BY CHRISTOPHER FEDER
I began my fire service career in 1995 and quickly found that I had a knack for technical rescue. In 2011, I became an officer and was initially responsible for training and drills. I had been a Pennsylvania state fire instructor since 2005, so training was nothing new for me. However, coming up with a weekly training/drill plan was new territory. Yes, there is a difference between training and drilling. Training is a formal lesson on a given task a student may not have mastered, whereas drilling is instruction or training on a skill that a student already has mastered. Writing the lesson plan, developing the curriculum, designing the PowerPoint®, and preparing training aids are some basic teaching fundamentals. Additionally, the instructor must have the knowledge, the skills, and the abilities to deliver that level of training.
Is there a difference between the person/officer conducting the training in the firehouse vs. the state fire academy instructor conducting a formal class? If we are doing hands-on rope rescue training, is a rescue plan required? Is there a difference between rope rescue training 50 feet in the air and a real-world rescue 50 feet in the air? The answers are yes and no. The only difference between being suspended in the air on rope for training and an actual incident is time. Training affords us all the time in the world, whereas real-world incidents don’t.
Ultimately, there are similarities and small differences. First, if you are conducting training or running a drill in a firehouse, you still need to develop a plan on paper, although it can be less formal than a basic fire training lesson plan, for example. For your in-station training/drills, you may want to address the goals, the objectives, the student outcomes, and so forth. You may also need to address a safety plan, a rescue plan, and first aid, depending on the training subject and its associated hazards. Again, this can be less formal, but you should still have some plan on paper. This will guide your planning and ultimately ensure you are following that plan. In training, we have all the time in the world to plan and prepare. Real-world incidents don’t allow us all that preparation time. In training, we have the luxury of minimizing hazards and reducing risks through proper planning. We can learn from our training and apply that information and knowledge to live incidents. Train how we fight, as people have told me. Breaking it down to the common denominator, if you fail to plan, you plan to fail. If in training we can minimize hazards and reduce risks, why have we lost and continued to lose our fellow firefighters in training? In December 2012, I started to research why people were dying in training and how we can prevent it in the future.
Rope Rescue Training Fatalities
I first researched training fatalities involving first responders conducting some type of rappelling/rope rescue training. From December 2012 until February 2015, I contacted the investigating authority involved in each fatality and asked for a copy of the report. In some cases, I had to obtain the reports through a public record request or under the Freedom of Information Act. By February 2015, I had copies of the 11 reports. I compared the case studies, looking for common denominators. Though these fatalities occurred while training, they were all considered line-of-duty deaths (LODDs).
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| (1) “Blindness” is the phenomenon in which one “looks but fails to see.” In the case study cited under “Lesson 5: Blindness,” an O-ring was installed incorrectly on a piece of equipment. The O-ring was used to keep the J-hook in place on the tri-link but had no bearing on the operation of the system. This photo shows the J-hook, the tri-link, and an O-ring correctly installed. (Photos courtesy of the United States Forest Service.) |
The federal National Institute for Occupational Safety and Health (NIOSH) researches worker injury and illness and makes recommendations for prevention. The NIOSH Fire Fighter Fatality Investigation and Prevention Program conducts independent investigations of select firefighter LODDs. According to NIOSH, the investigation’s purpose is not to find fault or blame but to provide recommendations that will help to prevent future deaths and injuries.
I researched and meticulously reviewed each case, reading the investigation and the medical examiners’ reports and reviewing photos and video provided. I then created a spreadsheet of the factors that contributed to the fatalities. Interestingly, I came up with five common denominators, the “Focus Five.” To ensure neutrality, the departments and individuals are not identified. Below are the Focus Five in no particular order.
Lesson 1: Safety
The first common factor was a lack safety. Commonly, the persons involved failed in one or more of the following areas:
- Providing and clearly identifying a safety officer. In some cases, there was a safety officer but that person was never clearly identified.
