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IN THEIR HONOR
The recent release of the NIOSH Investigation Report #F2007-28 detailing the deaths of a Captain Matt Burton and Engineer Scott Desmond of the Contra Costa County (CA) Fire Protection District is unquestionably a wake-up call for us all. The loss of two experienced firefighters in a structure encompassing less than 1000 square feet is proof that no incident, regardless of size, cannot be taken lightly.
In honor of Captain Burton and Engineer Desmond, I’d ask that we all take a moment to review this incident and compare the critical facts that relate to the jobs we perform each and everyday. Scott and Matt have provided us with some very powerful lessons, it’s our duty to respect their sacrifice and to ensure we never repeat the lessons they have given each of us.
Have you given any thought to your morning apparatus check and how such a small oversight could put you or your crew at risk?
“The E73 crew was using an apparatus marked “E74” because E73 was out of service.”
Passing command in many departments is considered taboo, but in this case it presented an opportunity for a minimally staffed crew to act in a life saving manner. Regardless of your position on passing command, the critical lesson is “closed loop communications” – when giving an order, the receiver MUST repeat the order before taking action.
“The IC was observed looking at “E74” at the time he passed command. The officer on E73 did not hear the radio transmission and was unaware that Victim #2 had passed command.”
Ventilation, regardless of the type or method, all forms of ventilation provide two things – removal of hot gases/particulates and the introduction of oxygen. Ventilation MUST be a coordinated action initiated upon approval of the attack team.
Ventilation induced flashover - It is not recommended to initiate positive pressure ventilation after firefighters enter the building. If used post fire control, fire fighters should be withdrawn to a safe (uninvolved) area or out of the building while it is pressurized. If used in positive pressure attack, the building should be pressurized and the effectiveness of ventilation verified by observation prior to entry.
All structures must be searched is a conversation that is currently being debated from coast to coast. The one caveat to this conversation is – TENABLE spaces for VIABLE victims. If you can feel the heat through your turnouts and are working in zero visibility, is this a tenable space for a viable victim?
“The conditions were hot and visibility was near zero.”
A 360-degree size-up has long been known as a “critical action step” for an effective size-up, but do we give proper consideration to what we see? Do we evaluate the roof and consider what forms of ventilation are appropriate? Are there outward signs contraindicating vertical ventilation (i.e., rain roof)? Do we take the time to relay our findings to incoming crews?
“Initially there wasn’t any smoke or fire coming from the 6-foot by 6-foot ventilation hole.”
To their credit, NFPA is currently working to revise the thermal requirements of the modern PASS alarm, but do we as firefighters take the necessary precautions to effectively prepare for a “safety system” failure? Have you ever taken the time to ask, “What if…?”
“The crew did not hear any PASS devices.”
Air management is another topic of many kitchen table discussions, but what role does it play in a 956 square foot house fire? The reality – the same as a 30,000 square foot warehouse. No one should be operating inside an IDLH environment with their low air alarm sounding. Our performance should always be a reflection of due caution.
“…exited while their low-air alarms sounded.”
The use of Flashover Simulators has become incredibly popular throughout the fire service, but what are we teaching our firefighters about fire behavior? Is it a badge of honor or are we walking away with a full-fledged understanding the dynamics of fire and the role ventilation plays in feeding the fire (good or bad)?
“Currently these qualifications do not include the need for a sound understanding of the physical, chemical, and thermal behavior of fire and do not make a connection between fire dynamics and the influence of tactical operations (positive pressure ventilation) and external factors (wind).”
Never forget the lessons they’ve shared with us…Thanks Guys!!!
Timothy E. Sendelbach is a 23 – year student and educator of the fire & emergency services currently serving as Editor-in-Chief for FireRescue Magazine and President of TES² Training & Education Services. Tim is also the immediate past president of the International Society of Fire Services Instructors. (ISFSI)
In honor of Captain Burton and Engineer Desmond, I’d ask that we all take a moment to review this incident and compare the critical facts that relate to the jobs we perform each and everyday. Scott and Matt have provided us with some very powerful lessons, it’s our duty to respect their sacrifice and to ensure we never repeat the lessons they have given each of us.
Have you given any thought to your morning apparatus check and how such a small oversight could put you or your crew at risk?
“The E73 crew was using an apparatus marked “E74” because E73 was out of service.”
Passing command in many departments is considered taboo, but in this case it presented an opportunity for a minimally staffed crew to act in a life saving manner. Regardless of your position on passing command, the critical lesson is “closed loop communications” – when giving an order, the receiver MUST repeat the order before taking action.
“The IC was observed looking at “E74” at the time he passed command. The officer on E73 did not hear the radio transmission and was unaware that Victim #2 had passed command.”
