impaired, as were more complex functions, including memory and logical reasoning. Armed with this knowledge, fire service leaders need to embrace the need for stress induced training in order to develop and improve firefighter decision-making ability on the fire ground. Varker and Devilly

(2012) said inoculation training maybe beneficial and is therefore a viable option for emergency services personnel during pre-deployment training. 49

Thompson and McCreary (2006) wrote that military training has traditionally focused on skill acquisition, and the development of technical proficiency, discipline, strength, endurance, and teamwork. Lectures and briefings provide basic knowledge, while demonstrations and repeated drills hone specific proficiencies.

Thompson and McCreary (2006) continued, certainly practice, particularly the overlearning involved in repeated drills, can have psychological benefits, reducing the novelty of, and thus the uncertainty associated with, the technical aspects of these tasks, thereby increasing confidence. Overlearning can decrease soldiers interference from competing responses and may be particularly important in complex tasks (Thompson & McCreary, 2006).

This article has direct application to the fire service. Firefighters engaged in overlearning life- saving skills such as building collapse recognition, recognition of pending flashover conditions and the ability to recognize changes in smoke conditions can improve their mental models and pattern recognition of potentially fatal environments. The primary purpose of training is to ensure the acquisition of required knowledge, skills, and abilities. The primary purpose of stress training is to enable the individual to maintain effective performance in a high stress environment (Driskell, Johnston, 1998). The intensity of stress reactions, and the ability to cope emotionally with a highly stressful event can be influenced by the extent to which an individual is prepared for the experience (Paton, 1994).

Lieberman’s research dovetails into the need for stress inoculation training developed by

Meichenbaum (1976), which works to blunt the sharpness of uncontrolled fear and panic.

Thompson and McCreary (2006) identified three targeted goals for stress inoculation training and reported research supported effects from its application: 50

1. Improved performance by changing problematic or sub-optimal behavior in high stress

environments.

2. Improved ability to self-regulate performance and responses.

3. Improved resiliency and coping in stressful situations.

Dr. David Feigley’s (1989) research identified a number of performance indicators of fear, they include, tardiness for training or assignments, frequent moving to the back of the line in training, excessive time checking, prepping, adjusting gear, odd behavior for the situation, presence of chronic fatigue or depression, multiple minor illnesses/injuries which inhibit training. Training instructors need to be aware of these performance indicators so firefighters demonstrating these behaviors can be identified and further developed (coached) to overcome their apprehension. Teaching new firefighters techniques to aid them in arousal control while under stress can be life saving. It is important to understand training should be focused on managing arousal and not to preclude or eliminate it. Training that involves both mental toughness skills and physically demanding components can prove to be valuable for firefighters.

Dr. Robert Nideffer (1978) wrote, it’s the ability to control attention under pressure and in response to changing demands that separates the average person from the super performer.

Since this researcher’s focus includes firefighters’ sub-optimal personnel readiness and firefighters that are not fully prepared to adapt when sudden and unpredictable changes occur, the introduction of the OODA loop is appropriate. OODA is an acronym for a decision-making process consisting of Observation, Orientation, Decision and Action. Developed by the late Air

Force Colonel John Boyd, a USAF pilot with extensive combat experience in Korea, discovered similarities in a variety of combat situations. Col. Boyd discovered if opponent A presented 51 opponent B with a sudden and unexpected situation, it allowed opponent A time and opportunity to gain an advantage.

If opponent B could not adapt to the new conditions, opponent B would eventually be defeated since decisions and actions that are delayed are often rendered ineffective due to the constantly changing conditions (Asken, 2010). The modern fire ground is a quasi battleground.

The fire (enemy) is on a destructive and potentially lethal tract. Fire crews quickly assemble, deploy specific equipment and move in predicable fashion to battle back the flames to save lives and property. Much like a modern battlefield, sudden and often unpredicted changes occur on the fire ground, flashovers, backdrafts, structural collapse and rapid fire spread are examples. A firefighter’s ability to observe the fire ground conditions quickly, orient themselves to what is happening, deciding how to counter what they are seeing and then acting appropriately is the

OODA loop in action. Drs. Honig and Lewinski (2008) reinforced the importance of critical decision-making under stress and the need for training and practice.

Murray (2004) has suggested that the use of mental imagery as a component of training is now being recognized as beneficial in maximizing skill levels of emergency responders. The former head of psychological training for the United States Olympic teams, Dr. Shane Murphy

(2005) says, “Imagery is the most important of the mental skills required for winning the mind game in sports.” Shouldn’t the fire service embrace a proven training methodology? John

Schmitt (1996) developed what has been called tactical decision-making games (TDG’s) for the

U.S. Marines. These scenario-based training sessions developed the young Marines in their decision-making ability.

It is noted (Klein, 2006) there are no generic skills that make individuals better decision makers. Rather individuals acquire more patterns of events and build stronger mental models, 52 thereby recognizing what to do in situations sooner. Gary Klein, a cognitive psychologist, has written extensively about how people make decisions under stress. Klein (1998) dedicated an entire chapter of Sources of Power, How People Make Decisions, to the study of firefighters and their decision-making abilities. The intensity of the stress reactions, any ability to call emotionally with a highly stressful event can be influenced by the extent to which an individual is prepared for the experience (Paton, 1994).

Klein wrote, (1998) These commanders showed us how people function under stress of having to make choices with high stakes. Our later studies showed us that military commanders use the same strategies as the fire ground commanders. Research suggested that individuals that make time compressed, high value decisions were using a form of mental imagery, Klein (1998) and his research team developed the Recognition-Primed Decision Model (RPDM).

This model suggests that prior experiences, both successful and unsuccessful, establish patterns and mental models within the fire commanders. The more experiences, the more a fire commander has developed mental models and recognizes patterns. As a fire commander sizes-up a situation he or she unconsciously uses prior experiences to recognize what priorities to set, what cues indicate success, what to expect next, and likely courses of action that should be successful. Dr. Klein and his team make a strong argument for repetitive, realistic training that will add to the mental models and pattern development in firefighter’s decision-making abilities.

Clausewitz, (1831) was a Prussian general and military theorist said that friction distinguishes real war from war on paper. In order to be good, a TDG must be realistic. In order to be realistic, it must have fog and friction built into it (Schmitt ,1996).

Dr. Darrell Ross, Chairman of the Department of Law Enforcement and Justice

Administration at Western Illinois University from 2006 - 2010 conducted research on peak 53 performance in lethal force encounters experienced by police officers. His research found that officers that “formulated flexible anticipations” (mental imagery of what to expect) survived deadly force encounters in-part because of their mental preparation and situational awareness.

Their own technical expertise cannot be discounted in the survival equation. Dr. Ross (2007) said, “They (police officers) mentally prepared themselves to recognize danger.” Firefighters must be capable of doing the same thing. Dr. Ross’s training methodology is applicable to the fire service as well. Fire service leaders and policy makers need to adapt training schedules to include psychological development for survival of firefighters as well as the technical mastery of skills.

The old paradigm of believing that an individual’s raw talent or nature were the limiting factors to their performance level has faded. Ward et al., (2008) put forth the theorem that expert and elite performance results from extensive participation in relevant training activities.

Feltovich, Prietula & Ericsson, (2006) highlighted traits that encompass exceptional and expert performance. They report that well designed training coupled with tactical performance imagery and frequent practice and training can aid in developing high performance skills. Specifically,

Feltovichet al., (2006) proffer the following:

1. Expertise is limited in scope and does not transfer over to other areas of performance.

2. Knowledge and content matter are important to expertise.

3. Expertise involves larger and more integrated cognitive units.

4. Expertise involves selective access to relevant information.

5. Simple experience is not enough for developing expertise.

If simple experience was transferable to expertise, one would expect every kid that had the experience of playing little league baseball would eventually end up in the major league and 54 hit a grand slam in game 7 of the world series to win the title. It is therefore reasonable to argue that membership in a fire company for several years does not transfer and does not equate to expertise as a firefighter. Expertise is developed by purposeful practice of correct methods over an extended period. Practice of a skill, known in the fire service as drilling, cannot be haphazard or sloppy or inconsistent.

Completing training sessions that are poorly run or of inappropriate techniques are only reinforcing poor behavior and not contributing to development of expertise. Proper and meaningful training, that develops firefighters through repetitive practice conditions fire crews to work quicker, more effective and with more confidence in their own abilities (Smith, 2008). The fundamental goal of training must be the development of proper skills as well as practice in making decisions and judgment as well as other cognitive functions (Crandall, Klein, Hoffman,

2006). In complex environments there are numerous subtle pressures that can lead to poor decisions and errors (Bearman & Bremner, 2013). Mediocrity in training is not acceptable when faced with the reality of potentially lethal encounters. Many lessons can be learned from reviewing past incidents that dramatically challenged fire crews to discern what made them so challenging and then study why decision makers (commanders) were successful or failed

(Crandell et al., 2006).

Hard lessons can be learned from the review of NIOSH fatality reports. Reading the details of a fellow firefighter’s last moments could shake even the most seasoned veteran to their core. These NIOSH fatality reports lay out in painful, exacting detail the series of events culminating in a final, fatal act. For serious and meaningful changes to occur within fire service organizations, a realization of what is truly at stake must be planted firmly on the fire house floor, like a battle flag. 55

Organizations must look internally and assess what organizational changes need to be adopted to provide the highest attainable level of safety for their firefighters. Public sector organizational cultures, which includes volunteer fire departments, create unique challenges for managers to evoke change (Schrader, Tears, Jordan, 2005). These organizations are facing increasing pressure to adapt to external environmental factors, whether it is training priorities, community service demands (EMS, HM, etc.), leadership promotion, leaders in the public sector organizations need to help their members understand and adapt to these changes (Valle, 1999).

The actions of an organization’s leaders, in this case fire chiefs and company officers, can serve as stimulus for changing an organization’s culture (Gordon, 1991). Setting the example of using personal protective equipment at emergency scenes, following operational procedures or seeking outside high-quality training are a few examples that can be viewed by fellow members as a benchmark to aspire too.

In addition to quality based internal training, formal academic educational opportunities are plentiful for aspiring fire service leaders. Numerous colleges, both online and within campuses of academic institutions of higher learning are scattered across the United States ready to prepare fire service leaders for the leadership challenges ahead. Fire services leaders need to be on the forefront in the utilization of an adult teaching methodology, andragogy.

Andragogy is a term that relates to lifelong adult learning and is especially applicable to the distance (on-line) education models. Numerous academic degrees are available, associate, bachelor, masters and even doctoral programs are available to those interested in higher education in the fire service. The fire service has embraced higher education and has developed a model curriculum in fire science. In 2000, as a result of a Fire and Emergency Services Higher 56

Education (FESHE) conference a curriculum for an Associate’s degree in fire science was developed (Loyd and Richardson, 2010).

According to Paul Snodgrass (2012), Mr. Edmund Walker (2009), the state fire training director for Massachusetts, had this to say about a FESHE conference: “They dragged me down to a FESHE conference and it was like a light bulb moment when talking to Ed Kaplan (NFA education chief) and participants,” Walker said. “There needed to be a correlation between higher Ed and the state training directors. It became evident that the entire goal of the FESHE initiative was to ensure a clear and consistent path for professional development for members of the fire service.”

Leadership

It cannot be overstated that strong leadership is necessary if any serious reduction in firefighter fatalities are to be expected. Officer development inclusive of higher education, directed at company officers and chiefs needs to be accomplished on a continuing basis. The idea that leaders are born, which is the pillar of the great man theory of leadership is incomplete. An individual may develop good communication skills, empathy, integrity and sound decision- making skills, however personal development and maturity are the mortar that hold these components of leadership together. Spencer (1896) wrote that one of the key shortcomings of the natural born leadership theory is that not all people who possess the so-called natural leadership qualities became great leaders. Good company officers (leaders) can be taught and developed with good mentoring and guidance from veteran fire officers that are skilled in their craft.

Spencer (1896) went so far as to suggest that leaders were products of the society in which they lived. That easily translates into men and women who are committed to being fire service leaders can learn the skills necessary to give them the best chance to succeed, if they are 57 immersed in a fire service culture that embraces high quality training and a relentless pursuit of excellence. Ask yourself, “Why should anyone be led by you?” A sign hangs in the Toledo Fire

Battalion Chief 1 office asking that very question.

The skills necessary in becoming a highly regarded fire service leader include more than simply developing one’s ability to point their finger and bark orders. Leadership competency should be built around a combination of technical ability (firefighting expertise), people skills

(caring for your subordinates) and conceptual skills, the ability to work with broader concepts and ideas (understanding the uncertainty of a fire ground). This combination of leadership abilities is identified as the skills theory of leadership developed by Robert Katz in 1955.

It needs to be understood that one, singular leadership style can have significant disadvantages. For example, when discussing behavior theory, also referred to as style theory, has three distinct leadership styles are detailed. The first, autocratic leadership theory reflects a

“my way or the highway” approach. This strong leadership model may be highly effective during emergency scenes, such as a well-developed fire in a multi-unit residential structure at 3 o’clock in the morning with trapped victims hanging out of their bedroom windows. Trying to develop a consensus among fire crews how best fight the fire and rescue the trapped victims is neither reasonable nor effective in such a time compressed, high risk environment.

The same leader can also employ a more democratic approach in her leadership style within the fire station. Seeking input from her subordinates on non-critical yet important issues can prove empowering to the crew and work to obtain buy-in on a topic. The very same individual that uses autocratic and democratic approaches to leadership with his crew can also, when applicable use a laissez-faire approach. 58

The more laid-back approach allows members within the fire crews to make decisions.

This leadership approach is very effective in teams that are very capable and talented. Well- seasoned fire crews may only need to know their boundaries, which are set by the leader, and then allowed to work within those establish guard rails. An effective leader is one that can ebb and flow between the three behavioral leadership theories applying each one when appropriate, to seamlessly to reach their objectives.

A measurable reduction in firefighter fatalities will not happen without individuals holding leadership positions stepping out of the shadows and actively leading their departments.

Positional authority alone is woefully inadequate in working toward implementing policies and conducting meaningful training. Training and education can help to reduce the problem of attending to negative dimensions of an emergency, and to increase the ability to pay attention to relevant cues for decision making (Ozel, 2001). Individuals given the opportunity to lead their organizations need to embrace the role and not merely seek to be the best friend of those they work with. Leaders that are working to improve their organizations will not always be popular. Leadership is more than a popularity contest and the end goal should be to get your firefighters home at the end of the emergency incident. John Maxwell (2018) wrote, the world becomes a better place when people become better leaders. Keeping fire fighters alive makes their families’ world a better place. 59

CHAPTER III. METHODOLOGY

The intent of this study was to determine what factors are attributable to 176 firefighter fatalities identified in the 149 NIOSH reports from 1998 – 2017 within the volunteer firefighter population. Additionally, the intent of this study was to identify leadership and policy development opportunities that arise as a result of the findings. Content analysis will assist in categorizing the data into factors for interpretation. This type of qualitative data analysis will serve as a research process for the subjective interpretation of the content through a systematic classification of coding and theme identification (Hsieh & Shannon, 2005).

Research Question

This study was guided by the following research question: What factors contributed to traumatic volunteer firefighter fatalities as revealed in the 1998-2017 NIOSH reports?

Rationale for Research Design

The qualitative data were derived from the documents that detail the tragic events that led to one or more firefighter deaths. The documents created by an investigative team of fire service experts tell the story of how and why firefighters died in the line of duty. This provided valuable insight for the future to prevent deaths. A qualitative approach was appropriate because it allows for the discovery and an understanding of the experiences of victims. Further, this study design permitted evaluation of a problem or incident and understanding of the conditions that occurred and the actions of those involved (Creswell, 2013). Qualitative analysis permits for a richer understanding of the data, much deeper than simply a numeric value. A portion of this study specifically assigns numeric values to characteristics, and their frequency of occurrence.

Identifying the fatal events and showing their frequency will help to propel the study to identify 60 patterns and offering recommendations for training and policy development aimed at firefighter fatality reduction.

Study Sample

This research, unfortunately, came to life on the backs of the dead. The population for this study comes from our nation’s volunteer firefighters. An existing data set represents a purposive sample reflected volunteer firefighter deaths in the line of duty as investigated by

NIOSH from 1998 until 2017. These dates make up the bookends of the sample, as they are the total number of completed and published NIOSH reports available at the time of this research.

The selected fatality reports include only those firefighters that perished as a result of a traumatic incident. Firefighters that perished due to a medical emergency, such as a cardiovascular event

(heart attack, stroke) were excluded for the purposes of this study. Traumatic deaths refer to those deaths that directly result from an injury sustained in the course of a firefighter’s training, response to or from and participation in an emergency scene. Medical emergencies such as heart attacks and strokes are a significant cause of firefighter deaths; however, they are not the focus of this research and remain as a potential research paper in the future. Each of the NIOSH reports includes three important and informative sections: an executive summary, contributing factors and key recommendations. This study will look at each firefighter fatality (149 volunteer NIOSH reports accounting for 176 deceased firefighters) and analyze the reports for recurring factors.

Some of the reports detail multiple fatalities at the same incident. Keeping in mind the study by

Kunadharaju et al.(2010) focused on career firefighters. This study focuses on the volunteer firefighter population. 61

Data Source

The data source for this research are one hundred 149 fatality reports conducted and documented by the NIOSH investigators. The reports can be located on the NIOSH website

(www.cdc.gov/niosh/fire). NIOSH reports are official documents that are researched and then written by an investigative team of fire service professionals after they fully investigate the fatality. A report is constructed in the same manner as all other published NIOSH reports. The report is assigned a number, typically the number sequence is year-number of fatalities for that year, such as 2015-06. The report is broken down in the following manner: an executive summary, which contains an overview of the incident’s main points. A list of contributing factors is then presented in bullet point fashion, this list is a result of the investigative team’s work.

Next comes a set of key recommendations, these are bullet points offered by the investigators aimed at reducing the frequency of future similar events. The next section is the introduction which recaps the executive summary. A profile of the geographic area, the involved fire department, and equipment follows the introduction. Next in the report is a section detailing the training and experience of the deceased firefighter and offers a close examination of the members training records and experience level. Often, but not always, a timeline is included that breaks down minute by minute descriptions of what was happening during the incident that lead up to the fatality. Ancillary information such as weather and road conditions are contained in the report if they are germane to the discussion.

The report then transitions into a section of the investigation of the event, it is full of details and often contains photographs and diagrams. Following the investigation section, the report restates the contributing factors as a means of reinforcement. The cause of death that has been documented by the autopsy findings is next. The final section of the report are 62 recommendations that are offered by the investigators are more detailed and supported by industry best practices. The recommendation section can be quite lengthy and full of details. The final section contains a set of references used by the investigators.

This data source has been purposefully selected because of the data’s ability to provide detailed information in which to explore the research question. As noted, the research question in this study has been developed from a previous study conducted by Kunadharaju et al. (2010), examining career firefighter deaths. Their data sample contained published NIOSH reports from

2004 to 2009 addressing career firefighter fatalities. Berg (2001) wrote that generating concepts from previous studies was very useful for qualitative research. This research builds upon and expands the previous work by Kunadharaju et al. (2010) with its focus on the volunteer population. Hsieh and Shannon (2005) suggested that content analysis begin with relevant research findings, which for the purposes of this inquiry will use the four factors of firefighter fatalities as outlined in the work of Kunadharaju, et al., (2010) as inspiration. All these written documents are available in a text format so there will be no need to modify the data for analysis.

The individual reports in the researcher’s data set have been electronically linked to the actual

NIOSH firefighter fatality report online at: https://wwwn.cdc.gov/NIOSH-fire-fighter- face/Default.cshtml?state=ALL&Incident_Year=ALL&Submit=Submit. This direct link to the report allows readers, if they choose, to quickly open and read the original report for themselves.

Data Collection

Each of the 149 fatality reports totaling 176 dead was read and analyzed by the researcher for categorization of 65 data points per report, for a total of 11,440 data points for analysis. The researcher developed the additional data points based upon information within the

NIOSH reports and his experience and education in the fire service. 63

Data points also include the four factors identified by Kunadharaju et al. (2010): (a) incomplete adoption of the incident command system, (b) under-resourcing, (c) sub-optimal personnel readiness, and (d) inadequate preparation for/anticipation of adverse events on the fire ground. The researcher was open to the possibility that yet undetermined data points may be discovered within the research data.

As identified by Kunadharaju et al.(2010), incomplete adoption of incident command means following or implementing only portions of currently established guidelines and best practices for incident management (not maintaining an incident commander). Under-resourcing refers to assigning or performing various functions or tasks without adequate resources (people, equipment, etc.). Sub-optimal personal readiness involves not following the established best practices to assure that operational personnel are adequately prepared to meet the demands of firefighting. In adequate preparation/anticipation involves not having enough plans strategies in place to deal with adverse events occurring during a fire ground operation.

In the development of this methodology, Microsoft Office Excel was used as the spread sheet software to compile and filter data from the reports. Each NIOSH report was examined for

65 potential data points. These data points were developed based upon my own operational experiences and items identified in previously read NIOSH reports involving career firefighters.

The spreadsheet was arranged to allow for the case file identification number to be hyperlinked to the full report on the NIOSH website to facilitate reader information.

Following a firefighter’s death, NIOSH decides based on decision matrix whether to investigate the fatality incident. If NIOSH selects the incident for investigation, then an extensive investigation into the circumstances and factors that culminated and ultimately resulted in the death of the firefighter is conducted. Firefighter fatalities are broken down into two major 64 groups: cardiovascular and trauma. The cardiovascular segment includes medical causes of death, such as heart attacks and strokes. The trauma category includes deaths resulting from falls, burns, being struck by falling objects, trapped in burning buildings etc. As explained, this study is designed to address only trauma-related fatalities. The number of annual firefighter fatalities was crossed referenced with reports published by the United States Fire Administration (USFA) detailing firefighter deaths during the same timeframe to ensure all investigated firefighter fatalities were included. The USFA and NIOSH are two independent governmental agencies that share information and work together to foster firefighter safety.

The records reviewed in this study are the NIOSH reports completed by the investigative team of firefighting experts, safety and general engineers, representatives of the NIOSH organization and technical experts from the National Fire Protection Association (NFPA). These investigators are professionals with extensive knowledge and experience in the fire service. None of the investigators of a NIOSH report are direct observers of the firefighter’s death or were present on the scene at the time of the firefighter’s death. The investigators obtain their information for their report by conducting interviews and direct investigative procedures.

The investigative material collected by NIOSH for the final report includes photos, reviews of departmental training records for the fallen fighter, incident commander, and officers, departmental policies and procedures, radio traffic of the incident, interviews of fire officials which include policy makers and those who were on the scene, coroner reports, police reports, incident narratives, and blue prints and diagrams providing intricate detail of the event structure.

This study utilized the final reports generated by NIOSH investigators as the main data source as they are the final work product of the investigation that has distilled all the information into a singular report. The researcher does not have access to all the documents used by the 65 investigative team and therefore is unable to cross reference those materials. An examination of all investigative materials collected in each fatality will remain the sole purview of the NIOSH investigative team.

The selected NIOSH firefighter fatality reports will be read, have field notes collected and categorized based upon document terminology, specific phrases, my own experience of thirty-eight years, and the training I have received during this time. The data have been broadly broken down into seven incident types to aid in segregation of information: apparatus crashes, firefighting/fire ground operations, technical/specialized operations, road/traffic, training, wildland firefighting, and non-firefighting incidents. These incident types are not new factors and should not be considered anything more than titles for a series of similar types of incidents.

