The Fire Instructor's Role in Preventing 'Friendly Fire' Training Events

Mike Ciampo training at FDIC International 2023

Fire Service Court | By John K. Murphy

Training is a necessary but dangerous part of our everyday fire department activities. Comprehensive and detailed training plans are part of the training officer’s responsibility, regardless if you are appointed, promoted, or assigned. Irrespective of the method that brought you to the training office, you are obligated to ensure that all your firefighters have a safe and educational experience and that no harm comes to those under your care.

“Friendly Fire”

Your job is to prevent “friendly fire” incidents and conduct a root cause analysis of any failure of any training event resulting in the death or injury of a firefighter. The term “friendly fire” originates from our military roots and is defined as, “Fired upon by one’s own side, especially when it harms one’s own personnel.” This does not always mean there was a firefighter death; numerous other events can cause recordable injury, sometimes disabling a firefighter, requiring this root cause analysis to prevent further occurrences.

We are not “your father’s fire department” and have transitioned from fire-only to become a multidimensional, all-hazards operation, from essential fire suppression to emergency medical services (EMS), community paramedics, and street counselors to hazardous material technicians, combustible-metal fires such as electronic vehicle lithium battery fires, and large-scale disasters and terrorist events. We also perform trench, high-angle rope, and confined-space rescues and provide the necessary medical care to the homeless and comfort care to our elderly population. Fire suppression has become multifaceted, with changes in technology and the fireground environment.

We are doing more with less—less staffing; less money; less equipment; less training time; and, at times, decreased community support with unfunded mission creep from our elected and appointed leaders. What we have plenty of, however, are calls for service taking away our precious training time.

In some organizations, firefighters on a 24- or 48-hour shift have a mindset that they only work an eight-hour day and everything after 5 p.m. is “my time.” We need to address and change that paradigm and realize you can drill at night and on weekends, and you should schedule your training for any time that is available.

Statistics

There are approximately 1,062,700 active career, volunteer, and paid-per-call firefighters in the United States. Of the active firefighting personnel, approximately 34% are career firefighters, 54% are volunteer firefighters, and 12% are paid-per-call firefighters.

Firefighter deaths or injuries occur during events, as all responses create a danger for firefighters. These events range from wildland or structure fires to illegal outside burns. Several deaths occurred on wildland fires resulting from aircraft crashes; firefighters were overrun by fire and burned, while others suffered fatal cardiac events. Deaths at structure fires include those killed in fires occurring in one- and two-family homes and other community or agriculture structures. Firefighters also die in structural collapses, are lost inside a structure while searching for a victim, and suffer fatal cardiac events. Some firefighters die responding to or returning from alarms in motor vehicle accidents (MVAs) or shot on arrival to the scene. In 2021, approximately 139 firefighters perished, many from COVID-19.

Training events average six to nine deaths annually and many, if not all, are preventable. Some examples include cardiac death during physical fitness activities, drowning during dive training, falling from an aerial ladder, MVAs during training, and falling from a fire escape on a training tower.¹

Improving Proficiencies

Given the inherent dangers of firefighting, the importance of improving skill sets and proficiency cannot be overstated. Training is beneficial in a number of ways, including the following:

Allows you to relearn the basics.
Enables firefighters to become familiar with updated strategies and tactics of firefighting.
Improves muscle memory through performing essential tasks.
Ensures proficiency in the use of personal protective (PPE) and firefighting equipment.
Helps develop new skills, rising to the challenges of new technology.
Builds a team mentality while fostering teamwork.²

Inadequate training and training without safeguards can be life threatening to firefighters. National consensus standards for training programs have been established for decades; however, some fire departments are not conducting training following these established standards. The reasons can include budgetary constraints, time constraints, insufficient number of available firefighters, and a lack of understanding of the standards and the benefits of complying with those standards.