Ventilation, regardless of the type or method, all forms of ventilation provide two things – removal of hot gases/particulates and the introduction of oxygen. Ventilation MUST be a coordinated action initiated upon approval of the attack team.
Ventilation induced flashover - It is not recommended to initiate positive pressure ventilation after firefighters enter the building. If used post fire control, fire fighters should be withdrawn to a safe (uninvolved) area or out of the building while it is pressurized. If used in positive pressure attack, the building should be pressurized and the effectiveness of ventilation verified by observation prior to entry.
All structures must be searched is a conversation that is currently being debated from coast to coast. The one caveat to this conversation is – TENABLE spaces for VIABLE victims. If you can feel the heat through your turnouts and are working in zero visibility, is this a tenable space for a viable victim?
“The conditions were hot and visibility was near zero.”
A 360-degree size-up has long been known as a “critical action step” for an effective size-up, but do we give proper consideration to what we see? Do we evaluate the roof and consider what forms of ventilation are appropriate? Are there outward signs contraindicating vertical ventilation (i.e., rain roof)? Do we take the time to relay our findings to incoming crews?
“Initially there wasn’t any smoke or fire coming from the 6-foot by 6-foot ventilation hole.”
To their credit, NFPA is currently working to revise the thermal requirements of the modern PASS alarm, but do we as firefighters take the necessary precautions to effectively prepare for a “safety system” failure? Have you ever taken the time to ask, “What if…?”
“The crew did not hear any PASS devices.”
Air management is another topic of many kitchen table discussions, but what role does it play in a 956 square foot house fire? The reality – the same as a 30,000 square foot warehouse. No one should be operating inside an IDLH environment with their low air alarm sounding. Our performance should always be a reflection of due caution.
“…exited while their low-air alarms sounded.”
The use of Flashover Simulators has become incredibly popular throughout the fire service, but what are we teaching our firefighters about fire behavior? Is it a badge of honor or are we walking away with a full-fledged understanding the dynamics of fire and the role ventilation plays in feeding the fire (good or bad)?
“Currently these qualifications do not include the need for a sound understanding of the physical, chemical, and thermal behavior of fire and do not make a connection between fire dynamics and the influence of tactical operations (positive pressure ventilation) and external factors (wind).”
Never forget the lessons they’ve shared with us…Thanks Guys!!!
Timothy E. Sendelbach is a 23 – year student and educator of the fire & emergency services currently serving as Editor-in-Chief for FireRescue Magazine and President of TES² Training & Education Services. Tim is also the immediate past president of the International Society of Fire Services Instructors. (ISFSI)
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Comment by Art "ChiefReason" Goodrich on April 26, 2009 at 10:46pm
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I went back and read once more “Brace for Impact”, “IN THEIR HONOR” and the replies to it AND the NIOSH LODD report issued on the two California LODDs.
I must go back to the comment …and at no point do I expect a firefighter to take the lead in a decision-making process, they should play their role via the CRM concept-inquire, inform and comply.
I agree with it as stated.
However; I believe that it is every firefighter’s duty to take the lead in the decision-making process where it determines THEIR personal safety.
I hate-literally hate-PPV as an offensive weapon because of poor decision-making on when and when not to use it. And NEVER when firefighters are inside somewhere between the fan and the exhaust outlet. At the very least, communication should be sent, received and confirmed that they are not in the room of origin, but elsewhere, in a room with the door shut.
Yeah; I’m “Monday morning quarterbacking” and though I despise the term, I’ll gladly take it in order to discuss the lessons learned.
At Contra Costa, there were two crews inside, without hose lines, when the PPV was initiated. That is a critical error on top of initiating PPV with crews inside. Without knowing their locations, it was not a viable tactic AT THAT TIME.
There is constant criticism for those of us who want to discuss NIOSH LODD reports. If we didn’t, the reports might very well be shrugged off as “we do what we do because we are what we are”. That is such BS.
Jay Tarley, Scott Jackson and Timothy Meriner weren’t at the fire, but their forensic investigation of the fire yielded a (29) page report with (9) key recommendations.
Does anyone else ever wonder why NIOSH can take a template and use it over and over?
Because, we make the same mistakes over and over. Often times, we see many of the same recommendations being made for another LODD.
So, having a template than can be applied again and again is disconcerting to me.
That we could learn from other segments of business and industry, especially where it will improve our success on the fire ground and reduce the loss of lives is something that must be explored.
What distinguishes firefighting from the rest is that we are closer to immediate, critical decision-making, due to quickly changing conditions from elements that within our control and outside of our control and if we can learn to gain more control over what is outside of our control from people like Sully Sullenberger or the military leaders, then I am perfectly comfortable with that.