- Conducting a safety briefing before the training evolutions. Although briefings did occur in some cases, safety was not addressed in all of them.
- Providing a competent and qualified instructor to oversee the operation. “Competent” means a person “who is capable of identifying existing and predictable hazards in the surroundings or working conditions that are unsanitary, hazardous, or dangerous to employees and who has authorization to take prompt corrective measures to eliminate them,” according to the Occupational Safety and Health Administration (OSHA). “Qualified” means a person with “specific training, knowledge, and experience in the area for which the person has the responsibility and the authority to control,” according to OSHA. A competent person may be a safety officer who ought to have the background in the area in which he is supposed to be identifying unsafe conditions or practices. We may interpret “qualified” as a recognized instructor in that area who is qualified to perform that task or job and to teach it. Of course, each department, agency, or authority having jurisdiction (AHJ) may have its own definition or requirements for an instructor, but overall the requirement is the same. The person instructing needs to be qualified to do so. In one case that stands out, the victim had climbed the rope, which was suspended from a tower ladder following the day’s training. This class was not a high-angle techniques program, but the rope was suspended to demonstrate raising and lowering. Two instructors were to have been present that day, but at the last minute the second instructor was called out on a personal matter. That left one instructor with approximately 20 students. At the end of the day as the class was cleaning up, the victim decided to climb the ropes independently without any level of personal protective equipment (PPE). The instructor and fire chief saw the victim climbing the ropes and ordered him to get down. At this point, the victim fell headfirst onto the pavement below and succumbed to his injuries. The investigation report outlined three clear contributing factors: an absence of a safety officer, a lack of PPE, and a large student-to-instructor ratio.1
- Conducting a primary and a secondary safety check of the systems, system components, and the equipment and PPE of the victims. When you are the one teaching, being trained, or rappelling, the culture should be such that anyone can check or double-check to ensure safety. A good instructor should not take offense if a student or another instructor checks his work, especially when it comes to high-hazard rope training. That should be seen as a much-needed level of redundancy, which we should be accustomed to in the fire service. Although I’ve heard my entire career that everyone is a safety officer, I can tell you that if the culture does not allow for that training, then everyone is not a safety officer. Note that in just about any training near miss or fatality, a lack of safety could potentially be the consistent factor that led to the incident. As far as we’re concerned, for these incidents, the four deficiencies above are the lessons learned and the areas that need immediate improvement.
Lesson 2: Training
In most cases, there was a lack of proper training. Additionally, the rope or rappel instructor was not qualified to supervise these techniques. In some of the cases, the victim had little experience and the instructor or person overseeing the training was equally untrained. They had enough experience and education to perform that skill under the direction of someone with a greater level of experience but not enough to oversee that training alone.
In one case, the person overseeing the evolution “supervisor” was not qualified to do so. The supervisor had little training in the mechanical device being used and trained one of the responders in the device. By this point, the victim had little information that was accurate and even less information on using the device properly. The mechanical device used was equipped with 7⁄16-inch rated National Fire Protection Association (NFPA)-compliant static kernmantle rescue rope, but the device was designed and tested for use with ½-inch NFPA-compliant static kernmantle rescue rope. The lack of proper training on this piece of equipment combined with using the wrong rope size contributed to this fatality.
In another case, the team members told their command staff they were doing one type of training but, in fact, did something different. They were doing what’s called a buddy rappel. In this case, the rappeller, a male, had a “buddy” on his back and was going to rappel a 50-foot tower on one rope with no safety (belay). According to the report, they were using “a 7⁄16-inch diameter, ‘Military Green Line,’ twisted-nylon, mountaineering-operations rope. The maximum recommended load for the rope involved in the accident is 315 pounds. The actual weight of the rappeller and the buddy plus their gear was estimated to be 484 pounds.” As the rappeller moved side to side descending the rope, so did the rope. Eventually the rope moved off a railing and onto a sharp object, which caused the rope to break (cut). Both people fell to the ground; one died.
