By Leigh H. Shapiro
When I was in the fire investigator training program for Connecticut’s fire marshal certification process, the material began making more sense to me in an unanticipated context. The primary text is National Fire Protection Association (NFPA) 921, Guide for Fire and Explosion Investigations. Reviewing Chapter 11, “Fire-Related Human Behavior,” the relevance of the material regarding firefighting struck me. The text is directed at the “actions and omissions of people associated with the incident scene” (11.1), meaning “occupant characteristics and decision making” (i.e., the civilians). This chapter resonated with me because it clearly relates to firefighters who, as human beings, behave just as civilians do (regardless of training, education, and experience) when faced with factors either within or beyond their control.
“Actions and omissions” stood out because it offers a broad yet obscure explanation for certain individual and crew fireground behaviors. As I reflected on this often in my career as a company officer and then as a chief officer, how many times have I forcefully questioned myself, crews, and individuals, “What are you doing?!” “Why did you do that?!” or, more importantly (postincident), “Why did that happen?!” I was trying to understand beyond the official reports, the evidence, and the witness accounts why things ended badly for firefighters at certain incidents. The question was, “How can we explain the unexplainable in firefighter behaviors?”
- Evaluating the Human Factor on the Fireground
- Critical Decision Making: The Single Most Important Predictor of Success
The NFPA 921 guidebook1 is the nationally accepted, best-practice, industry standard by which to conduct fire investigations. Chapter 11, “Fire-Related Human Behavior,” was derived from the 1994 U.S Fire Administration publication of the same title, which is based on research conducted by specialists in the fire scene analysis and human behavior fields (11.1.2). The findings provide insight as to how people react to fire emergencies both as individuals and in groups (11.1.1). The numerous factors that affect an individual’s/group’s human behavior before, during, and after a fire can be identified as characteristic of an individual, the population groups, the physical setting, and the fire itself. Furthermore, how these factors interact with one another to influence human behavior is explained (11.3). To best describe the correlation between civilian actions and reactions during a fire situation and how and why things end badly for firefighters at incidents, you must first embrace the principle of cognitive comprehension limitations (11.3.1.2) and the factors that cause, support, and facilitate this condition.
The psychology of human behaviors and, more importantly, failures under duress can explain how firefighters are reflex trained much like pilots: In essence, we are trained to react to specific algorithmic expectations regardless of the obvious obstacles and limited information, yet failures or deficiencies still occur for both. The Federal Aviation Administration (FAA) refers to this as the “startle response,” which states that control would have been maintained during an emergency if the pilot’s knowledge and skills were fully developed to prepare for (any) emergency.2 The FAA determined that with adequate training pilots can “practice overcoming the natural human tendency toward denial and rationalization” and may mitigate the incident properly.
So, how do you explain that, with all of the training the fire service receives, injuries and deaths still occur beyond the obvious situations such as collapse, entrapments, medical issues, and so forth? Focusing solely on firefighters, I found that chapter 11 references numerous factors that influence fireground behaviors and may assist in explaining them. Although written to explain civilian actions in a fire situation, it clearly applies to firefighters, too. This material, however, is not intended to denigrate firefighters; it is simply formulated to help us better understand and explain certain behaviors.
(1) NFPA 921, Guide for Fire and Explosion Investigations (2021 Ed.) (Photo courtesy of NFPA.)
Factors Affecting Behavior
The Individual (11.3.1)
Many characteristics influence human behavior in a fire situation. Physiological factors affect an individual’s abilities to recognize and accurately assess the presented hazards and to react and respond appropriately.
Physical Limitations (11.3.1.1)
Age plays a large part in the ability to recognize and react appropriately in an emergency. This includes mobility, physical disabilities, intoxication, and other circumstances that restrict or limit an individual’s ability to take appropriate action. How many firefighters do we know who are still on the line operating with prior compromising injuries; who are taking some type of medication that may affect their cognitive ability; or, by their own admission, are saying, “I’m too old for this!”?
Cognitive Comprehension Limitations (11.3.1.2)
This is the Holy Grail, as it largely explains why things happen. This section includes many components that affect firefighters directly. These limitations have the greatest impact on firefighters and are more likely to explain behaviors and can account for delayed and even inappropriate responses to hazards and conditions. Often, multiple factors are involved, such as alcohol/prescribed drug consumption prior to a fire (preignition), then carbon monoxide (smoke) inhalation postignition.
