Firefighter Safety at
Emergency Incidents
Issues and Ideas Papers Presented During a PERI Internet Symposium
Presented October 2000
Published by the Public Entity Risk Institute On the web at: www.riskinstitute.org
This material is provided free of charge, as a public service of the Public Entity Risk Institute (PERI), 11350 Random Hills Rd., Suite 210, Fairfax, VA 22030. Phone (703) 352-1846. Web: www.riskinstitute.org.
The Public Entity Risk Institute (PERI) provides these materials “as is,” for educational and informational purposes only, and without representation, guarantee or warranty of any kind, express or implied, including any warranty relating to the accuracy, reliability, completeness, currency or usefulness of the content of this material. Publication and distribution of this material is not an endorsement by PERI, its officers, directors or employees of any opinions, conclusions or recommendations contained herein. This material was prepared by independent authors, and PERI has not verified the information provided. PERI will not be liable for any claims for damages of any kind based upon errors, omissions or other inaccuracies in the information or material contained on these pages. PERI is not engaged in rendering professional services of any kind, and the information in these materials should not be construed as professional advice. Users bear complete responsibility for any reliance on this material, and should contact a competent professional familiar with their particular factual situation if expert assistance is required.
ii Firefighter Safety at
Emergency Incidents
Issues and Ideas Papers Presented During a PERI Internet Symposium
Presented October 2000
Published by the Public Entity Risk Institute 11350 Random Hills Road, Suite 210 Fairfax, VA 22030 Phone: (703) 352-1846 FAX: (703) 352-6339 On the web at: www.riskinstitute.org
iii Public Entity Risk Institute
The Public Entity Risk Institute's mission is to serve public, private, and nonprofit organizations as a dynamic, forward thinking resource for the practical enhancement of risk management. PERI pursues its mission by:
CFacilitating the development and delivery of education and training on all aspects of risk management, particularly for public entities, small nonprofit organizations, and small businesses. CServing as a resource center and clearinghouse for risk management, environmental liability management, and disaster management information. COperating an innovative, forward-looking grant and research program in risk management, environmental liability management, and disaster management.
For complete information on PERI's programs and information services, visit our Web site at www.riskinstitute.org.
To access a wealth of risk management intelligence, please visit the Risk Management Resource Center, at www.eriskcenter.org, a collaborative Web site operated by PERI, the Public Risk Management Association (PRIMA), and the Nonprofit Risk Management Center (NRMC).
Public Entity Risk Institute 11350 Random Hills Road, Suite 210 Fairfax, VA 22030 Phone: (703) 352-1846 FAX: (703) 352-6339
Gerard J. Hoetmer Executive Director ([email protected])
Claire Lee Reiss, J.D., ARM Director, Grant and Research Program ([email protected])
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Audre Hoffman Office Manager ([email protected])
iv Table of Contents
About PERI's Internet Symposium Programs ...... vi
Introduction to the Firefighter Safety Symposium ...... 1 By John Granito
Firefighter Occupational Safety ...... 3 By Stephen Foley
Aggressive Interior Firefighting: ...... 11 Improving Safety and Leadership By Thomas Von Essen
British Styles of Incident Safety: ...... 17 Command Decisionmaking and Team Knowledge By Mark W. Smitherman
Firefighter Safety and the Code and Standard Process ...... 27 By Russ Sanders
The IC's Role in Save Our Own ...... 31 By Alan Brunacini
v About PERI's Internet Symposium Programs
These Issues and Ideas Papers were presented during one of PERI's "virtual" Symposium Programs, programs that are conducted entirely via the Internet. The Firefighter Safety at Emergency Incidents Symposium was presented in October 2000.
This publication is also available electronically on PERI's Web site at www.riskinstitute.org and on the Risk Management Resource Center at www.eriskcenter.org.
How We Conduct a Symposium
Our programs consist of specially commissioned papers, and an open, threaded discussion. Participation in the discussion is free and open to anyone interested in the subject of the Symposium.
Each day during a PERI Symposium, we present an Issues and Ideas Paper (or Papers) written by recognized experts. Each paper addresses a different aspect of the subject of the Symposium.
The papers are intended to be thought-provoking -- raising risk management issues about the week's subject -- and practical -- offering useful ideas and solutions.
Papers are posted each morning of the Symposium for reading. We also send the papers via e-mail each morning to participants who sign up ahead of time.
The discussion portion of the Symposium is a threaded discussion, in which comments and replies are posted in our Symposium Center, and are accessible by all. Anyone can view or post comments.
Our Symposium Programs are an important way for us to meet our goal of facilitating the delivery of education and training on all aspects of risk management. Participation in the programs is free and open to anyone interested in the subject.
Future Programs
For the schedule and topic of future programs, please visit PERI's Web Site at www.riskinstitute.org.
vi Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
An Introduction to the Firefighter Safety Symposium
By John Granito Moderator
Fire service safety statistics for 1999 are sad ones -- for the firefighters who died or were seriously injured, for their families, for their departments, and for and the entire fire service. The 112 on-duty firefighters who died or were fatally injured in 1999 were the highest number since 1989, 21 higher than 1998. And this year has had its share already.
As I write this I have the report of an $80,000 fine levied by the state against a northwest city fire department for safety violations at an April structure fire. The five violations include a firefighter injured when an apparently overextended aerial collapsed, two firefighters injured when operating in the building’s interior -- one of whom is reported to have jumped from the third story when his air ran out (he is still off-duty) -- and an officer who is reported to have been ordered into the building alone. A year ago, a jury awarded a $5.6 million civil judgment to the widow of a firefighter killed in a structure fire in that same state. The jury found the local fire department was 75 percent responsible for the firefighter’s death.
Just this morning I learned of the recent death of a firefighter in a city I visited recently. The person who phoned me said that the firefighter jumped to get on an aerial as it responded from the station, fell, and was run over by the rear wheels. We all know of similar, tragic incidents.
It’s time to focus more attention on firefighter safety at operations, and that’s the purpose of this Symposium. To use the statement which appears in one of the five Symposium papers, “Hoping for the best is not an action plan.” The only way to reduce death and injuries is for every firefighter and officer in every department to develop a personal safe action plan, for every operating company to conduct its fireground assignments only in the safe mode, and for every department chief to insist absolutely on safe practices, safe tactics, and safe strategies.
During the five days of this Firefighter Safety Symposium you’ll read the thoughts of five experienced fire service people, each approaching safety on the fireground from a different direction. Steve Foley describes the terrible facts, and lists the major reasons why firefighters are killed at fires. Tom Von Essen describes what can be the bad results of aggressive attack coupled with poor leadership, and how a culture of safety must be built into and trained into a department. Russ Sanders looks at the fact that building codes -- especially for existing structures -- have very little to do with operating safety, and wonders why the fire service isn't more involved in advocating for code and standard development, adoption, and enforcement. Mark Smitherman describes the quite different safety strategy used in Great Britain, and Alan Brunacini takes a look
Introduction 1 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
at the relationships among incident command, fireground safety, and the new “saving our own” tactics.
Please remember that the purpose of the Symposium is not just to get you to read what five other people think about safety. It’s to get YOU and everyone else in your department to push for increased safety when operating. I can remember my first chief saying, “You can get seriously killed in this line of work!” When I was younger and gung-ho I thought that was both funny and very exciting. However, as I grew older and saw what he meant, I realized that the injuries and deaths of firefighters are terrible occurrences. Yes, the work is inherently more dangerous than most other types, but there are ways of making it safer!
A pretty smart Safety Officer told me that you do what you must do, but you do it as safely as you absolutely can using fireground strategies that have spelled out what it is that you will risk life and limb for.
The five Issues and Ideas Papers you will read during the week will provide some provocative -- yet practical -- ideas, and we hope will be valuable to you. The value of the Symposium, however, will increase exponentially the more you participate. I urge you to share your thoughts and viewpoints -- like most conferences we attend, the best and most helpful ideas will come from our colleagues. Please “speak up” from your computer keyboard each day.
