BY JEFFREY S. PARKER
Are we sacrificing proven methods in tactics and strategy when fighting structure fires? We have generally improved how we do things, especially with regard to personal protective equipment (PPE) and the greater availability of technology. However, there are many examples that show that tried-and-true principles are being violated. These examples have been identified in research that studied selected incidents that resulted in firefighter fatalities. The goal of my research was to determine how tactics and strategy depend on proper staffing and directly affect firefighter survival. Adequate staffing at incidents enables departments to use proper tactics to implement a strategy that fits the scenario presented. These tactics will lead to increased firefighter survival. Where sacrifices in tactics were made, they frequently were the result of having inadequate personnel at critical times during the incident. Inadequate staffing for preincident functions such as fire code compliance enforcement, training, preincident planning, and underappreciated administrative functions also indirectly negatively impacted firefighter survivability.
The fire service in general has a severe shortage of line and administrative staffing. When line staffing is short, administrative staffing is commonly sacrificed to compensate. The National Fire Protection Association (NFPA) has standards that guide us in our operations: NFPA 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments, 2010 edition, and NFPA 1720, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations and Special Operations to the Public by Volunteer Fire Departments, 2010 edition. Additionally, the standards identify administrative functions that rely on educated, experienced staffing. The fundamental requirement for both standards is that sufficient personnel must be at the fire scene in the early, initial, critical, high-risk/high-benefit potential period of time to initiate proper strategic and tactical tasks. Both standards use the word minimum.
Consider prevention the most effective and preferred way to keep the public and firefighters safe. When prevention fails, we have to rely on rescue and suppression. In this context, prevention means using the proper tactics that prevent adverse situations. The fire service has also focused on handling adverse outcomes by implementing firefighter survival and rescue training and some form of rapid intervention. At the same time, however, we need to ensure that improper tactics do not cause these adverse situations such as backdraft, smoke explosions, disorientation, and structural collapse that necessitate these types of firefighter rescues more frequently.
The fire service attempts to compensate for inadequate staffing by taking forced shortcuts in proper information gathering, decision making, and tactics. Invariably, when this diminished use, or complete abandonment, of proven practices gets us into life-threatening trouble, we adapt by adding additional risk to more firefighters to attempt to mitigate the original dire situation. The risk analyses for these situations are usually high-benefit/high-risk and are the types of situations that we should always want to avoid. Yet, they are increasing in number. This is where fire prevention and proper strategies and tactics have a direct effect on firefighters.
Focusing on fireground fatalities at structure fires, and not those primarily caused by a previous medical condition, the research mentioned above was an attempt to isolate actions on the fireground that contribute to tragic outcomes. A 2002 NFPA report found the following: “While the rate of nonheart attack deaths outside structure fires has been dropping, the rate for deaths inside has been rising”1 (Figure 1).
| Figure 1. Deaths Inside and Outside of Structures |
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| Graphs by author unless otherwise noted. Source: “U.S. Fire Service Fatalities in Structure Fires, 1977-2000,” Rita F. Fahy, Ph.D., National Fire Protection Association, July 2002, http://www.nfpa.org/assets/files/pdf/FFFStructure.PDF. Used with permission. |
This research includes statistics from 1977 to 2007 (Figures 2, 3). In 2007, there were 102 firefighter fatalities, with a median number of 108 per year. The National Institute for Occupational Safety and Health (NIOSH) was investigating firefighter line-of-duty fatalities as early as 1984 (Figure 4). However, only one or two incident reports were released per year. This number was greatly increased in 1998 when the Fire Fighter Fatality Investigation and Prevention Program experienced a dramatic increase in funding after a strong push from the International Association of Fire Fighters and the International Association of Fire Chiefs. Starting in 1999, NIOSH published about an average of 39 reports per year.
| Figure 2. Fatalities 1977-2007 Firefighter Fatalities vs. All Fires |
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| Figure 3. Fatalities 1977-2007 Firefighter Fatalities vs. Structure Fires |
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| Figure 4. NIOSH Firefighter Fatality Reports |
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As of October 25, 2008, NIOSH completed 377 Firefighter Fatality reports. It uses a decision tree to determine if an investigation is warranted in a particular incident. Many of these 377 reports include motor vehicle accidents (MVAs); accidents off the fireground; and incidents that occur during training, in the station, or at other emergencies. Heart disease caused a large percentage of these fatalities. Of the 377 reports, 63, or about 17 percent, involved structure fires.2
Research has shown that in addition to tactical difficulties, staffing deficits cause a lack of information flow and may indirectly impact proper command decisions through lack of preincident planning, insufficient training, and inconsistency in personnel in rank and numbers from one incident to the next.
A lack of personnel may cause many fire departments to overly depend on mutual aid, which has limitations when it comes to efficiency and safety. A large, geographically expansive department is not the same as many smaller departments using a frequent mutual-aid operation serving the same jurisdiction. Increasingly, understaffed departments rely on other surrounding understaffed departments to ramp up adequate staffing for relatively routine bread-and-butter structure fires. These departments are not organized consistently and do not train together sufficiently, do not know each other’s jurisdiction, and have not preplanned together. Neither do they have real administrative control of all the resources that will interact at a scene prior to the incident. Mutual-aid departments now commonly operate at a level much nearer to a task level instead of a branch level in an incident command system. Department members may be intermixed into sectors, groups, and divisions. This may work well, but it is not an ideal situation. The reports contained examples of how this situation contributed to unsafe conditions and hindered scene organization.
