By Dane Carley and Craig Nelson
“I had been hit by an IED in Afghanistan. I’d rather go through that than be burned again.” This is a quote from a pump operator who received steam burns during a pumping operation in early July 2017 as he operated a pump on a wildland fire on a U.S. Forest Service Type III engine as part of a strike team. The crew was assigned a pumping task on a long hoselay (1,000+ feet) that supported fire operations at the top of a hill where there was still active fire. The hoselay had been put in place the night before so the crews pulled their engines into place and attached a hose from each engine to the existing hoselay. The elevation difference between the engines and the nozzle was 734 feet, which created a significant head pressure of 368 psi. The crews working the previous night chose to overcome the head pressure by running two pumps in parallel, so this was done in the morning as well. Each pumper was connected to the hoselay via a short section of hose feeding water into a gated wye that was being used as a siamese.
The two pump operators had concerns about the hoselay for a couple of reasons. First, they recognized that parallel pumping is designed to increase the gallons per minute (gpm) pumped rather than the pressure so it was, at best, an ineffective way of transferring the water with so much head pressure. Second, they recognized that the pumps were struggling to maintain the operation. The pumps were operating at 250+ psi. The flow meter attached to the foam system on each engine’s pump indicated that one pump would flow approximately 30 gpm then the other pump would flow 30 gpm but both pumps never flowed water at the same time. This alternating action happened repeatedly over a long period of time (including the night before).
Both of these firefighters voiced concern over the operation to each other but did not pass their concerns up the chain of command. They had even developed an alternative and safer tactic. Instead, they not only continued the operation but increased the pump pressure to 275 psiwhen the nozzle crew told them they did not have water at the nozzle. Shortly after increasing the pressure, a leak was observed. As the pump operator moved to shut down the pump, the hose burst. The discharging high-pressure, heated spray of water hit the pump operator and caused burns to his lower torso, groin, and upper legs because it was so hot.
– Summarized from the Crescent Fire Scald Injury Facilitated Learning Analysis
Neither of the firefighters involved in the incident above were new firefighters. The pump operator who received the burns had been a firefighter for seven years. He was a U.S. Marine for four years prior to being a firefighter; apparently in an Afghan war zone based on his quote, so stressful situations were not new to him. Both firefighters/pump operators recognized that the hoselay was not appropriate for the situation and developed an alternative plan that would have moved the pumps to the top of the hill via a two-track road. Both firefighters worked in the wildland industry, which has been teaching crew resource management and higher reliability organizing concepts, such as speaking up when a hazard is observed, for many more years than the structural firefighting industry has. All of these factors were in favor of these two firefighters speaking up; yet neither did.
So why did they choose to continue operating in the established hoselay without saying anything? How does a fire department change the culture so that firefighters, from the newest to the oldest, feel comfortable speaking up when there is a hazard? Or to speak up even if there is just possibly a better way to accomplish the same objective?
ICS Is a Communication Tool First
One system that helps improve communication that everyone is already familiar with is the Incident Command System (ICS). ICS was developed to improve situational awareness by enhancing communication between different agencies operating at the same incident and enhancing communication between units/groups/strike teams working on the same incident from the same agency. The improved situational awareness that exists because of the enhanced communication allows the resources operating on the incident to work toward a common objective through teamwork. Unfortunately, the federal push of ICS from the Department of Homeland Security seems to have diluted this message and perpetuated a stronger message of ICS as a top-down management tool used to track costs for reimbursement.
ICS, in its true form, encourages discussion between groups/divisions to coordinate tactics and up the chain of command to improve decision making at all levels. In the incident above, the fundamental ICS principles would encourage the pump operators to bring the hazard to the attention of the strike team leader and present the alternative solution they had developed. The strike team leader would then do the same to the ops chief, and so on until the issue is was resolved.
Crew Resource Management and the PACE Process
A second system that is not as common in the fire service as ICS but has been used in other high consequence industries for decades is crew resource management’s (CRM) PACE process (acronym defined below). When PACE is taught to everyone from the newest firefighter to the most senior officer, it works well because everyone understands why the six-month firefighter is in a position to ask the 25-year captain about an alternative tactic to reduce the hazard to the crew. The PACE process does not mean having a committee meeting in the front yard of a burning house, but rather lays the groundwork so that everyone, including the six-month firefighter, has the tools to bring a hazard to the attention of someone who can fix it.
The PACE process is simple. It is a four-step process designed to bring a hazard to the attention of a more senior or higher ranking person in a respectful, constructive way. PACE stands for:
- Probe
- Alert
- Challenge
- Emergency intervention
Each step is an escalation from the next, and the process does not need to begin with the probe step. When a firefighter sees a hazard, he or she probes to find out more and bring their concern to the attention of the officer by asking a question. An alert is a statement that notes a specific hazard without any ambiguity. A challenge may escalate to a shout, for example, “Watch out for the falling porch!” Last, the emergency intervention is a physical move such as blocking the door to a building to prevent additional firefighters from entering.
Depending on time and the situation, a person who observes the hazard may move straight to the emergency intervention. However, crews that are trained in CRM and the PACE process often recognize that a junior member is using the PACE process at the probing level, so the process does not escalate to a challenge or emergency intervention in many cases. This is because the process has a defined method of conveying information that has been shown to be most effective. For example, planes have crashed with junior officers aware of the problem and vocalizing them but not being heard by the captain because the junior officer did not address the captain by name. Therefore, assertive but respectful PACE statements include:
- The name or name and rank (but never just rank) of the person being addressed
- The observer’s personal concern (why they feel it is a hazard)
- A definition of the problem (what the specific hazard is)
- An alternative solution
- A response from the person being addressed to confirm that the message was received
Using the PACE process in the incident described above, the pump operators could have started with the probing level because it was not a time-compressed situation. Therefore, the pump operators could have called their strike team leader shortly after arriving and said:
Engine 63, “Strike team leader, this is Engine 63.”
Strike team leader, “Go ahead 63, this is strike team leader.”
Engine 63, “Strike team leader, Engine 63. This pumping configuration appears to be pushing the pumps to their limits and seems like it could result in a failure. The pumps are pumping at a high pressure for an extended time and do not seem to be overcoming the head pressure well. We have found an alternative method that means moving one pump to a two-track road on the right flank of the fire that is near the top of the hill. This would free up one engine and position the pump in a better place. Strike team leader, will you advise if you would like us to do this or not?”
In most cases, this would be the end of the conversation (if everyone is taught CRM and the PACE process) because the strike team leader would have recognized that this was Engine 63 probing for a better way to achieve the same objective and reduce the chance of failure. The strike team leader would recognize the language and format of the question posed by Engine 63.
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Craig Nelson works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.
Dane Carley entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.
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