This grouping of similar types of incidents allows for a deeper examination and permits the reader to located data that is specific to one of the incident types. For example, if an officer is concerned about factors attributed to fire ground operations, she can easily look to the section

“Fire Ground Operations” for information. Other contributing factors that emerged from the data are included in each of the seven incident types are identified in chapter four.

Apparatus crash fatalities were defined as those involving a driver and or occupant while traveling to or from a fire related duty. Fire category includes all firefighters that perished while operating in an area or within a structure that is on fire. Fire building collapse includes firefighters killed as a result of a portion of the building collapsing on them and or a portion of building collapse that traps them inside a structure in which they are unable to evacuate and as a result die. Firefighters killed while operating along the road or highway that are struck and killed by other civilian motorists are included in road/traffic. Station maintenance refers to those that die as a result of a fall, being hit by a falling object or run over by an apparatus while at the 66 station. Firefighters killed during training evolutions such as firefighting training or SCUBA diver training are categorized in the training sections. Wildland fires are identified as grass, field and forest fires. Technical and specialized operations include hazardous materials, swift water, confined space rescue and silo fires.

Searching for common factors and trends is involved in qualitative content analysis.

Minichiello et al. (1990) wrote that looking for the expression of ideas in the text included factors as a coding unit. Qualitative content analysis allows a unit of text to be assigned to more than one category simultaneously based upon the interpretation of the researcher (Tesch, 1990).

This will be accomplished by identifying commonality in each of the firefighter’s deaths, and to understand what connections were made to facilitate the firefighters’ death.

The categorization (coding) development scheme has been completed solely by the researcher; therefore, conflict in data categorization among researchers is eliminated. However, to prevent coder drift, regular review of the major four factors’ definitions, identified in the original study by Kunadharaju et al. (2010), will be required, in that the design seeks to identify generalized findings from the use of 149 NIOSH reports. This approach seeks conclusions offered that are broadly based, able to be generalized to a wide population, subjective in nature, very flexible based on interpretation and are summarized to improve readability. 67

The researcher will use the following coding sheet to gather data as the NIOSH reports are being read, creating field notes of the report data for each of the 149 cases that resulted in the

176 firefighter deaths (see Figure 4). To avoid over-crowding on the data sheet, the potential combinations of incomplete adoption of the ICS, under-resourcing, sub-optimal personnel readiness and inadequate preparation for/anticipation of adverse events were not listed. The researcher will mark all applicable factors and then combine them in the Microsoft Excel sheet.

Inadequate Incomplete Dept. Robert C. Sub- preperation adoption of Day of Size / Coverage Krause Under- optimal for / Gender Hour of Population Residential / Null Incident the Month Year Calls State Area Dissertation resourcing personnel anticipation / Age the Day Density Commercial Command Week per Sq. Miles Research Notes readiness of adverse System Year events NIOSH Case 0 1 2 3 4

Dept. RIT Formal SCBA Lost / Safety Support SOPs Initial Struck by Interior / Years of Ran Out Policy Back-up EMS Conducting in Training Unit Disoriented Officer Staff on in Attack Falling Exterior Violatio Line on Site Search Experience of Air / Trapped Present Site Place Line Debris Operation Place Level Failure n

360 Training Traffic Trainin Pass Pass Buildi Operating RIT Technical / Fire Seat Offensive / Proper Complete / Records Officer / / Road g Device Device ng Lack of Alone in IDLH Activa Specialize Vehicle Belts Defensive PPE Scene Size- Reflect Firefighter Inciden Acciden Availabl Activat Collap Supervision Environment ted d Incident Crash Used Operations Worn up Task t t e ed se

Notes: Vent Coordin Flow Paths Rapid Fire with Attack Created Develop

Figure 2: Field note coding sheet.

2019

The sixty-five data points were comprised of the those identified above, plus those comprising the 11 additional points resulting from the combinations of the four factors from Kunadharaju et al. (2010).

Kunadharaju et al. (2010) identified four factors in their study. This researcher will use those factors as guides and apply them to the volunteer firefighting population. The marks on the 68 individual coding sheet were transferred onto the main data collection sheet to allow for analysis and identification of trends and factors.

Qualitative Data Analysis

Data were collected through my active participation in the in-depth review of the fatality report, a form of observation, the reading of interviews, and the creation of field notes:

• Data were then analyzed by looking for factors from the description of the reports’

authors (informants);

• The data reported in a rich description to explain the events of the case in the language of

the report author so that it is understandable to the reader;

• The researcher endeavored to make sense of and interpret the reports to explain the why

and how of the fatal event.

The frequency (fatality related to the factors) of an event is the number of times the event occurred as identified within the NIOSH reports. Once factors were identified, development of risk reduction strategies began. Openness to the possibility that there may be a unique set of conditions within the volunteer firefighter population that is causing the larger percentage of overall firefighter deaths must be considered.

Establishing Trustworthiness

Lincoln and Guba (1985) suggested that the criteria for evaluating interpretive research include credibility, transferability, dependability, and conformability. According to Bradley

(1993), credibility refers to the adequate representation of the material under study. This can be accomplished by providing the reader enough description and rich text so they may understand the area of study. Further, the repetition of the four major factors found in the numerous NIOSH reports aids in verification of the credibility of the study. Transferability suggests the data and 69 descriptions allow the reader to make their own judgments about the findings, thereby making their own decisions of its transferability to different settings for contexts (Zang & Wildemuth,

2011).

As indicated, qualitative content analysis provides for researcher interpretation based on factor identification and coding. The qualitative data is categorical in nature, and the researcher is searching for the patterns of events. Patton (2002) wrote that content analysis was the distilling of data from text and an effort at sense-making to identify consistency and meaning. Since the use of the term categorize is an acceptable alternative for the word coding, this study will use the term categorize (Glesne, 2011)

Researcher Positionality

I come into the assessment of the NIOSH data with more than 38 years of experience in emergency services, with experiences obtained from working in three fire departments that included one combination paid/volunteer department, and two career departments over the course of that time. The settings of departmental experiences include a small combination career/volunteer department, a large career urban fire department, and a midsize career department spanning the last twenty-five years.

I am not new to the fire service and is currently assigned to the Field Operations Bureau as a Battalion Chief. This position requires direct supervision of fire officers and firefighters operating at emergency medical scenes and fires as well as fire station activities. There are eighteen fire stations in the city. Prior assignments include the position of Captain and the

Program Director of the Fire & EMS Academy.

During my experience in the fire and EMS academy I was responsible for supervision of training matters related to fire and EMS for all fire personnel, approximately 485 uniformed 70 members. Additional assignments include being the Captain of Engine Company 6 responsible for the operational readiness of a fire/rescue crew. Finally, I held to position of Fire

Communications and Dispatch supervising officer and Fire Communications and Dispatch bureau Captain, emergency medical services instructor, fire academy instructor and line officer.

Experience includes fire suppression, emergency medical care, rescue operations, extrication, and special operations such as hazardous materials, rope rescue and weapons of mass destruction training.

I have lectured at conferences throughout the United States and Canada and travelled to numerous volunteer fire departments, training firefighters on a variety of firefighting topics.

Further I have published several firefighting journal articles and three exam preparation textbooks for emergency medical services. During trips to the volunteer fire departments, I have met some of the families of the volunteer firefighters, shared delicious dinners, cooked right in the firehouse kitchen with the children and spouses of the firefighters I would train with the next morning. I have made friends. I am no stranger to the culture of the firehouse and its wonderful sense of camaraderie.

The firehouse kitchen is to be respected and revered as a place for frank discussion, team building, gripe sessions and fine dining. There should be no confusion on the part of the reader that the researcher is an “insider,” and the approach to this research is to identify areas on the fire ground that are injuring and killing fire crews and offer ways to reduce the casualties. As a participant researcher, it will be important that my emotion and personal connections to fire crews do not tint my research lens. Fortunately, I do not personally know any of the deceased firefighters or members of their respective departments, that fact permits me to maintain my objectivity and prevents emotion and personal affiliations to interfere with data collection. 71

CHAPTER IV. DATA ANALYSIS

As indicated in Chapter one, this study analyzed factors that contributed to volunteer firefighter fatalities were identified in 149 NIOSH investigations of 176 firefighter fatalities.

This study used data from the United States Center for Disease Control (CDC). The CDC and the

National Institute of Occupational Safety and Health (NIOSH) has a program called Fire Fighter

Fatality Investigation and Prevention (https://www.cdc.gov/niosh/fire/). This program investigates firefighter fatalities across the country.

This chapter is organized in a manner to present the reader with data and then is followed providing explanation of the findings. This presentation is used to allow the reader to quickly garner the data findings and then if they choose to go deeper into the supportive information and explanation. Section headings provide a guide to allow a reader to jump to information they are seeking.

Analytical Approach

Following the reading and creation of the field notes for each of the reports, the data were entered a Microsoft Excel spread sheet. The reports were sorted according to the year in-which the incident occurred and then by the seniority within the year, for example, 1998-04 report information was followed by 1998-06. The spreadsheet was set-up from left to right with each year’s information traversing across the sheet. Cells within the spreadsheet would turn read when certain data was entered that triggered a negative finding. For example, review of the data sheet shows red in each cell that indicated seat belts were not worn by a firefighter during an apparatus crash. This allowed for the visual representation on the spreadsheet to view patterns.

Examination of the data sheet produces discernable visual patterns. These visual cues illustrated repeated negative events in separate incidents spanning multiple years. Study of the data sheet highlighted repeated failures that when put together showed conditions that were 72 present at the time of a firefighter’s death. Additionally, patterns were discernable vertically in the data showing repeated failures of the same type, for example, not wearing seatbelts over the

19-year study.

Demographics of the Study

The following tables offer demographics of the study to provide background of the population of this study.

Table 2: Population density.

Population Density Highest population 800,000 Lowest population 150 Mean 1,200 Median 4,000 Mode 19,098

Table 3: Coverage area.

Square Miles of Coverage Area Largest area 2200 Smallest area 1 Mean 25 Median 55 Mode 134

Table 4: Firefighter experience within the fire service.

Firefighter Experience in Years Most experience 51 Least experience 0.08 Mean 10 Median 6 Mode 2 73

Table 5: Department membership size.

Department Membership Most members 2000 Fewest members 7 Mean 30 Median 29 Mode 55

Age at Time of Death

The oldest firefighter was 80 years old, the youngest was 17 years. old. The mean age of the volunteer firefighter at the time of their death was 37 years old. The mean age of 37 years old represents the average age of all 176 firefighters. The median age of 28 years old represents the age of the firefighter halfway into the total data set for age. The mode represents the age of the firefighter that is most represented in the data set, meaning the plurality of firefighters killed in the line-of-duty from 1998 to 2017 were 34 years old.

Table 6: Age of firefighters at time of death.

Age at time of death Mean 37 years Median 28 years Mode 34 years

Table 7: Fatalities by state from 1998 – 2017 (n=178).

State n AK 1 AL 7 AR 2 CA 2 CO 3 DE 1 GA 2 IA 4 IL 8 IN 6 KS 1 74

KY 6 LA 2 MA 2 MD 2 MI 1 MN 3 MO 3 MS 7 MT 1 NC 12 ND 1 NJ 1 NM 1 NY 9 OH 11 OK 2 OR 4 PA 12 RI 1 SC 2 SD 7 TN 5 TX 22 UT 1 VA 3 WA 1 WI 4 WV 7 WY 3

Texas had a single incident, a fire and explosion, that accounted for ten fatalities alone in

2013. The three states with the highest number of volunteer firefighter fatalities from 1998 to

2017 were Texas with 22, Pennsylvania 12 and North Carolina 12. Eleven states had a single volunteer firefighter death. 75

Table 8: Frequency of fatalities by month (n=178).

Month n Jan 14 Feb 14 Mar 18 Apr 20 May 5 Jun 11 Jul 16 Aug 12 Sep 10 Oct 7 Nov 12 Dec 7

April, March and July were the deadliest months for volunteer firefighters from 1998 to

2017. No tendencies were noted to explain this finding.

Confirmation of the Work by Kunadharaju et al.

Four factors served as the initial focus of this research. Those factors were originally developed by Kunadharaju et al. (2010), in their study of career firefighter deaths. The four factors identified by Kunadharaju et al. (2010) are:

1. Incomplete adoption of incident command procedures.

2. Under-resourcing.

3. Sub-optimal personnel readiness.

4. Inadequate preparation for/anticipation of adverse events.

The four initial factors identified by Kunadharaju et al.(2010) are explained in the following paragraph. Incomplete adoption of incident command procedures means following or implementing only portions of currently established guidelines and best practices for incident management. Under-resourcing is having too few personnel readily available to execute the tasks 76 needed to be done on the fire ground. Sub-optimal personnel readiness is not following established best practices to assure that operational personnel are adequately prepared to meet the demands of firefighting (e.g., lacking or poor training for personnel, no standard operating procedures). Inadequate preparation for/anticipation of adverse events involves not having enough plans or strategies in place to deal with adverse events occurring during fire ground operations (e.g., not having a rapid intervention team available) (Kunadharaju, et al.,(2010).

This study identified 134 of the 149 NIOSH reports that confirm the work of

Kunadharaju et al.(2010). Each of the four original factors were factors in the deaths of 161 of the 176 firefighters. In 15 NIOSH reports, none of the original factors could be attributed to the firefighter’s death. Incomplete adoption of the incident command system as a single factor was not attributable to any firefighter fatality. Under-resourcing as a singular factor was attributable to one death. Sub-optimal personnel readiness was a singular factor in 12 deaths. Inadequate preparation for/anticipation of adverse events as a singular factor was attributable to six deaths.

The data revealed that most firefighter fatalities were attributable to combinations of the four initial factors identified by Kunadharaju et al.(2010). In total 142 deaths were attributable to 2 or more of the factors identified by Kunadharaju et al.(2010).

Table 9: Frequency of individual factors appearing in data (n=149).

Frequency of individual factors appearing in data n % Incomplete adoption of IC procedures 96 65 Under-resourcing 51 64 Sub-Optimal Personnel Readiness 136 92 Inadequate preparation for/anticipation of adverse 141 95 events 77

Table 10: Percentage of incidents that include a combination of factors 1, 2, 3, 4.

Originally developed by Kunadharaju, et al. (2010).

Incident types % All others combined 25% Factors 3, 4 23% Factors 1,2,3,4 24% Factors 1,3,4 28%

The following table illustrates the frequency, of the initial factors this study was based upon, that were applicable in this study. The data shows 134 of the 149 NIOSH reports in this study contain one or more factors from the study by Kunadharaju, et al.

For ease of identification only, the work of Kunadharaju, et al.,(2010) is labeled Factor 1 through 4, the number does not indicate anything more than identification for discussion and should not be considered a ranking system. This data illustrates the connection between the occurrence of firefighter fatalities and factors 1, 3 and 4 being contributing factors. Factor 1 indicates the incomplete adoption of the incident command system. Factor 3 is meant to identify sub-optimal personnel readiness and Factor 4 represents inadequate preparation for/anticipation of adverse events. 78

Table 11: Frequency of research factors and combinations of factors. Developed by

Kunadharaju, et al. (2010, for NIOSH reports) (n=149).

Research Factor n %

No attributable factor 15 10

Incomplete adoption of IC procedures 0 0

Under-resourcing 1 0.01

Sub-optimal personnel readiness 12 8

Inadequate preparation for/anticipation of adverse events 6 4

Incomplete adoption of IC procedure, Under-resourcing 0 0

Incomplete adoption of IC procedures, Sub-optimal 1 0.01 personnel readiness

Incomplete adoption of IC procedures. Inadequate 0 0 preparation for/anticipation of adverse events

Under-resourcing, Sub-optimal personnel readiness 1 0.01

Under-resourcing, Inadequate preparation for/anticipation 2 0.01 of adverse events

Sub-optimal personnel readiness, Inadequate preparation 40 26 for/anticipation of adverse events

Incomplete adoption of IC procedures, Under-resourcing, 43 28 Sub-optimal personnel readiness, Inadequate preparation for/anticipation of adverse events

Incomplete adoption of IC procedures, Under-resourcing, 2 0.01 Sub-optimal personnel readiness

Incomplete adoption of IC procedures, Under-resourcing, 3 0.02 Inadequate preparation for/anticipation of adverse events

Incomplete adoption of IC procedures, Sub-optimal 49 33 personnel readiness, Inadequate preparation for/anticipation of adverse events 1 0.01 Under-resourcing, Sub-optimal personnel readiness, Inadequate preparation for/anticipation of adverse events 79

Table 12: Prevalence of factors 3 and 4 in ALL fatal incidents 1998 - 2017.

Prevalence of factors % of fatalities Percentage of incidents where factors 3 and 4 75% DO appear together Percentage of incidents where factors 3 and 4 25% do NOT appear together

Table 12 illustrates how prevalent factors three and four are throughout the data. The combination of factor three, sub-optimal personnel readiness and factor four inadequate preparation for/anticipation of adverse events is widely found throughout the data set. This observation strongly suggests these two factors when combined have significant impact on firefighter fatalities.

New Factors Discovered by the Researcher

The data illustrated repeated, and similar types of incidents that resulted in the loss of life for a firefighter. Closer examination of the data revealed the failures on the part of an individual firefighter, such as failing to wear the appropriate protective clothing, was much more than simply an individual failure. The actions of individual firefighters were the result of much deeper, systematic failures within the firefighter’s organization. A direct line can be established illustrating higher order failures on behalf of fire service leaders and policy makers. For example, failures in departmental policy makers in establishing well researched, best industry practices as written standard operating procedures is akin to a pilot flying in the dark without instruments to guide her. Eventually, she’s going to crash despite her best efforts. This research illustrated numerous occurrences in which firefighters were lost due to departmental leadership failures. 80

Fire Dept. Policy Makers fail to implement departmental SOPs

Fire Leadership (Chiefs & Company Officers) have no procedural approach to emergency operations.

Failures to adhere to industry best practices creates conditions that prove fatal to fire crews.

Figure 3: Higher order reasons for firefighter fatalities.

The following factors were developed based upon the research data.

1. Failure in leadership at all levels, at various times within the individual fire departments.

2. Failure of fire service policy makers and fire service leadership to research, develop,

implement and enforce departmental standard operating procedures.

3. Failure to adhere to best industry practices within the fire service.

4. Substandard or a complete lack of appropriate training for the volunteer firefighters.

Examples of the above factors,

1. Ten firefighters were killed when an ammonium nitrate plant exploded during

suppression efforts. This research identifies the department involved had no pre-plan of

the hazardous materials plant, and never visited the facility to assess the danger despite

members of the department knowing the plant was near-by. NIOSH fatality reports from

1998 – 2017 revealed 54 fire departments out of the 149 studied had no documented

written standard operating procedures related to any departmental operation. 81

2. A firefighter died in a house fire due to a floor collapse. The department involved failed

to ensure establishment of a rapid intervention team and had poor accountability of the

fire crews operating on the fire ground. The data revealed 37 occurrences out of 47 fatal

incidents in which dedicated RITs were not available on the fire ground.

3. Firefighter died after being electrocuted by a downed powerline. The victim was not

wearing any personal protective clothing. The department lacked operational procedures

for electrical emergencies, responding in a firefighter’s privately-owned vehicle (POV)

and adherence to an accountability system. Of the 47 fatal fire ground incidents, a safety

officer was not assigned or present at 38 of the incidents.

4. Firefighter died in an apparatus crash. The victim was not wearing a seatbelt. The

department did not have a written standard operating policy requiring the use of a

seatbelt. Further, the driver in this incident did not have any documented departmental

driver training. In 20 incidents of fatal apparatus incidents, the written departmental

policy to wear a seat belt was not followed. Nineteen departments did not have a written

seat belt usage policy at the time of their respective fatal incident.

The previous points are a few examples demonstrating the findings by the researcher within the data. Further data is presented in the following sections discussing incident types. The incident type sections were established to allow the reader to find information and data related to a trend discovered within the data.

This research was conducted using all the published NIOSH Firefighter Fatality reports detailing volunteer firefighters who perished as a result of a traumatic event from 1998 through

2017. This list of fatalities was cross-referenced with available information from the U.S. Fire

Administration to ensure there were no duplicates in this work and that all available fatality 82 reports were studied. Volunteer firefighters that died as a result of a medical (i.e., cardiac arrest or stroke) event were not included in this study. The report sample was purposefully selected to focus on traumatic events. The data set includes 149 NIOSH reports totaling 176 firefighter deaths. Eighteen of the reports contained two fatalities, one report included ten fatalities.

Each report was read, and extensive field notes were recorded for each report and included examination for 65 individual data points. The field notes were then reviewed for completeness, the accumulated data was entered onto an Excel spreadsheet for further filtering and analysis. The researcher accumulated 11,440 data points for analysis in this study. The data were collected to answer the researcher’s guiding question: What factors contributed to traumatic volunteer firefighter fatalities as revealed in the 1998-2017 NIOSH reports?

NIOSH Firefighter Fatality reports from the CDC website were electronically linked to the report number in the Excel spreadsheet so the reader could quickly reference the report on- line if they chose to do so for further examination. The NIOSH reports were listed numerically and followed sequentially beginning with 1998-04 ending with 2017-10. Sixty-five additional data points stretched out to the right of each report number.

Examples of the newly discovered factors by the researcher will be contained within the following sections. The words “incident type” are used in the following sections to allow for cataloging of information. They create a filing structure in which data relevant to the heading can be located. They are not to be considered new factors; they are strictly for the use of data organization. Seven incident types were created by the researcher: apparatus crashes, fire ground operations, technical/specialized operations, road/traffic, training, wildland firefighting, and non- firefighting incidents. These incident types were selected based because were frequently noted in the data set. 83

Apparatus crashes, as an incident type, include both fire department vehicles and privately-owned vehicles (POV’s) driven by department members to and from emergency scenes. Fire ground operations addresses fatalities that occurred at structure fires, both residential and commercial buildings. These fatalities resulted from, but are not limited to, building collapse, falling through floors and becoming trapped, basement fires, rapid fire progression, becoming lost inside a smoke-filled building that is on fire, and severe burn injuries.

Technical/specialized operations encompasses events that required a greater level of training in a specific area such as hazardous materials, confined space rescue or open water scenarios. Road/traffic incidents are those in-which a firefighter was struck by a passing vehicle while operating at an emergency scene on a highway or road. Training incidents include all events directly related to a training evolution or training time period.

Station maintenance involves fatalities that occurred in or around the fire house while performing maintenance on equipment or apparatus. Wildfire operations includes grass, forest and field fires. Wildfires are inherently dangerous due to the fire attack strategy and tactical approach. Wildfires can encompass many acres and even expand to multiple square miles of fire.

This presents significant problems with command and control of fire crews, logistics, deployment of resources and rest and rehab for crews that have been operating. Additional complications with wildfire incidents are the topography, access to remote areas, and adequate numbers of suppression personnel. Wildfires require a completely different skill set compared to a common structure fire and therefore require specialized training and equipment.

Non-firefighting activities are those that cannot be directly attributed to firefighting such as equipment repair, equipment demonstration, vehicle maintenance and station/building maintenance. These activities are most often completed by members of the volunteer firefighter 84 community, these activities are vital to the smooth running of the fire station. Regular and routine station maintenance is supervised by the organizational leadership who provide funding and supplies.

Table 13: General incident type and number of firefighters killed (n=176).

General Incident types of Activities n Fire ground operations 58 Apparatus crashes 56 Road/Traffic 17 Training Events 7 Technical/Specialized Incident 19 Non-firefighting activities 9 Wildfire operations 10 Total fatalities 176

The following sections discuss the applicable data to the specific incident type.

