Everyone Goes Home® the 6 root causes of firefighter Line-of-Duty-Deaths Introduction


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Everyone Goes Home®-- THE 6 ROOT CAUSES OF Firefighter Line-of-Duty-Deaths

Since 2004, the National Fallen Firefighters Foundation (NFFF) has spearheaded industry-wide efforts to reduce line-of-duty injuries and deaths among firefighters. Through its Everyone Goes Home® program, the NFFF and its fire service partners develop and deliver training courses, advance health and safety initiatives and support research that will ultimately result in increased firefighter safety. Each of these efforts is designed to substantially and quantifiably improve outcomes by promoting the individual and/or organizational changes—procedural, technical or cultural—that address the root causes of line-of-duty deaths.
When we discuss root causes, we are talking about the most basic identifiable elements of a LODD. The first step in addressing these root causes was to identify them through a thorough examination of the data found within the firefighter fatality reports issued by NIOSH, USFA, and other state and national organizations. Initially this may have seemed like a difficult task, because firefighters die in myriad ways, and no two fatalities are identical. However, as we review LODD cases we begin to find striking similarities, and the same contributing factors recur with unnerving frequency: failure to wear a seatbelt; failure to perform an adequate size-up; failure to obey traffic laws; inadequate respiratory protection; etc.

If we delve further into each of these contributing factors and ask “why?” then we can begin to identify the root factors behind each fatality. “Why wasn’t the firefighter wearing a seatbelt?” “Why did the incident commander fail to make an appropriate and thorough size-up?” “Why did the driver run the stop sign?” When we can see the answers to these questions it becomes apparent that there are often startling commonalities among fatalities that initially appeared as truly disparate scenarios. These factors are the organizational and individual situations, behaviors and attitudes that are the true root causes of the fatal incident:

  • Ineffective Policies/Procedures

  • Ineffective Decisions

  • Lack of Preparedness

  • Ineffective Leadership

  • Lack of Personal Responsibility

  • Extraordinary/Unpredictable Circumstances

It should be noted here that the majority of firefighter fatalities and/or serious injuries have multiple identifiable root causes. In fact, a LODD is almost never the result of a single personal mistake, procedural miscalculation or a mechanical malfunction. More likely, there was a chain of events that led up to the fatality, each link of which is characterized by the presence of one or more contributing factors. When we closely examine each of these identified missteps—or links in the chain of events—we can ultimately identify one or more root causes.

These six root causes of firefighter fatalities were first defined during the 2004 Tampa Firefighter Life Safety Summit. This meeting was coordinated by the National Fallen Firefighters Foundation in support of the United States Fire Administration’s goal of reducing the rates of firefighter deaths and injuries. At the time, approximately 100 firefighters were losing their lives annually in the line of duty in the U.S.—one every 80 hours. This Summit was an unprecedented gathering of representatives of every identifiable segment of the fire service unified behind this common goal, and included those of all major national fire service organizations, occupational health and safety experts and survivors of fallen firefighters.

For two days, participants deliberated over the cultural, philosophical, technical and procedural problems existing within the fire service, and jointly identified the most important domains. Over one hundred recommendations were put forth during the Summit, which were then narrowed into a set of key initiatives with which to define the mission of the effort going forward. By the conclusion of the meeting, the 16 Firefighter Life Safety Initiatives had been agreed upon, and the Everyone Goes Home® (EGH) program was created.

During the Summit, the six root causes of firefighter fatalities were also identified and agreed upon. In preparation for the meeting, NFFF staff and contract employees had been tasked with conducting an extensive literature review of firefighter fatality reports. Using data gleaned from these documents, they were able to identify the common factors, and named the six root causes that could then be addressed through EGH programs and initiatives.1 In the future, defining and articulating these factors would serve as a way to attribute and classify causality in line-of-duty deaths, as well as serving as starting points for LODD prevention efforts.
As the first stage of development for the Vulnerability Assessment Program (VAP), the NFFF recently had an opportunity to revisit these definitions of root causes and to validate their ongoing relevance and applicability. The VAP, a joint effort of the NFFF, USFA and Honeywell, will ultimately be an online tool that enables fire departments to identify and address their organizational exposures and vulnerabilities to suffering a line-of-duty death and/or injury. The VAP will be scaleable, feature a user-friendly interface, and be applicable to all sizes and types of organizations. Upon completing the VAP assessment, fire department and agency personnel will then be able to use the resources that are available through the VAP to make the necessary changes in their operating policies and procedures, equipment use and maintenance, and safety culture that will reduce the likelihood of a future firefighter death or injury.

