By MICHAEL TEAGUE
For the past several years, firefighter line- of-duty deaths (LODDs) have remained fairly constant. In addition, approximately 70,000 firefighter injuries occur each year.1 The National Fire Protection Association estimates that each firefighter injury costs an average of $50,000; the total cost of firefighter injuries and deaths is more than $2.6 billion. In 2004, the National Fallen Firefighters Foundation and the United States Fire Administration developed the 16 Life Safety Initiatives. The goal was to halve the number of firefighter LODDs by 2014. Although some progress has been made, it appears unlikely that this goal will be met.
The reasons for the lack of progress are unclear at this point. To identify the causes of firefighter injuries and LODDs, Life Safety Initiative #9 states that all LODDs, firefighter injuries, and firefighter near misses should be thoroughly investigated. Most LODDs are investigated, whether by the National Institute for Occupational Safety and Health Firefighter Fatality Program or by state and local fire service agencies. Recently, I have seen many departments begin to investigate serious injuries, and some departments have begun investigating near misses.
Investigating deaths, injuries, and near misses can be a complex endeavor. Departments wishing to perform investigations should have a system in place to identify the incidents needing investigation. The agency should have a team of specially trained individuals capable of performing the investigations.
CHOOSING EVENTS TO INVESTIGATE
As stated previously, LODDs are almost always investigated, as are some major injuries. If your department works in one of the 27 states with state Occupational Safety and Health Administration (OSHA) plans, it is likely that these investigations are required by regulation. There usually is no statutory requirement to investigate near misses; however, much can be learned from investigating them.
The following events are major episodes that should be investigated:
- LODDs.
- Burn injuries.
- Injuries involving hospitalization.
- Multiple injured firefighters at the same incident.
- Self-contained breathing apparatus failures in immediately dangerous to life or health environments.
- Training injuries.
- Any incident where a Mayday is declared.
- Any incident with a rapid intervention crew/team or firefighter assist and search team (FAST) activation.
- Vehicle accidents involving serious injuries or major vehicle damage.
- Any event the incident commander or senior department official requests be investigated.
What about less significant occurrences? Should we investigate the minor back strain or the near misses? Studies show that for each serious event (LODD or major injury), there are 300 less serious events; they could be minor injuries and near misses. By investigating some of these less serious events and identifying their root causes, you may be able to learn where in the error chain you can intercede to prevent future serious events. Collecting data concerning minor injuries and near misses will allow the fire service to better understand injury causes and consequences.
The Firefighter Near Miss Reporting System is an excellent example of the data you can collect and analyze to find the causes of injuries and near misses. Also, the Drexel University School of Public Health’s Firefighter Injury Research and Safety Trends Project (http://publichealth.drexel.edu/Research-Centers/Research-Centers/FIRST/5121/) is developing a set of data points that relate to firefighter injuries which, when completed, will define a set of data for fire departments to study. By aggregating these data, the research may lead to the discovery of ways to prevent future injuries.
Investigating these minor events usually does not require a team of trained investigators. With a proper form, most of the data can be collected by the firefighter’s supervisor and reviewed by the health and safety officer. Once collected, the information should be entered into the Firefighter Near Miss Reporting System and a firefighter injury database. Major incidents should be investigated by a Serious Accident Review Team.
ONE INCIDENT, MULTIPLE INVESTIGATIONS
One event could result in more than one investigation. For example, a structure fire that caused a civilian death and a serious firefighter injury may result in as many as five separate investigations: an origin and cause investigation, a homicide/death investigation, an OSHA injury investigation, an administrative investigation, and a firefighter injury investigation. It is important that these investigations stay separate. This is especially true for the OSHA injury investigation. The OSHA compliance officer’s intent is to review the event that leads to an employee injury and ensure the employer is complying with OSHA regulations.
Administrative investigations may occur when management believes employees did not follow policies and procedures. These investigations could lead to employee discipline.
SERIOUS ACCIDENT REVIEW TEAM
A Serious Accident Review Team is a specially trained group of individuals assigned to investigate an accident or near miss. The team may have several members with different duties:
Team leader. Normally a chief officer, this person is responsible for heading the team and interfacing with department management personnel and assigns work to other team members and for releasing information, including preliminary reports and the final report.
Lead investigator. This person is responsible for securing the scene, collecting evidence, and conducting witness interviews and is often the primary author of the team’s final report. The lead investigator may need the assistance of other investigators. Some departments require that the lead investigator be a trained law enforcement officer.
Safety program representative. He is responsible for advising the team on occupational safety and health issues and serves as the team safety officer. Therefore, this individual should have training and experience as an incident safety officer. This representative will also be the liaison to state and federal OSHA agencies.
Training program representative. This person gathers the training records of all the employees involved and reviews them to see if employees were properly trained for the duties they were performing. He also assists the team leader and lead investigator in developing recommendations for the future training of employees.
Labor representative. If the organization’s employees are represented by a labor group, it is important to have a labor representative on the Serious Accident Review Team to ensure that collective bargaining agreements are adhered to. He does not represent the employees being interviewed but may arrange for proper representation if requested by the employees.