And if that makes me a “Monday morning quarterback”, then the snap count is on two. Ready? Break!
TCSS.
Art
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Comment by Timothy Sendelbach on April 24, 2009 at 7:12am
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Mark:
I'm willing to concede that in most cases "cooler heads" prevail.
It still seems you are comparing the Capt to our line firefighters - Absolutely not, the entire Editorial is focused on the company officers decision-making supported by crew resource management (CRM).
Again I think comparing military officers to our line firefighters is unfair - Again, my reference to decision-making is focused at the company officer level and at no point do I expect a firefighter to take the lead in the decision-making process, they should play their respective role via the CRM concept - inquire, inform, and comply.
Thanks for your post.
TESendelbach
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Comment by Oldman on April 23, 2009 at 11:43am
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"Commercial airline pilots are incredibly well prepared backed by education, simulator training, other crew members, engineers and countless other resources." Should this not be the same in the fire service? The education is here for us to use and learn from. Simulator training, whether flying an aircraft, or live fire training, while you may not get the exact same sensation of a simulation that real life provides, it normally is a lot safer then real life. Other crew members? This is why we should train and practice as a team. Flight crews utilize Cockpit Resource Management for various flight functions, whereby one person is not having to do all the work. It combines incident management, tactical ops, communications, and teamwork, and could and should be used on the fireground.
"Would the outcome have been the same in an aircraft he had never stepped into before?" More than likely, the results would be the same. Again, by utilizing CRM, the minor differences in flight characteristics between aircraft type would not change the overall objective. No two fires are the same, but using the same principles of CRM, can make the common objective of any fire, even with they different characteristics of each individual fire, a lot safer and more effective.
"We should definitely be looking at risks vs benefit, we should definitely be thinking about our safety, and we should be training and making intelligent decisions on the fireground , but I don't see how these types of of articles promote this as much as we think." These reports promote training, education, and decisions by doing one thing. They make us think. Why do we have textbooks? Makes no difference whether it is Delamr, IFSTA, or Jones and Bartlet, all the information comes from; somebody did this and it didn't work so well, so this should be the way to do it. I don't consider them as "Monday morning quarterbacking, but rather another chapter in a text book.
"If we really want to make significant reduction in Firefighter fatalities then we eliminate the easy ones first heart attacks/vehicle accidents." We will never "eliminate" these. We can perhaps strive to lessen their chances, and I don't see the rest as futile. When you look up the definition of cynical, my picture is right there, but the more information we put out there, whether it is healthy living, wearing seatbelts, understanding fire behavior and building construction, or ventilation tactics, the more we lessen the chances of these occurrences. It is up to us to learn.
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Comment by Mark Klaene on April 23, 2009 at 10:58am
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Thanks for the clarification Tim here are my thoughts based on this new understanding
Each and every day, company officers across the country are faced with high-pressure events requiring quick and decisive actions. In some cases (I would say in MOST ) , cool heads prevail
By contrast, the life-saving actions taken by Capt. Sully and his crew weren’t driven by restrictive policies that outlined what not to do, but rather guidelines that entrusted the crew to make good decisions in the face of unknown problems. These guidelines were backed by numerous hours of training that included simulations of water-based landings which clearly defined the safe and supportive actions of the entire crew.
(it still seems you are comparing the Capt to our line firefighters)
Similarly, safe and effective outcomes on the fireground or emergency scene are not driven by restrictive policies, but rather by training and self-discipline. At 0200 hrs, chief officers are seldom present to bear witness to the actions of first-arriving crews. It’s the delegated responsibility of a company officer to take the time to properly assess the risk and develop a strategy that encompasses personal and crew safety while initiating actions within their respective capabilities. Company officers also must be self-disciplined enough to slow down and prevent an aggressively offensive mindset from becoming the default setting among the crew.
I agree 100%
We don’t have to look far outside the confines of the fire service to find examples of effective decision making under high-stress situations. For years we have studied military leaders and their decision making during combat operations. Today, examples like Capt. Sully and the crew of US Airways Flight 1549 provide us with valuable civilian lessons of self-discipline, CRM and effective leadership. It’s our responsibility to find the value of these lessons and apply them to our own actions.
again I think comparing military officers to our line firefighters is unfair
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Mark:
While I value your opinion, the posting of my Brace for Impact Editorial was not directed at our brothers from Contra Costa. The link to my Editorial was posted in reference to Art's post which referred to the recent events in San Antonio.
Please take a minute to read Art's post and let me know if you agree.
I look forward to reading your thoughts.