Apparatus Crashes

In the 53 apparatus crash incidents, accounting for 56 fatalities, failure to wear a seat belt was the leading contributor to the number of firefighter fatalities. The lack of emergency vehicle driver training and absence of internal departmental standard operating procedures were also identified as factors in firefighter deaths. Within the category of apparatus crashes, the lack of seat belt use was the largest single contributor to firefighter fatalities.

Analysis of the 53 apparatus crashes identified 21 departments that had an existing written seat belt policy at the time of their respective fatal incident. During 20 of those 21 fatal incidents, the written departmental policy to wear a seat belt was not followed. Nineteen departments did not have a written seat belt usage policy at the time of their respective fatal incident. In ten of the fatal episodes it was not reported whether the involved department had an existing written seat belt usage policy. 85

Of the 56 apparatus crash fatalities, 40 were firefighters, 12 were officers, one was an emergency medical technician, and one was an underage junior firefighter. Of the fatal apparatus incidents involving officers (leadership positions), nine out of 12 officers were not wearing seat belts at the time of their vehicle crash. Seven of the nine officers involved in fatal apparatus crashes did not follow their departmental written policy to wear seat belts.

Apparatus crashes involve fire engines, water tankers, brush trucks, Emergency Medical

Services (EMS) vehicles and privately-owned vehicles (POVs) used by volunteer firefighters to respond to the emergency scene.

Three apparatus incidents involved firefighters being thrown from or falling from moving vehicles. A 21-year-old male lost his life when he was riding on the tail board of a water tanker and was thrown off as the vehicle drove away. The vehicle driver was unaware of the young man on the tail board and drove off down an icy road, briefly losing control of the apparatus resulting in the firefighter being thrown to the road. He died from his injuries. An 18-year-old woman responding to a reported structure fire in a departmental Emergency Medical Services (EMS)

SUV went left of center on the roadway, over corrected, traveled into a ditch, and rolled the vehicle multiple times. She was ejected from the vehicle and was pronounced dead at the scene.

The accident investigation by law enforcement revealed she was not wearing a seat belt and may have been traveling 20 mph or more over the posted speed limit of 55 mph. A 28-year-old firefighter perished when he fell off a pick-up truck tailgate that was traveling between training sites striking his head on the pavement.

Fourteen fatal water tanker crashes occurred from 1998 to 2017 and were analyzed. Only one firefighter was wearing his seat belt, 12 firefighters were not wearing seat belts and one incident was not reported whether a seat belt was worn. Water tankers, vehicles with large tanks 86 on the back which carry large volumes of water are involved in a significant number of fire fighter fatalities.

The first significant problem involves converted tankers that were originally used to transport gasoline and diesel fuel which were used by the military. These vehicles reached the end of their service life and were decommissioned by the military and then made available for donation to the fire service. The USFA has reported that very serious overweight situations and accidents have occurred with tankers that were once surplus military 2½-ton vehicles. These vehicles are usually worn out and no longer suitable for military service when received by fire departments.

The weight of the vehicle payload without personnel should not exceed 5,000 pounds

(2½-tons) when traveling off-road and 7,500 lbs. (3¾-tons) when traveling on the highway.

Since water weighs 8.3 pounds per gallon, 5,000 lbs. of water are about 600 gallons. The vehicle involved in this incident had a 1,200-gallon tank and the water weight alone from a full tank would be 9,960 lbs., thus exceeding the vehicle’s payload capacity when traveling either on the highway or off-road (NIOSH 2003-23). A 46-year-old firefighter was ejected from the vehicle, which did not have any seat belts and was pronounced dead at the scene (USFA, 2017).

It has been reported by the USFA and NIOSH (NIOSH 2006-06),

“Fatal incidents have occurred when fire department water tankers are operated

while exceeding their safe load carrying capacity. According to USFA, Safe Operation of

Fire Tankers, the most common safety issue affecting tankers made from used or

retrofitted vehicles is the tendency for them to be overweight when filled with water. This

occurs most often because water weighs 8.3 pounds per gallon and the tanker was

originally designed to carry fuel oil that weighs 7.12 pounds per gallon, or gasoline that 87

weighs 5.6 pounds per gallon. A common result of operating in excess of the GVWR is a

vehicle that will be subject to frequent mechanical breakdowns, may be difficult to steer,

and may have insufficient braking abilities. When converting a fuel tanker to a water

tanker, the vehicle’s suspension system, chassis, axles, tires, and braking system should

be upgraded so that the original GVWR is not exceeded. This type of upgrading is a very

complex and expensive process, however, acquiring a government/military surplus

vehicle is often the only cost effective means for small or rural departments to obtain any

type of fire service apparatus. Often fire department personnel are unaware of the

potential danger posed by failing to perform required upgrades and conversions to

apparatus acquired through surplus property programs. Entities supplying surplus or used

fire apparatus should provide pertinent safety information to the departments that are

receiving the vehicles.”

Firefighters driving their own vehicles (privately owned vehicles, POV) resulted in two deaths. Neither firefighter was wearing their seatbelt, and both were driving at high rates of speed, as identified by law enforcement investigation, at the time of their collisions.

Fire Ground Operations Fire ground operations includes all events in which a firefighter was killed. Of the 58 firefighter deaths in this section, all were male. Fire ground fatalities include, but are not limited to building collapse, falling through floors and becoming trapped, basement fires, rapid fire progression, becoming lost inside a smoke-filled building that is on fire, and severe burn injuries.

Medical emergencies such as heart attacks and strokes were not the focus of this study.

From 1998 to 2017, according to the available NIOSH reports, the volunteer firefighter population lost 58 members in 47 separate incidents involving fire ground operations. Fourteen 88 of the 47 fatal incidents were multiple fatality, the largest single incident loss of life totaled ten firefighters, which occurred in 2013 in Texas when an ammonium nitrate fertilizer plant caught fire and exploded killing ten firefighters instantly in a hazardous materials incident.

Sixteen firefighters died when they ran out of air in their self-contained breathing apparatus (SCBA) while conducting firefighting operations in conditions that were immediately dangerous to life and health (IDLH), meaning they consumed all the breathable air in the tank and their supply was exhausted. A SCBA 4500 psi, “30 minute” cylinder typically lasts in the range of 15 to 20 minutes for a firefighter working inside a toxic environment. A person’s physical fitness, experience in using the SCBA and activity level all affect the time frame an air tank may last. An example of an IDLH environment would be a residential house fire that is full of toxic smoke and high heat conditions. A SCBA is the tank that is worn on the back of firefighters that supplies them with breathable fresh air through their facemask.

Not a single incident of a SCBA unit failure was reported by the NIOSH investigators.

This means the SCBA performed mechanically as expected and was not a contributor in any of the fatal incidents. In nine of the 16 deaths in which running out of air was a factor, ventilation of the structure took place without coordinating that event with the fire attack team. Seven of those nine incidents resulted in multiple flow paths being created. Flow paths are pathways in which outside air is pulled into the burning structure creating paths of travel for products of combustion, super-heated air and fire to move quickly throughout the building. This condition leads to rapid fire development and places firefighters in grave danger inside the building.

Of the 47 fatal fire ground incidents, a safety officer was not assigned or present at 38 of the incidents. A safety officer is an individual that assists the incident commander and is considered a part of the command staff. The role of the safety officer is to ensure fire crews are 89 following safe practices, observing for the development of immediate safety hazards and reporting them to the IC, stopping fire crews from undertaking unsafe acts and taking a “big picture” view of the emergency incident to ensure safe operating conditions for all firefighters. A designated safety officer is an indispensable member on the fire ground and should be assigned to each significant emergency incident and on a structure fire. The safety officer assesses the entire scene looking for immediate threats to operating fire crews and then using their portable radio, communicates with the individual crew or the incident commander their observations to remove crews from immediate danger.

NIOSH fatality reports from 1998 – 2017 revealed 54 fire departments out of the 149 studied had no documented written standard operating procedures related to any departmental operation. During a NIOSH investigation, it is routine practice for the investigators to request copies of a departments SOPs. Specific to fire ground operations, 18 fire departments lacked any written standard operating procedures for fire crews to follow while operating on the fire ground.

The NIOSH investigators were unable to definitively determine if 28 of the departments had any written standard operating procedures or guidelines.

Standard operating procedures (SOPs) are written rules, policies, regulations, and procedures enforced to create structure for the normal operations of fire departments. SOPs also provide direction for how firefighters are to approach and solve specific problems such as training requirements, building fires, chemical spills, downed power lines, equipment maintenance, and auto fires. NFPA Standard 1720 (2014), Organization and Deployment of Fire

Suppression Operations by Volunteer Fire Departments, defines SOPs as a written organizational directive that establishes or prescribes specific operational or administrative methods to be followed routinely for the performance of designated operations or actions (Sec. 3.3.36). Section 90

4.1.1 of the same standard states the authority having jurisdiction (AHJ), shall disseminate the fire department’s organizational, operational, and deployment procedures by issuing written administrative regulations, standard operating procedures (SOPs), and departmental orders.

NFPA standards were developed through a consensus standards development process, approved by the American National Standards Institute, and are considered the best industry practices.

Unfortunately, these standards are not mandatory and volunteer fire departments are not required to follow these best practices.

Of the 47 fire incidents that resulted in firefighter fatalities, designated EMS personnel were not immediately available on the scene in 26 of those incidents. The data revealed that only ten incidents of the 47 had EMS personnel readily available on the fire ground to care for fallen firefighters. the remaining 17 incidents, following the NIOSH investigation it was unknown if

EMS were on the scene. Emergency Medical Services (EMS) personnel are a critical component of the fire suppression team on any fire ground. These medical professionals, consisting of medical first responders, emergency medical technicians and paramedics, provide immediate medical care and transportation to the hospital for injured civilians and fire crews.

The immediate availability of these potentially life-saving crew members cannot be overlooked.

Firefighters, according to the data, were reported lost, trapped or disoriented in 33 of the

47 fatal fire ground incidents. Rapid intervention teams (RIT), sometimes called rapid intervention crew (RIC), are teams of firefighters consisting of at least two, and often many more, that are immediately available to begin rescue efforts of an injured or trapped firefighter.

RITs are not meant to be used for civilian rescue; they are specifically designated to be used in the event a firefighter needs help. 91

RITs are assigned early in the emergency event and are held in reserve only to be utilized in the event a firefighter develops a problem and needs immediate assistance. For an injured, lost, or trapped firefighter in a burning building filled with toxic smoke and high heat conditions, time is of the utmost importance, delays in rescuing these firefighters increases their chance of dying.

The data revealed 37 occurrences out of 47 fatal incidents in which dedicated RITs were not available on the fire ground. Having a staged and readily available RIT committed only to firefighter rescue is the requirement of NFPA 1720, (2014), Organization and Deployment of

Fire Suppression Operations by Volunteer Fire Departments, Section 4.7.1 addresses this requirement. Fire personnel, according to the data, were reported lost, trapped or disoriented in

33 fatal fire ground incidents.

From 1998 through 2017, 37 firefighters died in residential structure fires. Residential structure fires were the most prevalent locations in which firefighters died between 1998 – 2017 while fighting fires. Residential structures include single family homes, duplexes, apartment buildings and mobile homes.

Commercial buildings, where business is transacted such as grocery stores, auto repair shops, and general stores, were the location for 35 firefighter fatalities between 1998 – 2017.

Fatalities occurring during operations inside of buildings totaled 45, fatalities occurring outside of a building accounted for 31 firefighters.

Firefighting is a team-oriented activity. The data identified six firefighters perished while operating alone inside an environment that was immediately dangerous to life and health

(IDLH). A team of two or more firefighters working together provides for a safer operational environment for all involved. NFPA 1720 (2014), section 4.6.1 states” initial firefighting 92 operations shall be organized to ensure that at least four members are assembled before interior fire suppression operations are initiated in a hazardous area”. Section 4.6.2 requires in the hazardous area, a minimum of two members to work as a team.

From 1998 to 2017, the data revealed that 20 firefighters lost their lives when three conditions occurred in concert: ventilation of the building was not coordinated with suppression teams, which resulted in the creation of multiple flow paths, which then spawned the conditions for rapid fire development. During suppression operations, coordinated events need to occur in a chronological order to ensure the safety of the fire crews and any trapped victims inside the building and the successful extinguishment of the fire.

The tactical objective is to flow water onto the seat of the fire as quickly as possible. The seat of the fire is the main location where the fire is located and burning intensely such as a bedroom, kitchen or stockpile. Fire crews that are advancing the hose line into the building must work closely with crews that have been assigned the task of ventilation. Ventilation is vital in the suppression effort as it creates openings that allow for the removal of heat and toxic smoke.

Improper ventilation techniques such as arbitrarily opening doors and windows can allow for the introduction of air into the building. A small fire could quickly grow and spread throughout the building if indiscriminate openings in doors and windows are made.

The openings create flow paths. Flow paths are pathways where fire, super-heated air and toxic gasses travel quickly toward the openings that have been created. This allows for rapid fire development that can easily entrap and overrun fire crews. Fire attack crews must have hose lines in place and be prepared to advance toward the seat of the fire followed by ventilation openings to prevent rapid fire progression. Rapid fire progression can create dire conditions 93 within a building that is on fire, drastically reducing the chances of survival for trapped occupants and placing fire crews at great risk.

Ten firefighters perished while conducting search operations for trapped victims. Nine of those ten firefighters died in residential structures, one in a commercial building. Three of the ten deceased firefighters were searching without the protection of a hose-line. The search for trapped occupants within a building that is on fire is a fundamental role of fire crews. Fire crews expend large amounts of energy and place themselves at great risk in their attempts to save lives. Search efforts are conducted in a coordinated effort, often beginning as close to the seat of the fire as possible. Some search teams work using the protection of a hose line, other teams search along- side a fire suppression crew.

The data revealed 35 instances out of 47 events where inadequate or lack of supervision was a contributing factor to a firefighter’s death. Supervising firefighters is the responsibility of the company officer. Fire crews are typically comprised of three or more firefighters with an officer. The officer customarily holds the rank of lieutenant or captain. This group is called a fire company and is assigned to an Engine or Truck for the purposes of responding to emergencies.

The officer is expected to supervise their crew, provide direction, make decisions as to the course of action to undertake and to assign tasks to various crew members.

Officers get their direction from the incident commander and then pass those orders down to the members of their company for completion of the assigned tasks. Close supervision of firefighters focuses on maintaining accountability of the crew in a dangerous environment, enhances safety of fire crews, and keeps fire crews focused on the assigned tasks. Inadequate or poor supervision of fire crews can lead to greater risk, incomplete assignments, and freelancing, which is the dangerous practice of acting independently of command instructions. Firefighting is 94 a team activity with specific tactics that must be carefully choreographed by the incident commander. Supervision of fire crews is a fundamental role of the company officer.

Of the 58 firefighter deaths, 21 did not have a PASS device on their body or attached to their equipment at the time of their death. Forty firefighters did have a PASS device attached to their body or equipment: however, only 20 had been activated to alert fellow firefighters they were in trouble. A personal alert safety system (PASS) is a device worn by a firefighter that sounds an alarm if the firefighter is motionless for 30 seconds. The point of the device is to draw attention from other firefighters in the area that someone is not moving, potentially in trouble and needs assistance. PASS have a distinctive sound at 95 decibels, that fire crews must become aware of early in their career. The sound of an activated PASS device indicates an emergency and should elicit an immediate response from the nearby firefighters and incident commander.

Early versions of the device were manually operated and were worn on the firefighter’s coat.

Modern PASS devices are integrated into the SCBA and begin sensing movement when the SCBA is turned on for use by the firefighter. If the PASS device fails to sense movement for

30 seconds, the alarm indicates the wearer is motionless. The PASS device is a critical piece of safety equipment and aids rescuers looking for a downed firefighter in a smoke-filled building or under rubble from a building collapse.

The NIOSH reports do indicate if a PASS device was available to a firefighter and if it was activated. The NIOSH reports do not always specify if the PASS device was integrated into the SCBA or a manual device. The data indicated that of the 58 firefighters killed during fire ground operations, 45 firefighters were wearing the proper PPE, while 12 were not wearing one part or another of their PPE. One report did not identify if the firefighter was wearing their PPE or not. 95

Proper protective equipment (PPE) for a firefighter consists of a fire coat and pants that are constructed of a flame-retardant material, typically Nomex (flame resistant) cloth, the clothing has a thermal layer and a vapor barrier to offer additional protection to the wearer. A fire helmet, a pair of leather boots, leather gloves, a protective hood worn under the helmet covers the head, neck and ears and offers thermal protection of those body parts for the firefighter. The ensemble is completed with a SCBA the firefighters uses to breathe from when operating in areas with toxic gases, smoke, and other dangerous products of combustion.

Wearing this protective clothing is a requirement for all firefighters and is addressed in NFPA

Standard 1500 (2007), Standard on Fire Department Occupational Safety and Health Program,

Section 7.2.1, Members who engage in or are exposed to the hazards of structural fire-fighting shall be provided with and shall use a protective ensemble that shall meet the applicable requirements of NFPA 1971, Standard on Protective Ensembles for Structural Fire Fighting and

Proximity Fire Fighting.

The data revealed 47 fire incidents that resulted in 58 fatalities, 18 times the incident commander had completed 360 degree assessment, 17 times a 360 degree assessment was not completed, and 11 times the 360 degree assessment was not applicable to the incident or was unreported if had been completed. The data show a 360-degree size-up of a building fire by an incident commander was completed in 50% of the fatal incidents.

A 360-degree assessment of the fire building is an important component of an incident commander’s size-up and should provide insight in what emergent problems are facing the fire crews as they arrive. This 360-degree walk around of a building is not always possible, building size, fencing or barriers may impede the assessment process. In those instances, sending another firefighter to the backside of a building to report conditions can fill in blank spots for an incident 96 commander, who typically, but not always, remains at the front of the building. For example, as a fire crew arrives at the front of the house of a reported structure fire and doesn’t see any smoke or flame doesn’t mean all is well. Only when the officer walks around the home does she see fire blowing out of the kitchen window in the rear of the home. At that point the fire officer having filled in the blanks of his or her assessment can they begin making the appropriate assignments to arriving crews. The 360-degree size-up is an extremely valuable tool in managing the fire ground. The information garnered from such an assessment should be used to guide an incident commander’s strategy and tactics.

Between 1997 and 2017, 31 firefighters perished after being trapped under or hit by a portion of a building, as the result of some form of building collapse during firefighting operations. Falling objects, in the form of building components from burning buildings on the fire ground, are not unusual circumstances. Roofing materials, loose bricks, chimneys, walls, floors, ceilings all have the potential for collapse once a building is subjected to the ravages of fire. Light weight building materials, such as trusses, quickly degrade as they burn and then collapse. According to Brannigan (2008), collapse maybe due to inherent structural instability, aggravated by the fire and/or collapse of a floor or roof with consequent impact load to the wall.

Firefighters being killed or injured by building collapses are common. Between 1997 and 2017,

31 firefighters perished after being trapped under or hit by a portion of a building, as the result of some form of building collapse during firefighting operations.

The data in this study revealed that of the 58 firefighter fatalities during fire ground operations, the data show firefighters were not trained adequately enough to execute the tasks they were undertaking at the time of their deaths on the fire ground. Firefighter training is of paramount importance. Ensuring fire crews are well trained and working in environments they 97 have received appropriate training is the norm. Lack of training in firefighting operations is dangerous to the firefighter and the community in which they serve. The community rightly expects their responding fire crews to be proficient at mitigating emergency situations. Poor and/or lacking training should be the concern of fire chiefs and policy makers around the nation.

Firefighter training levels are the subject of many reports and journal articles that can be found on the internet. The training levels of the firefighters in this study are shown below.

Table 14: Firefighter training level (n=75).

Training level n FF I (120 hrs.) 23 FF II (240 hrs.) 22 Advanced (+ 240 hrs.) 1 Basic 36 hours 12 SCBA Only 1 No Training 2 Unknown Training Level 14

Formal training programs offer a variety of training levels for firefighters. The basic 36- hour program is directed to volunteer firefighters as the minimal requirement needed to function as an interior (within a building that is on fire) firefighter. Firefighter 1& 2 (FF I, FF II) are more in-depth training programs that cover 120 to 240 hours respectively and prepares firefighters with a wide range of skills for emergency scenarios, such as handling hose lines, suppressing fires, conducting search operations, looking for fire extension in a building, and salvage operations to name a few. Most states leave it to the individual fire departments to determine their own level of training necessary for members to attain. Many states offer basic firefighting training programs, but they are not mandatory. For example, The NIOSH reports indicated that

South Dakota, Minnesota, Wyoming, West Virginia, Texas, New York, Illinois, and Alabama 98 did not have mandated training requirements for volunteer firefighters when their respective reports were written.

The data illustrated that of the 58 fatalities during fire ground operations, from 1998 to

2017, 52 deaths occurred during offensive firefighting operations. Firefighting strategy can be broken down into two general approaches. An offensive approach, in which fire crews aggressively advance on the seat of the fire with hose lines to extinguish the fire quickly and rescue trapped or injured victims. Offensive fire attack often places fire crews inside the building that is on fire, amid blinding smoke, toxic gases, high heat conditions and deteriorating conditions. Offensive attacks are based upon several factors that include the 360-degree assessment, risk to trapped or injured victims, a risk-benefit analysis of the building’s condition and the overall risk to firefighters.

The second strategic approach to fire suppression is a defensive approach. A defensive approach is undertaken when fire conditions within the building are so advanced the probability of saving anyone trapped in the building is zero and the extent of the fire is so great that risk of sending fire crews inside the heavily damaged building is too high. A defensive approach entails confining the fire to as small an area as possible, that may mean a single building or several buildings, depending on how quickly the fire spreads. Fire crews establish hose lines flowing large amounts of water from safe distances on to the burning structure. The incident commander deploys his fire crews to best achieve containment and extinguishment from a safe, exterior position. The defensive strategy is not without risk to fire crews, it is significantly reduced compared to the offensive strategy. The data showed that of the 58 fatalities from 1998 to 2017,

52 deaths occurred during offensive firefighting operations. 99

Technical/Specialized Operations These areas of specialization require advanced training and annual continuing education.

Technical and specialized operations are those that involve incidents such as structural collapse, hazardous materials spills and leaks, water rescue, high-angle rope rescue, confined space rescue, fallen through the ice rescue, and trench collapse rescue. These skill sets require many additional hours of training within that specialty to progress from an awareness level to operations-level and then to technician-level. For example, in general, when dealing with hazardous materials, an additional 64 hours of training is required to become a hazardous materials technician who can mitigate a hazardous materials spill or chemical leak.

Table 15: Firefighter fatalities related to technical and specialized operations.

Technical/Specialized Rescue Fatalities Fatalities Lacked Proper Training

Hazardous Materials 17 17

Swift Water 1 n/a

Confined Space 1 1

Technical Rescue 1 1

To highlight some of the other technical and specialized mandated training requirements the list below gives a general outline of training requirements:

• Confined Space Rescue: rescue from a space with limited or restricted access that is

not meant for continuous occupancy, such as a manhole, well, or storage tank. This

subset of technical rescue is aimed at removing victims who may become trapped 100

within these enclosed areas. The additional training required to be functional in this

discipline is 60 hours of specialized training.

• Rope Rescue: is the use of ropes, harnesses, pulleys and other various pieces of

equipment to remove or recover a trapped victim from a place inaccessible by ladder

or simply walking out. Examples include elevated bridges, silos, towers as well as

sewers, construction site excavations, and window washers on buildings. This

specialized rescue training would require up to an additional 80 hours of training to

become proficient in the skills necessary to perform at an expert level.

