WE HAVE A VERY DIFFICULT time talking about incidents when they result in firefighter deaths from firefighting. When I say “from firefighting,” I mean no disrespect to medically related or driving related line-of-duty deaths (LODDs)-they are truly tragic and legitimate events. However, I am specifically referring to the loss of a firefighter’s life while actively engaged in firefighting-as the result of thermal insult, asphyxiation, crushing injuries, or falls on the fireground.
We treat these incidents as sacred and understandably so; however, there is a natural firefighter tendency to want to understand more about what happened. We reconstruct the event based on what we know from hindsight was the outcome. We do not reconstruct the event to be critical or to blame anyone; that is not useful to us. We do it respectfully to try to give ourselves a simplified model of what happened to those firefighters so we might avoid similar traps in the future.
As we reconstruct recent multiple firefighter fatalities, it is clear that they all occurred in substandard commercial structures. Many lessons will emerge from the subsequent investigations and, undoubtedly, there will be some disagreement with the findings surrounding these events. Nevertheless, we all agree there should have been properly functioning fire protection systems in all of these structures. There is no room for discussion, no room for debate involving cost and benefit on this issue. So why weren’t they there? As we review these tragedies, it seems so obvious that it’s glaring. We are shocked over why they were not there.
There is an explanation for why some of our actions, decisions, or inactions appear to be so obviously flawed after a tragedy, or what researchers call a “failure.” The theory is appropriately called “drift into failure.” It is not complicated, and it offers the fire service tremendous hope. We just need to recognize that we are afflicted with it and work together to turn it around, as an alcoholic does on his road to recovery. “Drift” is an important word, because it means gradual, almost imperceptible movement. In our case, we have drifted into failure in several dimensions of our industry.
The failures (accidents) occur when we exceed our systems’ ability to protect us in situations that are highly dynamic and volatile. Drifting involves small changes or adaptations to existing proven firefighting practices, which, before several seemly innocent changes, were working well to protect us. These changes to our accepted practices by themselves appear insignificant; however, over time, and combined with previous adaptations and changes, they put firefighters at unacceptably high risk.
We have to understand that as we look at some of these tragic events and puzzle over the actions and decisions made, we have the advantage of 20/20 hindsight. Because we know the outcome, the decisions look completely unreasonable to us. However, the firefighters who made them at the time thought they were perfectly normal. The reason was drift. The bad decisions were preceded by a long string of bad decisions, so it did not take some wildly crazy decision to push the system way outside of its safety envelope, fatally outside of it. When these firefighters were locally making these decisions, they seemed perfectly normal “locally.”
We look at the recent tragedies and wonder how these buildings could ever have gotten so out of hand. Try to remember: When did you do your last serious building inspection? We used to call them company inspections, but we drifted into only short and quick B2 inspections. Then, drifting even further, we decided to do preincident plans. The result is that now we have unsprinklered 30,000-foot furniture stores, delayed commercial inspections, and untold numbers of vacant death traps. Worse yet, we are hoping some other governmental agency is looking out for our interests and is going to get the information to us-more drift.
This lack of control and intelligence is unacceptable. We can and must stop this aspect of our drifting. We need to have control over inspections wherever possible, and we must ensure all companies are familiar with the hazards they face. It is not enough to have good codes; we must ensure that we also have good enforcement. We can begin to stop this drift from control by becoming familiar with our local laws and statutes that support safe buildings and then identifying the unsafe buildings. Once we know the rules, we can manage their implementation by direct intervention or referral for action. For example, in Illinois, two important state statutes, § 425 ILCS 25/9 [Duties of owner or occupant; rules; inspection; notice] and § 425 ILCS 25/9f. [Premises owner’s duty of care], provide firefighters with significant tools for removing significant hazards.
These laws allow Illinois firefighters to inspect; they require them to identify and to notify all interested parties concerning any property that poses a safety hazard not only to firefighters but to the public as well. These statutes state that no person shall permit for any reason any building to become especially liable to fire or to become liable to cause injury or damage by collapsing or otherwise. As The Ol’ Professor Frank Brannigan used to say, “The building is your enemy! Know your enemy!” He would readily agree that we need to know and use our “weapons,” too.