Ultimately, the investigation findings cited other failures, including policies that were not up to date regarding buddy rappel, not informing the command staff of the intended training, not having a qualified instructor to oversee the buddy rappel, using the wrong type of rope (which will be addressed in Lesson 4: Equipment and PPE), and not having proper training in the newly installed fall protection “railing system” over which the rope was run and ultimately was cut. Additional issues were cited in this report, but, essentially, the participants were training on something beyond their scope. They were training for an upcoming competition.2
In many of the other cases, the instructors “did not know what they did not know.” Some personnel participating in the rope evolutions had no training while others did. In another case, it was never made clear whether the evolution was a drill or training. It was unclear who had what level of competency. As an instructor, if I know I am running a drill on a given task, ideally I should know that the people participating have already received a formal block of training in that task. If not, I need to adjust my drill plan to account for that. I may write a lesson plan that would allow for training and drilling at the same time and increase my student-to-instructor ratio. This would allow me to train people who have never conducted this task and to drill with the individuals who have already mastered the given task.
Lesson 3: Communications
Communications are another integral factor in these incidents. A main finding was the failure to effectively communicate with the team members on the training evolutions. This breakdown included not properly informing the team members about the training goals and objectives and the lack of proper communication within the chain of command about the type of training to be performed. Other areas of failure included lack of briefings and not assigning roles and responsibilities. In some cases, this lack of clarity was clearly identified as a deficiency.
Two cases stick out in particular, one related to a helicopter. Though helicopters may account only for a small percentage of rescue services in the United States or worldwide, the lessons learned are invaluable. A group was demonstrating a helicopter rappel for a public event. The crew practiced the rappel a number of times before the demonstration. All previous drills on this evolution required them to rappel out of the helicopter, get to the ground, and come off the rope. Other ground personnel would secure and walk back, holding the rope as the helicopter would land from the hover. This is a common helicopter rappel practice, especially in the military. The ground personnel secure the ropes to ensure they do not get entangled with the helicopter as it lands.
For the public demonstration, it was decided to cut the ropes following the rappel. This decision was made just before the demonstration and had not been practiced or readily talked about. To complicate matters, it was decided that both the rappel master and helicopter crew chief would cut the ropes simultaneously. The individuals rappelling dropped the rope out of the helicopter, and the victim’s rope became entangled on the helicopter skid. As the three remaining rappellers descended the rope, the victim was hung up because his rope was entangled. One of the crew who was to cut the ropes did just that on the left side. The other member also cut the ropes but failed to look out the right side and ensure both people rappelling made it to the ground safely. The postaccident investigation revealed that the decision to cut the ropes was made just before the demonstration, but it was not clearly specified who would be cutting what ropes. It was never definitively communicated how they were going to determine when it was safe to cut the ropes. Sadly, no one ever looked out the right side of the helicopter to verify the ropes were safe to be cut. They had never discussed verbal or nonverbal signals. They had never discussed using ground support people as a second or third set of eyes for safety. Once the ropes were cut, the victim fell approximately 75 feet and succumbed to his injuries.3
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| (2) This is presumably how the O-ring was incorrectly attached to the J-hook and tri-link. |
Another special case combined a breakdown in communications and a failure to check the equipment. This case involved a mountain rescue team. After a successful evolution using a stokes basket and an attendant, the ropes (main and belay) were pulled back to the rooftop and “reset” for the next evolutions. The crew rotated and reset using a live victim in the stokes. Once the rescuer and stokes basket were lifted over the parapet, the crew attempted to transfer the weight of the load onto the rope system.
The crew lost control of the load because it was never transferred to the rope. In fact, the load (stokes basket with a live victim and a rescuer) had started to fall, and one of the crew members held onto the stokes basket. All three people fell to the ground, approximately 45 feet. One victim was fatally injured; two others suffered career-ending injuries. Postincident analysis revealed that the cause of this incident was the failure to properly reset the system. The crew had pulled the rope back on the rooftop of the tower for the next evolution. No one reset the rope through the descent control device or the belay. Essentially, they had 50 feet of rope on the rooftop of the tower, and it was never communicated whether the system was properly reset.