Age. Age affects how firefighters perform. Mobility problems start to crop up, especially if there are previous injuries. My older brother was a lieutenant on the job back in the mid-1990s when he was involved in a major motorcycle crash that almost killed him. Thankfully, he recovered and returned to work, but with all the metal pins, rods, and screws inserted into his bones used to put him back together again, he was never the same. His mobility became more of an issue during the strenuous physical demands of the job too, especially in the winter and as he aged.
Mental comprehension level. Forcefully awakened from a deep sleep, thrust onto a careening fire apparatus in the dark of night, and then arriving on scene to commence a vigorous physical workout of setting up equipment and operations on the fireground is demanding enough. But how many times have we been confused or not fully aware of what was happening to us and around us? If we were computers, this would be the exact moment for a reboot!
Level of rest. Studies have shown that even moderate sleep deprivation has a similar impact on personal performance and, in some cases, mimics that of being legally intoxicated from alcohol. After almost 20 hours without sleep, performance was gauged to be the equivalent of 0.05% blood alcohol content. Studies also indicate that working long or irregular hours, as with shift and night work, directly correlates to fatigue and an increase in accidents.3 I once worked a 24-hour tour on our tactical unit (heavy rescue) one New Year’s Eve, and when the tour ended at 8 a.m., we had 25 runs under our belt, including a couple of vehicle extrications and fires. I was so exhausted that I barely made the drive home. I was delirious from fatigue! I should have gotten a ride home, but I was not in the proper state of mind to process that decision, never mind making critical life-and-death fireground decisions. This happens every day for some firefighters—we believe it is just part of the job to which we have to “adapt” accordingly.
Alcohol use. This is still prevalent within the fire service. We know this is the unspoken condition and that help is available, but drug and alcohol use are still a problem.
Developmental disabilities. Applicants and candidates for recruit school are processed through the exam components that include cognitive and agility tests, and after they pass they receive a physical exam. However, there is no mental exam to determine mental deficiencies or illnesses.
Inhalation of smoke/gases. This factor can explain some fireground behavior, usually when things are already starting to go sideways. The composition of modern smoke is much more toxic (in the amount of chemicals and the concentrations) than in fires of the past. Although we use self-contained breathing apparatus (SCBA), often enough, some firefighters are still be exposed to (and inhale) toxic gases and smoke.
Familiarity with Physical Settings (11.3.1.3)
Firefighters are keenly aware of their disadvantage at an incident of not knowing the physical setting of the operating environment; therefore, preplanning and training are critical to safety and success. If an individual had a fire in his own home, he would instinctively be a better judge of the fire’s development and progression than if he were lodging in a hotel room. It is basic human nature to be intimately familiar with your own surroundings, which gives you the advantage in an emergency. If you then factor in the physical and cognitive limitations above, that advantage diminishes significantly. Chapter 11 cites the example of someone appearing to be lost or disoriented within his own home during a fire, sometimes found deceased. Most often, firefighters have no prior knowledge of the physical setting in which they are operating. Subsequently, when things start to go bad, we are already at a disadvantage and must rely heavily on training and experience. When a lack of training, lack of experience, and cognitive and physical limitations overtake the situation, a near miss or, worse, a tragedy, can occur.
Groups (11.3.2.2, 11.3.2.3)
Chapter 11 states there is more than just certain characteristics that influence human behavior in a fire situation. Interaction between individuals often tends to influence how people behave as well.
Group size. People in a group are less likely to acknowledge and react appropriately to the sensory cues an emergency presents; the larger the group, the more likely this is. Research indicates that group members delay their responses until others in the group acknowledge the sensory cues and react, because responsibility for taking action is diffused among the group. Has this ever happened to you at a large incident where things are happening at a rapidly dynamic rate and someone is in charge of the group (crew) yet no one takes charge (even with fire officers present)?
Group structure. Groups with a formalized structure that has defined, recognized leaders and authority figures often react more quickly and in an orderly manner (which may not always be appropriate). Research also indicates that interaction between these group members often results in a sense of responsibility for the group, such as warning group members of danger as opposed to warning strangers. Group cohesiveness often results in a more unified and orderly response to danger, which also applies to fire crews. We have all worked with crews that were tight and with those that were anything but!
(2) Company officers report to the incident commander. (Photo by Pat Dooley.)
Group permanence. Fire crews work well together most often when they are familiar with each other, as you do with your regular crew. If others are introduced to the crew—e.g., overtime or detailed personnel, new recruits, and members newly transferred into the group or shift—it affects performance. How long the individuals within the group have interacted with each other influences behavior. Research indicates that more established groups, such as families and sports teams (similar to fire crews), tend to be more formalized and structured and react differently than a new or transient group, in which each individual presents conflicting behavior based on his own unique reactions and responses.