We have tremendous interest in the Symposium -- as this paper is being sent to you, the number of people who have registered to have the papers sent to them is approaching 1,400. Chiefs, officers, firefighters, instructors -- a full range of fire service people have signed up, along with local government administrators and risk managers, federal government and military personnel, and others.
When the Symposium begins on Monday, PERI will transmit a paper to you between 8 AM and 9 AM each morning (EDT). The paper will be simultaneously made available in the Symposium Center on PERI's Web Site. The threaded discussion will be open immediately for your comments.
The five papers can be downloaded by you for the benefit of others in your organization, and I’ll post a brief summary each day of my impressions of what transpired the day before.
The “presenters,” the folks at PERI, and I wish you a safe run.
John Granito Symposium Moderator
Introduction 2 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
Firefighter Occupational Safety
By Stephen Foley, Senior Fire Service Specialist, Public Fire Protection Division, National Fire Protection Association (NFPA)
In the past 30-plus years, the United States fire service has evolved from a single mission public service to one that provides a multitude of services. Within each one of those services provided is some level of risk -- inherent in the occupation of being a firefighter is a "level of risk." This level of risk has different meanings or impact on individuals, departments/brigades, and their reporting authority, which may have jurisdiction. This risk is “assumed” by some to be part of the occupation and that any injury or fatality is part of the risk. Somewhat of a “badge of courage,” if you will, within the occupation.
However, as this risk increases what processes have been put in place to address it?
In managing incident scene operations the risks are multi-faceted, depending on the type of operation. It is incumbent upon the Incident Commander to assess those risks continually throughout the operation. It is, and has always been a “risk versus benefit” process at an incident scene. Only recently has that process been required to be communicated through an incident command/management system that requires the Incident Commander to assess those risks while developing the strategy to employ to manage the incident.
In turn, this strategy (or as some would call goals), must have measurable tactics (or as some would call objectives) to accomplish that strategy. Finally these goals and objectives are put in place through an incident action plan which has input from those supervisory officers. Sounds simple, but as facts will show us it is not being done. Laws, codes and standards do not always provide the regulatory capabilities for enforcement, yet to date -- except in certain circumstances -- the enforcement of these carries little or no weight!
NFPA 1500, Standard on Fire Service Occupational Safety and Health Programs addresses the issue of risk management as an administrative issue prior to the response. In addition it also addresses risk management in the Emergency Operations chapter of the standard as well. Risk management includes a risk benefit process that outlines the following principles for all those operating at an incident scene. These are:
D 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 D 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 these risks.
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D No risk to the safety of members shall be acceptable when there is no possibility to save lives or property.
The National Institute for Occupational Safety and Health (NIOSH), a agency within the Centers for Disease Control (CDC), requested and received authorization and appropriations from Congress in 1998 to investigate all firefighter fatalities within the United States. This investigation process includes career, volunteer, military, and federal firefighters. In the investigation and reporting process, NIOSH posts investigation reports on its web page at (www.cdc.gov/niosh/firehome.html). [Please see Tables at the conclusion of this paper.]
With this being said, one should ask what are the contributing factors to firefighter fatalities, on the fireground here in the United States? As reported by NIOSH, they are as follows:
1. Lack of incident command/incident management, 2. Inadequate risk assessment, 3. Lack of firefighter accountability, 4. Inadequate communications, and 5. Lack of Standard Operating Procedures (SOPs).
In reality, items 2 through 5 are all integral to having and using an incident command system.
In the development of an incident command system, members must be trained in and use the system, not only for large-scale incidents but for all incidents to which they respond. This has been required under 29 CFR1910.120 OSHA regulations since1986 for response to hazardous material incidents. If required for use in those incidents, one would assume it should be used on all incidents.
The system has a built-in risk management process based on effective supervisory levels, span-of-control procedures, standard training evolutions, standard terminology, unity of command, and sufficient resource allocation and deployment. The incident command system, developed in the early 1970s, was employed to assist with the large- scale wild-land fire incidents in Southern California. Since then it has evolved and is used as an all-risk incident command system.
If there is no system in place, it is well documented that there sometimes tragic results: redundancy in resources, no command and control process, no accountability, lack of a communication plan, and a high-risk environment in which firefighters are placed. If no one has assumed command of the incident, then usually there are many who think they are in command. Multiple commands means multiple plans and really no on in charge, which is a truly risky environment from which to operate!
The incident command system is designed to grow modularly based on the complexity of the incident, not necessarily on the size of the incident. This modular
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expansion allows for a span of control of three to seven. This span of control process allows within the system the capabilities to effectively manage resources.
A resource in this discussion means personnel. It is incumbent upon the crew supervisor to keep track of the personnel assigned to them. In consort with that is a tracking system done either by command, or assigned by command, to track personnel by both location and function. So, effectively if there is an incident management system in place this part of accountability is being done.
A component of the accountability process is the ability to track personnel in and out of the incident scene, and to keep crew integrity. As members are assigned they enter and leave together. This accountability process also includes rehabilitation, air supply replenishment, and relief assignments. Some may think of accountability as just a process to count heads if an area or building is evacuated. It is much more than that, but that is also a component of the accountability process.
Lack of, or ineffective communication, usually leads to a multitude of problems. If command can not communicate with his/her personnel then they are out of business! Communication is so integral to incident scene operations it is the key to firefighter safety and survival.
If the premise of incident command is a defined strategy with tactical objectives, then the person in command must have communications with their supervisory personnel. If those supervisors need additional resources -- equipment and personnel -- to complete an objective, then they need to communicate with command. If those resources can not be provided, and the tactical objective(s) can not be accomplished, it impacts the strategy. If the strategy and type of operation is changed, based on information and another risk analysis, then everyone needs to know what the changes are.
Communication is also a component of the accountability process. The ability to communicate with supervisors overseeing a specific function or in a geographic location is part of the accountability process.
The communication process includes the use of “standard terminology.” If a crew is assigned to a specific location, say Division 4, and the crew requests additional personnel, do the additional personnel know what/where Division 4 is? National standards require the use of “clear text” in the use of communication transmissions. Slang, local jargon, amateur radio text, ten codes, and other colloquialisms only further hamper the communication process. Again, this is a component of incident command, and those agencies that operate within an agency's command system should be trained in the “proper” communication protocols.
The incident command system, and all of the components, require that a fire department have Standard Operating Procedures (SOPs) in the training and use of the system. Some fire departments are under the impression that a Standard Operating Guideline (SOG) is the same as a SOP. SOPs are a requirement -- not a guideline. If a
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department uses and enforces its SOPs, then the incident commander has a “level of confidence” in the utilization of the system and assignments at the scene. Many departments use their SOPs as an integral component of training, promotional procedures, and post-incident analysis.
In conclusion, the training of and use in Incident Command is paramount to the safety and survivability of firefighters. The incident command system is a “toolbox” for the incident commander. From that toolbox, the commander has numerous tools/resources to assist him or her in managing the incident. There are tools available for assistance at all types of incidents. These tools may be in the fire department, or other agencies. The key for the incident commander is to know how to use the tools to best manage the incident.
The inherent risks of the occupation require that an incident command system, using a “risk benefit analysis” be part of the standard in firefighting. As my friend and mentor Chief Alan Brunacini has said on many occasions “Firefighters have suffered the most unfair occupational discrimination of any occupation.” It’s time the profession examined what it does and how it does it. Only then can it begin to address those risks that kill and injure members of the fire service.