Legal precedent has established that a lack of understanding of the measures will not absolve the department of responsibility and accountability for a firefighter injury or death during training resulting in the award of millions of dollars to the firefighter’s survivors. Ignorance is not a defense.³

NFPA Standards

The development of National Fire Protection Association (NFPA) standards for firefighting recognizes firefighting as a dangerous profession. However, with proper attention to safety and health issues, on-duty fatalities can be reduced, including during training events.⁴ Adherence to these standards must take on a must-do mantra adopted by fire training officers and their departments. Many of these NFPA standards are adopted by states or local governments to improve firefighter safety. For example, NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program, provides the requirements for programs that will reduce deaths and injuries during emergency operations and training operations.

Firefighter deaths during training are particularly needless and preventable. The purpose of training is to teach proper techniques to prevent deaths and injuries during emergency operations and should certainly not be the cause of these casualties. Over the past 10 years, 91 firefighters have died during training activities.⁴ Ten of the 91 were fatally injured during recruit training, and 18 had one year of service or less.

Other relevant standards include the following:

NFPA 1402, Standard on Facilities for Fire Training and Associated Props, addresses the design and construction of fire service training centers.
NFPA 1403, Standard on Live Fire Training Evolutions, describes a process for conducting live fire training evolutions to ensure that they are conducted safely and in safe facilities and environments and that the exposure to health and safety hazards for the firefighters receiving the training is minimized.
NFPA 1041, Standard for Fire and Emergency Services Instructor Professional Qualifications, identifies the minimum job performance requirements for fire service instructors, including those supervising live fire evolutions.
NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, provides the medical requirements for candidate firefighters and identifies a category of existing medical conditions “that would preclude a person from performing as a member in a training or emergency operational environment by presenting a significant risk to the safety and health of the person or others.” This standard also establishes that a fire department physician must evaluate an incumbent firefighter with a medical condition and recommend possible restrictions from performing essential job tasks based on the firefighter’s medical condition.
NFPA 1002, Standard for Fire Apparatus Driver/Operator Professional Qualifications, specifies the minimum job performance requirements for service as a fire department emergency vehicle driver, pump operator, aerial operator, tiller operator, wildland apparatus operator, aircraft rescue and firefighting apparatus operator, and mobile water supply apparatus operator. The standard also requires that routine tests, inspections, and servicing functions on the systems and components of fire department vehicles be performed and that drivers and operators have the requisite knowledge and skills to operate the apparatus safely.
NFPA 1451, Standard for a Fire Service Vehicle Operations Training Program, includes ongoing training requirements for vehicle operators, including operators of personally owned vehicles.⁵ These are some, but not all, of the NFPA standards affecting the fire service.

Case Studies: Root Cause Illustrations

Medical emergency: rhabdomyolysis. This is a relatively rare condition found in active elite athletes, service members, and firefighters but one we must be aware of. A Fire Department of New York probationary firefighter suffered a medical emergency during training and died of natural causes, according to the medical examiner. It was discovered that the probationary firefighter suffered from rhabdomyolysis, an unusual condition where muscle tissue breaks down during strenuous or normal exercise under extreme circumstances, releasing proteins into the bloodstream.

Rhabdomyolysis is a life-threatening condition caused by muscle breakdown and muscle death. This dangerous muscle damage can result from overexertion, trauma, toxic substances, or disease. As muscle cells disintegrate, they release myoglobin protein into the blood. The kidneys are responsible for removing this myoglobin from the blood so urine can flush it out of the body. In large quantities, myoglobin can damage the kidneys. Kidney failure and death can occur if the kidneys cannot get rid of the waste fast enough. Several causes are listed, but heat stress and dehydration are the primary causes. Make sure your firefighters are well hydrated during and after training activities.⁶

Hyperthermia. This is an increase of core temperature and can cause death.⁷ A 32-year-old male career firefighter cadet participated in self-contained breathing apparatus (SCBA) maze training inside a “survival house.” The training was on the final day of a three-day fireground survival program. He wore PPE consisting of full turnout gear with SCBA while on air. He was nearing the end of the course when he collapsed. A Mayday was called, and he was removed from the building.