Roles and Norms (11.3.2.4)
Chapter 11 describes behaviors affected by group norms and roles, such as gender, social class, education, and occupational composition (fire service scalar hierarchy). Gender plays a big part in that women tend to be more clear-headed and report a fire immediately, whereas males tend to delay reporting because they often would rather initiate mitigation efforts such as suppression. Women and men process and act on information differently; the fire service is no exception.
Characteristics of Physical Setting (11.3.3)
The characteristics of the physical setting where the fire occurs directly impact its development and spread. Subsequently, they also affect fire-related human behavior. The building’s height, alarm/suppression systems, and number/location of exits affect behavior.
Location of exits. Research indicates that if the location of available exits is unknown to occupants or not adequately identified, they experience confusion and increased anxiety. This applies to firefighters, too. My department suffered a line-of-duty death (LODD) in 2014. As I was standing out in front of the fire building, a firefighter plunged headfirst out of a second-story window and landed in the bushes below. It was later determined that he did not know the way out; became disoriented; and, nearly blacking out, exited the only way he could.
Number of exits. The number of available exits also impacts behavior because if there are blocked, restricted, or unprotected exits, this may expose the occupants to the smoke, heat, and fire. The same applies to suppression crews, which is why it is critical to create a secondary means of egress—e.g., placing ground ladders when crews are operating in a structure.
Height of structure. Based on research, section 11.3.3.3 states some people believe they are less safe in taller buildings during a fire. Although movies such as “The Towering Inferno” do not help this dilemma, by design, modern high-rises are some of the safest structures in which a fire may occur. The intrinsically built-in active and passive safety systems such as alarm, sprinkler, and standpipe systems, in conjunction with smoke control, pressurized stairwells, and the rest of the Class I elements, make for an overall safer, more controlled environment.
Fire alarm systems. The constant repetition of false alarms and malfunctions plays a key role in occupants not responding appropriately to an activated alarm, and the fire service constantly battles complacency with crews not prepared to engage because of repeated false alarms.
This happened in my department with the first-due crew responding to an alarm activation in a convalescent home one winter night in 2003. The crew had been back and forth repeatedly over the previous several days; when the alarm came in again, they got off the apparatus wearing just their bunker gear. After walking through the building to the far end in the rear, they asked the charge nurse at the desk what was going on, to which she replied, “There’s a fire back there!” Ultimately, 16 occupants perished in that “fire back there”! The fire was venting to the outside and gave the crew no indication there was anything happening until the fire room door became uncontrolled; then we had a problem. The crew, as it so often happens, became complacent and walked in unprepared. I, too, have fallen for this too many times to count; this crew just got caught.
Fire suppression systems. The presence of sprinkler and standpipe systems and even a Class II/III house line in the hallway of a structure may affect behavior. It increases the margin of safety for occupants; they may think they have more time to respond appropriately to the incident. Firefighters know what to expect when entering a protected vs. an unprotected structure. In an unprotected structure, suppression evolutions may be hampered and, therefore, be more rigorous, even unsuccessful.
Factors in Delayed or Inappropriate Responses
Characteristics of the Fire (11.3.4)
Fire-related human behavior is directly related to both an individual’s and a group’s perception of the hazard and the threats that a fire or other incident presents. The fire or incident characteristics shape these perceptions and, hence, affect behavior.
Presence of Flames (11.3.4.1)
Although most individuals have an uneducated and uninformed perception of the presented hazard, perception is amplified with the presence of fire, which confirms the situation is not a false alarm. Because they don’t understand fire dynamics and behavior, they may not interpret a small fire as an immediate threat, as happened at the Station Nightclub fire in Rhode Island in 2003. Likewise, firefighters may see a small amount of fire and not immediately grasp the fact that a large amount of hidden fire is literally eating away the building’s core and rapidly compromising its structural integrity and their safety. Some may be overly focused on the “moth to a flame” dilemma as opposed to the unfolding “big picture” scope.
Presence of Smoke (11.3.4.2)
Like fire, a smoke condition affects behavior because of an ignorance of fire dynamics. Thick black smoke appears and is perceived as an immediate threat, whereas light gray smoke may be perceived as no threat. Although well trained, many firefighters may be inexperienced or untrained in how to read smoke and smoke conditions. Ignorance and inexperience may skew decision making, often leading to a “domino effect” of bad decisions.