In 2011, as part of the information-gathering phase of VAP development, NFFF personnel reviewed 1252 firefighter line-of-duty death reports for fatalities that occurred between 1999 and 2010.2 A retired chief officer from the Prince William County (VA) Department of Fire and Rescue, with 35 years of experience, was tasked with reviewing each fatality report in its entirety. He assigned an initial designation as to the one or more root causes that would be attributed to the case. A second chief officer, retired from the Fort Worth (TX) Fire Department after more than 30 years of service, then reviewed each case and provided input on the root cause classification; final determination was made by consensus.

The data collected from this study was then examined to affirm the continued applicability of the six LODD root causes derived at during the Tampa Summit, and to assess current trends. As had been found previously, in the majority of LODD events it was determined that two or more causal factors contributed to the fatality. Ineffective Decisions led to the highest number of LODDs followed by Ineffective Policies or Procedures. Ineffective Leadership and Lack of Personal Responsibility were next, followed by Lack of Preparedness and Extraordinary/Unpredictable Events. Most fatalities were associated with at least three root causes, while others included five. It should also be noted that the only category that was attributed as a sole factor was Extraordinary/Unpredictable Events.

-Vulnerability Assessment Project, NFFF/USFA/Honeywell 2012

For clarification purposes, the criteria which was used to determine whether or not a firefighter fatality constituted a line-of-duty death during this review was that established by fire service leaders in 1997 for determination of eligibility for inclusion on the National Fallen Firefighter Memorial:
  1. (a) Deaths of firefighters meeting the Department of Justice’s (DOJ’s) Public Safety Officers’ Benefits (PSOB) program guidelines, and those cases that appear to meet these guidelines whether or not PSOB staff has adjudicated the specific case prior to the annual National Fallen Firefighters Memorial Service; and (b) Deaths of firefighters from injuries, heart attacks, or illnesses documented to show a direct link to a specific emergency incident or department-mandated training activity.

  2. While PSOB guidelines only cover public safety officers, the Foundation’s criteria also include contract firefighters and firefighters employed by a private company, such as those in an industrial brigade, provided that the deaths meet the standards listed above.

  3. Some specific cases will be excluded from consideration, such as deaths attributable to suicide, alcohol or substance abuse, or other gross abuses as specified in the PSOB guidelines.

LODD Root Causes/Contributing Factors

-Vulnerability Assessment Project, NFFF/USFA/Honeywell 2012
Root Cause 1: Ineffective Decision Making
Ineffective Decision Making was the most common root cause among the fatality reports reviewed, and was identified in 766 of the 1252 cases, or 61%. While not every poor decision has a negative outcome, many do. Fatality reports are rife with examples of poor decisions with lethal consequences: the firefighter who neglects to buckle his seatbelt to save a few seconds; the incident commander who skips making an accurate size-up because he is convinced that he has a complete understanding of the situation; the apparatus driver/operator who runs a stop sign to get to the fire faster; and the fire chief who foregoes equipment maintenance to meet budgetary priorities.

Firefighters and fire officers clearly risk their own lives and those of their team members when they fail to make well-informed, risk-appropriate decisions. A poor decision can be the result of many factors: it may be the outcome of a firefighter’s failure to properly analyze a situation; to control their own thought processes when responding to the situation; or an inability or unwillingness to collect the information they need to make a sound decision.