• Water Rescue: to include rescue SCUBA diver and Swift Water (ex. flash flood

water rescue), up to140 additional hours specialized training is necessary.

Having the expectation that a firefighter arriving on a fire truck is trained and capable of handling a specialized rescue such as a water rescue or chemical spill is a misplaced assumption.

Road/Traffic Incidents

From 1998 through 2017, the NIOSH reports revealed 17 firefighters were killed when they were struck by a passing motorist or fell off a highway overpass. Ten of the 17 firefighters killed were not wearing the appropriate personal protective clothing (PPE) for highway operations. Emergency scenes on active roadways present high risks to fire crews of being hit by cars or trucks if the passing traffic is inattentive or unwarned of the fire crew’s presence.

Inclement weather which includes fog, snow, rain increase the risk to operating firefighters.

Nighttime is an additional risk that approaching motorists will not see fire crews. Crew operating in an area where traffic has not been stopped must create a buffer zone around their operational area that provides a cushion of safety. The use of fire apparatus, police cars, highway patrol cars, sheriff deputy cars, warning signs, flashing lights, traffic cones, flares can all be used 101 to create a temporary traffic control area (TTC). A TTC should be established to provide early warning to approaching traffic of your presence, slow the traffic and divert them away from the fire crews operating area.

The USFA provides a document, Traffic Incident Management Systems (2012), which clearly provides training and directions in how to protect an active emergency scene on an active highway in-which traffic has not been stopped. NFPA standard 1451, section 8.1.4.1, says, fire vehicles shall be used as a shield from on-coming traffic whenever possible. A sample SOP that may be adopted by a fire department to establish a temporary traffic control area can be found at www.respondersafety.com.

Further, the data showed that ten of the fire departments that suffered a loss did not have any standard operating policies or procedures for operating on active roadways, six departments did have an SOP detailing operation on active roadways. Ten of the 17 firefighters killed were not wearing the appropriate personal protective clothing (PPE) for highway operations. The use of highly reflective vests to alert drivers of your presence is a requirement for highway operations. NFPA Standard 1500, Standard on Fire Department Occupational Safety and Health,

Section 8.7.10 states,” When members are operating at a traffic incident and their assignment places them in potential conflict with motor vehicle traffic, they shall wear a garment with fluorescent and retro-reflective material visible from all directions.”

Training Fatalities

Five firefighters died during training evolutions from 1998 to 2017. Four died while participating in SCUBA dive training in a lake or quarry. One died while doing an activity he was not taught or expected to have been performing following the end of a training session involving rope rescue. Dive training is a high-risk operation. Being underwater does not allow 102 for a large margin of error on the diver’s part. Dive training occurs in an environment that is immediately dangerous to life and health (IDLH). Safety and stand-by resources must be in place in the event they are necessary to rescue a distressed diver.

Wildland Firefighting

Eight firefighters were killed while operating at wildfires from 1998 to 2017. Seven departments were involved. One fire department had two fatalities in the same incident. Six of the eight died of severe burns after being overrun by the rapidly advancing wildfire. One firefighter was run over by the fire apparatus as he tried to escape an advancing fire in thick smoke conditions and was not seen by the vehicle driver. One perished after encountering a downed high-voltage electric line. Only two of the eight firefighters were wearing the appropriate firefighting protective clothing. All eight firefighters were improperly supervised during these wildland operations.

Wildland firefighting occurs in an uncultivated natural state that is covered by timber, woodland, rush, or grass. A Wildland fire is an unplanned and uncontrolled fire burning in vegetative fuels. Wildland fires are not to be fought using strategy and tactics used in structural fires. Additional training in wildland fire is necessary if a fire crew is to be safe and successful in extinguishing the fire. The NIOSH reports indicated it was unknown if five of the involved fire departments had SOPs related to wildland fire suppression operations, departments had no SOPs addressing firefighting strategy and tactics to be used in wildland involved fire departments had

SOPs related to wildland fire suppression operations, departments had no SOPs addressing firefighting strategy and tactics to be used in wildland operations. 103

Non-firefighting Incidents/Station Maintenance Nine firefighters died during accidents that occurred during routine fire station maintenance. The fatal injuries can be divided into three areas, being hit by a vehicle at the fire station, falling at the fire station, and while demonstrating or performing maintenance on departmental equipment.

Summary

This research uncovered an extensive amount of data that illustrated how America’s volunteer firefighters died between 1998 and 2017. While the data revealed the prevalence of the factors proffered by Kunadharaju et al.(2010), a wider expanse of detail emerged from the

NIOSH reports. The initial factors that were the genesis of this study were significant in the deaths of firefighters. The most prevalent combination of the initial factors from Kunadharaju et al.(2010), were sub-optimal personnel readiness and inadequate preparation for/anticipation of adverse events. Their suggestion that a study of the volunteer firefighter population should be completed to determine the factors involved in firefighter fatality, did indeed demonstrate their initial findings were transferable to the volunteer firefighter population. Each of the 149 fatality reports totaling 176 dead created a mosaic of data that was read and analyzed by the researcher, an additional 65 factors were analyzed per report, for a total of 11,440 data points for analysis.

This mosaic of data resulted from the combination of all factors to include those offered by

Kunadharaju et al.(2010) and the newly discovered factors by the researcher.

These data points were then segregated into the emerging incident types of apparatus crashes, fire ground operations, technical/specialized operations, road/traffic incidents, training, wildland fires, and non-firefighting incidents. The development of incident types allows for 104 readers to review similar types of fatal incidents, for example, technical/specialized incident, and draw conclusions based upon the relevant data.

The data illustrated a lack of leadership at all levels within the individual fire departments. For example, failure to use proper protective equipment or the lack of departmental use of safety officers, demonstrate failures of the fire service policy makers to research, develop, implement and enforce departmental standard operating procedures. This was highlighted by the lack of SOPs and enforcement of what policies did exist such as seat belt usage.

Failures to adhere to best industry practices within the fire service were identified by the lack of RITs readily available and the failures to use proper PPE as examples. Substandard or a complete lack of appropriate training for the volunteer firefighters was apparent in numerous fatalities, for instance firefighters that died as a result of participating in technical and specialized operations when they had no training in that specific discipline, such as confined space rescue.

Chapter 5 will take the information distilled from the contributing factors and provide for an interpretation of the data. Secondly, implications for the data will be discussed that address opportunities for leadership and policy makers that impact the fire service. The chapter will close with recommendations to reduce firefighter fatalities and what contributions this study makes to the larger body of knowledge within the volunteer firefighter community 105

CHAPTER V. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS

Introduction This chapter discusses the findings of the data and what conclusions can be drawn from the data set. The data were collected from 149 NIOSH reports from 1998 to 2017 that detailed the events leading up to and including the moment a volunteer firefighter lost their life while in the service of their community. These 149 reports provide details of 176 men and women who died as a result of being a member of their community’s volunteer fire department. This study only focuses on traumatic deaths and purposefully excluded medically related deaths such as cardiovascular disease and strokes.

The data were analyzed, and separate field notes were made on each of the 149 reports to determine what factors contributed to the firefighter’s death and what leadership and policy development opportunities may exist, to reduce the fatality numbers in the future. This chapter will discuss each of those seven incident types with more depth and interpretation of the data.

Following the data interpretation, implications of the study and recommendations will follow.

The final sections will include the contributions of this study and what’s the future of the body of knowledge as a result of this work.

The data were analyzed to determine if and/or how many of the four factors were factors in the firefighter’s deaths, but the data was further examined for other factors that may emerge.

The emergence of incident types permitted detailed comparisons between similar events and produced rich and informative insight into each individual event as it unfolded. Identifying incident types also permitted the researcher to compare the events so even minute details could be unearthed. 106

Seven incident types emerged from the data and are best described as: apparatus crashes, fire ground operations, technical/specialized operations, road/traffic incident, training incidents, wildland firefighting, and non-firefighting incidents. Significant departures from best practices were discovered, including the lack of seat belt use, lack of supervision, scarcity of operational standard operating procedures and policies and the absence of both safety officers and rapid intervention teams (RIT) at structure fires. None of the departures from best practices are without an avenue for correction. Fire service leaders need to examine the implications of the data and establish internal controls to reduce the death rates of their firefighters. Policy makers can also use this information to make fact-based operational policies that decrease the risks to their communities’ firefighters.

Interpretation, Conclusions, and Recommendations from Data Findings

The four factors proffered by Kunadharaju et al. were applicable in this study’s population of volunteer firefighters and are addressed. Singularly and in combinations, the four factors totaled 16 potential data points. Additionally, the new factors discovered by the researcher are discussed in this section. The basis for the discovery of the new factors comes from the numerous data points identified within the NIOSH reports and recorded on the coding sheets. Forty-nine data points were developed based upon the researcher’s experience in reading numerous NIOSH reports for career firefighters, combined with the combination of factors identified by Kunadharaju et al. totaling 11,440 data points for analysis in this study. An expanded, deeper filtration was done to determine applicability of data points to the incident types using the filter feature of Microsoft Excel. The filter feature permitted selected analysis of data based upon the incident type. For example, in the incident apparatus crashes question emerged: what was the impact of not wearing seat belts, and/or did having a RIT team available 107 make any difference in the fatality? Clearly, not all data points applied to each fatality. This deeper filtration of the data illustrated connections in the separations from best industry practices in firefighting and a firefighter’s death. This ability to use Microsoft Excel and filter the numerous data points permitted connections to be made between failures and fatalities.

Apparatus Crashes

Dying in an apparatus crash was one of the most preventable tragedies during the 19- year period this study examined. Fifty-six firefighters died, 39 of them were not wearing a seat belt. Failing to wear seatbelts or drive fire apparatus that don’t have seatbelts installed (modified former military fuel trucks), which some of the refurbished water tankers did not have, is reckless behavior. There is no justification that excuses not wearing this fundamental safety device. The NFPA, the USFA among others, preach the need to wear seat belts when fire apparatuses are moving. Failing to wear a seatbelt is unfathomable. Some officers have demonstrated they are equally as non-compliant as the recruit firefighter. Of the fatal apparatus incidents involving officers, nine out of 12 officers were not wearing seat belts at the time of their vehicle crash. Seven of the nine officers involved in fatal apparatus crashes did not follow their departmental written policy to wear seat belts.

Officers and chiefs are expected to set the example for their firefighters to emulate. The behaviors of top management have a significant effect on an organization’s learning (McLagan,

2003). It should come as no surprise that firefighters are not using seat belts if their officers are not. This dangerous and risky behavior on the part of officers is a failure in leadership. Wearing seat belts in moving fire apparatus, which includes personally owned vehicles (POVs) that are used for departmental response is not new information, and excuses for not wearing seatbelts should be soundly rejected by all in the fire service community. 108

A further travesty that perpetuates apparatus crash fatalities are fire departments that fail to have a written standard operating procedure that directly instructs firefighters to wear seatbelts every time the fire apparatus is in motion. The data in this study revealed that 20 departments had no written seat belt policy and ten departments were unknown to have a seat belt policy. Fire departments leaders and community policy makers that do not have a written policy and procedures that are readily available, widely known by all members, veterans and recruits alike, and routinely reinforced are complicit when a firefighter is injured or killed. Enforcement of this life saving policy should fall upon everyone within the department, but certainly on the officers and chiefs that are expected to set the example of proper behavior. Departments need to hold their firefighters accountable for policy adherence. There should be departmental sanctions for not wearing a seat belt. We know that not wearing seat belts cost 39 firefighters their lives. If departmental leaders and policy makers are serious about protecting their fire crews, it is vital to develop a standard operating procedure (SOP), enforce it and monitor compliance.

Water tanker crashes accounted for significant number of the firefighter fatalities. While not wearing a seatbelt was the factor that resulted in their ejection from the vehicles, the crashes involving water tankers were too numerous to go unnoticed. A significant issue is the conversion of an old, outdated and worn out military surplus fuel vehicles that are converted into water tankers. These former fuel tankers were not designed or built to carry the additional weight that comes with hauling water. The suspension and brake systems were not designed or built to haul water. Brake and suspension failures occur most often because of the fact water weighs 8.3 pounds per gallon, the tanker was originally designed to carry fuel oil that weighs 7.12 pounds per gallon, or gasoline that weighs 5.6 pounds per gallon. This added weight to the vehicle drastically changes the handling characteristics of the vehicle. 109

Conclusions and Recommendations. A free vehicle from a governmental agency is not necessarily a good deal. Consider that the military or forest service is giving away a piece of equipment they no longer want, and it is often old and has been used past its service life. Budget crunched departments often do not have surplus cash available to make the necessary vehicle modifications to make the vehicle capable of safely hauling the increased water weight.

Failing to make the proper vehicle modifications to safely haul water is asking for serious trouble. Adding to the danger of injury and death is the addition of increased speed due to emergency responses. Throw in the two lane rural roads with soft shoulders and drivers are being thrust into conditions where the vehicle drifts off the road just a bit, there is an over correction by the driver, the vehicle flips over, ejects the non-seat belt wearing firefighter and now we begin preparations for a funeral.

Departmental leadership must develop, implement, and then consistently enforce a standard operating procedure that addresses seatbelt usage by all members. Officers should hold firefighters accountable for wearing seatbelts. The data clearly illustrate lack of seatbelt use has been fatal to firefighters. Annually, this seatbelt policy should be reviewed to ensure it is current, simply stated and understood by all departmental members. Access to the written document must always be easily available for departmental members to review.

Fire Ground Operations

Fire suppression is one of the most exhilarating and rewarding components of being a firefighter. Communities throughout North America rest peacefully at night because men and women stand at the ready to place themselves at risk to protect lives and property. However, firefighting is risky and often extremely dangerous. From 1998 to 2017, 58 firefighters died during fire ground operations while serving their communities. 110

Some examples of factors contributing to firefighters’ deaths include but are not limited to, 15 firefighters running out of breathable air in their SCBA while operating in an IDLH environment, 22 firefighters died due to rapid fire progression as a result of the creation of multiple flow paths because of uncoordinated ventilation with the fire attack teams. Building collapses, whole or in part, were a factor in the deaths of 24 firefighters. Often, multiple factors contributed to a firefighter’s death. For example, the data showed fatalities had multiple data points such as a lack of a safety officer present, running out of air in their SCBA, rapid fire progression and entrapment, failure to implement the incident command system, no departmental operational SOPs, interior and/or exterior operations and not wearing the proper PPE were potentially applicable to a firefighters demise.

In addition to the emerging factors discovered in the data, four factors were found to be directly attributable to fire ground fatalities. Introduced by Kunadharaju et al. (2010), those factors include failing to fully implement the incident command system, under-resourcing, sub- optimal personnel readiness and inadequate preparation for/anticipation of adverse events. These factors, when combined with the additional factors unveiled, create broad avenues for fire service leaders and policy makers to navigate while implementing departmental change.

Evidence based decision-making removes the guess work in policy formulation. As we have seen previously, 39 firefighters died who were not wearing seat belts. To reduce that number, ensure seat belt usage. The same use of the data to illustrate problems can be applied to fire ground operations.

The incident command system is a management tool that provides organizational structure to managing an incident. The discussion around full adoption and implementation of the National Incident Management System (NIMS) within volunteer fire departments is well 111 worn. In the end, whether a fire department fully adopts the government’s full incident management system is not an argument that will be settled here. What must be settled here is that the use of an incident command system (ICS) is warranted. A structured approach is necessary on the fire ground to provide for accountability, minimize duplication of efforts, and quickly address the most pressing challenges. ICS affords the commander a framework that places importance on firefighter accountability, specific task assignment and an organized approach to incident mitigation. Every department needs to adopt and use an ICS. Every department needs to train their members in how the ICS works and then practice the use of the ICS at every incident to which they respond. The ICS is scalable and can be used at any incident. Additionally, neighboring fire departments that regularly respond together must ensure they are using the same

ICS and using the same terminology so that, as they respond together at 2:00 in the morning, the incident proceeds smoothly.

Failure to adopt an ICS process reduces the overall effectiveness of firefighters. Poor accountability of your fire crews is unacceptable and dangerous. An incident commander that does not have good accountability of her crews on the fire ground will be in a very difficult position when a fire crew calls a mayday. Poor accountability suggests one does not know where fire crews are operating within a structure and getting rescue teams to them quickly will be delayed. In general, the ICS is constructed around five major functions: command, planning, operations, logistics and finance/administration (Bigely & Roberts, 2001).

Under-resourcing is best described as not having enough personnel at the scene of the incident when trying to accomplish numerous items simultaneously. This problem can leave firefighters operating in areas alone, something that is not a best industry practice and not sanctioned by NFPA 1720 (2014) Sec. 4.6., firefighters should always work in teams. The 112 problem of under-resourcing as an isolated factor only occurred once. The effects of under- resourcing were seen more often in combinations with the other factors of sub-optimal personnel readiness and inadequate preparation for/anticipation of adverse events. Failing to have a rapid intervention team (RIT) readily available as suppression efforts began can be traced back to under-resourcing.

Undoubtedly, initial arriving firefighters could be faced with an imminent life-threatening situation in which immediate action is necessary to save a life or prevent serious injury to a trapped victim in a house fire. In those instances, rapid response with an aggressive rescue and suppression effort are permitted by NFPA 1720 (2014), section 4.6.4 with less than four firefighters on scene. Firefighters take great risks to save the lives of savable victims, foolhardily running into a fully involved structure is not what this NFPA section implies. As firefighters prepare to begin the rescue effort, complete an initial size-up and ensure that efforts are going to be spent on reaching potentially savable victims. One must ask with this much fire and smoke, is anyone still alive to save? If so, what am I going to do once I find them? Should the best effort here be to extinguish as much fire as possible with the available personnel and make the conditions on the inside better?

Efforts to increase staffing at incidents that are potentially life-threatening to fire crews could include early mutual-aid dispatch with more than one neighboring department. Restricting interior suppression efforts, especially in a known vacant building, until additional staffing is on scene is also an option. Another example is the use of transitional attack (flowing water into the fire room from the exterior) to knock down the fire, lower interior heat conditions would be a better tactical approach until more help arrives. 113

Fire department members, including those who oversee policy development must understand the high-risk firefighters can be subjected to and establish SOPs that can be implemented with a small number of properly trained firefighters. As an example, the use of smooth-bore nozzles produces less nozzle reaction (back pressure against firefighters) than the conventional fog nozzles so widely used. A reduction in nozzle reaction makes handling hose lines easier, while still flowing at least 150 GPM per 1 ¾ inch hand line. An even greater reduction in nozzle reaction, which means fewer firefighters may be needed to handle the hose line, can be achieved when using a 2 ½ inch attack line with a smooth bore nozzle and flowing up to 250 GPM.

Water flow (GPM) for 2 ½ hand line tips:

1-inch tip = 210 GPM

1 1/8-inch tip = 265 GPM

1 ¼-inch tip = 325 GPM

Sub-optimal personnel readiness and inadequate preparation for/anticipation of adverse events can be addressed by policy improvement and training methodologies. Sub-optimal personnel readiness refers to fire crews that are not following industry best practices and therefore are not prepared to meet the demands of firefighting operations. For example, when fire crews indiscriminately and without direction from incident command, breakout windows, cut holes or open multiple doors in a structure fire.

This action can create multiple flow paths throughout the structure providing air to a ventilation limited fire. A ventilation limited fire is often very hot, with heavy, dark smoke conditions, without a lot of visible fire seen by fire crews. Creating openings into this type of building fire allows for the introduction of air, which containing oxygen, provides a necessary 114 ingredient for rapid fire development and fire progression throughout the building. Fire crews operating in this environment are at extreme risk of being overrun by a large flame front and possibly even being caught in a flashover condition. From 1998 through 2017, 31 firefighters’ deaths included the factors of uncoordinated ventilation, multiple flow paths created and rapid fire development.

Through training and education, firefighters must develop an understanding of controlling ventilation openings, ensure charged hose lines are readily available and in place close to the seat of the fire, capable of flowing water, before multiple ventilation openings are created. Even after all these preliminary moves are made, that is not a signal to just start creating multiple ventilation holes. Ventilation openings should be made opposite the attack team’s path horizontally and vertically if necessary. The incident commander should be coordinating this fire attack strategy.

Conditions will present themselves in which the pathway to the fire area is simply too hot to traverse toward the seat of the fire, for example up an attic stairwell or up to the second floor of a home. With heavy fire conditions in the attic, bedrooms or knee walls, instances will occur in which ventilation holes will need to be made horizontally and/or vertically to allow for the release of intense heat which will then allow for the advancement of a hose team toward the seat of the fire. It is critical that hose teams are in place and ready, before ventilation holes are made.

Punching holes into buildings with the expectation that we’ll get hose lines in there a bit later is dangerous and demonstrates poor strategy and tactics. The result of a poor strategical approach and sub-standard tactics includes greater risk of injury or death to firefighters working on the interior of the building, reduced survival probability for trapped victims and unnecessary additional property damage. Incident commanders and company officers can ensure hose lines 115 are moved into a safe location out of the extreme heat, yet immediately ready to flow water once the ventilation openings are made. Firefighting is already dangerous work, don’t make matters worse for your fire crews by employing unsafe strategies and tactics.

Training evolutions that prepare firefighters to advance charged hose lines up and down stairwells develops a firefighter’s ability to move a hose line smoothly, work in visually obscured environments and develop confidence and comfort in their personal protective equipment, including their SCBA. Ward et al., (2008) put forth the theorem that expert and elite performance results from extensive participation in relevant training activities. Company officers, firefighters and incident commanders using reality-based training (RBT) place students in scenarios that require execution of a set of skills under stress, to successfully navigate the training session (Murphy, 2012). RBT has a place in the fire service and should be used routinely to prepare firefighters for predictable events on the fire ground. RBT can and should evoke a stress response from the student.

This stress response is considered stress inoculation, which aids the firefighters in becoming familiar with stressful situations to help protect them from future events. Developing memory of how and why to do certain events helps to create mental models for the firefighter, giving them shorter reaction times when faced with a similar event in the future. Thompson and

McCreary (2006) wrote practice, particularly the overlearning involved in repeated drills, can have psychological benefits, reducing the novelty of, and thus the uncertainty associated with, the technical aspects of tasks, thereby increasing confidence. Meaningful, task-oriented training that evokes a stress response begins to condition firefighters in the “what to do” mindset.

Developing confidence in a firefighter’s ability to respond to problems on the fire ground enhances survival probability. 116

Consider for a moment what training a fighter pilot experiences in preparation for a mid- flight emergency requiring the immediate ejection from the aircraft to survive. Do you think those pilots are shown a poster board presentation with a few pictures and then sent off into the wild blue yonder? How about Super Bowl quarterbacks and their receivers, do you think they run the play once in practice and then expect to execute the play without difficulty against a determined defensive opponent? The answer is no. Your firefighters may in the course of their duties find themselves in an immediate life and death situation. Their ability to react and survive may hinge on the amount of and effectiveness of the training provided to them. New training that is directed toward a dangerous activity, fire suppression, an individual must be taught how to manage their stress and response with techniques in arousal/anxiety control (Hall, 2010).

Inadequate preparation for/anticipation of adverse events is the lack of plans or strategic approaches to deal with adverse events on an emergency scene. An example would be not having

EMS nearby or a rapid intervention team (RIT) immediately available on the scene of an emergency such as a structure fire. It is no secret that firefighters are injured and killed on the fire ground. Not having readily available assets to protect and rescue fire crews is demonstrative of having inadequate preparation for adverse events.