Documentation specialist. Any investigation into a serious injury or near miss will create a large amount of records, pictures, interview transcripts, and other evidence. The documentation specialist is responsible for collecting and cataloging these items and will receive, classify, catalog, and store all records created by the investigation team. The documentation specialist must be computer literate and be able to properly store hard copy, digital photographs, and video evidence. The documentation specialist also assists the lead investigator in cataloging and storing any physical evidence.
Technical specialists. They provide expertise in areas in which other team members lack knowledge and may include personal protective equipment (PPE) specialists, self-contained breathing apparatus technicians, communications technicians, emergency vehicle technicians, fire behavior analysts, aircraft experts, structural engineers, and geographic information system specialists. The number of technical specialists varies from investigation to investigation and depends on the type of incident.
If the incident involved automatic or mutual aid, all departments involved should have a representative on the Serious Accident Review Team.
INVESTIGATION PROCESS Phase 1
The investigation process can be broken down into four phases. The first step is to gather information. This includes documenting the scene, collecting physical evidence, identifying and interviewing witnesses, and accessing records. Document the scene and collect physical evidence immediately. Photograph and develop sketches of the scene. The evidence at the scene is perishable. Much of it will disappear if it isn’t rapidly collected. As with cause-and-origin investigations, it is best to document the scene before it is extensively overhauled. Document the placement of apparatus and hoselines before they are moved. Collect all PPE of the injured firefighter. If available, law enforcement crime scene investigators may assist in scene documentation.
Once all the perishable evidence has been gathered, develop a list of all personnel who need to be interviewed. Conduct the interviews in a comfortable environment. Offer employees labor representation. Record the interviews on audio or video, and transcribe the proceedings. Investigators should write a summary of the interview, identifying major facts. This simplifies the process of locating important information at a future date. You may need more than one interview team if a large number of participants are to be interviewed. Conduct the interviews before critical incident stress debriefings.
In addition to the training records of all involved parties, collect dispatch and fireground communication recordings; mobile data terminal records; equipment maintenance and inspection records; videos or photographs from personnel, bystanders, or news crews; and building plans. The documentation specialist should catalog all these records and store them as evidence.
Phase 2
Analyze the information gathered in the first phase to try to understand how and why the event happened. First, develop a sequence of events. Using dispatch records, radio communications, recording transcripts, and participant interviews, the Review Team should list the events chronologically. The goal is to develop an accurate sequence of events. Doing this can be quite complex and necessitates using multiple sources including dispatch logs, radio transmissions, individual statements, interviews, and electronically recorded mobile data terminal transmissions. When a specific group of events occurs simultaneously, try to place them in the best logical order.
Once the sequence of events has been developed, the Review Team should begin developing a set of findings-conclusions drawn from facts established by the review. The facts on which findings are based must be documented elsewhere in the report.
Next, the Review Team should identify the causal and contributing factors of the accident. A causal factor is any behavior, condition, act, or omission that starts or sustains the accident sequence. If a causal factor is eliminated, the accident would not occur. Causal factors must be based on the findings developed in the analysis phase of the review. For example, in a wildland fire burnover incident, a causal factor could be the following: Firefighters attacked the fire from unburned fuel.
Contributory factors are behaviors, conditions, acts, or omissions that affected the occurrence or outcome but were not causal. If a contributory factor is eliminated, the accident may still have occurred. For example, in the wildland fire incident mentioned above, contributory factors could be described as follows: Fuel, weather, and topography aligned to produce a rapidly spreading fire.
Phases 3 and 4
Develop a set of recommendations that, if adopted, would prevent or reduce the risk of a similar occurrence in the future.
The final phase of the review is developing the team’s report. The report should contain all the factual information pertaining to the incident. It should sequence events, findings, causal and contributory factors, and recommendations. Supporting data may be placed in the appendices of the report and may include fire behavior analysis, standard operating guidelines, a glossary, and dispatch transcripts.
Once the report is complete, it is important that it be disseminated as widely as possible. The wildland fire community has developed the Wildland Fire Lessons Learned Web site (www.wildfirelessons.net) for storage of these reports. The structural fire service does not have a similar Web site. The National Firefighter Near Miss Reporting System is not set up to handle the large reports often produced from these recommendations. Most reports are published on the department’s Web site.
As we begin to aggregate the data from investigations of LODDs, firefighter injuries, and near misses, we will be able to get a better idea of the root causes of these incidents. Only then will we be able to decrease the number of injuries and deaths of firefighters.
Author’s note: I was the principal author of two Serious Accident Reviews; copies are available for review.
References
1. Kater, M and Molis, J. “U.S. Firefighter Injuries-2010.” National Fire Protection Association, 2011.
2. International Association of Fire Fighters, Firefighter Line-of-Duty Death or Injury Investigation Manual.
MICHAEL TEAGUE is a captain and safety officer for the Sacramento (CA) Metropolitan Fire District. He is also a member of the Sacramento (CA) Regional Fire Services Serious Accident Review Team.