Making evidence-informed decisions that limit the exposure of a firefighter and his team members to risk during operations is integral to keeping firefighters safe. An individual’s inherent ability to make personal risk-management decisions at any particular point in time is directly impacted by variables which include training and experience, as well as leadership on the fireground. The safety culture of the department also factors into the equation: a culture which may condone or even encourage risky tactical maneuvers­ will increase the likelihood that a firefighter may decide to attempt an action that he is not trained to undertake, or does not have the appropriate equipment or personnel support to accomplish successfully.
It must also be noted that poor decisions can be made during any operational step, and many of the fatality reports reviewed cited multiple examples of ineffective decision-making. Poor risk management decisions made at the strategic level jeopardize the health and safety of every firefighter. During emergency response, performing the basic strategic-level safety routine found in the standard command functions should provide a framework for effective decision making, but unfortunately, we find that these functions of command were most often not employed in LODD events.
The availability of information, and the individual’s ability to process it, also play important roles in the decision-making process. Decisions made during size-up and while developing operational strategies at an incident are based on the availability of information, or lack thereof. Failure to conduct an initial size-up or failing to take adequate time to gather adequate information and process it will lead to decisions that are not fully informed, and will limit a firefighter’s ability to make decisions based upon that information.

Personality factors can also affect decision-making ability. An individual who is willing to accept or ignore inappropriately high levels of risk (the proverbial “adrenaline junkie” or thrill-seeking personality) has an increased likelihood of making a poor decision on the fireground. Similarly, a firefighter with poorly developed impulse control is also more likely to act before thinking out the consequences of a potentially dangerous action.

Root Cause Case Studies for Ineffective Decision Making are found on page 13 of the Appendix.
Root Cause 2: Ineffective Policies and Procedures
Ideally, a fire department’s activities are guided by comprehensive SOPs that support firefighter health and safety, and are consistently enforced by organizational leadership. When the entire department is operating from the same playbook, they are all following the same rules and regulations, understand organizational expectations and are working together toward a common goal. When SOPs go the extra step and articulate firefighter safety as an organizational value, it sends a strong and unified message to its members that each of their lives is valued. Conversely, inadequate and/or poorly enforced standard policies and procedures significantly increase the risk of death or injury to firefighters on the fireground, during training, and even while performing routine activities in the firehouse.

Among the case studies reviewed in 2011, Ineffective Standard Operating Policies and Procedures was the second most prevalent root cause among the cases studies, and was a factor in 640, or 53% of the 1252 cases. For a line-of-duty death to be attributed to Ineffective Standard Operating Policies and Procedures, one of two situations must be evident. First, do adequate SOPs exist within the organization? Second, do the chief and other officers actively and consistently enforce these policies? Established policies and procedures are put in place to clarify duties and performance expectations for all stakeholders, and are not intended to be explicitly technical, to provide in-depth detail about a job, or to take the place of training. Rather, they should define the basic parameters—the who, what, where, when and why—of every type of department activity, and should address any concerns that may be related to the task being performed such as safety, use of resources, and duties of members.

Without SOPs to guide their behavior, firefighters and officers often accept high levels of risk that are unwarranted. Within the cases reviewed, there are numerous examples of activities that should have been guided by the department’s policies and procedures, but weren’t: horseplay, freelancing, self-dispatching, utilization of dangerous training scenarios, not obeying traffic rules, speeding, not wearing seatbelts and others.
However, even if SOPs are in place, they are only as effective as the organizational leadership’s ability to ensure that they are adhered to by its members. Inadequate enforcement of SOPs, ignorance of their existence, and even a cultural acceptance of non-compliance all greatly increase the likelihood of serious firefighter injury or a fatality, and are frequently cited as causal factors in fatality reports.
SOPs should also comply with current health and wellness standards, including NFPA 1582 Standard on Comprehensive Occupational Medical Program for Fire Departments. Cardiac arrest is the leading cause of firefighter LODDs¸ and of the 552 heart attack cases reviewed 177 (32%) involved career firefighters and 354 (64%) were volunteer members. 219 reports indicated no NFPA 1582 medical evaluation program in place and 209 reports were left blank on this section of the USFA report filled out by the affected department. Only 124 (21%) responses indicated a full (61) or partial (63) NFPA 1582 medical evaluation program was in place at the time of the death.