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So I'm going to take a little different approach than all those that seem to support the "Brace for Impact" editorial. First I agree we need to make the right decisions on the fireground and these need to be made based on a risk/benefit and available resources analysis. I also disagree with the idea " you never know if someone is in a building unless you search it" . But that is not what happened here. 2 citizens were inside.
I do have issues with comparing 2 firefighters that COMBINED have 1/2 the experience, education, and likely income as Capt Sully. Commercial airline pilots are incredibly well prepared backed by education, simulator training, other crew members, engineers and countless other resources. Yes Capt Sully and crew did a great job , they followed well prepared checklists and highly developed procedures for an event that was "designed" to happen to an aircraft he knew. Would the outcome have been the same in an aircraft he had never stepped into before?
If you want to compare Capt Sully to someone in the fire service then anyone other than a Chief Officer would be unfair in my opinion.
I totally disagree that we can presume what the conditions were that these two firefighters saw and knew when they made the decisions they did. There were 2 people in the house, it was a small house and yes that is our job to rescue those people. NOT if they are already dead AND NOT if it might cost us our lives but can we really be sure that these two firefighters were wrong in their decision to try and save them. I won't make that judgement based on the report.
It certainly sounds like from the report that the firefighters did not do it by the "book" and may have skipped a couple steps and maybe that caused their death , I don't think we know that. Lets face it all of us take shortcuts in our daily life and get away with it. That doesn't make it right but sure makes it wrong to "cast the first stone"
We should definitely be looking at risks vs benefit, we should definitely be thinking about our safety, and we should be training and making intelligent decisions on the fireground , but I don't see how these types of of articles promote this as much as we think.
If we really want to make significant reduction in Firefighter fatalities then we eliminate the easy ones first heart attacks/vehicle accidents. If we can't do that then the rest is futile, and I don't see us doing it. Two firefighters lives were lost here for doing what we do , it isn't right, it isn't fair and yes we should learn from it but the monday morning quarterbacks need to be very cautious if they try changing the rules when they were not even at the game.
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Comment by Ed Hartin on April 22, 2009 at 8:13pm
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I e-mailed NIOSH regarding the link. Until the link is fixed, you can access the report at http://www.cfbt-us.com/pdfs/face200728.pdf.
Also visit the Compartment Fire Behavior Training (CFBT) Blog as there will be a post on this report tomorow morning and a more detailed look at the fire behavior involved within the next few weeks.
Ed Hartin, MS, EFO, MIFireE, CFO
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Tom:
You have disagreed with me in the past?
I can't imagine what topic it was!:-)
But, I used the link yesterday to download the report (I print them and use them for learning tool at the fire station) and it worked fine.
Today; it doesn't work.
I get email notification from the CDC for firefighter fatalities reports. CDC NIOSH, I believe.
TCSS.
Art
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Tim:
We are most definitely on the same page.
I have been involved in discussions where you hear many crying” training isn’t like the REAL thing”; “nothing will replace the REAL thing”; you haven’t been there if you haven’t fought an ACTUAL fire”.
Well, unless that stuff in the barrel is holographic or from a parallel universe, it IS real fire; just not the BIG fire that everyone wants to risk it all on.
Have you noticed that, as we progress, the same, old, tired arguments appear? They give old guys like me a bad name, because people in the service wants to credit everyone over the age of 40 with these statements.
There is that saying “you can’t change history” and where we continue to kill firefighters by the same mechanisms, then we are duty bound to change history. People are choosing to ignore some very good empirical data while on their way to another firefighter funeral.
Your comparisons to the “Miracle on the Hudson” is right on the mark. Having that training and preparation is a tool that you hope you should have to never use, but it’s nice to know when you go to the toolbox, it is there and can be used.
If you don’t train for it, thinking that you’ll never use it, you will show up ill-prepared to deal with a situation with potentially life threatening consequences. It will be too late to get the “tool” then.
My point with the situation in San Antonio is that I find it ironic that all too often, the firefighters are claiming that officers are putting them into harm’s way, but in San Antonio, it appears to be just the opposite.
I support that the chief wants to make sure that good decisions with regards to the safety of the firefighters are made, but I don’t want to see it go to an iron-clad policy that will handcuff the on-scene decision-makers.
Fire behavior and building construction should be required reading for all firefighters.
“Wet stuff on the red stuff” can go into the heap of terms no longer used like “groovy”.
Unless you’re washing a red Corvette.
We need to be teaching our firefighters survival tactics in this year of personal responsibility for safety.
And I don’t think that can be done without a solid base of fire behavior and building construction training.
Excellent article.
TCSS.
Art
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Art:
That link was brought to my attention last night. Check out my most recent Editorial and let me know if were on the same page - Brace for Impact.
TESendelbach
Editor-in-Chief
FireRescue Magazine
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