The overall added risk present at fires in large buildings became quickly evident in these reports. Tactics that are used daily and are reinforced by positive results cannot be used at these fires. One multiple firefighter fatality report noted that according to the NFPA, from 1989 to 1993, “3.1 firefighters died for every 100,000 residence occupancy fires, and 11.6 firefighters died for every 100,000 nonresidential occupancy fires, such as stores, offices, and warehouses.”3 This is nearly a threefold increase in the risk of death for firefighters (274 percent). A later NFPA report stated that for the five-year period of 2002 through 2006, 3.1 firefighters died for every 100,000 residence occupancy fires. This compares with 13.9 deaths for stores and offices and 9.0 for vacant/special, 8.8 for public assembly, 6.8 for manufacturing, and 1.3 in storage facilities.4 The following factors may contribute to the increased risk to firefighters in nonresidential occupancies:
- larger floor spans;
- lightweight or engineered elements that fail more quickly;
- increased disorientation risk;
- larger void spaces above ceilings;
- firefighters’ traveling deeper into the structure and greater distances from a safe exit;
- an increased need for command system organization; and
- a greater need for sectoring, information feedback, and reconnaissance.
Noteworthy in reviewing these firefighter fatality reports is that there was a relative lack of successful rescue efforts from rapid intervention teams (RITs), firefighter assist and search teams (FASTs), or rescue assist teams (RATs). It is important that we prevent these deaths by renewing the emphasis on using the proper strategies and tactics when doing our job. The same things are happening over and over. Having access to this type of information will undoubtedly improve our awareness and increase our ability to learn from the experiences of others. My goal is to boil these reports down to critical factors that we can recognize and, hopefully, avoid in our operations.
ANALYSIS
The NIOSH reports contain recommendations to address those factors that alone or in combination contributed to the tragic outcomes. After an extensive review, I determined and tabulated the factors and established a list of 25 of the most common factors present in the NIOSH investigative reports (Figure 5).
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| Figure 5. Top 25 Firefighter Fatality Factors in Structure Fires |
Before we discuss these factors, let’s look at some general conditions noted in the NIOSH Fatality Reports.
• Communications are a vital part of managing incidents. I did not isolate communications as a separate factor from the NIOSH reports, since it is such a fundamental part of everything we do on the fireground. However, early reports frequently mentioned the need for interior firefighters to have portable radios. Later reports noted that only officers leading interior crews had portable radios. Still later, reports rarely mentioned the absence of firefighters’ portable radios. Even though the communications problems created by the absence of radios seems to have declined, there are still communications problems in the forms of too much radio traffic, the need for additional channels, and the lack of reporting remote or interior conditions back to command.
• We need to separate proactive preventive measures from reactive rescue measures. The RIT function is reactive but necessary. The absence of and problems in the implementation of RIT were reported frequently; however, whether the presence of a properly functioning RIT would have had a positive effect on the incident’s outcome could not be determined. The presence and effectiveness of a RIT is critical, because it is the last resort for turning a desperate situation around. The reports document several rescues of firefighters in trouble. However, preventive efforts have a much greater impact on saving firefighters. We are being forced to practice in an unsafe manner and then react to the results. We do not have the resources to practice safely or even to rescue ourselves from the bad situations created. Many examples show how fast firefighters can be killed and that the most skillful RIT cannot change the outcome. In fact, we put more firefighters under greater risk by using RIT.
While attempting to manage a personnel deficit, we face the dilemma of whether to assign early-arriving firefighters to RIT or to the tasks we need to accomplish early in an incident to prevent adverse events on the fireground, including ventilation, second or backup lines, forcible entry, and ladder placement. Some research shows that interior firefighter rescue is time consuming and difficult. We must focus on increased awareness and the use of tried-and-true, scientifically researched preventive measures, including good strategic decision making and coordinated good practice tactics.
Following is a discussion of my list of the top 25 factors present at firefighter fatalities in structure fires based on the NIOSH reports I reviewed.
1 Command System, Organization, Transfer of Command. Just more than half (51 percent) of the reports studied included this factor. A problem sometimes surfaced when command was transferred to personnel who had not yet arrived at the scene. This transfer becomes a source of confusion involving the location, action, and function of personnel already at the scene, because it does not follow the proper principles in transferring command. Usually, this is a result of a staffing deficit. This also results from the “fast-attack” mode and the “nothing-showing/investigating mode.” The “fast attack mode” [called the “fast-action” mode by Chief (Ret.) Alan Brunacini] may be indicated when the incident commander (IC) performing at the task level “can quickly solve or stabilize the problem.”
According to Brunacini, “The operation is now in a somewhat compromised, nonstandard command status.”5 Some chiefs believe that it is desirable to have the first-arriving company officer establish a formal command post outside of the structure and direct operations from there.6 They add, however, “Few departments have sufficient staff to allow the company officer to establish a stationary command post on arrival.” When the first-arriving officer uses the nothing-showing/investigating mode, once something that necessitates attack is found, this command mode should convert to a stationary mode or fast attack mode. The first company must investigate in the nothing-showing mode of operation, because there is no indication of fire or smoke that must be dealt with. Once the investigation reveals otherwise, the IC needs to deploy additional resources; assign his crew members as needed; and revert to a stationary, strong command mode. When these modes are not converted early or when the transfer is not accompanied by a transfer of information, that’s when problems ensue, such as in strategic decision making; accountability; or the lack of a single, coordinated, one-directional, one-strategic-mode attack.
As stated earlier, NIOSH also notes that difficulties increase in the command function as the number of departments operating on the scene increases. In one report, a mutual-aid department looked on its chief as the IC. Having separate companies or crews from one department is not the same as having multiple companies or crews from multiple departments. Ideally, the goal is to have all crews operate in a standardized operation and have standard capabilities. This is not always the case. NIOSH emphasizes the importance of properly transferring command. This concept also applies in varying degrees to other functional responsibilities at any level. We must respect the separation of roles—from strategic to tactical to task.