The 2011 literature review indicated that the lack of effective SOPs is a more frequent occurrence in volunteer departments. This may be attributed to the financial resources and time needed to develop and write these guiding documents and to keep them current and relevant. However, there is clearly a greater cost at stake here, that of a human life. For organizations which have resisted adopting SOPs for financial reasons, reduced cost options—such as adapting those of other organizations or using pre-written SOPs—should be explored.

Root Cause Case Studies for Ineffective Policies and Procedures are found on page 15 of the Appendix.

Root Cause 3: Ineffective Leadership
It is often said that an organization is only as effective as its leadership, and this seems particularly true in fire departments. The multiple levels of command—both those within the organizational hierarchy and that of the ICS structure during incident response—all have profound effects upon the safety and well-being of the individual firefighter. Whether it is the incident commander on the fireground or the chief officer who establishes and enforces organizational priorities, every firefighter is directly impacted by the quality of his or her leaders.
Unfortunately, a lack of strong leadership anywhere in the chain of command greatly increases a firefighter’s risk of line-of-duty death or injury. Ineffective Leadership was the third most frequent root cause among the LODD reports studied, and was cited in 554 or 44% of the 1252 cases examined in the 2011 review. At the initial Firefighter Life Safety Summit cases that were attributed to ineffective leadership ran the gamut from allowing horseplay and freelancing to concerns with incident command and safety oversight. Other examples of ineffective leadership included the failure to create effective policies related to health and wellness and poor strategic and tactical direction on the fireground.

Due to the scope of this category, it is always important to carefully consider the events that lead to a LODD to ensure that this is applied appropriately as a root cause. Critical observation must be made of the qualifications of all levels of unit and department leadership, their focus and vision on department goals or missions, and communication styles both within the command structure and with the firefighters.

Ironically, it is the lowest level of leadership, and that with the least amount of experience, that most directly affects a firefighter’s safety. The company officer is usually accountable for the day-to-day activities of his or her team, ensuring that SOPs are complied with, that firefighters are trained and that equipment is properly maintained. They serve as teacher, role model and mentor for firefighters, and pass on the department’s culture—both its positive and negative aspects—to the next generation. Most importantly, company officers are tasked with ensuring that the firefighters in their unit are educated and trained to make good risk management decisions. As first line supervisors, they and the firefighters that they command are directly engaged in the operational activities that expose them to high levels of risk. It is particularly important that in this capacity, the company officer is ethically disposed to teaching and modeling safety and good personal risk decisions, and to actively limiting risk to his or her firefighters.
Unfortunately, this is the level of leadership that is most likely to demonstrate their inexperience, make risk-inappropriate decisions and fail to limit risk during operations and even during everyday activities. Compounding the situation, company officers are sometimes promoted into the position with little or no formal Incident Command training, and their lack of skills results in unnecessary risks taken on the fireground. It should also be noted here that ineffective leadership at the company officer level can be indicative of similar problems as we go up the organizational hierarchy; how can a company officer model safety in leadership, when it has never been modeled for him or her?

Ineffective Leadership can also be symptomatic of other problems within the organization, and is closely intertwined with all of the other root factors. As was discussed previously, when leaders do not enforce their compliance, SOPs are ignored. When chiefs and other officers do not prioritize training or neglect equipment maintenance, that lack of preparedness can increase the risk of a line-of-duty death or injury. When chief and company officers do not hold firefighters accountable for their own safety, lack of personal responsibility comes into play.