This is a classic case of why we must verbalize and conduct physical inspections of systems again and again. We should be checking it hands-on, verbalizing as we check along the way, and have a second or third person do the same. In this case, none of these precautions were taken.4
Lesson 4: Equipment and PPE
Regarding equipment, in some cases, it failed. In other cases, it was not used, which could have resulted in a different outcome. Some equipment failures were the result of improper use. In only one of the cases was the rope separated (cut-in the buddy rappel described above).
Another significant case involved a department that felt helmets were not necessary for this training evolution. The head gear they had were ballistic helmets, designed to protect the head from bullets from small arms weapons and commonly used by military units, law enforcement, tactical EMS personnel, and the media in combat war zones. Military and law enforcement commonly use these helmets when rappelling because the helmet is part of their issued PPE. It was felt that wearing these helmets would cause unnecessary injuries in rappelling if the rappeller suddenly had to stop descending and lock off his descent control device; the weight of the helmet would injure the neck. According to a witness, they had new lighter helmets in their cache, which they had previously ordered but had to return because they were too small.
This would prove to be a fatal decision. In this case, the official medical examiner’s report stated the cause of death was “blunt force head trauma due to fall.” I cannot say if wearing a helmet would have saved the victim’s life, but we know through our training and experiences that having some type of head gear offers some level of protection. To make matters worse, this is the same case mentioned above where the members were using 7⁄16-inch NFPA-compliant static kernmantle rope in a mechanical device that was designed for use with ½-inch NFPA-compliant static kernmantle rope. When asked why they were using smaller rope with the device, the witness reported that it “had not failed before using the smaller rope.” The witness went on to also say that he “didn’t know the difference between ½-inch vs. 7⁄16-inch rope.” The device did not fail; the smaller rope caught the locking cam in the mechanical device only after the rope had slipped a few feet. By then, the victim had already descended 10 to 20 feet and gained significant momentum; that combined with the rope stretch caused the victim to strike an object on the ground. Though this was a tragic accident, it stresses the significance of wearing the proper PPE and following the manufacturer’s guidelines.
Lesson 5: Blindness
One of the significant findings, and in a category of its own, is inattentional blindness, or perceptual blindness. This is one of many phenomena that has been linked to accidents, not just training fatalities. One of the case studies explained this in detail: “Inattentional blindness is the ‘looked-but-failed-to-see’ effect. It occurs when attention is focused on one aspect of a scene and overlooks an object that is prominent in the visual field and is well above sensory threshold.”5 A misconfigured harness was overlooked (photos 1-3). An example of inattentional blindness is looking for your car keys all over the house and then noticing them where you looked the first time. Additional findings include change blindness, failing to notice that something is different from what it was. Large changes to a visual scene are very likely to go unnoticed if they occur during saccades (eye movements) because visual analysis is suppressed during that time. This is similar to being shown photos but not noticing some of the changes that occur from one photo to the next.
Finally, another phenomenon that can be tied to these case studies is bias. For the purpose of this article, it is the tendency to favor something/someone over another because of preconceived expectations. For example, you are about to conduct a rope rescue drill and you have two firefighters. Firefighter 1 is from a large metropolitan city that averages about two dozen high-angle rescues annually. Firefighter 2 is from a small-town volunteer fire department. Subconsciously, you may favor Firefighter 1 and assume that because that person is from a big city department and goes to many “real-world” incidents relating to rope rescue, you may overlook an aspect of the equipment while conducting a safety inspection. This oversight or “bias” may be in part because you assume Firefighter 1 has completed the appropriate checks and rigged the equipment properly when, in fact, he may not have. Conversely, you may assume that Firefighter 2 needs to be triple-checked because he is from a small town fire department. In fact, both should be checked equally to ensure their safety.