In general, all scenes need to be organized. If we detect chaos, our job is to organize the situation. In one report, crews were said to be getting confused with regard to geographic directions. This involved designations such as “north,” “south,” “east,” and “west.” Always designate the address side of the structure as the A side, then B, C, and D as you travel around the building in a clockwise fashion. Use letters horizontally; reserve numerical designations for vertical floors. The designation “Side 2” could be confused with “Division 2,” which may have the second floor.
Part of the officer’s job as a crew leader is to solve the crew’s problems. Problem solving should not interfere with the responsibilities of leading and supervising. When a RIT scenario occurs, you must maintain and reinforce organization at the scene. In one case, the RIT operation became chaotic; naturally, all hands wanted to help. There should be a formal assignment of functions, and there should be no question as to who the commander is, or the consequences could be deadly. Firefighters should be taught from the beginning of their career that discipline in the command system is a life-and-death issue. As was shown in several of the reports, no matter how well intentioned, freelancing could be deadly not only for the freelancer but for others as well.
Early officer training must emphasize the importance of the officer’s role and the need for the officer to let go of task-level actions. Part of the difficulty here is that individuals frequently perform at all vertical levels of a department—one day, they are incident command; the next, they are driving the truck; and the next, they are putting a hole in a roof. This task-level involvement goes back to staffing deficits. We are trying (forced) to do strategic-, tactical-, and task-level work at the same time. In one report, the IC was faced with the unfortunate decision of whether to direct the fire or drive a rescued child to a hospital. We need to practice (tabletop) the command system at structure fire scenarios. All personnel need to improve on how to provide credible and succinct reports of conditions to their superiors. This will help them concentrate on coordination rather than reconnaissance. Inadequate staffing leads to disorganization.
2 Rapid Intervention Teams. About half (48 percent) of the reports studied included this factor. Although the factor was noted, however, it is not known how it related to preventing a fatality—the result varied greatly from one situation to another. The Phoenix (AZ) Fire Department7 found through research it conducted that there are severe limitations with the firefighter rescue concept even in a relatively well-trained, motivated, adequately staffed department. Many of the NIOSH reports noted that a RIT was not assigned prior to the need for firefighter rescue. There were reports where the operation of the RIT was disorganized. Organization of the operation is essential for success and minimizing risk to the victim and rescuers. In some reports, the RIT was formed by pulling firefighters from other assignments. Abandoning these assignments may increase the danger for all involved; these firefighters may be fatigued or low on air. Attack lines in the area may be the only source of orientation for lost or trapped firefighters attempting to escape, for protecting themselves from heat, and for providing the quickest method of being found by rescuers. This line is their lifeline. Use additional lines brought in by the RIT for any firefighting necessitated in the rescue attempt prior to locating downed firefighters. Attack lines of different colors are helpful in identifying crews.
In some of the NIOSH reports, Command did not answer requests for a RIT. This invariably was because of radio communication difficulties, including scene noise such as gasoline-powered positive-pressure gas fans, truck engines, and so on. (The development of electric fans that have higher cubic-feet-per-minute rates and are quieter would help.) Other reasons may include too much radio traffic on the same frequency, command distractions, or talking or monitoring one channel at the time the request for a RIT was made over a second channel. We need to ensure that the listening priority is for hazard zone personnel.
RIT teams need to think of their function in three modes: firefighter rescue preparation, hazard zone firefighter safety enhancement, and firefighter rescue. The first two should always take place; the last one should be done when called. In the prep mode, the RIT crew needs to assemble anticipated equipment and make judgments on probable firefighter trouble scenarios. In this mode, RIT may consult with the safety sector, which is making similar considerations. Emphasis should be placed on minimizing the distances from hazard zone rescue to safe areas. This reduces risk and maximizes efficiency. You may need to breach walls or liberally open up a building to provide for emergency escape. Coordinate this opening operation with Command, since the resulting ventilation must be coordinated. Coordinate all preparatory operations with the IC. Preparatory tasks should not inhibit the team’s readiness and should not put the team in hazardous situations since, most likely, no secondary RIT will be assigned as yet before the first one is deployed with a rescue. This all requires additional staffing.
3 Ventilation. This factor was cited in 46 percent of the firefighter fatality reports. It is the primary factor related to fire behavior. Deaths have been related to too much, too little, and uncoordinated ventilation. In some settings, ventilation can also cause accumulated fine fuels, such as dust to be stirred up, and increase the surface areas exposed to oxygen, causing rapid combustion up to and including explosions. We have known for decades that we must coordinate ventilation with fire attack. We must put much more emphasis on fire behavior. We should all know that PPV will push oxygen into the building and heat and combustion products away from the seat of the fire. From a fire-behavior perspective, this could be good and bad. Eliminating heat and combustion products is good. Increasing the oxygen content in hidden spaces is bad. Positive-pressure ventilation (PPV) use can prevent and cause flashovers and backdrafts.
If we don’t let the heat and combustion products out, they are forced somewhere else into the structure. You must control the exit point. The ideal exit point is horizontally proximal to the seat of the fire and vertically as high as is practical and can be safely accomplished. This is the hottest part of the fire, the area where the most hazards and damage exist, and is above the area where the margin of survivability is the lowest. Knowing this, the technique used to make the exit point at this location must allow for the safety for firefighters. Natural wind direction may change the ideal exit point at a less than ideal location and may change the attack direction. Firefighters must have a safe area to retreat to that allows enough air for escape. If this area is a stairwell, vent the stairwell. The smoke venting in the stairwell must be greater than the smoke entering from the fire floors.