Conclusions and Recommendations. Incident commanders and company level decision makers should be the first in-line when it comes to preparing for bad things to happen on the fire ground. Hendricks and Campbell (2016) wrote in The Kansas City Star, firefighters often died because their commanders made poor decisions and strategic errors that put them in excessive danger. Captain Kevin Kalmus of Austin, Texas (as cited by Hendricks & Campbell, 2016) concluded, that we allow the same events to occur year after year that lead to firefighter fatalities. 117

Departmental policy must be developed that require firefighter protection teams, such as

RIT, are readily available when committing fire crews to interior suppression activities. In this study, the data shows 132 instances in which departments either had no policies, only had administrative policies, or couldn’t produce policies and procedures that guided their departments firefighters’ actions. Lack of policies and procedures which provide for the protection of fire crews is inexcusable. It is important to understand that in the context of the fire service, policy decisions made by community leaders’ impact more than just fiscal concerns.

Community safety, regional insurance ratings, and quality of life issues for the population are a few of the issues that must be addressed. Poor policy implementation within the fire service can have long term negative effects for a community.

For example, Texas, 2013, 10 firefighters were killed, 260 people were injured, and hundreds of homes were damaged when an ammonium nitrate fertilizer plant caught fire and exploded. The processing plant was a total loss. The investigation into the blast revealed the fire department was aware of the large cache of ammonium nitrate at the plant, however, the department never conducted training or developed a pre-incident plan on how to deal with a fire at the facility. Neither the community nor the fire department leadership had an emergency response procedure or policy to address the risks at the fertilizer plant.

Well-developed standard operating procedures based upon industry best practices are necessary if there is an expectation of institutionalizing them within departmental culture. Policy development should additionally be supported by data, such as contained within this research.

Data driven policy development that considers the principles and values of the organization are indispensable. When these SOPs are then regularly trained upon and reinforced by senior 118 firefighters and company officers it is reasonable to believe that real transformational change toward safety within the department can take place.

The fire service is in need of volunteers. Departments that are poorly organized in terms of command staff, lack of policies and procedures and poorly trained are not appealing to potential volunteers. Why would community members join a poorly run organization, especially an organization in which they could be injured or killed. Community leaders that are concerned with departmental participation need to look at how the organization is administered; they may well find out why their community cannot find willing volunteers.

Technical/Specialized Operations

Arriving to the scene of a hazardous materials spill or a reported drowning or the report of workmen unresponsive in a manhole sets in motion a series of events for which the minimally or moderately trained firefighter is not prepared to mitigate. Each of the types of incidents require an additional and differing level of skills that are only obtained through specific technical and specialized training. Being a firefighter, an officer, or a chief officer in and of itself does not make an individual capable of handling technical and specialized emergencies.

Nineteen firefighters died as a result of their lack of knowledge with technical incidents.

Hazardous materials incidents accounted for 12 of the deaths. One incident alone, in Texas

(2013-11), resulted in the explosive deaths of ten firefighters when an ammonium nitrate plant exploded during a fire involving 40 to 60 tons of ammonium nitrate. Although members of the department were aware of the plant’s storage of fertilizer and chemicals, no pre-plan or training was conducted to prepare for an emergency on the site. One victim reportedly told fellow firefighters that burning fertilizer would not explode. The explosion created a crater 93 feet in 119 diameter and 10 feet deep. Debris from the plant was scattered for 2.5 miles. The department did not have any standard operating procedures and had no pre-incident planning procedure.

Grain and coal silos present the challenges of being confined spaces and/or containers with hazardous materials. Five firefighters died at silo fires, four because they failed to recognize oxygen-limiting silos and one because of water being introduced to a coal fire which contributed to the exothermic reaction of the coal, thereby increasing the fire problem. All the silos involved exploded. The traditional firefighter education does not contain a section addressing fires in silos, this is addressed in specialized and technical training curriculum.

In total, nine incidents took the lives of 19 firefighters. The data shows that six of the nine fire departments involved did not have any policies or procedures on how to deal with these technical and specialized incidents. The remaining three departments were designated as

“unknown” if they had SOPs by the NIOSH reports.

Conclusions and Recommendations. Fire departments across the country are increasingly being called to incidents that don’t involve something burning. Community fire departments are steadily becoming all-hazard response organizations that require more diverse and specialized training. Community expectations that once a firetruck arrives, all is well, is foolish and dangerous. Complex and technical rescue situations require complex and technical training. Fire service leaders, at the direction of fire service policy makers, should perform a needs assessment of their response districts. The needs assessment should include identification of high hazard areas, such as railroads, fertilizer plants, power distribution plants, water ways, lakes and ponds industrial sites to name a few. This assessment can then be used to generate questions such as, what do we do if this happens? How do we respond? What will we do when we get there? What additional training do we need? Can we share expertise and equipment with 120 our neighboring departments? Technical and specialized operations demand a response more advanced than what a basic firefighter can accomplish. Failing to understand this elevated response need will result in additional firefighter deaths and a false sense of security for a community.

Road/Traffic Incidents Ten fire departments lost a total of 12 firefighters to incidents in which they were struck and killed while operating on a roadway with traffic still moving in their direction. All ten of those departments either lacked or could not produce SOPs for operating on roadways at the time of the NIOSH investigation. In total, 17 firefighters were killed in 16 incidents. Six departments involved had SOPs, yet in two cases the departmental policy was not complied with.

Having a written policy does not guarantee nothing bad will happen, but policies and procedures provide an operational framework which has been shown to be effective and safe for fire crews to work within. Enforcement of the safety procedures and policies is the responsibility of the fire service leaders, the company officers and chiefs. Policy makers must take the time to institutionalize best practices giving their personnel the best chances for survival. The USFA administration’s document, Traffic Incident Management Systems (Document fa_330.pdf) can provide a department with an excellent, cost free, guide to safely operating on active roadways.

Distracted drivers present significant risk to firefighters that are standing or working on roadways. Developing, implementing and enforcing traffic control zone procedures will enhance firefighter safety, expand the safe working area on active roadways and increase the awareness of approaching drivers to an emergency scene ahead. Slowing traffic down, providing early warning of reduced lanes ahead and creating a physical barrier around emergency responders will prevent injuries and deaths. 121

Conclusions and Recommendations. Thinking about proper fire apparatus placement on an active roadway, such as an interstate highway, provides for a physical barrier between the distracted driver on their cell phone, for example, and the fire and EMS crews working at an emergency scene. A distracted driver striking a fire apparatus and being deflected around the emergency personnel is far better than that same driver striking the fire, EMS and police personnel on the scene. Fire departments should actively review their response districts looking for blind turns, high speed roadways and areas which provide line of site issues for drivers and pre-plan how they would set-up their fire apparatus to shield their personnel.

Training

Seven firefighters died during training evolutions. Two firefighters perished while training during live fire incidents. One because he stayed behind after lighting the fire to watch the fire development and became trapped. He did not have the protection of a hose line and was operating alone. The second was a young man who was used as a “trapped firefighter” for RIT training. The young man in this case had no formalized training prior to this incident and this was the first time he reportedly used an SCBA in a live fire exercise (FA2001-38).

Live fire training is inherently dangerous and using live firefighters as “victims” is reckless and irresponsible. The NFPA has a specific standard, NFPA 1403, Standard on Live

Fire Training Evolutions that must be consulted and used as a road map when conducting this high-risk training operation. Firefighters should never be used a victim, any more than you would use a live baby to conduct search operations for victims trapped in a house fire with heavy smoke conditions.

Underwater scuba diving accounted for four firefighter deaths during training. Dive training can be very risky to those individuals who may have recreational dive training and are 122 wishing to parlay that recreational training into public safety diving. Advanced open water training provided by the Professional Association of Diving Instructors (PADI) is not intended to be used as a substitute for public safety dive rescue training. Open water certified PADI dive instructors who conduct public safety dive training should not be doing so as the disciplines between recreational diving and public safety diving are different. Guy Haskell (2019), PADI

Inst. Cert. 15609, indicated during an interview that thinking advanced open water scuba or rescue diver training is a reasonable alternative for public safety diving is patently absurd.

Haskell indicated no reputable scuba diving instructor should be conducting advanced open water diver training under the pretense it prepares scuba divers for the rigors of public safety rescue diving.

A newer program from PADI, Public Safety Diver is training that is specific to public safety diving and the rigors that are associated with the practice. Firefighters interested in conducting SCUBA operations for any public safety purpose, such as rescue, recovery, and/or criminal investigations should seek out training from a reputable organization such as PADI or

Dive Rescue International (DRI) for specialized training.

Conclusions and Recommendations. A firefighter that arrives to a training session in their car should not be leaving that same training session in an ambulance. Training that includes hands-on evolutions must be conducted in as safe an environment as possible. The student to instructor ratio should not exceed 5:1, giving each student ample time with an instructor. Any training that is potentially dangerous such as ventilation drills on a peaked roof should have a designated safety officer at the training site. Consideration should also be given to having an

EMS ambulance readily available with a dedicated crew to quickly treat and transport any inured firefighter. All live fire training must adhere to the requirements set forth in NFPA 1403, 123

Standard on Live Fire Training Evolutions. This standard ensures fire crews are trained in a safe setting and minimizes risks during the training.

Wildland Firefighting Wildland firefighting does not employ the same strategy and tactics as structural fires.

Wildfires present a serious and challenging operational environment and cannot be approached without specific training in how to combat them safely. Typically, even the PPE worn at structure fires is vastly different than the PPE worn at structure fires. Common structural fire gear is too bulky and is not designed for the working environment of a wildland fire. Proper PPE for wildland firefighting should be available if it is reasonable your department will be faced with those challenges.

Wildland firefighting also has its own set of specific terminology, equipment and strategic and tactical approaches. Ten firefighters lost their lives while operating at wildland fires within their districts. Three were electrocuted by unseen downed powerlines that started grass fires. Six firefighters were severely burned, one firefighter was run over by the suppression vehicle in heavy smoke conditions.

Nine different fire departments suffered firefighter deaths due to wildfires. Nine different communities buried ten firefighters. Ten families grieved the loss of a loved one as a result of a wildfire. Six of the deceased firefighters were not wearing the proper PPE at the time of their deaths. None of the departments involved had written SOPs directing crews how to approach and attack wildfires.

Conclusions and Recommendations. Training specific to the challenges of wildland firefighting must be provided to firefighters where there is a reasonable chance, they may be called upon to combat such an opponent. Training with neighboring departments is also highly 124 encouraged as wildfires often merge into adjoining fire districts which require mutual aid.

Ensuring the use of a common radio frequency, common terminology and an incident command system is imperative. A large open field fire encompassing 200 acres at 2 AM following a lightning strike is no time to realize you are unprepared as a department.

Non-firefighting Incidents/Station Maintenance

Sadly, nine firefighters died during activities around the fire station which included maintenance activities, demonstrating equipment, falls and vehicle movements. The data does not indicate these deaths are attributable to any specific firefighter failures or departmental omissions. While it is the intent of all those within the fire service to follow safe practices, it is important to regularly review departmental operations to ensure that members are not unnecessarily at risk for injury or death, this must include routine station maintenance procedures. Working with another person is strongly recommended in every operation around the firehouse, even if that person is there to call for help should someone be incapacitated from and injury or unexpected medical emergency.

Application of the Study

The information discovered in this study can easily be assimilated into any fire department in the country, career or volunteer. The empirical evidence shows that not following industry best practices results in lives lost and is not restrained by whether the firefighters are career or volunteer. For example, fire departments across the country that review this data can see that not wearing seat belts was a factor in firefighter deaths. Frankly, the information contained within this study has international applicability. Firefighters across the globe can benefit from wearing seat belts, working in teams, using the incident command system and attending meaningful, well-developed training. Company officers and chiefs across the country 125 should be better prepared to understand that failing to implement the incident command system is dangerous and places their crews at risk unnecessarily.

The vast majority of the 149 NIOSH reports studied here included recommendations for initial and then on-going additional training. Every single firefighter in the country can benefit from better designed training, given at regular intervals, that is specific, and task-related.

Training that evokes a stress response from the trainee is highly desirable as it helps to develop mental models for future similar incidents. This study shines light upon the incidents where training was non-existent or substandard and hopefully informs departmental leaders not to make the same mistakes.

All the information in this study is transferable to members of the fire service. The information contained within this study should elicit reflection by the reader into their own organizations. Application of information in this study can be used immediately to guide departmental decision-making, policy and procedural development and the establishment of training objectives. Implementation of policies and procedures based upon data within this study can save lives. Departments that have not suffered the loss of a firefighter can reduce risks to their members as a result of this information.

This research is capable of changing behavior as it highlights how firefighters died over a

19-year period and then offers recommendations that can reduce the chance of dying in a similar incident. As a result of this work, fire service personnel at all levels, firefighters, company officers, chiefs and policy makers can distill down to the events that killed 176 of their colleagues and take action, such as developing SOPs or improving training programs to avert an analogous result. The factors discussed in this study that attributed to firefighter fatalities are numerous and when found in combination with each other created a lethal combination. 126

Implications for Policy, Practice, and Leadership

The data illustrate that failing to adopt established best industry practices results in firefighter deaths. Fire departments that failed to establish and then train with formalized procedures suffer the consequences in harsh ways. Firefighters that disregard safe practices whether through a conscious decision or ignorance have paid the ultimate sacrifice. Families have been irreparably damaged by the loss of their loved ones. Unless action is taken by all the stakeholders, which include the firefighters, company officers, chiefs, and the policy makers that lead fire departments, the funerals will continue at an alarming rate. The loss of 176 firefighters over the period of this study only scratches the surface of the pain and suffering that resulted.

The families left behind, wives, husbands, and children, are all victims of the loss.

Similar tragedies can be averted. Simply using available safety devices such as seat belts may have saved 39 firefighters lives. Departments with written SOPs, understood by their membership and trained upon, enhance survival because those SOPs should be grounded in best industry practices. The NFPA provides excellent resource materials in their published standards.

These standards are developed by some of the fire services best minds and draw on a wide expanse of experience and research in each standard.

Using the information contained within this research fire service leaders and policy makers have information necessary to look at their own organizations an enact SOPs that will save lives. I have developed five simple organizational assessment questions to assist fire service leaders in looking at their departments.

Annually fire departments should reflect on their organizations to determine the following:

1. What are the principles and values of our organization? 127

Answers to this question can be used to market the department to recruit as well as retain

volunteers more successfully. Secondly, these answers will aid in establishing the culture

of the organization and set foundations of how members will interact with each other and

the community.

2. What are the major risks to our community? Do we have areas where there is a

potential for a large loss of life or major property damage? Does the potential exist

for our department to respond (even in a mutual aid setting) to a hazardous materials

incident, a water rescue or a confined space emergency?

The information collected in answering these questions will set forth training needs,

departmental operational procedures and identify departmental capabilities.

3. Does our organization adhere to best practices within the fire service? For example,

do we use proper PPE every time, do we provide meaningful and realistic training to

our members, and do we as an organization have readily available written policies

and procedures for our members to follow during emergency operations?

4. Does our fire department select and promote the best qualified members to leadership

positions based upon their training and expertise or their popularity? This should be

an easy fix.

5. Have we as an organization reasonably assessed our capability to respond effectively

to calls for service within our jurisdiction? Answers to this question require radical

honesty and absolute transparency. Any other approach is disingenuous and

dangerous.

Once written answers are collected for the above assessment, planning should be undertaken to design, develop and implement policies. One approach to policy development is to form a large 128 steering committee that represents all the key stakeholders interested in the project. This group should include the firefighters, command officers, and community leaders. The other approach is to form a smaller steering committee composed of just a few members of the leadership community who have volunteered to work on the project and are strongly committed to it. Both types of committees can succeed, but the large group is most effective in settings where the stakeholders share similar opinions about firefighter safety and can work together harmoniously; the small group works best significant conflict is a potential.

Frequent failures occur in policy implementation when foolish allocation of resources occurs (Miles & Huberman, 1984). Mishandling of time, money, space, personnel and materials and equipment can doom a policy project. For example, volunteer fire department budgets are historically limited, spending resources on unproven computer software or on-line training systems that are difficult to use can create more problems than originally existed.

Leadership opportunities present themselves to each firefighter, company officer and chief every time the alarm sounds. Experienced firefighters are often looked up to by less experienced members and what you do, or do not do, sets in motion behaviors for others to follow. Company officers and chiefs should ensure they commit themselves to continuous training whether it be through fire service magazines, podcasts, on-line videos, local and national training conferences and monthly quality training sessions with their fellow firefighters.

Company officers and chiefs should ensure they supervise their subordinates closely, not micromanaging them, but watching over them to ensure their safety and compliance with departmental SOPs. Leadership is not always about being popular, leadership, among other things, is getting people to do what needs to be done without undue risk or cutting corners.

Leadership involves demonstrating a high level of competence in firefighting to your crews, so 129 they learn to trust your judgement and follow you when times are tough. Leadership is being able process information and to make decisions, under time compression, and then adjusting actions based upon conditions as they evolve.

Requiring appropriate training before allowing a new firefighter to participate in emergency scene operations is an absolute. Requiring specific training that applies to firefighting must be standardized and consistent throughout the fire service. Allowing the authority having jurisdiction (AHJ) to set their own individual training requirements is neither prudent nor reasonable. This stance assumes the AHJ knows what training is important in the first place.

State minimum training standards should be consistent throughout the country for any member entering the fire service. Minimum functional capabilities need to be established to ensure committed men and women who wish to serve their communities as volunteer firefighters are prepared. Poor and/or lacking training runs the risk of allowing firefighters just enough access to an emergency scene to get themselves or someone else injured or killed.

This study unearthed data that demonstrated inadequate training led to numerous fatalities. For example, newer, less experienced firefighters being permitted to drive fire apparatus to an emergency without having been trained how to drive the apparatus. Because of their unfamiliarity with the rig, they lost control, over corrected, and were killed when the vehicle went off the road and rolled over. Or the 24-year-old firefighter with two years of experience entered a residential structure fire with a partially charged hose-line, became lost in heavy smoke conditions and died. Department records indicate he had only completed a few hours of peer led training in SCBA, pump operations, water tactics and general firefighting. His home state has no training requirements for volunteer firefighters. How many more are we as fire service professionals willing to sacrifice? 130

Fire departments are encouraged to develop procedural and policy manuals that are based upon the best fire service practices. The NFPA has excellent standards that can be used as SOP development guides. Training for firefighters must be standardized at a state level and not left up to the authority having jurisdiction. Regular on-going departmental training must be grounded in best practices. Training resources that include access to fire training centers and financial support needs to be made available from the state. Many lessons can be learned from reviewing past incidents that dramatically challenged fire crews to discern what made them so challenging and then study why decision makers (commanders) were successful or failed (Crandell et al., 2006).

State fire authorities should consider the development of satellite training centers that smaller rural fire departments would have the ability to access. Fire departments need to seek out fire service experts who can provide training to their departments in their local fire stations at a reasonable cost. Hands-on training should not be deferred in favor of on-line viewing of training.

In addition to practical skill development of fire service personnel, fire service leaders should seek out and attend training on leadership methodologies, such as the five practices of exemplary leadership developed by Kouzes and Posner (2007). While some may scoff at the idea of model the way, inspire a shared vision, challenge the process, enable others to act and to encourage the heart, developed by Kouzes and Posner (2007) this leadership model is highly effective in the fire service and volunteer departments would be well served if they embraced this leadership approach.

Senior firefighters and command officers have opportunity every time they are at the fire house or on an emergency scene to model the way. Younger firefighters watch what you do during a morning apparatus check. If they see you cutting corners, not checking equipment properly, you’re sending them a message that it is acceptable for them to behave the same way. 131

Company officers and chiefs need to set the example for proper practice, for example, wear your seat belt, wear the proper PPE, adhere to the incident command system, the list can go on. Set the proper example for those members that you lead.

Fire service leaders need to take opportunities to talk with your crews, have a cup of coffee with them and detail your vision of how things can be around the fire house. Seek to inspire the members of your crews to want to perform well, to learn, and refine their skills as emergency responders. Use your experience in the fire service to excite and motivate those newer firefighters. Those members that understand the leadership’s vision for the department can better understand their role within the organization.

Challenging the process is shaking things up. Fire service leaders need to actively work to change to the trajectory of firefighter deaths. Fire service leaders can impact their own departments by establishing operational procedures and requiring proper training before fire personnel are placed at risk. Fire service leaders can challenge the process by looking at their organizations and making structural departmental decisions based upon best industry practices.

Policy makers can require that fire departments look both internally and then to the outside for ideas to better improve their service delivery to a community that very much needs their help.

Departmental leadership must decentralize their command and control when it comes to empowering their company officers and chiefs to make decisions and lead their subordinates by using the enable others to act mantra. A fire administrator that micro-manages company officers does not develop critical thinkers capable of clear and rapid decision-making. Micro-managers create company officers that make decisions based upon “what do I need to do to not get in trouble” tonight. I have had experience working for both types of deputy chiefs. One allowed his subordinates to make decisions and put plans into motion. This deputy created an atmosphere of 132 learning and growth, which spurred further development of skills. The other, a micro-manager, created an environment of hostility, resentment and professional stagnation. What style of leadership do you wish to be remembered for?

After years of being assigned to operations, (the street I have had the opportunity work with some of the finest fire crews in my city. It has been my experience that each day most firefighters come to work to do a good job, serve the community and when able, to save lives.

The work is continuous, as calls for serve continue to rise. Fire departments across the country are being inundated with calls for service. Enabling the heart is recognizing that the firefighters’ contributions mean something, and to regularly show them appreciation for what it is they do.

Fire crews are not expecting a medal at the end of each week for going on runs. Fire service leaders need to make the connection with those firefighters they work with and ensure they feel appreciated. Build relationships of mutual respect with your fire crews, you’ll be glad you did.

Suggestions for Future Research Future research should review of fire training programs offered by individual states to determine what if any differences there may be and what the firefighter fatality death rates are within the states. Secondly, research should be conducted into the implementation of a mandatory minimal training program for volunteer firefighters in all states. Currently not all states have a mandatory training requirement for volunteer firefighters, this creates the opportunity for significant training deficiencies and inequities throughout a state. Further, these training inequities could conceivably affect neighboring departments that rely upon each other for mutual aid.

Additional research could be conducted that addresses how small departments, with smaller membership of firefighters provide coverage for large service areas and doing safely and 133 effectively. Research could also be conducted that identifies volunteer fire departments that could be used as exemplars for other departments to learn from. Lastly, more research could be conducted that focuses on the high rate of firefighter fatalities related to medical emergencies such as cardiac arrest and strokes.

Conclusion

Review of the data shows that firefighters are dying in consistent ways. Yet despite

NIOSH investigations year after year, the recommendations from each fatality report remain consistent also. Use an incident command system, train firefighters better, develop policies and procedures, maintain better accountability of personnel on the fire ground, and employ sound strategy and tactics every time. Fire service leaders have the information needed to implement change to reduce firefighter fatalities. Yet we don’t do it.

Numerous departments throughout this study didn’t have operational policies or procedures. Firefighters with minimal training were permitted to operate in an environment that was immediately dangerous to life and heath, often without enough supervision. Firefighter protection mechanisms such as safety officers and rapid intervention teams were an afterthought on many fire grounds. Something as simple and straightforward as wearing a seat belt in a fire apparatus was ignored, and as a result 39 people lost their lives.

The evidence necessary to implement a transformational change is available in this study.