References
D NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 1997 edition. D NFPA 1250 Recommended Practice for Emergency Services Organization Risk Management, 2000 edition. D Emergency Incident Risk Management, A Safety and Health Perspective; Loflin and Kipp. Van Nostrand Reinhold1996 D Occupational Health and Safety Standards Handbook; S.N. Foley. NFPA Publications 1998
About the Author
Foley serves as a staff liaison with NFPA for Technical Committees responsible for fire service occupational safety and health, fire service organization and deployment, and emergency services communications. He serves as editor and head author for NFPA’ s Fire Service Occupational Safety and Health Handbook, authored chapters in the ICMA Managing Fire Services book, the Fire Chiefs Handbook, as well as other publications. In addition Mr. Foley has lectured extensively on fire service related topics in the United States and across Europe. He serves as an adjunct faculty member at the US National Fire Academy, and lectures in the Brigade Command Course at the British Fire Services College. Mr. Foley retired from the municipal fire service after 25 years, serving 12 of those as a Fire Chief in Massachusetts.
Firefighter Occupational Safety 6 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
Figure 1: Firefighter Fatalities By Year, 1977 to 1999, and Volunteer vs. Career
Year Deaths Volunteer Career 1977 157 82 70 1978 172 100 64 1979 125 57 58 1980 138 69 61 1981 136 65 58 1982 127 67 50 1983 113 51 54 1984 119 59 43 1985 128 66 55 1986 120 55 51 1987 131 68 48 1988 136 81 43 1989 118 65 43 1990 107 62 25 1991 108 66 36 1992 75 44 24 1993 78 54 21 1994 104 38 33 1995 97 59 29 1996 96 65 27 1997 97 58 31 1998 91 49 33 1999 112 70 38
Figure 2: Firefighter Fatalities by Type of Duty, 1999
Fire Ground 56 Resp/ret 32 Training 4 Non-fire Emergency 10 Other on-duty 10
Figure 3: Firefighter Fatalities by Cause of Injury, 1999
Stress 57 Falls 4 Caught 24 Exposure 4 Struck By 21 Embolism 2
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Figure 4: Firefighter Fatalities by Nature of Injury, 1999
Heart Attack 51 Embolism 2 Internal Trauma 23 Drowning 2 Aneurysm 2 Burns 8 Stroke 3 Crushing 4 Electrocution 3 Heat Stroke 1 Asphyxiation 13
Figure 5: Firefighter Fatalities by Age and Cause of Death, 1999
Age Heart Attack Non-heart Attack Total 16-20 0 5 5 21-25 1 5 6 26-30 0 11 11 31-35 2 5 7 36-40 4 6 10 41-45 3 8 11 46-50 11 7 18 51-55 9 2 11 56-60 9 4 13 Over 60 12 8 20
Figure 6: Fireground Deaths by FPU, 1999
Wildland 19 Public assembly 4 Nursing home 1 Residential 16 Stores 2 Vacant 7 Storage 3 Under renovation 1 Street/roads 3
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Figure 7: Structure Fire Death Rates per 100,000 Fires, 1994-1998
Stores/offices 15.2 Manufacturing 12.4 Storage 11.3 Public assembly 8.9 Vacant, special 7.4 Residential 3.9 Educational 0.0 Healthcare, 0.0 Correctional
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Firefighter Occupational Safety 9 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
Firefighter Occupational Safety 10 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
Aggressive Interior Firefighting: Improving Safety and Leadership
By Thomas Von Essen Fire Commissioner, City of New York
The faster we extinguish the fire, the less damage to the building, the less possible harm to the occupants, and the less potential for injuries to firefighters. No one can argue with that premise. Unfortunately, this frequently leads to a reckless and often uncoordinated attack that at times is impossible to rein in once it has been unleashed. Often, the risks taken and the injuries sustained may far outweigh the benefit of a shortened operation.
The fact that all fires eventually go out, no matter what we do, should make us stop and think: While we were working, did we use safe procedures? Did we take unnecessary risks? Safe operations should not be left to luck. Remember, “hoping for the best” is NOT considered a plan of attack.
In May of 1970, my firefighting career began in a busy South Bronx Ladder Company. I worked for more than 16 years in the field, and have served for seven years as a Union official, three years as Union President, and for the past four years as Fire Commissioner. The FDNY, a force composed of 15,000 firefighters, fire officers, Paramedics, and EMTs, is second to none. I love firefighters and believe they are the finest group of people you can find anywhere. Because of this, in my tenure as Commissioner, the training and safety of our personnel has always been my highest priority.
But with 204 Engine Units, 143 Ladder Units, 13 Rescue companies, 420 Ambulances, and many more Haz Mat and support units, all operating in 50 Battalions, there are great challenges to generating the type of leadership that produces success and efficiency as well as very increased firefighter safety.
Fighting fires is a battle, which, like all battles, requires planning and leadership. We need Officers to be safety oriented leaders and teachers. Are we too aggressive? This question cannot be answered the same for all situations. Of course we are too aggressive sometimes and, sometimes, it is absolutely necessary. When we operate normally, we become accustomed to dangerous situations. When things go bad is when we really need teamwork and leadership.
When things go bad, it is usually the less experienced, less trained, weaker team that breaks down. As the level of experience decreases, the need for leadership increases.
Excellent Battalion Chiefs want to work in “busy areas.” You often will hear them say how easy it is, because the members don’t need to be told what to do -- they just do it. But we also need our great officers to work and lead in areas of the City with less
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activity. Currently, our system provides little leadership to areas that are the least active, but where leadership training and motivation need to be most active.
With less fire duty and less interested chiefs, officers, and firefighters, a company can become quite mediocre. We must try to change that formula because it can lead only to disaster. I have watched mediocrity lead to disaster at fires. That is not acceptable. The officers in charge have to be certain about the risks involved and the ability and desire of the work force they have moving with them in a dark, smoky hallway. Less active units especially need leadership. Instead of sitting around listening to the old complainers, knowledgeable and enthusiastic officers are just what these young firefighters need. Leadership is the absolute key to any issue, in the fire service, certainly including safety.
Our top-notch units are that way not because of brilliant decisions made by the managerial team in place, but because of years of tradition and pride. That tradition and pride is passed along by the excellent officers and firefighters who find their way to these units. When we speak to many excellent Battalion Chiefs and Company Officers about working in less active units where they really could make a difference, we find an attitude of “that’s your problem, not mine.”
At FDNY, we are trying to change this culture. We rotate young Lieutenants to increase experience and expose them to different role models. We rotate new probationary Firefighters for three years, a year at a time, to units that are very different. We now assign Battalion Chiefs to the Bureau of Operations as opposed to issuing permanent assignments -- so we can move them more easily to help FDNY in its efforts to share their different levels of expertise among all 50 Battalions in NYC.
There never has been real leadership training in FDNY. We ask people to study and memorize thousands of pages of material to gain promotion. Some of the information is useful, but much is a waste of time. It is equally important -- and at the higher levels, more important -- to assess and reward leadership and managerial skills.
In my four years as Commissioner, I have tried to address these areas from every direction possible. We started with probationary Firefighter’s school and eliminated many hours of indirect conditioning and non-firefighting activities. We refocused our training by placing greater emphasis on skill-based conditioning, such as forcing doors and stretching hand lines up six-story buildings in full gear, with the goal of achieving a much more job-relevant gain.
We gave Captains digital cameras to scrutinize their districts and photograph interesting buildings, which they could then use to create drills for presentation on computers in their respective firehouses. We require Battalion Chiefs to regularly attend and participate in company drills, which is absolutely necessary to help our young officers. Of course, this already was occurring in many of our units throughout the city.
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We also send Captains from Headquarters to give drills in units that need special help, and use these experienced Officers to help teach younger Officers how to prepare and deliver a better drill. We expanded our Battalion Chiefs quota so we would have more of these Senior Officers available to train and mentor. We take the Captains off the line three months before their expected promotion to B.C. and have them work with our best and most senior Battalion Chiefs. We began night training, increased exercises with utility companies, and conducted more disaster exercises with other agencies and the military. We established five more Squad Companies, giving them hundreds of hours of additional training, aimed at creating more units with levels of training similar to our Rescue units. We established a yearly medical for everyone. We have spent more money, resources, and effort on training, with safety emphasis, in the past four years than FDNY expended in the prior 15 years.