Firefighters cannot count on a chimney such as the interior stairs out of a basement for an escape path. Uncoordinated ventilation tactics taken without considering fire behavior can be deadly in serious fires. Do not count on windows used for significant venting for escape. Sometimes, the inability to vent properly is an indicator that a shift in strategy, from offensive to defensive, is needed. Because of our need to check void spaces such as those above false ceilings, we need to be prepared for the possibility of a smoke explosion, a backdraft, or flashovers. In cases where spaces rich in heated combustion by-products exist, venting needs to be on the exit point instead of the air entrance point. This lets heat out without letting oxygen in. It is also easier said than done. Backdrafts reportedly occurred when ceiling tiles were lifted to check for fire extension. Subsequent adverse sudden changes in conditions caused deadly disorientation and untenable environments. There are three killers even with all PPE in place: explosion, flashover, and collapse. Ventilation often is not done because of staffing shortages, or it gets modified to a point that it fits the tactic that can be performed with less equipment or staffing, and this is killing us.
4 Staffing Inadequate or Delayed. Of the fatality-related incidents studied, 43 percent had firefighting staffing deficits on-scene that factored into the poor outcome. Many preventable known factors come into play because there weren’t enough hands available to do what we know should be done. “Offensive attacks are people intensive.” (6) The fire service needs to implement a comprehensive public educational campaign about the need for adequate personnel to successfully fight fires. It is the firefighter’s need and the public’s need.
In one instance, the crew took an aggressive approach to ensure adequate fire flow and deployed a 2½-line with two-person staffing. Three to four people are recommended to handle a line of this size. In several reports, staffing numbers increased only after several minutes in the critical stages of the incidents had elapsed. The staffing of three on an engine prevents the completion of any meaningful task in a hazardous area because of NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, 2007 edition, and the Occupational Safety and Health Administration’s two-in/two-out rule. It also means that these departments are planning and expecting exceptions to this rule in life-threatening rescue situations, which happens to be our primary mission.
Critical task needs force leaders to abandon critical management functions or at least cause their effectiveness to diminish. One report involved an agency whose personnel were cross-trained as law enforcement personnel and firefighters. There are severe limitations in the effectiveness of this type of operation in terms of expertise, experience, and availability when the emergency requires the complementary services of law enforcement and the fire service.
Reports specifically addressed incidents in which aggressive tactics were employed and the operation suffered from inadequate apparatus, equipment, and staffing. There are undoubtedly some jurisdictions that are capable of properly and safely employing only defensive tactics.
5 Structural Collapse. This factor tied for third place among the most prevalent factor (43 percent) in the firefighter fatality reports. It is also tied as the number one factor (ventilation) related to the science of fire behavior. There are numerous reports of firefighters’ falling through burned-out floors. Trusses were not cited as a major contributor to the failure in many of these floor failures. The factors included structures with solid wood joists. The reports did not specify if the structures were protected by drywall encasement. Many of the roof collapses occurred with the presence of the usual weakness indicators of lightweight metal and wood-truss construction and large, open, long-span areas.
Facade, porch roof, and wall collapse examples were included. We must recognize and respect these hazards and designate and enforce collapse zones. Vertical roof ventilation is still conducted at the most dangerous, structurally damaged area of a fire building. It should be performed only when personnel are supported by something other than the burned roof structure, such as a roof ladder or an aerial device. Full PPE, including self-contained breathing apparatus, at least one buddy, and a hoseline must be in place. Building construction education should move to the top of the list.
According to a 2003 study conducted by the National Institute of Standards and Technology (NIST), the number of collapse fatalities on an annual basis has declined since 1979.8The percentage of collapse fatalities caused by being caught or trapped in the structure has increased. A majority (more than 65 percent) of collapse fatalities occurred during fire attack. Would staffing for adequate size-up, scene organization, and safety positions prevent some of these fatalities?
6 No Thermal Imaging Camera (TIC). About 38 percent of the fatality reports involved incidents where thermal imaging technology was not used. We need more TICs. They are analogous to the advent of the SCBA in the 1960s. TICs are needed for exterior size-up and reassessment, interior assessment, interior orientation for rescue and attack, overhaul, and firefighter rescue. Many of these situations occur simultaneously on the fire scene.
We now see the need to increase the use of the TIC in exterior size-up and other fireground applications. As the technology progresses, maybe every firefighter will have his own miniature TIC. It is very sad in today’s world to see firefighters still getting lost in smoke and being unable to escape before running out of air. When considering what we primarily deal with—total darkness and heat—the TIC should be a required tool for every firefighter.
7 Lack of Accountability. A more common problem in earlier years was a total lack of an accountability system. More recently, even with a system, a member is accidentally misidentified and a personal accountability report of all members results in the response “all accounted for.” Later, it was discovered that a member was missing. In one report, an electronic system was used, and there was a misidentified firefighter. The system at the basic level relies on the crew leader to know who is present; this does not change until all are out of the hazard area and the crew is formally disbanded and put back into the pool of standby, tactical reserve, rehab, or “on-deck” resources. Some of the reports showed that when crews intermix in the hazard area, or when one crew member runs out of air, exits, or is replaced, confusion occurs. This is related to the concept of crew integrity. The leader cannot keep track of changing personnel in the darkness and chaos of the fire environment. Crews should get ready together, enter together, and leave together and stay together until the crews are officially regrouped.
Subdivide or sector large horizontal and vertical areas. This facilitates management and accountability. No personnel in the hazard area should be without a crew of at least two. Accountability also means that attention is being paid to personnel in the hazard area. We must keep close tabs on these personnel. Every person at the incident must have an assignment, even if that assignment is “standby.” Unassigned personnel have a tendency to freelance. Arriving firefighters may instinctively assess the level of control being exerted by command and quickly learn what degree of freelancing will be acceptable. Early strong command presence is needed to avoid this phenomenon.