Every fire department, no matter how small, must develop a series of operational policies and procedures, or risk losing firefighters to preventable accidents. Training and education of firefighters must be consistent and meaningful and create stress in the trainee so they develop mental models they can use in the future to problem solve when faced with a similar situation.

Those unsure of how to write SOPs, or conduct meaningful training, should contact someone 134 who can help. Fire department leaders can work together with neighboring departments to develop response policies and procedures. Lack of time or personnel or funding is not an excuse to cut corners for the safety of firefighters.

The risks to firefighter’s well-being are high enough without cutting corners of safe operational practices. The effects of cancer on firefighters as a result of their exposure to the products of combustion is taking a heavy toll. Today’s fire crews are exposed to volatile cocktails of chemicals from burning plastics and synthetic materials. The International

Association of Firefighters says cancer is now the leading cause of death among firefighters.

Thirty years ago, firefighters were most often diagnosed with asbestos-related cancers, today the cancers are more often leukemia, lymphoma or myeloma. The relationship between firefighting and the diagnosis of cancer is irrefutable. This connection has caused 38 states to enact legislation within workman’s compensation laws declaring that if a firefighter is diagnosed with cancer it is presumed to have been work related.

This research provides fire service leaders and policy makers with data that can be used to improve the operational conditions their fire crews work within. There are enough hazards associated with being a community’s firefighter, needlessly or carelessly risking their safety and welfare because of lack of procedures, policies or training is shameful. Fire service leadership at all levels should implement changes that can impact what transpires on the emergency scene that can lead to fewer firefighter trauma related fatalities.

In 1998, a 34-year-old firefighter was killed when the fire apparatus he was driving went off the road, rolled over, ejected him from vehicle and he was killed instantly. In 2017, a 68- year-old firefighter was killed instantly when the water tanker he was driving to a reported structure fire went off the road, rolled over, ejected him from the cab and came to rest on top of 135 him. It was 19 years between these incidents. The same outcome occurred, neither department had a seat belt policy, neither firefighter driving the apparatus wore a seat belt. Both are dead.

Why? Haven’t we learned anything? 136

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APPENDIX A: MEMORIAM OF VOLUNTEER FIREFIGHTERS LOST IN 2018

In Memoriam of those Volunteer Firefighters as reported to the USFA, who lost their lives from a

traumatic event in 2018 while in service to their communities.1

Larry Marusik Dakota Snavely Ellinger Volunteer Fire Department East Side Fire Department Texas North Carolina

M.V. Hudson Daniel J. Lucius New London Volunteer Fire Department Carroll Township Fire and EMS Texas Ohio

John Randle Dennis Straight Wamego City Fire Department Charlotte Road-Vanwyck Volunteer Fire Kansas Department South Carolina Thomas Nye Marion Fire Department Dustin Grubbs Massachusetts Magee Volunteer Fire Department Mississippi Christopher P. Truman Lake Mills Fire Department Russell Hayes Wisconsin El Dorado Springs Volunteer Fire Department Missouri Natalie Dempsey Mizpah Volunteer Fire Company New Jersey North Carolina Douglas C. Ambrozewycz David Fischer Perth Amboy Fire Department Sturgis Volunteer Fire Department New Jersey South Dakota Richard L. Sales Madison “Maddy” Lee Clinton, Jr. Reynolds Volunteer Fire Department Friendship Volunteer Fire Department North Carolina Oklahoma Michael Edwards Cory Barr Pratt Volunteer Fire Department Sun Prairie Volunteer Fire Department West Virginia Wisconsin Tom Craigo Michael Goodnight Pratt Volunteer Fire Department West Liberty Fire Department West Virginia

1 At the time of this research, NIOSH had not yet completed any investigations into the above fatal incidents. 159

APPENDIX B: CAREER VS VOLUNTEER FATALITY NUMBERS

An analysis of twenty years of historical data from the United States Fire Administration (USFA) indicates that volunteer firefighters are dying in larger numbers than career firefighters

U.S. Fire Administration 1998 - 2017

All Career and Volunteer Firefighter Deaths from 1998 - 2017 150

125

100 Number of Fatalities Number 75

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Career 37 38 38 368 34 30 36 34 29 50 34 36 28 27 28 29 30 32 23 33 Volunteer 49 71 59 63 50 59 72 71 61 63 66 47 56 51 42 47 56 47 56 48 160

APPENDIX C: DEFINITION OF KEY TERMS

Accountability system – a method of accounting for all personnel and emergency incident in ensuring that only personal specific assignments are permitted to work within the various zones.

Aerial ladder – a power operated ladder permanently mounted on a piece of apparatus.

Air cylinder – the component of the SCBA that stores of the compressed air supply.

Air management – the way in which an individual utilizes in limited air supply to be sure it will last long enough to enter a hazardous zone, accomplish needed tasks, and return safely.

Arched roof – a rounded roof usually associated with a bow-truss.

Arson – the malicious burning of one’s own or another’s property with a criminal intent.

Assistant chief – mid level chief often has a functional area of responsibility, such as training, and answers directly to the Fire Chief.

Attack line – the hose that delivers water from a fire pump to the fire. Attack hoses range in size from 1 inch to 2 ½ inches.

Automatic adjusting fog nozzle – a nozzle that can deliver a wide range of water stream flows. It operates by in internal spring-loaded piston.

Awareness level – provides training that gives first responders the ability to recognize a potential hazardous materials emergency, to isolate the area, and to call for assistance, awareness level responders take protective actions.

Backdraft – the sudden explosive recognition of fire gases when oxygen is introduced into a superheated space previously deprived of oxygen.

Back up personnel – individuals who remove or rescue those working in the hot zone in the event of emergency.

Balloon frame construction – in older type of wood frame construction in which the wall stars 161 extend vertically from the basement of a structure to the roof without any fire stops.

Bearing wall – a wall that is designed to support the weight of a floor or roof.

Boiling-liquid, expanding-vapor explosion (BLEVE) – an explosion that can occur when a volatile liquid is heated.

Booster line – a rigid hose that is 3/4 “ or 1” in diameter. This hose only delivers 3260 GPM, what can do so at high pressures. It is used for small outdoor fires.

Bowstring trusses – trusses that are curved on the top and straight on the bottom.

Buddy system – a system in which two firefighters always work as a team for safety purposes.

Bunker coat – the protective coat worn by a firefighter for interior structural firefighting, also call a turnout coat.

Bunker pants – the protective trousers worn by a firefighter for interior structural firefighting, also call turn out pants.

Captain – the second rank of promotion, between the lieutenant and battalion chief. Captains are responsible for a fire company and for coordinating the activities of that company among the other shifts.

Chain of command – a rank structure, from the firefighter through the fire chief, for managing a fire department and fire ground operations.

Chainsaw – a power saw that uses the rotating movement of the chain equipped with sharpened cutting edges. Typically used to cut through wood.

Chief of the department – the top position in the fire department. The Fire Chief has ultimate 162 responsibility for the fire department and usually answers directly to the mayor or designated public official.

Command – the first component of the incident management system. This is the only position in the ICS that must always be staffed.

Command post – the location at the scene of an emergency where the incident commander is located and where command, coordination, control, in communications are centralized.

Command staff – staff positions establish to assume responsibility four key activities in the incident management system. Individuals at this level report directly to the incident commander.

Command staff include the safety officer, public information officer, and liaison officer.

Confined space – a space with limited or restricted access that is not meant for continuous occupancy, such as a manhole, well, or tank.

Control zones – areas at a hazardous incident that are designated as hot, warm, or cold, based upon safety and the degree of hazard.

Deck gun – apparatus mounted master stream device intended to flow large amounts of water directly onto a fire or expose building.

Defensive attack – exterior fire suppression operations directed at protecting exposures.

Direct attack – firefighting operations involving the application of extinguishing agents directly onto the burning fuel.

Discipline – the guidelines that a department sets for firefighters to work within.

Division – an organizational level with in IMS that divides an incident into geographic areas of 163 an operational responsibility.

Driver/Operator – often called an engineer, this person operates the fire apparatus. The driver/operator is responsible for getting the apparatus safely to the scene, setting up, and operating the apparatus on scene.

Egress – a method of exiting from an area or a building.

Emergency incident rehabilitation – a function of the emergency scene that cares for the well- being of the firefighters. It includes a physical assessment, revitalization, medical evaluation and treatment, and regular monitoring of vital signs.

Emergency traffic – an urgent message, such as a call for help or evacuation, transmitted over a radio that takes precedence over all normal radio traffic.

Engine Company – Engine companies are responsible for securing a water source, deploying hose lines, conducting search and rescue operations, and putting water on the fire.

Entrapment – a condition in which a victim is trapped by debris, soil, or other material and is on able to extricate himself or herself.

Evacuation signal – warn all personnel to pull back to a safe location.

Extension – fire that moves into areas not originally involved, including walls, ceilings, and attic spaces, also the movement of fire into uninvolved areas of a structure.

Extension ladder – an adjustable length, multiple section ladder.

Exterior wall – a wall often made of wood, brick, metal, or masonry that often makes up to the outer perimeter of the building. Exterior walls are often loadbearing.

Extinguishing agent – material used to stop the combustion process, extinguishing agents may include liquids, gases, dry chemical compounds, and dry powder compounds.

Face piece – component of SCBA that fits over the face. 164

Firefighter – this person is tasked with anything from hose line placement to extinguishing fires.

Generally, the firefighter is not responsible for any command functions or supervising other personnel.

Fire helmet – protective head covering worn by firefighters to protect the head from falling objects, want trauma, and heat.

Fire load – the weight of combustibles in a fire area or on a floor in buildings and structures, including either contents or building parts, or both.

Flashover – the condition were all combustibles in a room or confined space have been heated to the point at which they release vapors that will support combustion, causing all combustibles to ignite simultaneously.

Fog stream nozzle – device placed at the end of the firehose that separates water into find droplets aid in heat absorption.

Forcible entry – techniques used by firefighters to gain entry into structures, vehicles, aircraft, or other areas when normal means of entry are locked or blocked.

Forward staging area – a strategically placed area, closest to the incident site, where person now and equipment can be held in readiness for rapid response to an emergency event.

Freelancing – dangerous practice of acting independently of command instructions.

Hazardous materials technician – firefighters who receive training in chemical identification, leak control, decontamination, and cleanup procedures. They would be called to handle the threat of weapons of mass destruction. 165

Horizontal ventilation – the process of making openings so that smoke, heat, and gases can escape horizontally from eight building through openings such as doors and windows.

Hot zone – the area immediately surrounding a hazardous incident site that is directly dangerous to life and health. All personnel working in the hot zone must wear complete, appropriate clothing and equipment.

Ignition phase – the phase of fire development where the fire is limited to the immediate point of origin.

Immediate danger to life and health (IDLH) – an atmospheric concentration of any toxic, corrosive, or asphyxiant substance that poses on immediate threat to life or could cause irreversible or delayed adverse health effects.

Incident action plan (IAP) – the objectives for the overall incident strategy, tactics, risk management, and member safety that are developed by the incident commander.

Incident Command System (ICS) – the first standard system for organizing emergency incidents.

Indirect attack – firefighting operations involving the application of extinguishing agents to reduce the buildup of heat released from a fire without applying the agent directly onto the burning fuel.

Interior attack – the assignment of a team of firefighters together a structure and attend fire suppression.

Interior wall – a wall inside A building that divides a large space into smaller areas. 166

Ladder belt – a belt specifically designed to secure the firefighter to a ladder or elevated service.

Large diameter hose (LDH) – hose in the 4”, 5” and 6” range.

Lieutenant – a company officer who is usually responsible for a single fire company on a single shift, the first in line of company officers.

Light weight construction – the use of small dimension members such as 2x4 or 2x6 wood assemblies as structural supports in buildings.

Load-bearing wall – a wall that supports structural members or upper floors of a building.

Master stream device – a large capacity nozzle that can be supplied by two or more hose lines or fixed piping. Can flow in excess of 300 gallons per minute.

National Institute for Occupational Safety and Health (NIOSH) – a federal agency responsible for research and development on occupational safety and health issues.

National Fire Protection Association (NFPA) – the association that develops and maintains nationally recognized minimum consensus standards on many areas of fire safety and specific standards on hazardous materials.

Offensive attack – an advance into the fire building by firefighters with hose lines or extinguishing agents to overpower the fire.

Parapet walls – walls on a flat roof that extend above the roofline.

Passing command – option that can be used by the first arriving company officer to direct the next arriving unit to assume command.

Personal alert safety system (PASS) – device worn by a firefighter that sounds alarm if the firefighter is motionless for period.

Personnel Accountability Report (PAR) – a report confirming that all members of a company are present.

Personnel accountability system – a method of tracking the identity, assignment, and the location of firefighters operating at an incident scene.

Positive-pressure ventilation – ventilation that relies upon fans to push or force clean air into a structure.

Pre-incident plan – a written document resulting from the gathering of Gen. In detail information be used by emergency response personnel for determining the response to reasonable anticipated emergency incidents at a specific site.

Primary search – an initial search conducted to determine if there are victims who must be rescued. Alright

Products of combustion – heat, smoke, and toxic gases.

Protective hood – a part of a firefighters PPE designed to be worn over the head and under the helmet to provide thermal protection for the neck and ears.

Rafters – solid structural components that support a roof.

Rapid intervention team (RIT) – a minimum of two full adequate personnel on site, is a ready state, for immediate rescue of injured or track firefighters.

Rescue – those activities directed at locating endangered persons at an emergency incident, removing those persons from danger, treating be injured, and providing for transport to an appropriate healthcare facility.

Rescue company – rescue companies are usually tasked with rescue of victims from fires, confined spaces, trenches, and high-angle situations. 168

Resource management – a standard system of assigning and keeping track of the resources involved in the incident.

Risk-benefit analysis – the process of weighing predicted risks against potential benefits and making decisions based on the outcome of that analysis.

Rollover (flame over) – the condition where unburnt products of combustion from a fire have accumulated in the ceiling layer of gas to an enough concentration that they ignite momentarily.

Safety officer – the position within ICS responsible for identifying and evaluating hazardous or unsafe conditions at the scene of the incident.

SCBA harness – part of SCBA that allows firefighters to wear it as a ”backpack.”

SCBA Regulator – part of the SCBA that reduces the high pressure in the cylinder to a usable lower pressure and controls the flow of air to the firefighter.

SCUBA dive rescue technician – a responder trained to handle water rescues and emergencies, including recovery and search procedures, in and under ice situations. SCUBA stands for self- contained underwater breathing apparatus.

Search – the process of looking for victims who are in danger.

Search and rescue – the process of searching a building for a victim and extricating the victim from the building.

Seat of the fire – the main area of the fire.

Self-contained breathing apparatus (SCBA) – respirator with independent air supply used by firefighters to enter toxic and otherwise dangerous atmospheres.

Self-rescue – the activity of a firefighter using techniques and tools to remove himself from a hazardous situation.

Size up – the ongoing observation and evaluation of factors that are used to develop objectives, 169 strategy, and tactics for fire suppression.

Solid stream – a stream made by using a smooth bore nozzle to produce a penetrating stream of water.

Span of control – the number of people that a single person supervises. The maximum number of people that one person affectively supervises is between three and five.

Standard operating procedures (SOP’s) – written rules, policies, regulations, and procedures enforced to create structure for the normal operations of the most fire departments.

Target hazard – any occupancy type or facility that presents a high potential for loss of life or serious impact to the community resulting from fire, explosion, chemical release.

Technical rescue – a complex rescue incident involving vehicles or machinery, water or ice, role techniques, a trench for excavation collapse, or hazardous materials, in which requires specially trained personnel and special equipment.

Technical rescue team – a group of rescuers specially trained in the various disciplines of technical rescue.

Thermal imaging cameras (TIC) – electronic devices that detect differences in temperature based on infrared energy and then generate images based on that data. Commonly used in obscure environments to locate victims.

Thermal layering – the stratification, or heat layers, that occur in a room as a result of a fire.

Training officer – responsible for updating the training of current employees and for training new firefighters in the current techniques of firefighting and emergency medical services.

Transfer of command – reassignment of command authority and responsibility from one individual to another.

Truck company – truck companies specialize in forcible entry, ventilation, roof operations, 170 search and rescue operations above the fire, and deployment of ground ladders.

Truss – a collection of light weight structural components joined in a triangular configuration that can be used to support either floors or roofs.

Two in/Two out rule – a safety procedure that requires a minimum of two personnel to enter a hazardous area and a minimum of two backup personnel remain outside a hazardous area during the initial stages of an incident.

Unified command – ICS option that allows representatives from multiple jurisdictions and/or agencies.

Ventilation – the process of removing smoke, heat, in toxic gases from a burning structure and replacing them with the clean air.

Vertical ventilation – the process of making openings so that the smoke, heat, and gases can escape vertically from a structure.

Warm zone – the area located between the hot zone in the cold zone at an incident.

Wildland – land in an uncultivated natural state that is covered by timber, woodland, rush, or grass.

Wildland fire – an unplanned and uncontrolled fire burning in vegetative fuels.

Wood frame construction – buildings with exterior walls, interior walls, floors, and roofs made of combustible wood materials. Type V building construction as defined in NFPA 220. 171

APPENDIX D: COMPLETED CODING SHEET 172 APPENDIX E: NIOSH REPORT AS EXEMPLAR

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April 24, 2014 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland

Executive Summary On April 24, 2013, a 24-year-old male volunteer fire fighter sustained injuries at a residential structure fire and died eight days later at a metropolitan trauma center. At 0109 hours, Special Unit 418 (SU418) responded with two fire fighters from the first-due volunteer fire station. SU418 was the first unit on scene receiving reports of occupants trapped in the building from police and occupants screaming that a man was trapped on the second floor. The two fire fighters donned their personal protective equipment and made entry. Engine 56 (E56) arrived with a captain and 3 fire fighters. The captain assumed command, conducted a nd size-up, and struck a 2 alarm due to heavy fire in the Residential Structure rear of the structure. Truck 404 arrived and was (NIOSH Photo) instructed to start rescue and ventilation operations. E56’s crew stretched a 1 ¾-inch hoseline to the front door and met one of the fire fighters (the victim) from SU418. The SU418 fire fighter stated that there was an occupant trapped somewhere on the second floor. E56’s nozzleman noticed the 1st floor hallway access was severely limited, due to the hoarding of objects along the walls and on the floor, so they took the stairs to the second floor landing where it was very hot and smokey. When E56 and SU418 reached the 2nd floor, the nozzleman opened the nozzle in short bursts (penciling) to cool down the 2nd floor. The nozzleman radioed Command to get the 2nd floor ventilated. Hearing a personal alert safety system (PASS) alarm, the nozzleman called out to the SU418 crew with no response, and then called a “Mayday.” E56’s backup man went around the nozzleman towards the sound of the PASS alarm. After pushing the door open to a bedroom located on the “B/C” corner of the house, he crawled into the bedroom and found a fire fighter standing and pointing to a second fire fighter on the floor behind the door. The downed fire fighter was found with his gloves, helmet, hood, and facepiece removed. With the help of the nozzleman, they got the unresponsive fire fighter down the stairs and onto the front porch. The downed fire fighter was put on a backboard and taken to Medic 56. Paramedics were able to re- establish a pulse and respiration. The fire fighter was transported to a local hospital and then transferred to a metropolitan trauma center. Unfortunately, the fire fighter passed away from his injuries eight days later.

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Contributing Factors • Civilian at risk in the structure • Blocked access/egress due to hoarding that added to the fuel load • Multiple stairways • Uncoordinated response to an emergency scene • Facepiece removed in immediately dangerous to life or health (IDLH) environment • SU418 crew left the portable radio in the special unit • Loss of crew integrity • Lack of size-up and situational awareness by initial crew • Lack of ventilation.

Key Recommendations

• Ensure that emergency response deployment protocols are developed to prevent uncoordinated responses to an emergency scene • Ensure that crew integrity is properly maintained by voice or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere • Ensure that fire fighters are trained in size-up, risk management, and situational awareness • Ensure that all responding apparatus are staffed with a properly trained and qualified officer • Ensure all fire fighter riding positions are provided radios and fire fighters are trained on their proper use • Ensure fire fighters are trained in self-contained breathing apparatus (SCBA) emergencies • Ensure that fire fighters are properly trained in air management • Ensure that fireground operations are coordinated with consideration given to the effect of ventilation.

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program” which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with State or Federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not name the victim, the fire department or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232- 4636).

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April 24, 2014 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland

Introduction On April 24, 2013, a 24-year-old male volunteer fire fighter sustained injuries at a residential structure fire and died eight days later in a metropolitan trauma center. On May 2, 2013, the U.S. Fire Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On May 12-16, 2013, a general engineer and an investigator from the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to Maryland to investigate this incident. The NIOSH investigators met with members of the career fire department, with members of the volunteer fire department, the county fire investigator, and the County Dispatch Center Director. The NIOSH investigators visited the site and took photographs. The NIOSH investigators interviewed officers, fire fighters, and emergency medical services personnel on scene at the time of the incident. The investigators reviewed fire department standard operating procedures, training records, dispatch records, witness statements, and the medical examiner’s report. Fire Department This combination department consists of 1,050 career members and approximately 2,000 volunteers. The department operates out of 25 career stations and 33 exclusively volunteer stations within the county. The volunteer companies function as independent fire departments, which operate under the county deployment plan. The stations serve a population of more than 800,000 people in a geographic area of approximately 612 square miles of land and 28 square miles of waterways.

Career Fire Department The 25 career fire stations operate under three battalions, which include 28 engine companies, 7 truck companies, 28 advanced life support (ALS) medic units, and 23 brush units. The department also operates a hazardous materials response and support unit, a decontamination unit, and an advanced tactical rescue (ATR) team specially trained for unusually difficult, complex rescues, such as building collapses, water rescues, trench rescues, high-rise rescues, and other special operations procedures.

The career department uniformed personnel consists of staff administrative offices, an operations division, a fire training academy, and a fire marshal’s office. The county police department operates an arson squad and determines the fire cause and origin in conjunction with the fire officers and incident commander. The operations division shift schedule consists of a 10-hour shift and a 14-hour shift each day. Four shifts work two 10-hour shifts (0700–1700), two 14-hour shifts (1700–0700), and are off for four days. There are three battalion commanders on duty 24 hours per day; one of which is also the Division Chief and shift commander. Off duty battalion chiefs are on call.

Page 1 175 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland Volunteer Fire Department The volunteer fire companies include 61 engine companies, 6 truck companies, 17 ALS medic units, 6 tenders (tankers), 9 heavy rescue (squad) units, plus brush and support units. More than 2,000 citizens volunteer in the fire service as active responders, fundraisers, and support personnel. Though volunteer companies are independent, private non-profit corporations, the county operates a combination fire service with career and volunteer fire fighters working together to form a county fire and emergency medical services (EMS) organization.

The affected volunteer fire department operates 2 engines (Engine 412 and Engine 413), 1 heavy rescue (Squad 414, 1 Medic Unit (Medic 415), 1 light rescue/brush truck (Special Unit 418) and 1 utility vehicle (Utility 419). The volunteer fire department has approximately 80 active members including a fire chief and administrative staff, serving a population of approximately 30,000 in a 6 square mile area. Active volunteer members are defined as personnel who respond to 10 or more incidents in a calendar year. The fire structure was 0.32 miles from the first due volunteer fire station. Staffing and Response The minimum staffing on each engine and truck for the career fire department is four fire fighters, including an officer. If the officer is on leave or detailed to another position or function, another officer (Captain or Lieutenant) is detailed to fill the vacancy. The career fire department does not utilize fire fighters as acting officers at the company level. For working fire incidents, additional command and control resources are dispatched, along with a rapid intervention team (RIT), medic unit (if not already dispatched), a rehab unit, and an air unit. The division chief and safety officer are dispatched to an incident after a second alarm is requested. All of the department officers are trained and capable of filling the safety officer position if assigned. On a box alarm assignment, if an assigned volunteer company does not have proper staffing for the apparatus, the next closest unit is dispatched.