Can we measure the results? Are we doing any better at preventing serious injuries? Are we too aggressive? Are fires being extinguished more quickly? More safely? Is less damage being incurred? Can we justify losing a firefighter’s life in an effort to save another? I believe these are all questions worth trying to answer in our continuing efforts to increase safety and improve leadership. We are beginning a program to try and measure those training efforts and see if they have made a difference.
Leadership decisions must be made on the fly in emergency situations. I believe this needs to be taken into account in reviewing a particular action or operation. However, officers should be asked about the criteria used to formulate their decisions, be held accountable for their actions, and told what was wrong with their incorrect decisions afterward.
I believe that when a Firefighter gets pumped up at a “good job,” the task of putting out the fire becomes his or her primary concern. A concern for his safety is not his or her number-one priority. But, it must be the priority of the leader. People must be first; everything else comes after that.
Sometimes, the difficulties of the operation seem to make safe practices almost impossible. A leader never should accept this concept. Sometimes the fire cannot be put out. Leaders must be able to say, “This is nuts; let’s get out of here and regroup." Working safely will not just happen. It can only happen when the leaders have created a team that has a clear goal and is prepared for the challenges that face them.
We constantly must reinforce safe behavior. If not the immediate team leader, then the Battalion Chief must assess whether unsafe behavior is being reinforced.
Success should not be defined as simply putting out the fire.
A successful operation is safe extinguishment, without encouraging or reinforcing unsafe procedures. Taking excessive risk to accomplish the goal is not acceptable and can lead a team to disaster. Because we got away “lucky” today does not mean that this behavior, gone unchecked, won’t be lethal in a future operation.
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We should not encourage fearless people who can cause the whole team to be put in harm's way. We should encourage initiatives and actions that are thoughtful, and supported by a need to take the risk. Good leaders must be able to demand instant obedience. They never will get it if they have not inspired the Firefighter to do his or her best, and if they haven’t demonstrated in past operations their own levels of competence and professionalism.
Why has Alan Brunacini had such great success in Phoenix? He is boldly innovative and has stayed around long enough to prove the critics and nay-sayers wrong. But another reason is the intelligent union leadership in Phoenix. Working together on goals as important as safety will ensure success. I often have found startling hypocrisy in regard to real concerns for safety from the local union’s side. Looking the membership in the eye and stressing training, wearing proper clothing, encouraging physical fitness, and adhering to safe operational procedures is not just a management responsibility, but a responsibility of all those in leadership positions.
Can we justify losing a Firefighter’s life in an effort to save another? I believe we can. At the same time, I believe that most Firefighter deaths are preventable. What may start as a necessary action often could and should be stopped by better on-scene leadership.
I have watched operations where the Incident Commander could have had greater control over what is going on inside. The information transmitted from the interior fire floor to the IC often is inaccurate and not reflective of the larger picture, which is changing rapidly. The ability of the IC to get his or her troops out of harms’ way quickly often is lacking. Leaders should routinely work on getting teams to react instantly to their commands, so when it is necessary, the team will react. When things go wrong, everyone involved seems to acquire a selective memory. We cannot improve if we are unwilling to address operational errors.
Maybe I take training and safety more seriously since I have had to speak to the families of Firefighters we have lost. I cannot, for the life of me, understand how leaders responsible for the safety of their team do not treat this responsibility as a sacred trust. More than the inherent dangers we face, more than the unknown, the need for leadership that is at all times concerned about safety, is critical. Rather than slipping further and further into a lackadaisical approach to safety, we should be working toward principles of training and accountability that are used in High Reliability Organizations (HRO) such as nuclear power plants and aircraft carriers.
Of course, our operations are very different, but the mindset should be the same -- absolute adherence to rules that are designed to take as much chance as possible out of the mix. We have convinced ourselves that fire is unpredictable and that a level of injury is unavoidable. I believe that level should in no way be as high as we have accepted.
Many of the accidents we have are the result of poor leadership and inadequate training. No matter how much we improve our apparatus, clothing and equipment,
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without a commitment from leadership to stop worrying about hurt feelings and being everyone’s pal, the level of injuries will never drop to the irreducible minimum. We must do a better job of assessing our effectiveness.
On Monday morning, it is unacceptable to look at the fire activity of the weekend and say we had six jobs and 40 injuries, mostly all minor. This approach to injury has created a mindset that injuries are always acceptable. Bosses are not accountable and there really aren’t any questions asked. We should break down each fire, ask why, where, when, how -- injuries should not be “part of the job.”
I believe this situation has changed in many cities that either never practiced aggressive interior firefighting or realized a while back that most operations could be handled less aggressively and more safely. Yet reading many reports of operations -- especially in the older cities with cultures and traditions more entrenched and harder to change -- leads me to believe it is still a significant problem. Our efforts to enhance training and safety at FDNY have had significant success. In the near future, we will concentrate on getting these principles of leadership to be more widely accepted and practiced. We have had phenomenal leaders at FDNY because of traditions that we never want to lose. Continuing those traditions while creating new leaders with an even greater concentration on safety, is the challenge. I have no doubt that FDNY will meet it.
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British Styles of Incident Safety: Command Decisionmaking and Team Knowledge
By Mark W. Smitherman Deputy Chief Fire Officer, Nottinghamshire Fire & Rescue Service
The paper is drawn from the autho'rs personal research, which formed part of a Brigade Command Course, attended in 1998 at the British Fire Service College, and also from an ongoing post-graduate university research programme. It centers on the concept of Command Decisionmaking and Team Knowledge, and also includes a brief examination of the U.K. method of Operational Risk Assessment. It concludes by examining what needs to be done to facilitate not only improved performance but also cultural change within a Learning Organisation.
USA – UK Comparison Very different forms of urban and rural domestic building construction, and the significance of wildland firefighting activity, together with some fundamental differences in operational methodologies are examples of why it is difficult to compare directly the United States with the United Kingdom. But do the more obvious differences between our two national firefighting environments account for the fact that a fire-fighter on average will die for every 44,000 fires in the U.S. compared with a fatality for every 316,000 fires reported in the U.K.? US firefighters are more likely to die during firefighting activity by a factor of nearly 7 to 1. Why? (Based on average number of fires over ten year period 1989-1998: Operational Firefighting fatalities – [US 443: UK 13].)
U.S. post-incident investigations have identified a number of factors that have contributed to the deaths. These include: communications, freelancing, building construction, fire fighter health, and risk/benefit analysis. There is considerable similarity between the issues identified as critical within the U.S. experience and those that have been historically identified in the U.K.
In the early 1990s the U.K. fire service embarked upon a crusade to introduce effective systems of command, based upon a foundation of risk assessment and evaluation. Unfortunately, the impetus was a number of firefighter fatalities, which resulted in extensive investigations by the Health and Safety Executive (HSE), a quasi- autonomous government agency which has significant statutory powers in relation to the Health and Safety of the U.K. workforce. The level of scrutiny to which the HSE exposed the service was unprecedented in its history and resulted in a fundamental root and branch evaluation of operational safety and performance.
The process heralded a difficult and, to some extent, a traumatic time for many brigades throughout the U.K. A considerable level of resources were focused on addressing the many problems that were uncovered in systems and procedures. Most importantly, the self evaluation is still ongoing and is firmly embedded into the U.K. service dimension as a dynamic and continuous process. In essence, the impetus for
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change stemming from the early 1990s has embedded within the U.K. service a structured and all-encompassing approach to operational risk management.
It is the responsibility of U.S. fire departments to individually or collectively assess their relative positions in relation to the development of operational risk management systems. However, it is interesting to note that the U.S. equivalent of the HSE, the National Institute for Occupational Safety and Health (NIOSH) warned all US fire departments to review their safety programs and emergency operating procedures in 1994, indicating that “failures to establish and follow these programs and procedures are resulting in injuries and deaths of fire fighters” (NIOSH ALERT: September 1994). This concern continued in 1999: “fire departments should implement and review occupational safety programs and standard operating procedures to prevent serious injuries and deaths of fire fighters” (NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters due to Structural Collapse (DHHS [NIOSH] Publication August 1999).