Command needs to know at all times each member’s name, location, function, level of hazard, to whom he reports, who reports to him, and the radio identifier. At the basic level, tags are given to the sector officer or command. A command board or tactical worksheet can be used. They can show all functional and geographic positions filled and the name of the person filling the position. The command board must show relationships of positions. The accountability board must show the association of individuals and their crew leader. The accountability function has to be practiced along with command procedures at the tabletop level.
8 Incident Safety Officer Not Assigned. At 35 percent of the incidents covered in the NIOSH reports studied, there was no assigned safety officer. This means that safety was not the sole focus of any individual on the scene. When this is the case, the IC retains this function, even though the IC always retains responsibility for the safety of all responders. Nothing in the reports states that the absence of a safety officer in itself directly caused adverse events. The reports do point out that having a safety officer helps put more focus on safety. The IC has competing interests—determining the benefits of fulfilling the mission vs. the risks to safety of responders, for example. The proper balance is the key. The focus on the mission may distract the IC from the safety interest. The safety officer helps ensure that continuous attention will be focused on risk reduction.
One example of a need for a safety officer is at a scene with a live wire down. Word of mouth about safety concerns is not enough, as we are distracted and lose focus. Strong physical barriers or strong, direct enforcement of exclusionary zones for safety concerns like wires down or collapse hazards are needed. Safety is a mobile position that may be set up as a stationary command post position with safety assistants who are mobile or sectored. The buddy system still applies to safety personnel in hazardous areas.
9 Strategic Decision Making. Strategic decision making was shown to need improvement in 35 percent of the reports. Once the initial strategy is determined, a continual reevaluation needs to be undertaken as conditions change and additional information is received. NFPA 1500 describes “acceptable risk” as follows: “What is the survival profile of any victims in the involved compartment? We will risk our lives a lot, in a calculated manner, to save SAVABLE LIVES. We will risk our lives a LITTLE, in a calculated manner, to save SAVABLE property. We WILL NOT risk our lives at all for a building or lives that are already lost.9 In other words: “We will risk a lot to save a lot, we will risk a little to save a little, and we will risk nothing to save nothing.”10
The worst-case scenario from a firefighter safety viewpoint is one in which the firefighter arrives near the end of the buildup to flashover with occupants’ lives at risk in a large, undivided area. (6) There were several fatality reports where no lives were at risk and there was significant firefighter risk. Situations were cited in which the fire department received repeated reports of occupants being in the building. The IC needs to recognize the location of the victim and whether the victim is beyond survivability at that point in time. Firefighters need to emphasize and train dispatchers to thoroughly question callers relative to occupant status.
The mere possibility that occupants may need rescue may be enough to incur some level of risk; however, you must assess the information’s credibility and accuracy when firefighters may incur a higher level of risk. There are many examples of firefighter fatalities and injuries that were the results of taking significant risks based on questionable information. Dispatchers, police, or other responsible persons need to understand the importance of credible occupant information.
All members need to be trained to recognize pertinent information and to succinctly communicate interior conditions to command. Although we may recognize similar situations on different days and can see them as “standard” events, resource availability and capability may be very different from one day to the next. Most departments have a constantly dynamic resource list from which to draw, except for the larger metropolitan departments that may assign “standard resources” to “standard events.” These dynamics may make for an offensive mode of firefighting today and a defensive mode tomorrow. All departments should have a goal to standardize staffing, apparatus, and rank structures on standardized responses.
Spending an increased time in a burning building without experiencing a catastrophic event should not increase our confidence; on the contrary, it should decrease it. ICs are being forced to make very tough decisions to provide a service level the public expects but which is not supported by the operational resources necessary to provide that service according to best practices and industry standards. We need to educate the public on how we should operate so that they may make an informed decision on resources and expectations.
10 Buddy System/Crew Integrity Concept Not Maintained. About a third (32 percent) of all firefighter fatality reports from structure fires contained incidents where either crew integrity was lost or firefighters worked in hazardous areas without a partner in close contact. Two is the minimum number of members permitted in a working crew in the hazard zone; this is known as the buddy system. If one member gets into trouble, the other is there to assist. Many tasks take a minimum of two members to complete. This concept has been a tried-and-true firefighter safety concept for many decades. Each “buddy” should check the other’s PPE prior to entry.
Crews may have more than two members up to a manageable span of control for the task and environment. There must be a leader, who must know who is in the crew. Crew members must know who the leader is. In a zero-visibility, hostile environment, this number may be limited to a maximum crew size of one leader and about five subordinates or fewer. Most departments do not have the luxury of working crews that match the companies that respond. In this case, a pool of personnel must be assembled into crew sizes as needed, assigned a radio designation, and briefed on assignment (by standard operating procedure or other manner). This crew should stay together through assignment, rehab, and onto tactical reserve or “on deck.” At this point, they may stay as a crew or be reassembled. When one firefighter gets low on air, all crew members should exit together, and all bottles should be refilled. If a group refill does not occur, invariably, as soon as the crew returns to work, another firefighter will need air. Furthermore, it is inviting disaster to split crews inside the hazard area. (6)
Firefighters must instinctively stay associated with their crew and their source of orientation, even in relatively good conditions. There were several examples of sudden unexpected changes of conditions, to hostile, zero-visibility conditions, where firefighters could not orient themselves to their hoseline or their respective crew members. Crew integrity is essential if the accountability system is to work. Mistakes made in this system, cause erroneous missing personnel reports that initiate an unnecessary search fraught with the greatest of risks to other firefighters.
11 Incident Commander Involved in Tasks. Virtually one out of three of all the NIOSH reports contained incidents that had the IC involved directly in performing at the task level. The IC, sector or group leader, and division officers need to focus on performing the functions of their level of responsibility. However, the greater the gap between levels of command, the greater the detriment to operations, such as the IC’s being constrained by performing task level functions that include pumping the truck, deploying the attack line, ventilating, and performing an interior size-up.