CPR was begun, and on-location paramedics during the training provided advanced life support (ALS), including cardiac monitoring, intravenous fluids and medications, and rescue airway. They also initiated active cooling measures because the cadet firefighter’s core body temperature was 108.2°F (42.3°C). The firefighter was transported to an emergency department; after his arrival, additional cooling measures were taken, and ALS continued for 57 minutes. Resuscitation efforts were not successful, and the firefighter was pronounced dead.

The autopsy report listed “hyperthermia and dehydration” as the cause of death, stating, “The exact cause of the hyperthermia is unknown.” The investigators concluded that the physical exertion of the training performed in full PPE/SCBA contributed to the firefighter hyperthermia and exertional heat stroke. Several subsequent hyperthermia events occurred during training during high-temperature and high-humidity conditions.

One recently studied issue is heat retention by firefighters in combat and exertional training situations. Training officers must recognize the symptoms of heat stress in their trainees, prevention, and firefighter education related to signs and symptoms. Following are two key recommendations to help reduce heat stress-related injuries and fatalities:

Ensure that a comprehensive rehabilitation program is in place and operating that follows recommendations in NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises.
Strengthen the heat stress program by implementing or reinforcing the following recommendations for all training courses:

Before training:

Ensure that trainees are medically cleared by a physician knowledgeable about NFPA 1582, including the physical demands of firefighter training and the PPE used.
Educate and reeducate trainees on the importance of reporting off-duty injuries and medical conditions, including using over-the-counter medications or dietary supplements.
Have staff, preferably paramedics or advanced-level emergency medical technicians (EMTs), on site assess trainee risk for heat-related illness before strenuous training including any training in full turnout gear. Consider the use of a checklist or other screening tool.
Ensure that trainees and instructors are well-versed on NFPA 1584, including recognizing early signs and symptoms of possible heat-related illness and understanding potential consequences if not promptly reported and treated.

During training:

Ensure that on-site paramedics or advanced level EMTs regularly monitor trainees for early signs and symptoms of heat-related illness, including overall appearance, mental status, vitals, and so on, at a frequency based on training duration, intensity, and other relevant factors.
Take frequent cooling breaks and ensure that trainees remain hydrated throughout all phases of physically demanding tasks.

After training:

Ensure that trainees rehydrate during rehab to replace fluid losses from sweating. For multiday exercises, encourage trainees to increase fluid intake during time away from training during off-duty hours and rest days to reduce the risk of dehydration on subsequent training days.
Educate and solicit input from trainees and instructors about removing barriers, natural or perceived, to reporting or seeking medical attention for signs/symptoms of possible heat-related illness.

Fall from a Roof

During a training event, a 29-year-old career firefighter fell, carrying a “roof kit” (two six-foot trash hooks strapped together with webbing for shoulder carry) up an aerial ladder during a training exercise.⁸ At the morning roll call, the company was informed they would be conducting a training evolution later that morning simulating a fire incident on the fourth floor of a local six-story hotel. The training involved an aerial ladder, two engine companies, and a rescue from the same station. The firefighters wore their PPE including their SCBA. Many firefighters were in acting positions and had transitioned to their roles before arriving at the hotel.

The apparatus operator correctly positioned the aerial ladder in front of the hotel; raised the aerial ladder at a 73° angle; and extended the 100-foot ladder to 86 feet, placing the ladder’s tip near the roof line. The engine companies pulled hoselines and entered the hotel to ascend to the fourth floor. The truck company was to climb the aerial ladder, enter the hotel through the roof bulkhead door, and descend to the fourth floor. The firefighter who was first to ascend grabbed the roof kit, cradling it on his left shoulder, and stepped onto the pedestal. The leading member began to climb and, as soon as the tiller member saw the top member reach the top of the bed section of the aerial ladder, the tiller member began to ascend.