It is apparent that the same impetus exists on both sides of the Atlantic, although the U.K. service for the last decade has been subject to considerable scrutiny. Any success it has achieved has been vested in its ability to use such scrutiny effectively, and for individual fire brigades to internalise and own the problem.
In effect, the development of an Incident Command System should be seen as part of a Brigade’s overall organizational system for managing risk, and not merely a means of implementing operational procedures. In my view this is the key to success, but it is also my view that it is still in its early days and considerable development is still required before the UK fire service can be confident that it has met the challenge.
It has been established in the UK that in order to provide an acceptable level of protection at incidents, health and safety management must operate successfully at three levels – Strategic, Systematic, and Dynamic.
Strategic Systematic Dynamic 4Policy 4Hazard identification 4Operational Risk 4Priorities 4Risk Assessment Assessment 4Resource 4Implementation of 4Incident Command allocation control measures System 4Positive Culture 4Standard Operating Procedures 4Post Incident Review
Within any Safety Management system the Strategic and Systematic elements are fundamental, but the remainder of this paper will concentrate on some key issues which impinge on the front-line Dynamic element of the system; namely:
S Facilitating risk assessment during operations. S Incident Command Decision Making methods. S The Commanders role within the Command Team.
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S Information Management and Control. S The concept of the Learning Organisation.
Operational Risk Assessment
The strategic and systematic level, through a process of vertical and horizontal managerial integration, will provide the support necessary to ensure that operational personnel are able to remain safe in dynamic and hostile environments. However, the foundation of Dynamic Operational Risk Assessment is the ability of individual firefighters to make professional judgements about the appropriate use of available resources in order to maintain their own safety and to contribute to the safety of others. Therefore all firefighters must be:
S Competent to perform tasks assigned, S An effective member of a team, S Self-disciplined to work within accepted systems of work, S Adaptable to changing circumstances, and S Able to recognise his or her own abilities & limitations.
Selection, training, and competency programmes must ensure that each of these prerequisites are embedded within individual firefighters.
In reality, the ability of an officer to command an incident is inextricably linked to the ability of individual firefighters to operate as a Safe Person and to be part of the total command process and not merely a result of it!
The Commander, in effect, is dependent on the command vision of all participating firefighters and junior officers for success. Therefore, each firefighter must fully understand and continually make dynamic assessments within his or her own area of operations. All firefighters in the U.K. have received structured training inline with the following risk assessment methodology.
(continued on next page)
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Evaluate the situation, tasks & persons at risk
Select systems of work
Proceed with Assess the chosen Consider viable systems of work alternatives tasks
Yes Are the risks proportional to the benefits No
Re-assess systems Yes Can additional No Do not proceed of work control measures be with tasks introduced
However, Operational Risk Assessment is only one aspect of a total Incident Command System.
The Incident Command System (ICS)
In the U.K., within recent years the concept of ICS has taken hold. The model which now is adopted on a national basis incorporates many elements of the U.S. system: Clear Lines of Command; Span of Control; Sectorization; Decision Support; and Inter- Agency Working. The recognition of “Tactical Mode” operations within the ICS is perhaps the most significant recognition of U.S. methodology within the U.K. approach. The command categorizations of Offensive, Defensive, and Transitional modes of operation is being progressively adopted throughout the U.K. as a standardized approach to minimizing Operational Risk. Yet the adoption of such modes of working is pointless if the basis of evaluation and decisionmaking is flawed as a result of ineffective information gathering.
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Team Based Command Knowledge
Incident Commander
Pre-established Hierarchical generic risk Command information Sector Structure Commands Knowledge Management Function Operational Risk Information route
Command of an incident is essentially about information: getting it, judging its value, processing it into useful form, acting on it, and sharing it with others, so it percolates throughout the whole command structure of the incident. However, information is only valuable if it contributes to effective decisions and actions. It isn’t the amount of information, but the delivery of key elements of information where and when needed in a usable form - pulled on demand for analysis, simulation, and status queries - pushed to intermediate commanders when critical for alerts, advisements, and to effect rapid operational change. It’s about rendering information into knowledge!
Operational risk information must be communicated, linking individual firefighters to crew commander to sector commander and ultimately to incident commander. In effect, a team approach to risk management must be facilitated within the ICS. Each source of information must be integrated and routed by an effective communications network within a clearly defined information management and support system. The command team concept is perhaps the clearest route to enhancing command knowledge on the fire ground.
Sequential Command vs. Team Command Structures
There is no doubt that incidents are commanded by a team-orientated approach, even though a team response method is not necessarily applied. Officers in the U.K. will tend to structure into a team formation at large incidents by sectoring and zoning, both geographical and functionally. The team structure is formed at the scene of operations. All other command officers progressively move through the role of incident commander
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to delegated function. Is this the most effective way of establishing a command team under dynamic conditions?
Under dynamic conditions, commanders tend to focus intensely on the front line operations, quite understandably, in an attempt to control the development of the incident. What is emerging from my research is that it is quite common for the initial commander to become totally submerged within the operational level, and therefore he or she may not assume tactical command.
A direct knock-on effect is often the slow implementation of a command point; a tendency to neglect external communication and information needs; and delay in the implementation of sectors resulting in a lack of initial incident organization and structure. If the commander is submerged operationally to the point where he or she becomes insulated from the external environment, the ability to gain information is severely restricted, if not totally removed. The lack of support during the initial stages will tend to mean that the initial commander operates as an entrepreneur, forming the central focus for all decisions. Is this also reflected within the US experience?
Submerged Initial Command level
Initial Commander
Insulated from external Dynamic Operational environment Domain
A lack of ability to access information will tend to result in the application of a mechanistic and relatively inflexible style of decisionmaking. The commander within this domain is operating under the most temporally constrained conditions and needs information for structured risk assessment purposes. If insulated from the external environment, the ability to gain information will be limited.
The sequential response method, where command rapidly and repeatedly transfers from Incident Commander to higher ranking Commander, appears to be flawed in a number of areas. Firstly, the need to brief each new commander consecutively throughout the incident becomes onerous and potentially increases the delay in gaining information and establishing a co-ordinated infrastructure.
A team response method would address a number of present shortfalls within the system. An immediately dispatched command team which, for example, could be
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dispatched at the point at which multiple calls are being received, would ensure that a pre-coordinated response is available at the incident, at the earliest opportunity. This form of response offers a number of advantages by providing an almost immediate command structure at the scene, which would improve the ability to gain information and increase the rate of situation assessment. Subsequently it would increase the rate at which comprehensive information can be dispatched from the incident and would facilitate the rapid development of a communications network.
A robust communication network is seen within the U.K. as absolutely essential. It provides the means for expanding the situation assessment of the team, both the immediate team and the distributed team, comprising monitoring officers and control operators. Situation assessment is an emergent product of communication. It is dependent on the rate at which the team members can verbalize what they perceive in the environment around them. Therefore situation assessment can be enhanced by providing an immediate team response to pre-risk assessed incidents, thereby facilitating rapid incident organization and support infrastructure. Theoretically, the output of this approach is an increased rate of dynamic risk assessment.
By applying structured training initiatives which focus on developing team cognitive competency, whereby team members can interpret each others' actions, and to anticipate others' information needs, requires a fundamental change to the concept of team training presently undertaken within the service.
A team cognitive approach to team training will provide the basis for co- ordination, in conjunction with shared procedural and role knowledge. Command literature points towards pre-planning strategies, where the goal is to 'pre-process the problems' likely to be encountered, considering planned events, potential events, and the means to face them. If this concept is systematically applied to team training it will reduce the need to establish the team’s operating system under time and workload pressures. Team training must therefore concentrate on priming them to be ready to implement a structured team at the incident scene, so that they can respond quickly and with little effort.