ICs should guard against overly zealous task involvement under the “fast-attack” mode. When the IC cannot avoid being involved in tasks, the tasks should ideally be those that allow him to be in a position to see the overall picture, be available to receive information, and direct others. Supervisors must have confidence in tactical- and task-level personnel. Many of these situations are caused by staffing shortages.
12 Preincident Planning Needs. More than a fourth (29 percent) of the reports indicated the necessity of preincident planning. Every department should have a preincident planning program. Preplans need not involve only building and structure fires; they may also cover typical nonbuilding fires and technical rescue and hazardous materials incidents. Frank Brannigan, author of Building Construction for the Fire Service, strongly encouraged: “Know your buildings.”11Note things like construction features, obscure hazards, and ventilation profiles. We need varying amounts of information when at the emergency scene on each of our properties. In some cases, complex preincident plans will be needed, such as for strip malls, hospitals, and industrial complexes. In most cases, we will need only a single building preplan. This could be the layout of a typically constructed house in our response district, a partial plan, or a small bit of information or notes—for example, an owner or tenant calls to let us know about an oxygen tank or a handicapped person residing on the second floor.
Base the priority criteria for preplans on civilian life hazard, firefighter hazard, and a complexity level that would guide you in assigning a numerical value of 1 through 5. Complete the properties with higher totals first. The fire service needs to take advantage of modern technology to decrease our risk and add to efficiency. This is another example where a staffing deficit may hinder our ability to enhance the way we do our job. It takes an educated fire safety professional to coordinate a program from design to information gathering to system implementation, final plan production, and continuous necessary revisions.
13 Basement Fire—First-Floor Entry. About a fourth of the fatality reports pointed out the hazards of entering the first floor over a basement fire. Many firefighters fall through the first floor after making entry. Often, the location of the fire is unknown. This lack of information can be eliminated with a proper size-up using a walk-around and a TIC. Do not enter an area over the fire until the area below is at least under the control of hose attack crews on the same floor and, preferably, when the structural integrity has been reasonably confirmed. There have been examples of firefighters’ falling through the floor in years past, but then there were numerous firefighters and hoselines in place on the lower floor. The firefighters may have been injured but not severely injured or killed. Now, when the same thing occurs, there is no crew or hoseline on the floor below. The firefighter succumbs in an untenable fire environment or is disoriented. In this case, there is very little room for error.
We should be very wary of floor structures above basement fires just as we are concerned about ventilating the roof when the fire is on the top floor. We use a roof ladder when ventilating a roof. We recognize that we are cutting a hole over the hottest part of the fire. We are careful of the potential failure of the roof structure.
When the basement is on fire and other floors are involved, the basement should be the first attack entry point. Attempt to vent the basement, preferably on the hottest (burn) side to the outside. A second crew must protect the interior stairs from the rest of the building, but only after the basement fire has been well controlled or has been controlled enough so that if a firefighter falls, he will not lose his life from burns or asphyxiation. There will be crews below covering the basement area. Fires need to be fought from the lower levels up. There are many examples of firefighters who have been killed while operating above the fire floor. This is happening too frequently and will increase with new construction methods unless we adjust our tactics.
When a basement on fire has an exterior stair entrance and an interior stair entrance, the exterior stair is the best bet for safety and should be the fire attack point. Both options will cause us to descend stairs (down a chimney), but the exterior has less chance of being burned out. The path to the interior stairs may not be structurally sound, and should a firefighter fall, he would have to ascend out of a hole to escape the hazard. The exterior stair entrance will provide an escape path more often, even if the floor above collapses.
A fall through the floor into a basement frequently leaves you without your hoseline for protection and without the orientation to find a safe exit. On the other hand, if the first floor collapses when you have entered at the basement level, you will have your hoseline. When a flashover occurs in the basement, an exterior stair escape path provides a much shorter, direct, although untenable, path to safety than the interior stairs (chimney). When you ascend the interior stairs, you still will have to maneuver on the first floor to get to safety. You will likely have to endure a second untenable environment on the first floor while attempting to escape. Some may say that the interior option is the first choice so that the occupant’s path to escape can then be protected. This is true; however, this first-in approach without the fire below having been knocked down is killing firefighters. Proper staffing allows both floors to be covered simultaneously.
14 Searching Without a Hose or Guide Rope. One fourth of the reports had firefighters becoming disoriented when not following a hoseline or a rope line back to an area of safety. Firefighters should not overly rely on a right-to-left or a left-to-right search, except for the smaller, simplest “open” buildings. An “open” building is one that has a good set of windows. Windows serve as orientation guideposts and sources of emergency escape and access to help. A common finding in the reports was a nonline search above the fire. This is the typical scenario in the 3 a.m. house fire. Fire is located on the lower levels, and the occupants are probably on the upper levels. Deadly disorientation has occurred in even moderately sized homes. Using these same tactics in the modern, larger, open-layout homes, businesses, and larger commercial stores is very dangerous.
Firefighters also became disoriented when the environment suddenly changed to “prolonged zero visibility.”12 The concept of staying with a hoseline or rope has limits also. When the distance is greater, the chances of a firefighter’s losing the hose are also greater. Search will be more successful when the fire is knocked down, smoke is vented high and fresh air is coming in low—and before structural integrity is affected. However, you must have the staffing and coordination of tactics to make this happen. The entire concept begins to look like a “chain of survival” for interior firefighting.