The tiller member entered the inner midsection of the aerial ladder and noticed the top member had stopped approximately 60 feet up the aerial ladder to adjust the roof kit on his shoulder. Then, the tiller member noticed that the apparatus operator started ascending behind him. The tiller member heard a yell and looked up to see the top member falling down the left side of the ladder. The tiller member tucked in close to the ladder as the falling firefighter brushed by him and landed on the deck portion of the apparatus below. He was attended to by on-scene paramedics and transported to the local trauma center. The firefighter later succumbed to his injuries.

Following are contributing factors to this tragic training incident:

Loss of three-point contact carrying roof kit.
Life belts not used.
Overall weight of PPE and tools.
Angle of aerial ladder.

To prevent such incidents, fire departments should ensure the following:

Safe and secure carrying methods for equipment/tools.
A designated safety officer is appointed for training evolutions.
The use of a life belt for firefighters to minimize risks any time they stop to do work while ascending/descending an aerial ladder.
The overall weight of equipment/tools does not compromise safety.
The placement of aerial ladders should yield the optimal climbing angle for firefighter safety.
A regular review and update to all standard operating guidelines.

Fatality in an Acquired Structure for Live Fire Training

A 29-year-old female probationary firefighter died while participating in a live-fire training evolution at an acquired structure.⁹ The victim’s class was conducting a live-fire training drill required by the department’s training protocol for their NFPA 1001, Standard for Fire Fighter Professional Qualifications (Fire Fighter I). The victim was part of a four-person engine company, led by an adjunct instructor, that made the initial attack on a training fire in a vacant, condemned, three-story, end-unit town house.

The scenario called for the victim’s crew to enter the front of the town house and proceed to the third floor to find and extinguish any fire. They were to bypass any fire on the second floor so that the second-due engine could practice suppression on that floor. As they proceeded to the third floor, the victim’s crew encountered heavy fire on the second floor and third-floor stairwell. The victim, who was operating the nozzle, and the adjunct instructor attempted to fight fire on the third floor, but conditions made it untenable.

The adjunct instructor was able to exit through a window located on the third-floor landing, followed by a firefighter who was backing up the victim on the hoseline. However, the victim got stuck attempting to exit the window that was 41 inches above the floor. The victim became unresponsive as the adjunct instructor and other firefighters attempted to free her from the window. After she was freed, she was transported to a local trauma center, where she was pronounced dead.

The investigators concluded that, to minimize the risk of similar occurrences, fire departments should do the following:

Conduct live-fire training exercises in accordance with the most recent edition of NFPA 1403.
Ensure all training and education, including live-fire training, is conducted under the direct supervision of qualified instructors who meet the requirements of NFPA 1041.
Provide the training academy and safety division with adequate resources, personnel, and equipment to accomplish their training mission safely.
Screen firefighter recruits to ensure they meet the physical performance requirements as established by the fire department prior to a training program.
Develop and maintain a comprehensive respiratory protection program that complies with NFPA 1404, Standard for Fire Service Respiratory Protection Training.
Ensure all recruits meet the requirements of NFPA 1582 prior to entering the training program.
Develop inspection criteria to ensure that all PPE meets the requirements of NFPA 1851, Standard on Selection, Care, and Maintenance of Structural Fire Fighting Protective Ensembles.
Ensure coordinated communication between the instructor-in-charge and the live-fire training participants.
Use the incident command system and a personnel accountability system for all incidents, including live-fire training exercises, that meets the requirements of NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety.
Create a training atmosphere that is free from intimidation and conducive to learning.

States should develop a permitting procedure for live-fire training to be conducted at acquired structures and ensure all NFPA 1403 requirements have been met before issuing the permit. This fire training death had a major impact on the department, including the resignation of the chief, the reorganization of the training division, a lawsuit by the surviving family members, numerous recorded safety violations before and during the training event, and other issues that affected the fire department.

Training Fire: Basement Training Tower Burn Room

A 47-year-old male career captain was severely burned during a live-fire training evolution in the burn building at the Pennsylvania State Fire Academy.¹⁰ A career fire officer, he was also an adjunct instructor at the academy. The academy was teaching a “Train the Trainer” suppression instructor development course when the incident occurred. The victim was in the basement of the burn building adding pallets to the fire prior to the last evolution of a five-day training course.