A team structure, as opposed to sequential response model, potentially holds the key to reducing dynamic risk, because it flattens workload demand on the limited cognitive resources by utilizing the expanded cognitive abilities of the team. Such expansion of cognitive capacity, arriving at the incident rapidly and being able to immediately implement a shared task/risk model, can create an increase in thinking space, which provides the early opportunity to move from a mechanistic or risk reactive mode of working to an organic or highly flexible risk responsive decision style.
The application of a task-contingent training approach would potentially enhance team performance by providing shared knowledge, which is grounded in common team training. Many within the UK fire service would hold the view that fire brigades already undertake team-training initiatives. In many respects highly efficient training of teams is regularly undertaken within the service, but what is required is team training which goes
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beyond integration, logistics and resource management issues, and centers on the specific aspects of team cognition and decisionmaking methodologies. We need to concentrate on the softer issues of team development as well as the harder procedural aspects of ICS and SOPs. Yes, systems must be correct but procedures are merely tools, the operational command vision that commanders can impart on teams, and the individuals that form such teams, is the key to success.
Developing Teams through Organizational Learning Organizational learning occurs when individuals within an organization experience a problematic situation and inquire into it on the organization's behalf. They experience a surprising mismatch between expected and actual results of action, and respond to that mismatch through a process of thought and further action that leads them to modify their understandings of organizational problems and to restructure their activities so as to bring outcomes and expectations into line. In order to become organizational, the learning that results must become embedded in the images of organization held in its members’ minds and/or in the systems, memories, programs, and culture embedded in the organizational environment. The traditional problem diagnoses and associated Post Incident Review used within the U.K. are frequently symptomatic, and corrective actions are often ineffective. It is proposed that a team decisionmaking process intervention must be incorporated. It should include aspects of team member cognitive capabilities, team composition and process, and management receptivity. Participation within the process must ultimately affect individual, team, and organizational capabilities.
Within the service are we seduced by the root cause of a problem? Typical post- incident review programs are based on narrow frameworks that focus on particular kinds of causes and corrective actions. For example, incident review programs are often described as a search for “root causes”: “the primary or direct cause(s) that, if corrected, will prevent recurrence of performance problems, undesirable trends, or specific incident(s).” Although this seems sensible, upon close examination the very concept of “root cause” focuses attention on a single cause rather than an exploration of multiple causes or chains of events. There is a tendency to concentrate effort on equipment and human error issues, but very little on organizational, programatic, and cultural issues, i.e. an over-concentration on causes that are proximal to the problem. Often the fire service needs to dig deeper than the “sharp end” issues it is so comfortable dealing with!
In the organizational context, the question is, how is learning facilitated? The opportunity may be vested within a process where retrospective knowledge from incidents will systematically tend to influence the organization in general. This will tend to take place when participants in the command process share their new knowledge and viewpoints with others outside the review process. Anecdotal evidence supports the view that more people hear about incidents and analysis through informal discussions and story telling than from reports and formal training.
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In the longer term, both individual and organization become more sensitive to problems in general, the atmosphere encourages more inquiry, challenging assumptions and developing an environment in which the aim is constant improvement in performance. The potential benefits are mobilizing support for self-analysis and change, improving communication throughout the organization, preventing a wide range of future problems, and finding ways to improve. The following represents performance review within the organizational learning context.
Observed
effects of
Performance
Review Process
Organizational strategies &
values
Therefore by observing and analyzing the team decision making process within a performance review context, the system must ensure that a double feedback loop is incorporated, which not only provides information for corrective action, but also facilitates the means of addressing underlying assumptions and strategies and values which are embedded within the norms and culture of the fire service.
However, talk is cheap! A learning organization must be facilitated, and that responsibility rests firmly with senior management. Management must lead and create cultural change within the service, it must open itself up to the identification of problems and must constantly provide evidence of its desire to improve. “Sharp End” risk is just as much a product of culture and leadership as it is an issue of systems and procedural efficiency.
General References
D Command Teams & Decision Synthesis, Action Research Methodology, Brigade Command Course International Project, BCC 01/98, M.W. Smitherman
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D Dynamic Management of Risk at Operational Incidents, Health & Safety: A Fire Service Guide, Her Majesty’s Stationary Office (ISBN 0 11 341221 5). D Fire Service Manual Volume 2: Fire Service Operations, Her Majesty’s Fire Service Inspectorate Publications Section, 1999 (ISBN 011 341191 X).
About the Author
Smitherman is Deputy Chief Fire Officer of Nottinghamshire Fire & Rescue Service and has served in the British fire service for 21 years. Until July 2000, he served as a Senior Divisional Officer with Strathclyde Fire Brigade, Scotland, where he Commanded Strathclyde’s North Command, an area which encompasses the Clyde shipbuilding area and the remote islands of the Inner Hebrides. Smitherman also held operational command responsibility for the greater Glasgow metropolitan area and had responsibility for forming and leading Strathclyde’s Risk Management Unit. Prior to Strathclyde he served with the London Fire Brigade for 15 years, rising to the rank of Divisional Officer. His experience in London predominated within the inner city with a mix of commercial, industrial, and urban firefighting experience. The last post he held within London was as a member of a specialised inspectorate, with responsibility for evaluating operational command performance. It was predominantly due to his experience within the inspectorate -- established as a result of a number of London firefighter fatalities -- where he developed his interest in operational command decisionmaking.
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Firefighter Safety and the Code and Standard Process
By Russ Sanders, Central Regional Manager National Fire Protection Association (NFPA)
The National Fire Protection Association, International (NFPA) recently reported that in 1999 firefighter deaths reached a ten-year peak. According to the report, 112 on- duty firefighter fatalities occurred in 1999, the highest annual U.S. firefighter death toll since 1989, which saw 118 deaths. The report noted that "Stress and overexertion, usually resulting in heart attacks, continue to be the leading cause of fatal injury for on- duty firefighters. .."
Over the past several years much has been reported about the need for on-scene accountability, firefighter physical conditioning, and training. In fact, NFPA has developed dozens of standards to address these issues. However, it was the second- leading cause of fatal injuries to on-duty firefighters that caught my eye. In second place was entrapment, which claimed the lives of 24 on-duty firefighters in 1999.
NFPA also reported that, “Although on-line of duty deaths have declined over the past two decades, the rate of deaths per million structure fires has dropped very little…The largest portion of deaths--50%--occurred on the fireground.” The six firefighters who died in a Worcester, Massachusetts warehouse in December 1999, and the three firefighters who died soon after at a structure fire in Iowa, are grim reminders of the dangers firefighters face while fighting structure fires of all types.
An NFPA paper titled "Fire Ground Fatalities As a Result of Structural Collapse: 1990-1999" reported that 966 firefighters died during the period. Of these 966 fatalities, 441 occurred on the fire ground. "Fifty-three of the 302 deaths at structure fires were the result of structural collapses. This included 38 firefighters caught or trapped in 24 fires and 15 firefighters fatally struck by collapses at 13 fires... The largest number of deaths were the result of floor collapses (20 deaths), followed by roof collapses (16 deaths) and ceiling collapses (2 deaths)"
Over the past years I have seen numerous changes designed to improve firefighter safety. Improved on-scene accountability systems, better firefighter gear and equipment, and improved communications are only a few of the many important improvements that have been implemented in fire departments across America. From my personal experience as a firefighter, I know that each of these improvements and many others I have not listed in this paper are important components of effective and safe on-scene operations. However, from the statistics listed above, it is obvious that all of us in the fire protection and life safety businesses need to do more.
One important means of improving firefighter safety that most of the fire service - - including management and firefighters -- continues to overlook is participation in code
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and standard development, adoption, and enforcement processes. This is especially true when it comes to building, fire, and life safety codes for the built environment.
I'm not referring to the development of codes that regulate new construction. Fire leaders and firefighters should be leading the way in the push for building, fire, and life safety codes and standards that require an "appropriate level of safety" in existing buildings.