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| (3) Three different equipment rigging setups. The top setup is rigged correctly using a Kong clip. The middle setup is rigged correctly using an O-ring. The bottom setup is rigged incorrectly using an O-ring. |
This blindness can be addressed through training, diligence, and redundancy. Redundancy, hopefully, provides a series of levels of checks and balances to ensure firefighter health and safety. The best way to ensure safety is to cultivate a culture that supports it. Firefighters should be encouraged to ask questions and learn. Good instructors use this approach as a tool to teach and mentor and do not become offended if someone asks questions or double-checks their work. Periodically inspecting equipment and communicating with people are also good avenues to pursue. I can’t stress enough that you need to put a plan on paper. Everybody needs to know who is in charge, who the safety officer is, what the plan for a real-world emergency is, what to do if something breaks, and so forth.
Interestingly, I repeatedly find when I go to a station to teach that many fire stations do not identify who is staffing what truck or do not assign a duty crew. This can be a problem. If no one knows who’s going on the call, what do you think will happen when the alarm comes in? You guessed it. People scatter for their gear and to get in a seat with a self-contained breathing apparatus (SCBA). This can be very dangerous, depending on the type of training. This is no different from any of the above lessons on safety, communications, or training. People should know roles and responsibilities so they know what to expect of others. A clear line of communication can go a long way to making the environment safer, improving training, and ensuring the proper use of equipment.
A review of these lessons identifies some of the contributing factors in these cases: inadequate skills training for the instructors and individuals; failure to implement a risk assessment and hazard analysis; poor supervision of individuals because of a lack of qualified instructors; lack of safety; a breakdown in communications between the instructors and students; and a failure to follow safety procedures, manufacturer guidelines, or good industry practices. We can learn from these incidents-we must do our research before we train or drill. Rappelling and rope rescue are desirable skills. Let’s ensure that these first responders did not die in vain. Let’s learn from these deaths so that everyone goes home.
References
1. National Institute for Occupational Safety and Health Report F2011-12. (October 5, 2011) “Volunteer Fire Fighter Dies after Falling from a Rope -Minnesota.” http://1.usa.gov/1TzxUaY.
2. U.S. Department of Energy, Office of Environment, Safety and Health. (August 1995) “Type A Accident Investigation Board Report on the April 3, 1995 Rappel Tower Fatality at the Department of Energy Savannah River Site.” Report No. DOE/EH-0483. http://1.usa.gov/1TGqX9k.
3. U.S. Army Accident Report. (1990). “Rappelling Accident, Forbes Field, Kansas, 1990.”
4. Alaska Department of Public Safety, “Investigation into the death of a member of the Juneau Mountain Rescue Team, 1992.”
5. U.S. Forest Service, Willow Helibase Rappel Accident, July 2009. “ Rappel Accident Human Performance Analysis,” Jim Saveland, Ph.D., Ivan Pupulidy, M.Sc., http://bit.ly/1oBuQzp.
CHRISTOPHER FEDER is a lieutenant with the Trappe (PA) Volunteer Fire and EMS Company and has been in emergency services since 1995. He started his career with the Penn Wynne-Overbrook Hills Fire Company, Lower Merion Fire Department. He is the rescue training coordinator for the Montgomery County Fire Academy, the task force leader for the county urban search and rescue team, and a hazmat technician with the county Hazmat Response Team. Feder is a Pennsylvania State fire instructor and rappel master. He specializes in rope rescue and has written articles on technical rescue. Feder is an Army veteran of Afghanistan and is in the Pennsylvania Air National Guard, where he continues his military service in the emergency management field.
Christopher Feder will present “Line-of-Duty Deaths While Training in Rope Rescue/Rappelling” on Wednesday, April 20, 10:30 a.m.-12:15 p.m., at FDIC International 2016 in Indianapolis.
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