Training and Experience The state of Maryland requires training for volunteer fire fighters that consists of NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter I, Hazardous Materials Awareness, Hazardous Materials Operations, and First Responder. The process requires annual recertification. The career fire department involved in this incident has a recruit school, which is 18 weeks in length and consists of NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter I, Fire Fighter II, Hazardous Materials Awareness, Hazardous Materials Operations, and First Responder.

In the state of Maryland training hours are as follows: Firefighter I is 108 hours Firefighter II is 60 hours First Responder is 45 hours Hazardous Materials Operations is 24 hours Hazardous Materials Awareness is 12 hours.

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In the county fire department and EMS organization, a volunteer fire fighter may work in an immediately-dangerous-to-life and-health (IDLH) environment if they meet the following requirements: NFPA 1001, Fire Fighter I Hazardous Materials Operations CPR OSHA 1910.1080 Bloodborne Pathogens certification Completed medical surveillance SCBA fit test.

For career officers, the training requirements are as follows: Lieutenant - NFPA 1021, Standard for Fire Officer Professional Qualifications, Fire Officer I; Captain - NFPA 1021, Standard for Fire Officer Professional Qualifications, Fire Officer II; Battalion Chief - NFPA 1021, Standard for Fire Officer Professional Qualifications, Fire Officer III; Division Chief and above - NFPA 1021, Standard for Fire Officer Professional Qualifications, Fire Officer IV

The SU418 fire fighter (victim) had been a volunteer fire fighter for more than 8 years and had received training on topics that included: NFPA 1001, Standard on Fire Fighter Professional Qualifications Firefighter I; Hazardous Materials Operations; Hazardous Materials Awareness; Emergency Medical Technician- Basic; Rescue Site Operations; and Vehicle and Machinery Rescue.

The captain who was the initial incident commander had more than 28 years of experience and received training on topics such as: NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter III; NFPA 1002, Standard on Professional Qualifications for Driver/Operator; NFPA 1031, Standard on Professional Qualifications for Fire Inspector, Fire Inspector I; NFPA 1033, Standard on Professional Qualifications, Fire Investigator I; NFPA 1041, Professional Qualifications for Fire Service Instructor, Fire Instructor II; and NFPA 1021, Standard on Professional Qualifications for Fire Officer, Fire Officer III.

The Battalion Chief had more than 27 years of experience and had completed training on topics such as: NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter III; NFPA 1041, Professional Qualifications for Fire Service Instructor, Fire Instructor III; NFPA 1021, Standard on Professional Qualifications for Fire Officer III; and Hazardous Materials Operations. Personnel Accountability System Each member of both the career and volunteer departments are assigned two personnel accountability tags. Each tag consists of a picture, an identification number, and a barcode. One tag is given to the officer at the beginning of the shift (career personnel) or when the apparatus is responding (volunteer personnel) to an incident. One tag stays on the apparatus and the other tag goes to “Command” or a “division/group supervisor.” The tags are white for fire operations and blue for EMS personnel.

Page 3 177 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland Structure The residential structure was a three story brick and wood exterior Victorian style home built in the late 1800’s with a pitched roof consisting of wooden rafters and metal sheeting over wooden lath boards. The structure was approximately 3100 square feet that comprised 3 floors plus a partial basement (see Diagram 1, Diagram 2, and Diagram 3). The structure had a staircase just inside the main entry door to the 2nd floor. The house was built with a second staircase, referred to as a servant’s staircase, off the 1st floor studio (original dining room) which went to the 2nd floor just adjacent to the main staircase. This was a multi-family structure with the 1st and 2nd floors set-up to be individual apartments. The 3rd floor consisted of a large bedroom and storage area. The structure had a basement with access on the 1st floor underneath the main stairway. The basement was used primarily for storage. The utilities were both natural gas and electric.

Diagram 1. Fire structure’s 1st floor layout and approximate location of fire origin. Servant stairway is in light blue and are partially underneath main first floor stairway to 2nd floor. The servant stairway accesses the 2nd floor just several feet from the main stairs. Note: All areas were extremely cluttered (hoarding condition) to the point of limited access. (Courtesy of the Fire Department)

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Diagram 2. Fire structure’s 2nd floor layout. Approximate location of injured fire fighter and civilian victim marked with an “X”. Note: All areas were extremely cluttered (hoarding condition) to the point of limited access. A fire fighter from E56 stated he could not advance down the hallway on the 2nd floor due to furniture and other clutter. (Courtesy of the Fire Department)

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Diagram 3. Fire structure’s 3rd floor layout and the bedroom where the civilian victim was prior to the fire. Note: All areas were extremely cluttered (hoarding condition) to the point of limited access. (Courtesy of the Fire Department)

Page 6 180 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland Equipment and Personnel On April 24, 2013, at 0109 hours, the county dispatch center transmitted a box alarm assignment for Box 41-20. The units assigned were a battalion chief, four engines, one truck, two squads, an emergency medical service supervisor, and an ALS medic unit to a residential structure fire with people trapped.

Table 1 identifies the apparatus and staff dispatched on the first alarm assignment, along with their approximate dispatch time and on-scene arrival times rounded to the nearest minute.

On the notification of a “working fire,” a RIT Task Force is dispatched, which consists of an additional engine, truck, and ALS medic unit.

Table 1. First-alarm Equipment and Personnel Dispatched

Resource Designation Staffing Dispatched On-Scene (rounded (rounded to minute) to minute)

Battalion Chief 22 (IC) Battalion Chief 0109 hrs 0124 hrs

Engine 412 (E412) Officer and 3 fire 0109 hrs 0115 hrs fighters

Engine 401 (E401) Officer and 3 fire 0109 hrs 0127 hrs fighters

Engine 56 (E56) Captain and 0109 hrs 0116 hrs 3 fire fighter 1st engine on scene; Called “arrived” late to make sure of location.

Engine 312 (E312) Officer and 3 fire 0109 hrs 0117 hrs fighters Truck 404 (T404) Volunteer fire chief, 0109 hrs 0117 hrs driver/operator, and 3 fire fighters

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Resource Designation Staffing Dispatched Resource Designation

Squad 414 (SQ414) Fire fighter 0109 hrs 0123 hrs

Medic 56 (M56) 2 Paramedics 0109 hrs 0115 hrs

Emergency Medic Lieutenant 0109 hrs 0117 hrs Supervisor Unit 5 (EMS5) Squad 322 (SQ322) 3 Fire fighters 0109 hrs 0127 hrs

Special Unit 418 (SU418) Fire fighter (victim) Special Unit 418 self- 0114 hrs and another dispatched prior to fire fighter Engine 412 and Squad 414 obtaining a full crew at 0113 hours

Engine 19 (E19) Captain and 0113 hrs 0122 hrs 3 fire fighter Medic (M19) 2 Paramedics 0113 hrs 0122 hrs

Truck 18 (T18) Captain and 0113 hrs 0127 hrs 3 fire fighter

Timeline An approximate timeline summarizing the significant events of the incident is listed below. The times are approximate and were obtained by studying available dispatch records, photos, run sheets, witness statements, and fire department records. The times are rounded to the nearest minute. The timeline is not intended, nor should it be used, as a formal record of events.

• 0109 Hours BC22, E412, E401, E56, E312, T404, SQ414, M56, EMS5, and SQ322 were dispatched to a residential fire with people trapped;

• 0113 Hours SU418 self-dispatched; E19, T18, and M19 dispatched as RIT Task Force;

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• 0114 Hours SU418 arrived on scene; Smoke showing from the rear of the structure; Police on scene; Occupants were screaming a person was trapped on an upper floor;

• 0115 Hours E412 and M56 arrived on scene;

• 0116 Hours E56 arrived on scene; SU418 believed to have entered structure;

• 0117 Hours E312, T404, and EMS5 arrived on scene;

• 0122 Hours E19 arrives as the rapid intervention team;

• 0123 Hours SQ414 arrived on scene; E56 enters structure with SU418 fire fighter, who re-enters ahead of them;

• 0124 Hours BC22 arrived on scene; E56 at top of stairs on 2nd floor, encountered heavy smoke and heat and requested ventilation;

• 0125 Hours E56 heard PASS alarm and called a “Mayday”; E19 was doing a 360 degree size-up at this time;

• 0127 Hours BC22 assumed command and re-affirmed the Mayday; SQ322 arrived on scene; E56 located the fire fighter and were bringing him out; E19’s RIT met E56 inside the door to help bring out the fire fighter;

• 0130 Hours The IC requested the 2nd floor windows be ventilated;

• 0131 Hours E312 battled heavy fire on 1st and 2nd floors of Side C;

• 0134 Hours EMS5 enroute to the hospital with the fire fighter;

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• 0137 Hours SQ322 located civilian victim on 2nd floor and removing him through Side A window;

• 0147 Hours Fire knocked down.

Personal Protective Equipment The victim was wearing structural fire-fighting coat and pants, gloves, hood, boots, structural firefighting helmet with eye protection, and self-contained breathing apparatus (SCBA) with an integrated personal alert safety system (PASS). It was reported that the SCBA cylinder valve was in the off position when the victim was brought outside and assumed to have air in the cylinder. At the time of the investigation, the PPE was in the custody of the police department and NIOSH was unable to evaluate it. The SCBA passed its last annual flow test in August 2012. The fire fighter had passed his respirator fit test in April 2013.

The fire department had an external contractor evaluate the SCBA. The initial evaluation by the contractor revealed that the facepiece was missing the external exhalation valve on the left side. An external exhalation valve was recovered by the police investigators the next day in the bedroom. When the SCBA was tested by the external contractor with the external exhalation valve reinstalled the SCBA passed all tests except for the high pressure leakage. The positive pressure system worked properly. Weather Conditions According to data from the U.S Department of Commerce, National Oceanic and Atmospheric Administration, the sky conditions were "clear" with 8 mile visibility. The temperature was 45 degrees F (7.2 degrees C); dew point was 42 degrees F (5.6 degrees C); relative humidity was 89%; and the wind speed was 0 mph. Barometric pressure was 29.94.1 Investigation At 0109 hours, county dispatch responded to the call of a residential structure fire with occupants trapped and dispatched Battalion Chief 22, four engines (E412, E401, E56, and E312), one truck (T404), two squads (SQ414 and SQ322), an emergency medical service officer (EMS5), and a medic unit (M56). Special Unit 418 (SU418), as the first-due volunteer station, self-dispatched with two fire fighters to the incident. SU418 was the first on scene and conferred with police and occupants. The occupants were screaming that a man was trapped on the second floor. The two fire fighters donned their turnout gear and SCBA and made entry into the structure. SU418 was equipped with a portable radio, but neither fire fighter took the radio with them. Engine 56 (E56) arrived with a captain, who assumed command and conferred with police. While pulling up on scene, E56’s Operator stated he saw the SU418 crew don their turnout gear and SCBA. The E56 operator assisted the two fire fighters from E56 with stretching a 1¾-inch hoseline from E56. The E56 captain, initial Incident Commander (IC), entered the front yard to get a view of the residence which set back off the road and was obscured by trees and shrubbery. The IC went down Side B via the driveway, to conduct a size-up. He encountered vehicles, piles of firewood, and numerous other large items that limited access around the Page 10 184 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland residence. On Side C, the IC encountered numerous other obstacles, several vehicles including an RV and piles of miscellaneous items, in the backyard. He observed heavy fire from the ground floor windows extending towards the second floor. At this point, “Command” requested a 2nd alarm for Box 41-20.

At approximately 0117 hours, the E56 operator started pulling a second hoseline off the engine as E412, EMS5, and Truck 404 arrived (see Diagram 4). The IC instructed the T404 Officer in Charge (OIC) to get the structure laddered, start ventilation, and assist with the interior search. Two E56 fire fighters had stretched a charged 1¾-inch hoseline to the front door and met one of the SU418 fire fighters (the victim) on the front porch. The SU418 fire fighter stated that there was an occupant trapped somewhere on the second floor and they had heavy smoke and heat on the 2nd floor. The fire fighter re-entered the structure ahead of the E56 attack crew. The E56 nozzleman noticed the 1st floor hallway access was severely limited, due to accumulation of furniture, art supplies, etc., along the walls and on the floor, so they took the stairs to the second floor landing where they encountered heavy heat and zero visibility. When E56 reached the top of the stairs at the 2nd floor, the nozzleman opened the nozzle in short bursts (penciling) to cool down the 2nd floor. The servant’s stairwell provided a means for the heat and smoke to rise right in front of the fire fighters at the top of the stairs (see Photo 1, Diagram 1, and Diagram 2). An unknown fire fighter went past the crew towards the stairs. The nozzleman felt his arms getting hot and radioed “Command” to get the 2nd floor ventilated. The T404 OIC and a fire fighter were on Side C, threw an 18-foot ground ladder, and took out the 2nd floor window above the 1st floor bathroom. Two other T404 fire fighters threw 20-foot and 16-foot ground ladders to the porch roof but never vented the 2nd floor windows on Side A.

At 0124 hours, BC22 arrived on scene, went to the front of the fire structure, and had a face-to-face with the IC. At this time, the E56 attack crew, hindered by clutter within the structure, tried to advance down the 2nd floor hallway and heard a PASS alarm. The E56 crew called out to the SU418 crew with no response. The nozzleman tried contacting the SU418 crew via radio with no response. At this point, he called a “Mayday.”

At 0127 hours, BC22 assumed command and re-affirmed the Mayday with the county dispatch center and activated the RIT. The E56 backup man went around the nozzleman towards the sound of the PASS. After pushing the door open to a bedroom located on the B/C corner of the house, he crawled into the bedroom and found/felt a fire fighter who was standing up. This fire fighter, from SU418, was pointing to a fire fighter on the floor behind the door (see Photo 2 and diagram 2). The fire fighter was face down with no helmet, hood, facepiece, or gloves. These items were later recovered from the bedroom. The E56 fire fighter reached around and pulled the unconscious fire fighter up and yelled to the nozzleman that he had the downed fire fighter. With the help of the fire fighter from SU418, the E56 crew got the unresponsive fire fighter down the stairs. They were met just inside the door by the E19 RIT, who then helped get the fire fighter to the porch. The RIT captain removed the fire fighter’s SCBA and noticed the cylinder valve was in the closed position. At approximately 0129 hours, the victim was put on a backboard and taken to Medic 56 that was staged at a commercial building just south of the fire structure. Paramedics were able to re-establish a pulse and respiration. At approximately 0134 hours, the fire fighter was transported to a local hospital and then transferred to a metropolitan trauma center. Unfortunately, he passed away from his injuries eight days later.

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At 0137 hours, SQ322 located the civilian victim on the second floor. The civilian victim was removed through the Side A 2nd floor window to the porch roof and down a ground ladder. At approximately 0147 hours, E412, E312, and other companies on scene had knocked down the fire, primarily on Side C, and were checking for extension.

North

Residential Green areas represent Area with vehicles, hedges, lawn items, wood, shrubs and SU418 etc. trees T404

Fire All attack

Structure lines were

1¾ “ E56

Cluttered Driveway

E412

Commercial

5" supply

lines E312

Commercial

Diagram 4. Initial apparatus and hoseline placement at the scene.

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Photo 1. The servant’s stairwell, off the dining, near the origin of the fire in the kitchen which provided a chimney effect for the heat and smoke to the 2nd floor where the fire fighters were conducting their search. (NIOSH Photo)

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Photo 2. The bedroom where the downed fire fighter was found behind the door. This post-incident photo is absent of the clutter that existed. (NIOSH Photo)

Fire Behavior According to the investigating Detective from the County Police Department, the fire originated in the rear of structure in the kitchen area on the 1st floor. Indicators of significant fire behavior • Smoke and fire on Side C upon arrival • Heat and heavy black smoke on 2nd floor • Heavy fire on Side C both 1st and 2nd floors • Servant’s stairway provided direct access for heat and smoke to rise to 2nd floor (see Photo 1)

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• Vented 2nd floor windows on Side C • Fire under control 32 minutes after arrival.

Contributing Factors Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that led to the fatalities:

• Civilian at risk in the structure • Blocked access/egress due to hoarding that added to the fuel load • Multiple stairways • Uncoordinated response to an emergency scene • Facepiece removed in immediately dangerous to life or health (IDLH) environment • SU418 crew left the portable radio in the special unit • Loss of crew integrity • Lack of size-up and situational awareness by initial crew • Lack of ventilation.

Cause of Death According to the death certificate, the medical examiner listed the victim’s cause of death as smoke inhalation and thermal injuries with complications. Upon arrival to the emergency room the fire fighter’s carboxyhermoglobin was 47.3 percent and he had burns on his left hand and forehead. Recommendations Recommendation #1: Fire departments should ensure that emergency response deployment protocols are developed to prevent uncoordinated responses to an emergency scene.

Discussion: The International Association of Fire Chiefs and the National Volunteer Fire Council discourage the practice of self-dispatch among emergency response personnel to emergency incidents without notification or request. They have issued a joint policy statement stating that, “Uncontrolled and uncoordinated arrival of resources at emergencies cause significant accountability issues as a result of personnel freelancing and creating additional safety risks to firefighters, civilians and others who are operating within the parameters of the incident action plan. Chaos at the scene occurs, creating additional safety risks because these companies or individuals are not aware of the overall strategic plan. Further, unrequested emergency units and emergency personnel at incidents disrupt the accountability and incident management system. An incident management system requires that a formal structure is utilized to determine the needs of an incident. The needs of the incident are in most cases directly related to personnel and equipment. When resources show up that have not been requested, the incident management system fails. Unplanned resources in many cases block roads, create traffic jams, restrict access and ultimately affect the safety of those fire fighters who are

Page 15 189 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland operating at the scene by denying them needed resources. Freelancing of personnel and fire companies adversely impact incident management systems and require that the Incident Commander assign more personnel to control and coordinate these resources that were not requested.”2

In this incident, SU418 self-dispatched while E412 was waiting for a full crew. The initial Incident Commander noticed the presence of SU418 vehicle at the scene but was unaware where or what the SU418 crew was doing.

Recommendation #2: Fire departments should ensure that crew integrity is properly maintained by voice or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere.

Discussion: When a crew enters a structure, the members must remain in contact by visual (eye-to- eye contact), verbal (by radio or by person-to-person), or direct (by touch) contact. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, states in Paragraph 8.5.5, "Crew members operating in a hazardous area shall be in communication with each other through visual, audible, or physical means or safety guide rope, in order to coordinate their activities."3 Additionally, NFPA 1500 Paragraph 8.5.6 states, "Crew members shall be in proximity to each other to provide assistance in case of an emergency."3

The International Association of Fire Chiefs, Safety, Health, and Survival Section has redefined the Rules of Engagement for Structural Fire-Fighting. One of the objectives is to ensure that fire fighters always enter a burning building as a team of two or more members and no fire fighter is allowed to be alone at any time while entering, operating in, or exiting a building. A critical element for fire fighter survival is crew integrity. Crew integrity means fire fighters stay together as a team of two or more. They must enter a structure together and remain together at all times while in the interior, and all members come out together. Crew integrity starts with the company officer ensuring that all members of the company understand their riding assignment, having the proper personal protective equipment, and having the proper tools and equipment. Upon arrival at the incident, the company is given a task to perform by the Incident Commander. The company officer communicates to the members of the company what their assignment is and how they will accomplish their assignment. As the members of a company enter a hazardous environment together, they should leave together to ensure that crew integrity is maintained. If one member has to leave, the whole company leaves together.4

It is the responsibility of every fire fighter to stay in communications with crew members at all times. All fire fighters must maintain the unity of command by operating under the direction of the Incident Commander, division/group supervisor, or their company officer at all times. The ultimate responsibility for crew integrity and ensuring no members get separated or lost rests with the company officer. They must maintain constant contact with their assigned members by visual observation, voice, or touch while operating in a hazard zone. They must ensure they stay together as a company or crew. If any of these elements are not adhered to, crew integrity is lost and fire fighters are placed at great risk. If a fire fighter becomes separated and cannot re-connect with his/her crew immediately, the fire fighter must attempt to communicate via portable radio with the company officer. If reconnection is not accomplished after three radio attempts or reconnection does not take place within one minute, a

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Mayday should be declared. If conditions are rapidly deteriorating the Mayday must be declared immediately. As part of a Mayday declaration, the fire fighter must next activate the radio's emergency alert button (where provided) followed by manually turning on the PASS alarm. Similarly, if the company officer or the fire fighter's partner recognizes they have a separated member, they must immediately attempt to locate the member by using their radio or by voice. If contact is not established after three attempts or within one minute a Mayday must be declared immediately.4

In this incident, the crew from SU418 rushed to rescue the civilian trapped on the second floor and left their radio in the special unit. After being driven back down the stairs by heat and smoke, the victim spoke to the E56 engine crew with a hoseline on the porch and re-entered with the engine crew behind him. At some point the victim and his partner became separated. When his PASS alarm went off his partner re-located him just prior to the engine crew.

Recommendation #3: Fire departments should ensure fire fighters are trained in effective size-up, operational risk management, and situational awareness.

Discussion: Size-up is a systematic process which consists of a swift gathering of information based upon critical incident factors which leads to the development of a strategy and Incident Action Plan. This process leads to making efficient, effective, and safe decisions on the fireground. The fireground is a very dynamic and rapidly changing environment. The initial size-up cannot be delayed or overlooked nor can it be a time-consuming process. The size-up has to be methodical, concise, and ensure all the necessary information is gathered and then communicated to the dispatch center and other responding units. This is done in conjunction with the assuming command of the incident.5

The size-up consists of specifics such as but not limited to: • type of building and construction, • occupancy type, • location and volume of fire, • life safety issues, • exposure problems, • building access and egress, • water supply, • available staffing • offensive fire attack versus defensive operations.6

The first arriving officer has to conduct a 360o walk-around of the structure, if possible, to gather this information. Once the information gathering has been completed, the officer can develop a strategy and Incident Action Plan for the particular incident.

In addition, the officer needs to provide a brief initial status report to the dispatch center and to responding units. The initial status report should include: • building and occupancy type, • description of conditions,

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• instructions to others, • requests for additional resources.5

The initial status report is a necessary element of incident management as this ensures that everyone who is responding to or is on scene at the incident has a clear picture of what is occurring.

Operational risk management needs to be integrated into this process by the first arriving officer or member. The risk to fire department members is the most important factor to be considered by the first arriving officer/Incident Commander in determining the strategy and Incident Action Plan that will be applied in each situation. The concept of risk management should be utilized on the basis of the following principles: • activities that present a significant risk to the safety of members shall be limited to situations where there is a potential to save endangered lives; • activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of members, and actions shall be taken to reduce or avoid those risks; • no risk to the safety of members shall be acceptable when there is no possibility to save lives or property; • in situations where the risk to fire department members is excessive, activities shall be limited to defensive operations.3

All fire fighters operating at an incident should maintain situational awareness and conduct a continuous risk assessment throughout the incident, reporting unsafe or changing conditions to the Incident Commander. Fire fighters need to understand the importance of situational awareness and personal safety on the fire ground. The fire ground dangers and hazards can and do change as the incident becomes larger and the event duration increases. Situational awareness is defined as recognition of the immediate surroundings. On the fireground, every fire fighter should be trained to be constantly alert for changing and unsafe conditions related to their immediate surroundings. This applies not only to the conditions found within a burning structure, but to the exterior fire ground as well.7

The opposite of situational awareness is tunnel vision where the fire fighters become so focused on fire-fighting operations, rescue, or other operational assignments that they fail to sense changes in their environment. Fire fighters can maintain their situational awareness by looking up, down, and around as well as listening for new or unusual sounds and feeling vibrations or movement. Fire fighters and officers should communicate any changes in their environment to other members as well as to the Incident Commander.