Effects of Toxic Gases and Oxygen Depletion (11.3.4.3)
During a fire situation, civilians often inhale the by-products of combustion, including the toxic gases in smoke. The depletion of oxygen below 15%, because of the progression of the fire, coupled with those gases is a recipe for changes in human perception and behavior. Section 11.3.4.3 indicates these changes manifest in delayed or inappropriate responses to the incident, along with a severe decrease in strength, stamina, mental acuity, and perceptual ability. Although firefighters use their SCBA in an immediately dangerous to life or health atmosphere, how many times have we heard stories of old-school “smoke eaters” who did not wear them or who used “cheaters” in addition to the more common issues of premature mask removal, masks being dislodged because of some type of interference, or even a malfunction. Once a firefighter inhales the same smoke and gases that a civilian would, albeit under different circumstances, the same physical effect holds true.
Human Factors Related to Fire Spread (11.7.1)
The actions or omissions of the people present before and during a fire can significantly affect fire spread, either accelerating or slowing it. These actions include opening/closing doors or windows and rescue, to name a few. Lieutenant Nicholas Papa of the New Britain (CT) Fire Department recently published Coordinating Ventilation: Supporting Extinguishment and Survivability 4 in which he emphasizes the critical importance of managing the openings within a building to support the firefighting operations and victims’ survivability; uncontrolled doors and windows within a fire compartment can be detrimental to the outcome.
Recognition and Response (11.8)
In a fire, an individual’s survivability depends on his ability to recognize and appropriately respond to the presented hazard. Both civilians and firefighters must be able to perceive the danger, make an appropriate decision to act, and execute that action.
Perception of Danger (Sensory Cues) (11.8.1)
People become aware of a fire through several sensory cues. Factors such as being awake, asleep, or impaired affect perceiving these cues. Impairment can be physical; mental; or the result of drugs or alcohol, the inhalation of toxic gases, or low oxygen levels. Often, being jolted from a deep sleep, as in a firehouse setting, can set the stage for a disoriented firefighter being thrust into a complex environment for which he is not fully ready to safely engage.
Sight. The direct view of smoke or fire, visual alarms, and even the flicker of an indirect flames.
Sound. The sounds of crackling, glass breaking, audible alarms, voices shouting, crying children, and even dogs barking.
Feel. Rising temperatures, failing structural members, and even the wash of smoke over the body.
Smell. The unmistakable odor of smoke and to an experienced firefighter what it specifically “smells like.”
Decision to Act (Response) (11.8.2)
An individual’s degree of impairment plays a major factor in the decision-making process on how to respond to the severity of the perceived danger. Firefighters are well trained, yet this thought process still plays out based on the individual in that we don’t know for certain which, if any, impairment influences our decision-making process.
Escape Factors (11.8.4)
Firefighters often decide to ignore sensory perception of danger cues to complete their task at hand—i.e., rescue or other suppression activities. Chapter 11 states the success or failure of escaping a fire depends on many factors including identifiable escape routes (e.g., ground/aerial ladders, secondary stairwells, fire escapes/porches), the distance to the escape routes, fire conditions, blocked escape paths, familiarity with the structure, and occupant impairments. When you consider all the physical hurdles firefighters must face in making informed decisions, then throw on top of that the real possibility of some type of identified impairment, and this can become a recipe for disaster.
Heuristic Techniques
A heuristic is a mental shortcut that allows us to make decisions quickly without having all the relevant information. They are rules of thumb that allow us to make a decision that has a high probability of being correct without having to think everything through.5
Although there are numerous variations of heuristics, Salt Lake City (UT) Clinical Law Professor Ian McCammon has adapted and applied six pertinent techniques to recreational avalanches for skiers.6 I overlaid these six points on firefighter behavior and found the following startling similarities:
Familiarity. The belief that our behavior is correct because we have done it before. Our brains use shortcuts and experiences to guide decisions, giving the appearance that familiarity indicates safety when, in fact, it may not. Firefighters often employ this technique from the “senior man” perspective, but sometimes there can be a stark contrast between being clever and lucky and sound decisions based on actual knowledge.
Acceptance. This is engagement in activities that we believe will get us noticed or accepted by those we like or respect or by those whom we want to like and respect us.
Firefighters may follow other firefighters or officers into an unsafe condition or perform unsafe acts or make riskier decisions to be accepted, often because others have done it.
Consistency/Commitment. To maintain consistency, once the initial decision has been made, subsequent decisions are easier. Our brains use this shortcut because completely reevaluating a plan takes time and effort. Firefighters often face limited time to make rational decisions based on the information they have. This all-in mentality can quickly become dangerous groupthink!
Expert Halo. Groups tend to follow a leader even when that person may not have the best decision-making skills or adequate experience but often projects a halo of expertise. Such a leader can lead a group into dangerous situations.