Root Cause Case Studies for Ineffective Decision Making are found on page 18 of the Appendix.
Root Cause 4: Lack of Personal Responsibility
Ultimately, firefighters must be accountable for their own safety. A firefighter or officer demonstrates a lack of personal responsibility when they fail to take into consideration their own health and safety when participating in any fire organization activity. A lack of personal responsibility can dramatically impact the quality and safety of job performance, and most disturbingly it can also put the life of other team members at risk.
Within the most recent literature review, Lack of Personal Responsibility was identified as a root cause in 554 reports, or 44% of the 1252 reports. It was cited in most cases where firefighter fatality is the result of an apparatus or POV accident, and speeding, failing to use seatbelts and a lack of compliance with traffic signals or laws were frequent examples. Unfortunately in the case of vehicular accidents, a lack of personal responsibility may elevate the level of injury from survivable to fatal. It can also increase the likelihood of collateral death and/or injuries when others on board the apparatus, in other vehicles, and even pedestrians are involved.

Lack of personal responsibility also manifests itself in health and wellness issues. Numerous cases were noted in which fire department members had serious medical conditions that should have precluded their participation in emergency response activities. Some of these individuals clearly ignored the symptoms of the condition and failed to get adequate medical help, while others defied doctor’s orders and continued to participate in emergency operations.

It bears repeating that heart attacks and strokes are consistently the leading cause of line-of-duty death for firefighters, and every firefighter is responsible for their own physical health. There are decades of research studies that indicate that obesity, high cholesterol levels, lack of exercise, smoking and a genetic predisposition to cardiac issues are all key coronary risk factors. Despite this well-publicized evidence, some at-risk personnel are still unwilling to take part in health and wellness programs, even when it would obviously be in their best interest.
Cost should not be a barrier to firefighter health and safety. In addition to resources available offered by the organization or municipality, there are numerous free, downloadable online resources available to firefighters and fire departments, including the National Volunteer Fire Council’s Heart Healthy Firefighter; USFA Health and Wellness Guide for the Volunteer Fire and Emergency Services; the IAFF and IAFC’s Fire Service Joint Labor Management Wellness-Fitness Task Force; and others that can be found on the NFFF’s www.everyonegoeshome.com and www.lifesafetyinitiatives.com websites. At the very least, NFPA 1582 compliance should be mandated by departmental SOPs.
Root Cause Case Studies for Lack of Personal Responsibility are found on page 21 of the Appendix.

Root Cause 5: Lack of Preparedness

By the very nature of their duties, firefighters must be prepared to face a virtually limitless number of response situations. Unfortunately, firefighters are sometimes killed when they attempt to conduct a level of operations for which the individual or the organization is not prepared. Lack of Preparedness was cited in 389, or approximately 1/3 of the 1252 fatality reports reviewed in 2011.

Lack of Preparedness is also often symptomatic of poor decision making, because no firefighter should ever attempt to do something that they are unprepared or ill-equipped to undertake. However, many LODDs that occur on the fireground are the direct results of situations in which a firefighter attempts a maneuver, despite the lack of proper personal protective equipment or tools. Alternately, individuals may also attempt maneuvers that they are either untrained or inadequately trained to undertake.
Lack of preparedness can be evident at the organizational level. Planning is critical to safe operations, and lack of comprehensive SOPs, or the failure to follow or enforce them, is frequently a contributory factor in firefighter fatalities. Lack of pre-planning for high-hazard events and areas within a district can also lead to the assumption of inappropriate levels of risk. Failure to train for, and to utilize, command procedures, particularly not establishing incident command, are often cited as contributory factors in fatal incidents. These scenarios can occur in both career and volunteer departments, and can be indicative of a culture that accepts—or even encourages—maneuvers that are beyond the capability of that organization.
Some examples of lack of preparation include:

  • A company advances a 1 ¾” line into a commercial structure and immediately need a second line to be deployed. The company is overwhelmed by volume of fire.

  • Firefighter struck at the scene of a MVA. Firefighter failed to secure the scene properly with visual cues to direct traffic or create a barrier between oncoming traffic and the scene.

  • Firefighter is overcome by fumes at HAZMAT incident. There was no record of training for response to hazardous materials.
  • Firefighter is overcome by smoke after running out of air while operating inside a burning structure. No RIT team was in place to respond and retrieve the downed firefighter or to provide supplemental oxygen.

Root Cause Case Studies for Lack of Preparedness can be found on page 23 of the Appendix.

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