Aging, improperly maintained buildings create hazardous conditions both for the public and for firefighters. Yet many fire service leaders seem content to sit on the sidelines and let others take the lead when it comes to code issues. In fact, I believe fire service participation in the building code development, enforcement, and adoption processes is the most neglected firefighter safety issue of the past 50 years.
First, let's take a look at the importance of code and standard development.
In terms of life safety, the goal of building and fire codes is to allow occupants to safely exit the building. I've always found it interesting that -- to my knowledge -- not a single provision has ever been written in any building code to address firefighter safety issues. The fact is, well after the occupants have exited a burning building, firefighters must remain inside that building to conduct their secondary search and complete extinguishment and salvage operations. In this regard, I was very pleased to read NFPA's recent news release announcing its plan to work with numerous partners, including the Western Fire Chiefs, to develop a complete set of consensus codes. In announcing this new initiative, NFPA made clear that firefighter safety would be a consideration in the development of its consensus codes set.
There is a clear and direct correlation between building construction features and systems and firefighter safety. An obvious example is truss construction. Many of us in the fire service have personally witnessed the dangers and tragic consequences of fighting fires in buildings with truss-constructed roofs and floors. Numerous case studies have proven what every experienced firefighter knows: Truss construction is extremely dangerous when exposed to fire and heat. Would truss construction be widely used today if the fire service had actively participated in the building code process in past years? My guess is the answer is a qualified "yes".
Truss construction offers many advantages over stick construction, including the all- important cost factor. However, if the fire service had been actively involved in developing building codes, I would expect to see much stricter requirements on the use of truss construction in today's building codes. For example, my guess is we would see more stringent automatic sprinkler requirements for unprotected truss construction. However, until the fire service plays a more influential role in the development of building codes, we will never know the answer to this and similar questions.
Fire service participation should not be limited to the development of codes and standards. A related and equally important consideration is the state and local code and
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standard adoption process. The best codes and standards written are of little value if the legislation and/or regulation adopting them dilute their effectiveness. To ensure that codes and standards are adopted in a manner that enhances fire and life safety, fire service professionals must be active participants in the adoption process.
To my dismay, I have actually witnessed fire officials (albeit very few) support legislative provisions that virtually assure an unsafe working environment! An excellent example of the type of legislation I am referring to is often called "Mini/Maxi Legislation." Simply stated, mini/maxi legislation limits the code official's enforcement authority to the provisions of the adopted code for the life of the building. In other words, the code official can not allow less, nor require more, than the stated provisions of the code that were in force at the time the building was constructed.
I have no problem with the "mini" part of mini/maxi legislation. Every code I am aware of is written to provide a minimum acceptable level of fire and life safety. Certainly diluting code provisions below what is in the code is a dangerous practice. However, in terms of firefighter (and civilian) safety, the "maxi" part of mini/maxi legislation is bad business.
For example, if a local fire chief feels his or her department can not provide adequate protection for a planned housing development on the outskirts of town, a simple solution may be to require that the new homes be protected with an NFPA 13D sprinkler system. However, if the building code doesn't require that one- and two-family dwellings be sprinklered (and none that I know of do), the fire chief’s hands are tied.
Let's consider another example -- one I personally faced while serving as the fire chief in Louisville, Kentucky. Like many cities, the City of Louisville's landscape included numerous unsprinklered high-rise buildings. These buildings were built in the middle 1970s and earlier, when building codes did not require that high-rise buildings be equipped with automatic sprinklers. For the next 100 years after these buildings are constructed, firefighters are faced with the impossible challenge of protecting the people living and working in these structures. Further, as has been proven time and again throughout the world, unsprinklered high-rise buildings present an extreme risk to firefighter safety. However, because sprinklers were not required at the time when the buildings were constructed and because Kentucky is a mini/maxi state, nothing short of special legislation would allow me to order that these deadly hazards be corrected.
After a hard fought three-year battle the City of Louisville did pass a special ordinance requiring that all high-rise buildings in the city be retrofitted with automatic sprinklers. However, along the way our cause was helped by tragedies such as the One Meridian Plaza high-rise building fire that claimed the lives of three Philadelphia firefighters. One of the biggest disappointments of my professional life was when I heard an experienced assistant fire marshal testify in support of mini/maxi legislation.
I am not so naïve to suggest that greater fire service participation in the building code development, adoption, and enforcement processes would eliminate firefighter
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injuries or deaths. In fact, it's unlikely that fire service participation in these processes would even prevent all of the firefighter deaths and injuries that occur each year in structure fires due to structural failures. Firefighter safety is a multi-dimensional problem that must be attacked on all fronts.
Further, this paper is in no way meant to detract from the good work of building officials and other professionals who have been very active in the code processes. Their hard work and dedication are to be commended. However, I am suggesting that fire service involvement, participation, and leadership in the code processes are important and, for the most part, overlooked components of the overall equation to prevent firefighter deaths and injuries.
Countless papers, books, and standards have been published on the need to improve firefighter cardiovascular conditioning, on-scene command and control, and training and equipment. This is important work that must be continued. However, attention given to the importance of firefighter participation in the code processes discussed in this paper pale in comparison to the interest and energy that has gone into addressing the many other causes of firefighter deaths and injuries. It is for this reason that I feel that the lack of fire service participation in the building code development, adoption, and enforcement processes is the most neglected firefighter safety issue of the past 50 years!
Let's not forget that when others are making their way out of a burning building, firefighters are swimming upstream to enter. Clearly, firefighters have a unique interest in building systems, design, and construction. If firefighter concerns in these areas are to be adequately addressed, firefighters must be influential, active participants in the code development, adoption, and enforcement processes. When this happens, we will have addressed another important component in the overall scheme to prevent needless firefighter deaths and injuries. Until this happens, we will continue to fall short of this lofty goal.
About the Author
Russ Sanders serves as NFPA's Central Regional Manager, Executive Secretary of the NFPA Metropolitan Fire Chiefs Section (Metro Section), and NFPA's Ambassador to the United Kingdom. In his role as Central Regional Manager, he is responsible for promoting the adoption and use of NFPA Codes, Standards, Education Programs, and Membership in nine states and all of the Canadian provinces except British Columbia. As the Metro Section Executive Secretary Russ coordinates activities and meetings for the Section members, and as NFPA's Ambassador to the United Kingdom he works with UK fire officials to promote education programs and safety codes and standards. Russ recently co-authored a comprehensive text titled "Structural Fire Fighting," published by NFPA. Prior to joining the NFPA staff in 1995, Russ was Chief of the Louisville, Kentucky Fire Department (LFD - End -
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The IC'S Role in Save Our Own
By Alan Brunacini Chief Phoenix Fire Department Phoenix, Ariz.
The American fire service has recently developed a survival program called "Save Our Own.” The program is designed to teach task level skills that help firefighters extricate themselves from dangerous, life-threatening structural firefighting situations. The do-it-yourself rescue training involves activities such as using ground ladders as slides, the use of rescue ropes, making openings in walls as exits, and a variety of other unorthodox techniques that can be used under typically desperate, episodic conditions to quickly get our workers away from immediately life-threatening hazard.
The training is action oriented, exciting and involves the development of personal manipulative skills and the special use of tools and equipment. Firefighters love the training because they actually get to practice the acrobatic techniques, not just study the theory. There is enormous clarity to the material. Practicing the evolutions makes firefighters feel like firefighters.
While current Save Our Own training provides an excellent opportunity for firefighters to become more personally effective, it so far has only addressed the task level of operation. To solve the problem of firefighter deaths and injuries at structural fires, the program must be expanded to describe the Save Our Own functions that must also be performed at the tactical level by sector officers and the strategic level managed by the incident commander. In fact the NIOSH top 5 causes of firefighter deaths include:
D Lack of incident command D Inadequate risk assessment D Lack of firefighter accountability D Inadequate communication D Lack of SOPs
The list clearly shows the need to actively involve the strategic and task levels of command and operation.