Tracks/Scarcity. This is the tendency to value resources or opportunities in proportion to the chance you may lose them, especially to a competitor. How often do we hear one fire company trying to outdo another? Pride takes over and we are often hearing someone declare, “We only have one shot at this!”
Social Facilitation. This is the tendency to believe that a behavior is correct because others are also doing it as well. A group that is confident in their skills and abilities based on their experiences tends to make riskier decisions or to follow other groups because following is easier than leading. Fire companies and crews, unfortunately, often engage in this dangerous behavior, normalizing the deviance from policy right up until something bad happens.
Reflex training is constantly battling human nature. When cognitive comprehension and the ability to act accordingly are compromised, bad things can happen to firefighters. If there is a lack of focus on processing information or on safely executing a task, hesitation, or a complete inability to recognize the gravity of the situation, failure is more likely. Frequently, firefighters will attempt to correct an already forgone situation, based in part on the application of heuristic techniques.
A National Institute for Occupational Safety and Health study of an LODD in 2010 indicated that when the firefighter was found (deceased) in the stairwell, he still had his SCBA face piece in place, yet his air tank was completely empty.7 Wouldn’t human nature make the firefighter quickly remove the mask when he thought he was out of air and in trouble? How do you explain this scenario after all the research indicating human nature more often takes over for clear-headed thinking in situations of distress?
During my recruit training on SCBA in 1988, we were taught that if you ran out of air or had a serious malfunction, rip your mask off your face and take your chances during self-evacuation rather than suffocate to death! There can be numerous rationalizations based on the research indicated here, but we can only speculate to explain the reasoning.
What is a normal fight-or-flight instinct to a civilian is fervently resisted and deliberately ignored by firefighters because it is our nature to stand our ground, react and respond, and problem solve to a positive result; our brains override our bodies (because it is our job). The foundation for all firefighters is their training, education, and experience in conjunction with steadfast preparation for any inevitability. When intellectual clarity is challenged beyond capacity or the integrity of psychological lucidity is somehow compromised, however, the default mental setting is to revert to our core human behaviors.
Based on my research, when applying both Chapter 11’s “Fire-Related Human Behavior” combined with the application of heuristic techniques to firefighters and fireground behavior, a direct correlation emerges, formulating the basis for a clearer understanding between this material and firefighter behaviors (beyond training, education, and experience).
Dissecting the psychology of human behavior under duress provides some insight as to why bad things happen frequently that is devoid of rational explanation. If able to recognize the immediate perilous situation at hand, firefighters may often question their own decision-making processes, especially whether they should initiate a Mayday. Several ideas rushed through my mind when I faced this situation: “I should solve the problem (that’s why I’m here).” “I don’t want any backlash or to have others think that I don’t know what I’m doing or can’t handle it.” Instead of calling a Mayday when I think I’m in trouble, I am fighting with my own instincts to do my job and complete my tasks, which has now metastasized into a functional bad habit.
Firefighter survival fundamentally depends on steadfast proficiencies consistent with knowledge, skills, discipline, mental focus, situational awareness, and the effective ability to apply critical thinking. Our training is in constant battle with our own human nature and, in the end, when pushed to our limits with cognitive factors beyond our control, ultimately, our ingrained/instinctual human behavior wins the day.
Endnotes
1. NFPA 921, Guide for Fire and Explosion Investigations. National Fire Protection Association: Quincy, MA, 2021.
2. FAA Aviation Safety: Startle Response. Federal Aviation Administration Safety Team (FAAST). FAASafety.gov., 2021.
3. A.M Williamson, Anne-Marie Feyer. Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication. Occenvmed.com, 2000.
4. Nicholas Papa, Coordinating Ventilation: Supporting Extinguishment and Survivability. Fire Engineering Books and Videos, 2021.
5. Conceptually. Heuristics. https://conceptually.org/concepts/heuristics.
6. Ian McCammon, Heuristic Traps in Recreational Avalanches: Evidence and Implications. Avalanche News, (68), Spring 2004.
7. CDC/NIOSH, A Career Lieutenant and a Career Firefighter Found Unresponsive at a Residential Structure Fire-Connecticut – F2010-18, June 2011. https://www.cdc.gov/niosh/fire/pdfs/face201018.pdf.
Leigh H. Shapiro retired as a deputy chief from the Hartford (CT) Fire Department after 28 years of service. He has numerous degrees and certifications, is an adjunct professor for the University of New Haven and Gateway Community College fire science programs, and is an instructor for Connecticut’s Fire Investigator Pre-Certification Program.