Three students in the course found the victim on the floor of the burn room as they were advancing a hoseline during their evolution. The students immediately carried the victim outside, where emergency medical care was administered. The victim was transported by ambulance to a community hospital, where he was stabilized prior to transport by helicopter to a regional trauma/burn center. The victim later died from his injuries.

The investigator concluded that, to minimize the risk of similar occurrences, fire departments and training academies should do the following:

Ensure two training officers are present with a charged hoseline during the ignition or refueling of a training fire, in accordance with NFPA 1403.
Determine the minimum amount of flame, heat, and smoke required during live-fire evolutions to perform the training while ensuring firefighter safety.
Use the minimum fuel load necessary to conduct live-fire training.
Have a written respiratory protection program and ensure SCBA face pieces are properly inspected, used, and maintained.
Have burn rooms with at least two exits.
Avoid having basement burn rooms.

Training academies should also consider doing the following:

Install instrumentation within live-fire training structures to record information such as heat, the effects of suppression, and the byproducts of combustion.
Install a ventilation system within the burn structure.
Have a qualified engineer evaluate fuel loads, heat retention, and the instrumentation and ventilation systems of live-fire training facilities.

This death ended basement fire training across the country until it was deemed safe by training facilities following the National Institute for Occupational Safety and Health (NIOSH) recommendations.

Thoughts and Recommendations

Following are some considerations regarding fire training to avoid fatalities and other serious accidents:

Fire training is not boot camp.
Plan training from the end of the event to the beginning. Think the plan through as well as the possible bad outcomes that could occur over the course of the training event. Then, run it by your safety officer.
Pretraining orientation sessions are equally important to the students and training staff.
Everyone is the safety officer and can stop the evolution when a hazardous condition becomes obvious to the participants.
Conduct a posttraining “hot wash” or “tailboard discussion” to discuss and dissect the training evolutions.
In the words of Mike Tyson, “No plan survives the first punch.”

Because we should conduct training exercises in controlled settings, they must be designed to not endanger the participants. This requires following recommended safety procedures combined with competent instruction and qualified instructors that must result in a level of safety necessary to protect the lives of those participating. Remember, many firefighter fatalities consistently indicate that the number one cause of on-duty firefighter fatalities is sudden cardiac death, also the case during training activities.

Also, we must be mindful of the multiple long-term effects of training activities. As an industry, we are well aware of sudden cardiac death among on-duty firefighters, as has been discussed extensively in available NFPA, NIOSH, OSHA, United States Fire Administration, and other reports and trade journals. The reports indicate the steps the fire service should take to reduce the risk of heart attacks among firefighters, incorporating the standards found in NFPA 1582 focusing on conducting the following:

Annual medical evaluations.
Screening for coronary artery disease (CAD) risk factors.
Conducting exercise stress tests (ESTs) for those with multiple CAD risk factors and giving appropriate treatment for those risk factors.
Restricting the job tasks that firefighters with positive stress tests are allowed to perform.

Other risk factors for CAD include diabetes, smoking, high cholesterol, high blood pressure, family history of the disease, and obesity or physical inactivity.

MVAs during training sessions or while traveling to or from training sessions represent an area where ordinary precautions and attention to driving rules and road conditions should have an impact. Seat belts should be worn at all times in all vehicles.