15 Operating Above the Fire. Operating above the fire was a factor in 22 percent of the reports. This includes first-floor entry above a basement fire, searching the upper floors over a fire, and vent crews’ operating on a roof. We are well aware that heat rises, causing smoke to rise and weakening our work platform. Many of these tragedies can be avoided if “operating above fire” became instead “operating above a well under-control fire.” Along with structural weakness, overwhelming fire and disorientation/asphyxia frequently occur in these cases. Whether operating above a fire with or without a hoseline, the danger is increased with the rise in elevation in relation to the seat of the fire. The presence of water decreases the risk. Additional distance and the need to descend through a chimney-like area for escape add to this risk.
16 Water Problems. About 21 percent of the fatality reports showed water delivery problems as a factor. The kinking of the attack line contributes to a loss of water. Fire behind attack crews has burned through their attack line. This shows the need for a second or backup line. Firefighters must know the water is at the nozzle and the air has been bled before entering the fire environment. Practice supply line tactics at the pump hookup and at the hydrant. As the fire service emphasizes attack lines with adequate fire flow, we must also supply the adequate staffing to handle these larger lines. We can deliver the needed fire flow through single large lines or multiple, smaller, more maneuverable lines; however, we may not have the staffing for either option.
17 Lightweight Structural Members (Truss and Others). Ten cases of the 63 NIOSH investigated had lightweight material assemblies involved in a collapse—bar joist trusses, 2-inch × 4-inch wood trusses, prefabricated wood I-joists, weight suspended by metal rods, and roofs and floors. Modern construction design’s challenge is to balance construction cost with structural fire integrity. In a very broad, general sense, it is a struggle of mass vs. math. Overall, fire resistance rises with more material mass, and construction costs rise with more material mass. This applies to all building materials, including wood and steel.
As technology advances and advancements in computerization are realized, more precise design will make more and more efficient structural design possible. In this case, efficiency means less material is constructed in a method that provides superior strength as an assembly. An assembly requires connections to remain assembled. The connections of members depend on the assembly’s strength. Steel connections and adhesives are vulnerable to heat. Frequently, these connections are the first to go in a fire; consequently, so does the structural strength of the assembly that depended on them. Components with less mass react poorly in fire. Hence, more efficient, lighter-weight (mass) structural assemblies and components don’t do as well in a fire. As the late Frank Brannigan observed: “In recent years, the economics of using geometry (e.g., truss shapes) over mass had a tremendous effect on structures.” (11) As more is known about actual fire severity, the efficiency of fire safe design will increase. This will place a greater burden on inspection and enforcement and on the fire service to provide proper staffing to accomplish this.
The Empire State Building weighs about 23 pounds per cubic foot, and modern high-rise buildings weigh about eight pounds per cubic foot. (8) A strong argument could be made that the Empire State Building would have survived longer structurally than the World Trade Center did on 9/11 and would have allowed many more occupants and rescuers to escape, given the fire load that occurred, with the simultaneous loss of passive and active fire protection. Modern buildings today are so dependent on compartmentation that nearly any fire that breaches the inner fire barrier into the structural frame will force decisions with two bad choices: quick decisions for defensive attacks or an even greater increase in firefighter injuries and fatalities. These newer buildings will not have much structural fire resistance when you take away the inner shell and active fire protection. Staffing is needed to contend with this challenge to enhance code development, conduct code compliance inspections, and enforce codes to ensure the protection of structural components and for preincident planning.
18 Searching a Smoke-Filled Area Without the Protection of Water. This factor was present in about one out of every six fatality reports. Searching the fire floor away from the attack line contains a degree of hazard, as fire extension can get beyond the attack crew’s coverage. This factor was more often seen while conducting search on the floors above the fire floor without a hoseline. The interior stairs of residential buildings present the vertical chimney effect. Protecting the stairs is critical, as are firefighter emergency escapes at windows and controlled ventilation of the upper stories. This all takes proper staffing and coordination.
When doing anything above the fire, use extreme caution. When entering a window from a ladder or the roof, consider the difficulty of getting back out the window quickly when you need to. Upper-floor window escapes frequently require large rear or side ground ladder placement on sides inaccessible by aerial ladders or without porch roofs. The rear of many apartment buildings or homes has greater height from the ground. This also takes staffing. An argument could be made that ladder work has fallen off in departments with staffing deficits.
19 No Backup Line Provided. One out of every six scenarios contained this factor. The attack crew is entering an unknown hostile environment. The fire can intensify. The crew can fall through a hole. There can be nozzle problems or a kink in the line. The flow needed may have been underestimated. The escape path may be blocked by flare-ups. The second line should be staffed properly, and it is not a backup if it goes in a different direction. There were examples of backup lines that were uncharged, roof vent crews with no protection line, and backup lines that ended up on the wrong floor. Firefighters were severely burned when falling through a floor because they were unable to use their first line for protection; water was lost in their attack line because of kinking, and there was no backup line and crew. This fundamental tactic has been sacrificed because of limited staffing.
20 Simultaneous Use of Defensive Strategic Mode/Offensive Strategic Mode. Defensive mode tactics contain opposing hose streams, large and dense streams that can cause structural collapse. Most defensive operations are “surround and drown” type events. The natural upward and outward escape of heat and combustion products is reversed when elevated streams are initiated, which are often necessarily directed downwardly. This is no place for firefighters to be conducting offensive operations. All members must be aware of the strategic mode of operations. All members must be accounted for and in safe positions when switching from offensive to defensive.
21 Delayed Alarm. Delayed alarms let the fire intensify, and assumptions about structural integrity may not be valid. The recommended response time recognized by the NFPA is centered on making an interior attack prior to flashover. Delayed alarms push attacking firefighters into or past flashover into the period of time where passive fire protection has been compromised and fire affects the structural components. This is a crucial concept to teach the general public. Many concepts are in place to allow occupant escape. Delayed alarms directly cut into firefighter escape time. Public use of portable fire extinguishers has good points and bad points. It is good that small fires can be stopped, but it is bad that the use of these extinguishers can delay fire department notification and occupants may become trapped while attempting self-extinguishment. In one case, extinguishers were used for 15 minutes before the fire department was notified; a firefighter died.