The International Association of Fire Chiefs, Safety, Health and Survival Section developed the Rules of Engagement for Structural Fire-Fighting. These rules of engagement have been developed to assist fire fighters, fire officers, and the Incident Commander in risk assessment and “Go” or “No-Go” decisions. The fireground creates significant risks to fire fighters. The goal is to reduce fire fighters from the exposure to unsafe conditions and stop unsafe practices.4

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The Rules of Engagement for Structural Fire-Fighting can assist the Incident Commander, company officers, and fire fighters in assessing their situational awareness. One principle applied in the Rules of Engagement for Structural Fire-Fighting is that fire fighters and company officers are the members most at risk for injury or death and should be the first to identify unsafe conditions and practices. The rules integrate the fire fighter into the risk assessment decision making process. Where it is not safe to proceed, the rules allow a process for that decision to be made while still maintaining command unity and discipline.

Rules of Engagement for Fire-Fighter Survival: • Size-up your tactical area of operation. (Pause for a moment, look over the area of operation, evaluate individual risk exposure, and determine a safe approach to completing your tactical objectives.) • Determine the occupant survival profile. (Consider occupant survival as part of your individual risk assessment and action plan.) • Do not risk your life for lives or property that cannot be saved. (Do not risk your life when fire conditions prevent occupant survival and when significant or total destruction of the building is inevitable.) • Extend limited risk to protect savable property. (When trying to save a building, limit risk exposure to a reasonable, cautious, and conservative level.) • Extend vigilant and measured risk to protect and rescue savable lives. (During high-risk primary search-and-rescue operations where lives can be saved, manage search-and-rescue operations in a calculated, controlled, and safe manner while remaining alert to changing conditions.) • Go in together, stay together, and come out together, when two or more fire fighters are operating as a team/crew. • Maintain continuous awareness of your air supply, situation, location, and fire conditions. (Maintain situational awareness by knowing where you are in the building and what is happening around you and elsewhere that can affect risk and safety.) • Constantly monitor fire ground communications for critical radio reports. • Report unsafe conditions or practices that can harm you. Stop, evaluate, and decide. (Officers should prevent exposure to unsafe conditions or practices by allowing any member to raise an alert about a safety concern without penalty and by mandating supervisors address safety questions to ensure safe operations.) • Abandon your position and retreat before deteriorating conditions can harm you. (Be aware and exit early to a safe area when you are exposed to deteriorating conditions, unacceptable risk, and a life-threatening situation.) • Declare a Mayday as soon as you think you are in danger. (Officers should ensure fire fighters are comfortable with declaring a Mayday as soon as they think they are in trouble.)4

At this incident, the two SU418 fire fighters arrived on scene in a utility vehicle without the benefit of proper staffing on the fireground. Focused on rescuing the civilian, they left the portable radio in the fire department vehicle; did not have the protection of a hoseline; did not realize the fuel load created

Page 19 193 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland by hoarding and its impact on ingress/egress issues; did not maintain situational awareness; and became separated.

In a scenario of arriving first on-scene, when occupants are screaming and shouting about a trapped occupant, the situation can easily dictate a focus on the rescue of the occupant and at the expense of conducting a proper size-up. The size-up should be conducted along with the incorporation of risk management plus maintaining situation awareness. These are all critical elements essential to fire fighter safety which should not be overlooked.

Recommendation #4: Fire departments should ensure that all responding apparatus are staffed with a properly trained and qualified officer.

Discussion: The importance of having a properly trained and qualified officer assigned to an apparatus is crucial to the success of the company or response unit from both a management perspective as a well as fire fighter safety. A company officer is given the responsibility to effectively and efficiently manage the company or response unit and ensure for the assigned member(s). NFPA 1720: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments requires that members responding to an emergency incident shall be organized into companies or response units and shall have the required apparatus and equipment. A company officer shall at all times be aware of the identity, location, and activity of each member assigned to the company.8 Also, NFPA 1201, Standard on Developing Fire Protection Services for the Public states in Chapter 9 – “Organization for Fire Protection”, Paragraph 9.4.1, “A company officer or qualified acting officer shall be assigned to be in charge of each company at all times. An assistant officer also shall be assigned in the case of volunteer companies”.9

A company officer has the knowledge, skills, abilities, and competencies to function as the leader of a company or crew. The company officer functions in both an administrative and operational capacity. The focus of this recommendation is the operational component, which is vital to the successful outcome of any emergency incident. Many times, the initial Incident Commander is a company officer. The first arriving officer is the person who can directly evaluate conditions and use visible information to develop the on-scene decisions which can produce rapid, efficient action. The first arriving officer is responsible for initiating the incident management process at the very beginning of the event. If this window of opportunity is missed, there will not be another opportunity. If this assumption of command is missed, the impact can affect the remainder of the incident and the members responding to the incident.5

The first arriving resource is responsible for initiating the incident management system which includes performing a scene size-up which includes a thorough risk assessment. The first arriving resource then provides a brief initial status report which confirms the assumption of command of the incident. Command is developing a strategy and Incident Action Plan as well.

There are three levels that function on the fireground – strategic, tactical, and task levels. The first arriving resource assuming Command insures that initial management functions and incident action

Page 20 194 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland occur in a coordinated and integrated way. This prevents uncoordinated operations (freelancing) from occurring and having to overcome the obstacles when Command is finally established. The three operational levels are clearly defined and established. In this incident, two fire fighters responded in SU418 without an officer. Their response time was about one minute and they were the first to arrive on scene. When they arrived on scene, there was no size-up given, no initial status briefing, no assumption of command, no accountability, no hoseline available, and no rapid intervention team established at that time. Neither fire fighter had a portable radio which was left in the cab of SU418. The actions of the two fire fighters were affected by the fact that occupants were screaming that a person was trapped inside the building. The two fire fighters immediately went into the structure and to the 2nd floor. Due to the high heat and smoky conditions, they retreated back to the front porch and met the crew from E56. The two crews went to the 2nd floor where the SU418 fire fighter may have experienced an SCBA emergency eventually being found.

There are many functions of incident management that have to occur in a very brief period of time at the beginning of an incident. Fire fighters operate primarily on the task level and situations such as those encountered during this incident may cause them to overlook the tactical and strategic levels. An officer is responsible for ensuring all three operational levels are properly coordinated from the beginning of an incident.

Recommendation # 5: Fire departments should ensure all fire fighter riding positions are provided radios and fire fighters are trained on their proper use.

Discussion: The National Fire Protection Association (NFPA) 1561, Standard on Emergency Services Incident Management System, Section 6.3 Emergency Traffic, states in section 6.3.1: “To enable responders to be notified of an emergency condition or situation when they are assigned to an area designated as immediately dangerous to life or health (IDLH), at least one responder on each crew or company shall be equipped with a portable radio and each responder on the crew or company shall be equipped with either a portable radio or another means of electronic communication.”10 The joint U.S. Fire Administration (USFA) and International Association of Fire Fighters (IAFF) report, Voice Radio Communications Guide for the Fire Service,11 provides an overview of radio communication issues involving the fire service. Effective fireground radio communication is an important tool to ensure fireground command and control as well as helping to enhance fire fighter safety and health. Every fire fighter on the fireground should be provided with their own radio in case they become lost or separated from their crew.

Receiving interior/exterior status updates is critical to the safety of fire fighters on the incident, rescue/recovery efforts, and overall control of the incident. The fireground is very dynamic, and conditions can either improve or deteriorate based on fire suppression activities, and available resources, and most importantly assessments/size-ups of the incident are necessary to detect a change on the fireground.

It is every fire fighter’s and company officer’s responsibility to ensure radios are properly used. Ensuring appropriate radio use involves both taking personal responsibility (to have your radio, having it on, and on the correct channel) and a crew based responsibility to ensure that the other members of

Page 21 195 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland your crew are doing so as well. Radios should be designed and positioned to allow the fire fighter to monitor and transmit a clear message. These radios should be well maintained and inspected by qualified personnel on a regular basis.

The fire department involved in this incident typically issues three radios per fire apparatus. The company officer and the driver carry a radio. On engine companies, the hydrant fire fighter is assigned a radio. On truck companies, the fire fighter responsible for forcible entry at the rear carries a radio. During this incident, SU418 had a portable in the vehicle but neither fire fighter grabbed it prior to leaving the vehicle. Both the International Association of Fire Chiefs (IAFC)12 and the International Association of Fire Fighters (IAFF)11 recommend that all fire fighters be assigned a radio. In 1999, the U.S. Fire Administration technical report Improving Firefighter Communications identified a number of radio communication issues, including the need for all fire fighters to have portable radios. The report stated “Ideally, every firefighter working in a hostile environment should have a portable radio with emergency distress feature.”13 The IAFF Fireground Survival Program contains training on radio communication procedures in emergency operations including how to call a Mayday.14

Recommendation #6: Fire departments should ensure fire fighters are trained in self-contained breathing apparatus (SCBA) emergencies.

Discussion: Repetitive skills training with SCBA is vital for fire fighters working inside an IDLH atmosphere. SCBA skills training is an ongoing process that should be performed regularly to ensure that fire fighters "know their SCBA." The benefits of repetitive skill training with SCBA are an increased comfort and competency level, decreased anxiety, lower air consumption, increased awareness of the user's air level, noticing and using the heads-up display (HUD), and an automatic muscle memory response of the vital function controls, such as the don/doff buttons, main air valve, emergency bypass operating valve, rapid intervention crew/universal air connection (RIC/UAC) and the buddy breather connection. Repetitive skills training can also provide the user with an increased ability to operate these functions and controls in a high-anxiety moment or an emergency. Many times these skills will be necessary with gloved hands, limited vision, and reduced ability to hear commands from others. Performed in conditions that are non-IDLH, repetitive skills training helps build the fire fighters' muscle memory skills so their hands will be able to activate the controls with gloves on and the operation will be a conditioned or second-nature response. Fire fighters have died in IDLH conditions because they did not react properly to a malfunctioning SCBA or out-of-air emergency.15

Fire fighters should never remove their facepiece in an IDLH atmosphere. Self-contained breathing apparatus may experience partial or total malfunctions. For example, if a regulator malfunctions a fire fighter can often open the emergency bypass valve to purge the exhalation valve or get air. If the pressure-reducer malfunctions, airflow can be controlled by partially closing the cylinder valve to get some flow of air. The key to most situations is to not panic and concentrate on skills training. Most procedures recommend calling for help and/or activating your PASS device, and attempting to exit the structure. An emergency training protocol should be established for each type of SCBA in an emergency situation and utilize programs compliant with NFPA 1404 Standard for Fire Service Respiratory Protection Training.

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Note: In 2012, NIOSH NPPTL lifted the prohibition on Emergency Buddy Breathing Safety System (EBBSS) for structural fire fighting only. The NFPA technical committee revised the language to include performance criteria for an EBBSS connection, in the 2013 edition of NFPA 1981.16

In this incident, the victim apparently experienced an SCBA emergency and went into a near-by room to try and fix the issue by removing his facepiece without the knowledge of his partner. It is assumed this is where they became separated. The victim was overcome by the toxic conditions and his PASS device was heard by the engine crew at the top of the stairwell. The victim’s external exhalation valve was later recovered in the bedroom.

Recommendation #7: Fire departments should ensure that fire fighters are properly trained in air management.

Discussion: Chief Bobby Halton, retired chief and Editor in Chief of Fire Engineering notes, “If you run out of air in a working fire today, you are in mortal danger. There is no good air at the floor anymore, no effective filtering methods, no matter what others may say to the contrary.” The only protection for fire fighters in the toxic smoke environments in today’s fires is the air that they carry on their backs. Like SCUBA divers, fire fighters must manage their air effectively and leave enough reserve air to escape in case of unforeseen occurrences while inside a structure fire. Fire fighters must manage their air so that they leave the immediately dangerous to life or health (IDLH) atmosphere before the low-air alarm activates. This leaves an emergency air reserve and removes the noise of the low-air alarm from the fireground.17 Air management is a program that the fire service can use to ensure that fire fighters have enough breathing air to complete their primary mission and to escape an unforeseen emergency. Fire departments and fire fighters need to recognize that the smoke in modern construction is an IDLH atmosphere and manage their air along with their work periods so the fire fighters exit the IDLH atmosphere with their reserve air intact. NFPA 1404 Standard for Fire Service Respiratory Protection Training states that fire fighters should exit from an IDLH atmosphere before the consumption of reserve air supply begins; a low-air alarm is notification that the individual is consuming the reserve air supply and that the activation of the reserve air alarm is an immediate action item for the individual and the fire-fighting team.18

The vast majority of the structure fires responded to are single or multi-family residential occupancies. For some fire departments, a typical strategy is an aggressive offensive fire fight to achieve the tactical priorities. Generally, fire crews are able to search these structures quickly, put out the fire, and exit the hazard zone without having to give much thought to air management.

There are usually multiple points of egress close by should a rapid retreat to the exterior become necessary. It's critical to insure firefighters exit the hazard zone with an emergency reserve of air.

According to NFPA 1404, all members utilizing an SCBA in the hazard zone of an incident shall monitor the amount of air in their SCBA cylinder as well as their rate of air consumption in order to exit the hazard zone prior to the low air alarm activation of the SCBA.18 Just as ocean divers are trained to surface with an emergency reserve of air, firefighters shall exit the hazard zone of an incident with an emergency reserve of air. It is critical that firefighters understand that the initial 67%

Page 23 197 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland of the air supply is the "working and exiting air".16 This includes air utilized for gaining access, working toward the tactical objectives, and exiting the hazard zone.

Company officers shall frequently assess their crew's air consumption rates and decide the crew's exit time based on the individual with the greatest assumed air consumption rate. It is the individual firefighter's responsibility to continually assess and report his/her air consumption to his/her company officer.

In this incident, the two SU418 fire fighters entered the building with their SCBA and facepieces reportedly on. They tried to get to the 2nd floor without the protection of a hoseline, but were unable due to the high heat and smoky conditions. They retreated to the front porch of the structure where they met E56. Both crews entered the structure and went to the 2nd floor. The victim apparently had an SCBA emergency and went into the bedroom and closed the door. Perhaps in a self-survival mode he did not have the mental acuity or focus to attempt exiting the structure. The crew from E56 heard a PASS Alarm sounding and found the victim on the floor not wearing his helmet, facepiece, or gloves and unresponsive. The other fire fighter from SU418 and E56 moved the victim down the stairs and were met just inside the door by the E19 RIT, who then helped get the fire fighter to the front porch.

Recommendation #8: Fire departments should ensure that fireground operations are coordinated with consideration given to the effect of ventilation.

Discussion: NFPA 1021, Standard for Fire Officer Professional Qualifications, section 4.6.1 and A.4.6.1(A), requires that all fireground operations conducted are based upon the overall strategy and incident action plan (IAP) developed by the IC. The essential element is to ensure that fireground operations (strategy, tactics and tasks) are coordinated and communicated so that everyone understands the plan. Strategy is the overall goal or goals of managing the incident. Tactics are selected and based on strategic goals and employed through tried and true fireground objectives — such as rescue, exposures, confinement and extinguishment of the fire, overhaul, ventilation and salvage. Based on size-up findings, the IC needs to prioritize the delivery of these tactics to put out the fire, ensure it stays out and conserves as much property as the complexity and fire size allows. The IC must train and prepare to develop a strategy and IAP based upon information acquired and factors observed for every incident. This practice provides the basis for a standard incident management approach to every incident. Decisions made and the actions they produce can be no better than the information on which they are based. The IC must develop the habit of using the critical factors in their order of importance as the basis for making the specific assignments that make up the IAP.19 This standard approach becomes a huge help when it is hard to decide where to start.

The IC must create a standard information system and use effective techniques to keep informed at the incident. Information is continually received and processed so that new decisions can be made and old decisions revised based on new data and information received. The IC can never assume action- oriented responders engaged in operational activities will just naturally stop what they are doing so they can feed the IC a continuous supply of top-grade objective information. It is important that if the

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IC or Supervisor requests a progress report from a company with no response they should continue to make contact until they get a satisfactory report.

During most critical incident situations, the IC many times must develop an IAP based only on the critical factor evaluation information available at the beginning stage of operations. Many times, that information is incomplete. Even though the IC will continue to improve the IAP's quality, the IC will seldom function during the fast, active periods of the event with complete or totally accurate information on all factors. This is most evident during confused, time-compressed initial operations. This continual improvement in the accuracy and timeliness of incident information becomes a major IC function.20,21

An essential tactic of any IAP is if and when to ventilate. An IC will have the option of deciding if natural, mechanical, horizontal, vertical, or hydraulic ventilation may work best for each type of fire structure and situation. Generally, in two-story residential structures with fires on the first floor, utilize windows closest to the seat of the fire. Consider ventilating the second floor as soon as possible. When the fire is on the second floor, ventilate this floor first. If possible, start by ventilating the outside windows of the room of origin first and coordinate the movement of air within the structure. Keep the doors to rooms closed once searched and especially control the doors to rooms where windows have been taken out. Control the flow of air from the inside to the outside if possible.22

With the amount of plastics and hydrocarbon-based products found in homes today and coupled with engineered building products, the increased intensity of fire growth and heat paths can have a significant impact on interior crews and their safety.23 Interior crews can face significant heat when searching for the seat of the fire, especially in an environment where minimal ventilation causes the retention of heat.24 This then poses the danger of a flashover when adequate ventilation occurs. In this incident the engine crew mentioned the extreme amount of heat and black smoke that was at the top of the stairwell which was in close proximity to where the victim was found. The engine crew requested ventilation.

At this incident, the fire structure was built in the late 1800’s and had a servant’s staircase, off the dining area near the fire’s origin, which the fire department was unaware of initially. In addition, the structure contained a large amount of combustible and hydrocarbon-based products due to hoarding which produced a heavy black smoke. The servant’s staircase provided a means for the smoke and heat to travel to the second floor very quickly causing visibility on the 2nd floor to be near zero. Ventilation was called for early in the incident but was not completed until after the victim was rescued. References

1. National Oceanic and Atmospheric Administration, http://www.ncdc.noaa.gov/cdo-web/results

2. The International Association of Fire Chiefs (IAFC) and the National Volunteer Fire Council (NVFC) Discourage the practice of self-dispatch among emergency response personnel to emergency incidents without notification or request;

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http://www.iafc.org/files/downloads/ABOUT/POLICY_STATES/IAFCpol_SelfDispatchAmon gPersonnel.pdf

3. NFPA [2013]. NFPA 1500 standard on fire department occupational safety and health program. 2013 ed. Quincy, MA: National Fire Protection Association.

4. IAFC [2012]. Rules of engagement for structural firefighting. Fairfax VA: International Association of Fire Chiefs, Safety, Health and Survival Section [http://www.iafcsafety.org/downloads/Rules_of_Engagement_short_v10_2.12.pdf].

5. Brunacini, AV [2002]. Fire Command, 2nd Edition. National Fire Protection Association. Quincy, MA. 2002.

6. NIOSH [2010]. NIOSH alert: preventing deaths and injuries of fire fighters using risk management principles at structure fires. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No.2010-153 [http://www.cdc.gov/niosh/docs/2010-153/].Date accessed: November 2013.

7. IFSTA [2008]. Essentials of fire fighting, 5th ed. Oklahoma State University. Stillwater, OK: Fire Protection Publications, International Fire Service Training Association.

8. NFPA [2010]. NFPA 1720: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments. 2010 ed. Quincy, MA: National Fire Protection Association.

9. NFPA [2010]. NFPA 1201: Standard on Developing Fire Protection Services for the Public. 2010 ed. Quincy, MA: National Fire Protection Association

10. NFPA 1561[2008]. NFPA 1561: Standard on Emergency Services Incident Management System, 2008 Edition. Quincy, MA: National Fire Protection Association.

11. USFA / IAFF [2008]. Voice Radio Communications Guide for the Fire Service. Joint publication by cooperative agreement with the International Association of Fire Fighters (IAFF) and the U.S. Fire Administration (USFA). October 2008. http://www.iaff.org/08News/PDF/RadioCommunications.pdf. Date accessed: April 1, 2014.

12. IAFC [2011]. Position Statement: Assignment of Portable Radios/Two-Way Communications Devices to Every Firefighter on the Fireground, dated April 1, 2014. International Association of Fire Chiefs. Fairfax, VA. http://www.iafc.org/associations/4685/files/IAFCposition_Daniels_PortableRadiosPositionStat ement.pdf. Date accessed: April 1, 2014.

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13. USFA [1999]. Special Report: Improving Firefighter Communications. U.S. Fire Administration / Technical Report Series: USFA-TR-099/January 1999. Department of Homeland Security, Emmitsburg, MD.

14. IAFF [2010]. IAFF Fire Ground Survival Program. International Association of Fire Fighters. http://www.iaff.org/HS/FGS/FGSIndex.htm. Date accessed: April 1, 2014.

15. NIOSH [2011]. Career fire fighter dies while conducting a search in a residential house fire– Kansas. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2010-13 http://www.cdc.gov/niosh/fire/reports/face201013.html.

16. NFPA [2013]. NFPA 1981 Standard on open-circuit self-contained breathing apparatus for emergency services. 2013 ed. Quincy, MA: National Fire Protection Association.

17. Gagliano M, Phillips C, Jose P, Bernocco S [2008]. Air management for the Fire Service. Tulsa, OK: Penn Well Corporation, Fire Engineering.

18. NFPA [2013]. NFPA 1404, Standard for fire service respiratory protection training. 2013 ed. Quincy, MA: National Fire Protection Association.

19. NFPA [2014]. NFPA 1021 Standard for Fire Officer Professional Qualifications. 2014 ed. Quincy, MA: National Fire Protection Association.

20. FEMA [1996]. Risk Management Practices in the Fire Service, 1996. Washington, DC: Federal Emergency Management Agency.

21. Brunacini AV and Brunacini N [2004]. Command Safety. Across the Street Publications.

22. Lee, M [2008]. Ventilation Basics by Structure Type. http://www.firerescue1.com/fire- products/ventilation/articles/403097-Ventilation-Basics-by-Structure-Type/. Date accessed: November 2013.

23. Lee, M [2008]. Fireground Tactics Priorities – RECEO VS. FireRecruit.com. http://www.firerecruit.com/articles/426027-Fireground-Tactical-Priorities-RECEO-VS. Date accessed: April 1, 2014.

24. Lee, M [2007]. Be Alert to Basement Fire Hazards. FireRescue1. Com. http://www.firerescue1.com/fire-attack/articles/291024. Date accessed: April 1, 2014.

Page 27 201 Report # F2013-13 Volunteer Fire Fighter Found Unresponsive With His Facepiece Off Dies Eight Days Later – Maryland Investigator Information This incident was investigated by Matt E. Bowyer, General Engineer, and Murrey Loflin, Investigator, with the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, WV. An expert technical review was provided by Richard D. Riley, Operations Chief, Clearwater, Fire and Rescue. A technical review was also provided by the National Fire Protection Association, Public Fire Protection Division.

Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these Web sites.

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