Before starting training, fire departments should also do the following:

Establish easy-to-understand, written standard operating procedures (SOPs) for all training activities and ensure they are implemented and enforced.
Conduct a hazard analysis before each training exercise to identify and address safety issues in advance.
Ensure instructors are certified to NFPA 1041.
Ensure that a sufficient number of certified instructors are available to conduct the specific training and maintain optimal student-to-instructor ratios, as per NFPA 1403.
Establish a mandatory wellness/fitness program to ensure compliance with NFPA 1583.
Ensure training participants have successfully completed all course prerequisites.
Ensure that participants are screened to determine physical capacity and fitness to participate in the training by the host department and the participating departments.
Medically clear firefighters for respirator use and full-duty fire suppression by a physician knowledgeable about the physical demands of firefighting, in accordance with NFPA 1582.
Per NFPA 1521, Standard for Fire Department Safety Officer Professional Qualifications, designate a qualified and certified individual to be the safety officer to review SOPs and monitor all training activities.
Ensure that all new training curricula undergo a comprehensive safety and validation review by training supervisors before implementation.
Ensure that the training environment and facilities are inspected for hazards, which should be eliminated or identified.
Ensure that adequate time is allotted to safely carry out the training exercise.
Ensure that all equipment, including PPE, is inspected and in good working order.
Ensure that a 360° ground and vertical size-up is conducted for all training activities, as would be done in an actual event.
Establish and follow a pretraining checklist.
Provide pretraining safety briefings, including a facility walk-through, for all participants.

Additionally, fire departments should do the following related to training:

Adopt and follow the North American Fire Training Directors Rules of Engagement for Safe Fire Service Training.¹¹
Ensure that a sufficient number of fire suppression apparatus and equipment are readily available and inspected for live-burn training evolutions.
Ensure adequate fire flow is available during the various training scenarios, either through fire hydrants or tanker operations.
Ensure that the proper types and adequate amounts of extinguishing agents are available for live-burn training evolutions.
Be aware of the material used as accelerants and combustibles in acquired structure fires as to their burning properties, thermal properties, and the amount of smoke produced.
Ensure adequate space is provided for proper placement of all necessary apparatus.
Ensure that all established NFPA standards and fire department procedures are followed.
Monitor participants’ physical stress and watch for signs of overexertion.
Establish and maintain a rehab area stocked with appropriate hydration and nutrition supplies per NFPA 1584.
Ensure all training participants wear the appropriate PPE at all times.
Ensure that appropriate personnel (e.g., rapid intervention team) and equipment are available for assistance, rescue, emergency treatment, and transport.

It is your responsibility to prevent “friendly-fire” deaths or injuries during a training event. Review the available material to determine how other training event failures resulted in the deaths and injuries of many firefighters. If there is a friendly-fire training event, everything related to training must shut down and a root-cause analysis completed to determine the cause of the training failure. This is a “must-do” action to ensure the safety of the firefighters we train.

References

1. Firefighter Fatalities in 2020 (nfpa.org).

2. Workplace Solutions: Preventing Deaths and Injuries of Fire During Training Exercises (cdc.gov).

3. IBID.

4. Career and Volunteer Firefighter Deaths Related to Training, 1996–2005. www.nfpa.org.

5. www.nfpa.org.

6. Rhabdomyolysis: Symptoms, Treatments. www.clevelandclinic.org.

7. Fire Fighter Fatality Investigation Report F2016-05 | NIOSH | CDC

8. Fire Fighter Fatality Investigation Report F2017-15 | NIOSH | CDC

9. Fire Fighter Fatality Investigation Report F2007-09 | NIOSH | CDC

10. Fire Fighter Fatality Investigation Report F2005-31 | NIOSH | CDC

11. Rules You Can Live By. www.naftd.org.

JOHN K. MURPHY, JD, PA-C, MS, EFO, began his fire service career as a firefighter/paramedic and retired as a deputy chief after 32 years of service. He is an attorney licensed in Washington whose focus is on firefighter health and safety, firefighter risk management, employment practices liability, employment policy, internal investigations, and expert witness and litigation support. He was a Navy corpsman with the Marine Corps. He is a lecturer, an educator, an author, a legal columnist, a blogger, and a member of Fire Engineering’s Fire Service Court Blog Talk Radio Show. He is also a lecturer at the IAFC Fire Rescue International and I-Women conferences. He is a National Fire Academy instructor and a distance learning instructor for the University of Florida Fire and Emergency Services programs.

The Fire Instructor’s Role in Preventing ‘Friendly Fire’ Training Events