While the three levels must be closely connected, each level can only perform their assigned part in the Save Our Own system. To be consistently effective, Save Our Own must be done on all three levels. Each level must be "positioned" to do their job on their assigned level. The levels cannot "make up" for the non-performance of some other level. We must front-end load every level with the ability (SOPs/Training/Application/ Critique/Revision) for everyone to do the job. Going "back to basics" on the task level will not fix tactical/strategic level performance problems; that is simply sending firefighters back to hose and ladder school will not improve an ineffective IC who is unconscious personally, out of control, or absent (for any reason).
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Performance problems on every level many times show up as safety problems on the task level (where firefighters actually get injured/killed.) When this occurs, the firefighters must somehow survive IC and sector screw ups (in addition to their own). So far, our service has only addressed Save Our Own on the task level (which we should continue). Until we include all three levels in an integrated safety approach, the injury and death of firefighters will continue.
We know that huge safety/survival problems occur when there is not an effective IC in place performing the standard functions of command. Simply put, effective overall incident safety must start at the top with the IC. While the tactical and task levels must do their part in Save Our Own, the IC is the only person/place who can establish, maintain, and revise the overall offensive/defensive strategy for the incident. The overall incident strategy creates the basic command and operational system used to manage -- and move, if necessary -- the position and function of the firefighters working in the hazard zone. No one else is responsible for or able to "add up" what is going on all over the incident site and then to safely assign and move the troops. The management of the overall offensive/defensive strategy is the responsibility of the IC-task, and tactical levels cannot make up for an ineffective or non-existent IC.
Integrating safety and command is the only consistently effective way to cause safety to always occur. The IC doesn't have time to do a separate safety "add on.” We must make safety and command interchangeable -- absolutely connected and done together every time. We must cause worker welfare to become the basis of effective operations. Having the IC automatically perform the basic strategic level safety routine using the standard 8 command functions creates an understandable, non-mysterious, teachable, doable IC safety game plan. The standard 8 command functions include:
1. Assumption/Confirmation/Positioning 2 Situation Evaluation 3. Communications 4. Deployment 5. Strategy - Incident Action Planning 6. Organization 7. Review & Revision 8. Transfer/Continuation/Termination
The material that follows describes how the command function safety routine should occur.
Assumption/Confirmation/Positioning
A major safety factor is how initial incident command actually does or does not occur. Having the first arriving responder automatically assume and confirm command and become IC 1 creates the strongest and safest incident beginning. This up-front approach eliminates any zero impact periods for command and control and greatly reduces
The IC's Role in Save Our Own 32 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium freelancing. IC 1 must transmit a standard initial radio report that describes conditions and the operational action that will be taken. Initial and ongoing command positioning becomes a major safety factor the IC uses to maintain an awareness of incident status and to be in the best communications position. Many times a company officer will assume a fast attack command position that will be upgraded by a command officer who transfers command and establishes and maintains a stationary command post position.
Situation Evaluation
IC 1 must develop a rapid, systematic, accurate size up that includes an evaluation of critical safety factors ("red flags"). Building an incident organization using companies and sectors as information, reporting, and recon agents is a major way the IC builds an information management system. The IC must continue to strengthen the information that relates to current and forecasted conditions to protect the troops working in the hazard zone, continually reconsidering conditions and maintaining an awareness of elapsed incident time eliminates dangerous surprises.
Communications
The IC must initiate, maintain, and control effective incident communications. Transmitting the initial radio report sets up the IC as the communications focal point from the very beginning of operations. The IC uses the organization chart as the communications flow plan with companies and sectors as information management partners. The IC must maintain continuous communications availability by using the command post position and staff to improve communication. This ongoing communications availability becomes a major safety factor because it creates the ability for the IC to manage and move (as necessary) the troops based on current and changing conditions.
Deployment
The deployment system is in place to provide and manage a steady, adequate stream of appropriate resources. The IC must base the deployment plan on the most accurate event profile as possible. The profile must evaluate current conditions and predict what will occur in the future. The IC must monitor and manage within on-line response times. As responders arrive, the IC must also utilize staging, assignment to specific roles/tasks, and accountability SOPs to get the firefighters into a standard work cycle. The IC uses a tactical work sheet to maintain current, accurate resource inventory and tracking. The IC must continually balance resources with tasks and not overmatch the firefighter's capabilities.
Identify Strategy/Develop Incident Action Plan (IAP)
The IC must use a regular, systematic method to make strategy decisions and to develop and initiate an IAP. Overall incident operational strategy is either offensive or defensive. Offensive operations are conducted on the interior of the fire building.
The IC's Role in Save Our Own 33 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
Defensive ops stay outside and away from the fire building and attempt to control the fire from the exterior and protect exposures. Evaluating conditions and deciding on inside or outside attack is a major way the IC protects the troops. Standard risk management also becomes an important part of incident safety -- that is, we will take a significant risk to protect a savable life, a little very controlled risk to protect savable property, no risk for what is already lost. The IC must develop a short, simple, understandable IAP that provides a strong operational game plan. The IAP integrates the attack effort and increases overall safety because everyone is mobilized under the same plan.
Organization
The IC must develop an effective incident organization using the sector system to decentralize and delegate geographic and functional responsibility; this organization covers the entire incident operation and keeps everyone connected. Building the organization is a major way the IC uses to maintain an effective span of control. The IC serves as a resource allocator to sectors -- this creates the ongoing awareness of who is where, doing what, and who is their boss. The IC uses the organization to accomplish tasks, to evaluate conditions and to forward critical info to the ICD. This is a major way the IC continually "adds up" situation status and worker safety.
Review and Revision
The IC must complete the steps required to keep the strategy and IAP current. The regular command system components established in the beginning provide the framework for midpoint review and revision. Standard management elements like strong command, sectors, effective communications, standard strategy, and IAP planning become the command and control foundation the IC uses once operations get going to keep those activities safe and effective. The IC must receive, confirm, and evaluate progress reports to maintain an awareness of the status of conditions and the effect of operational action. It can be fatal for the workers if the IC is operating on an outdated set of evaluations -- so the command system must always be prepared to make quick transitions based on worsening conditions.
Continue/Transfer/Terminate Command
Workers in the hazard zone must be continually protected by an effective IC. The command system must develop a standard approach to command transfer and to operating the midpoint and final stages of command. The command system must always operate with a single IC and must eliminate having no IC or multiple ICs. Having a number of officers on the scene can create big-time problems if there are not effective command assumption and transfer SOPs in place. Command is transferred to take advantage of the command staff and to strengthen the overall command capability. The system must also develop an organization that outlasts the incident problem and protects the customers and the firefighter. If the incident problem overpowers or outlasts the organization, it typically creates serious safety problems for everybody and everything associated with the incident.
The IC's Role in Save Our Own 34 Firefighter Safety at Emergency Incidents - A Public Entity Risk Institute Symposium
About the Author
Alan Brunacini has been a member of the Phoenix Fire Department since 1958. He was promoted through the ranks and was appointed to the position of Fire Chief in 1978. He heads a fire department with over 1400 members in a city with a population of more than one million.
Chief Brunacini is the Chairman of the NFPA 1710 Technical Committee for Fire Service Organization and Deployment Projects for paid departments. Chief Brunacini is past Chairman of the Board of Directors of the National Fire Protection Association, the first active fire service member to hold this position in NFPA’s 93 year history. He is also past Chairman of the Fire Service Occupational Safety and Health Committee of NFPA- which was responsible for the development of Standard 1500. This document adopted in 1987, is aimed at reducing firefighter deaths and injuries, while promoting health and fitness programs and is having a major impact on the fire service.
He has instructed at workshops and seminars, dealing with Fireground Operations, Health and Safety, Customer Service, end Fire Department Management. His book, Fire Command, has become a popular text for students of fire fighting. He has recently completed a second book entitled Essentials of Fire Department Customer Service.
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