22 Opposing Attack Directions. This has been a tactical error for many decades. Coordination and prevention of freelancing will go a long way in preventing this problem.
23 Attack Line Pulled Out of the Hazard Zone Prior to the Exit of All Firefighters. In three instances, the chance for distressed, lost firefighters to find their way to the exit using the hoseline was lost. This sometimes occurs because of poor accountability and control. No one knew firefighters were still inside trying to find their way out. Attack lines must not be removed until command approves it, and this is only after a personnel accountability report confirms all hands are safe. Always consider the attack line a “lifeline.”
24 Fire Attack Entry (Safe Point), Long Distance to Fire Attack. The NIOSH reports showed that entering a smoke-filled building a long distance from the fire attack is asking for trouble. You need to minimize the distance from the hazardous attack point to a safe area. The longer the distance, the greater the risk of disorientation, underestimating how much escape air is needed, and increasing the difficulty of a firefighter’s rescue. Very long hoselines are difficult to advance, may require larger feed lines/wyes, and need more firefighters. The concept of attack from unburned to burned areas may need to be revised in larger structures such as commercials, supermarkets, and warehouses, all of which should be sprinklered. Excessive attack line loops in the interior and intermingled, crossed attack lines contribute to disorientation, confusion, and delay of firefighter escape. Staffing must be available to properly advance and withdraw attack lines. A straighter path of line to the exit with most of the extra line outside is preferred instead of a coiled line inside. However, staffing is required to feed, retrieve, and withdraw the line as needed.
We cannot use the everyday residential fire as a model of success on commercial fires. In these fires, we can enter the front door, attack from the unburned side, and push it out the burned side. This is still ideal, but the distance factor on larger occupancies affects safety. We may need a flank attack to push the fire to the burned side. A defensive posture may be indicated if proper venting cannot be accomplished safely.
25 Electrical Utility Control. Fire command must call for electrical service companies to shut down power as early as possible in a fire incident. Power utility companies must be encouraged to decrease response times, as we all depend on their rapid response in an emergency. Firefighters should shut off power at circuit panels in buildings, if safety permits, while awaiting power crews. When lines are down, a safety officer should be stationed in close proximity to the hazard but in a safe enough position to be able to prevent others from coming in contact with the wires. Physical barriers may be placed around a dangerous hot zone.
Understanding the pattern of these factors will enable the fire service to more effectively articulate the inescapable fact that firefighting requires an adequate number of firefighters to fill the many important roles both prior to and during structure fires. We must make good decisions and perform coordinated, correct tactics that use sufficient personnel to maximize firefighter effectiveness and survivability.
Endnotes
1 “U.S. Fire Service Fatalities in Structure Fires, 1977-2000.” Rita F. Fahy Ph.D. National Fire Protection Association, Fire Analysis and Research Division. July 2002.
2. Fire Fighter Fatality Investigation and Prevention Program, Fire Fighter Fatality Investigation Reports. National Institute for Occupational Safety and Health (NIOSH), http://www2a.cdc.gov/NIOSH-fire-fighter-face/state.asp?state=ALL&Incident_Year=ALL&Submit=Submit. (Firefighter deaths associated with the tragedy at the World Trade Center in 2001 were excluded from this study.)
3. “Partial Roof Collapse in Commercial Structure Fire Claims the Lives of Two Career Fire Fighters – Tennessee. NIOSH Fire Fighter Fatality Investigation and Prevention Program, Fire Fighter Fatality Investigation Reports, http://www.cdc.gov/niosh/fire/reports/face200318.html/.
4. “Firefighter Fatalities in the United States – 2007”, Rita F. Fahy, Paul R. LeBlanc, Joseph L. Molis, NFPA Fire Analysis and Research Division, June 2007, http://www.nfpa.org/assets/files/PDF/osfff.pdfl/.
5. Brunacini, Alan V, Terry Garrison. Fire Command, 2nd Edition. National Fire Protection Association (Heritage Publishers Inc., 2002).
6. Klaene, Bernard J. “Ben” and Russell E. Sanders, Structural Firefighting (Jones and Bartlett Publishers, 2000).
7. Kreis, Steve, assistant chief, Phoenix (AZ) Fire Department, Fire Times, “Rapid Intervention Isn’t Rapid,” May 2003, http://www.firetimes.com/story.asp?FragID=8399/.
8. “Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002.” National Institute of Standards and Technology (NIST),NISTIR 7069 (November, 2003), http://fire.nist.gov/bfrlpubs/fire03/PDF/f03024.pdf.
9. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, 2007 edition, Appendix A.8.3.2.
10. Jeff Goins, “Risk Analysis at Normally Occupied Structure Incidents,” Fire Engineering, October 29, 2007. http://emberly.fireengineering.com/display_article/310355/25/none/none/BRNIS/Risk-Analysis-at-Normally-Occupied-Structure-Incidents.
11. Brannigan, Francis L. Building Construction for the Fire Service, Third Edition, NFPA, 1992.
12. Mora, William R., captain, San Antonio (TX) Fire Department, “U.S. Firefighter Disorientation Study 1979 – 2001,” July 2003.
JEFFREY S. PARKER is a 31-year veteran of the fire service and is a lieutenant/paramedic with the Fort Thomas (KY) Fire Department, where he has served for l8 years. He is a Kentucky State fire instructor and was a 16-year member of the Dayton (KY) Volunteer Fire Department, from which he retired as captain. He has been a paramedic for 25 years. He is an adjunct faculty member of the University of Cincinnati, at which he earned an associate of applied science degree in fire science technology and a B.S. degree in fire and safety engineering technology.
