By Brian Brush and Anthony Kastros
The National Institute for Occupational Safety and Health (NIOSH) is the agency responsible for investigating firefighter line-of-duty deaths (LODDs). From the investigations, NIOSH publishes reports with findings and contributing factors to make recommendations for the prevention of future incidents. Over the years, a pattern has developed; a group of five causal factors is present in nearly all of the incidents.
- Fireground Communications and the NIOSH 5
- Tactical Supervision for Known Rescues
- Civilian Rescue: The Reason We Exist
The NIOSH 5, as they are commonly referred to in trade journals, texts, and classes, are (1) improper risk assessment; (2) lack of incident command; (3) lack of accountability; (4) inadequate communications; and (5) lack of, or failure to, follow standard operating procedures (SOPs). These are command/strategic and tactical level, “upstream” problems that appear on dysfunctional firegrounds that have been identified as contributing factors to deaths or injuries.
These same five factors lead to other, more common, events like near misses, significant injuries, missed victims, and excessive fire losses. Limiting the NIOSH 5 to LODDs can marginalize these factors. We have an opportunity to recognize them in our other negative incidents or even look for them in all after-action reviews. More importantly, we can train to proactively recognize these five factors and prevent them from coming into existence in the first place.
Identifying the NIOSH 5
If you recall any incident to which you responded where operations “went south,” you will likely identify that one or more of these factors were present. Whether or not the incident made a NIOSH report, there are still huge lessons to be learned. Although good luck reinforces bad habits, the failure to identify the potential of those close calls is negligence. Even worse, failure to identify how to prevent these factors, over time, will lead to something tragic, whether a lost civilian, lost firefighter, or career-ending injury. This article will delve into each of the NIOSH 5, with case studies for each factor to illustrate the lessons learned to be found in other incidents besides LODDs.
(1) An incident commander in formal command at a fixed position maintaining supervision, span of control, and available resources. (Photos by Eric Hurst.)
Risk Assessment
Units responded to a report of a fire in a nail salon supply facility. The building contained well beyond the permitted amount of acetone-based product. The reporting party told dispatch that everyone was out of the building. This crucial information was never reported to responding companies or the chiefs.
The building had an open-web bar truss roof assembly. Within four minutes of companies arriving on scene, the roof collapsed with companies on the roof and in the building. Up to eight firefighters could have been killed. There were no fatalities, and injuries were minor.
This didn’t make any NIOSH reports, but it sure had all the factors present. The most prevalent was risk assessment. Crews did not know the level of fire load, contents, roof assembly construction, and that everyone was reported out of the building.
Since then, the region looked at risk assessment, size-up, and commercial fires differently. Training, SOPs, and recognizing the common practice of treating commercial fires like residential fires were critical to preventing a similar event.
Communications
Units responded to an apartment fire with a report of five victims trapped. The first chief arrived and asked the company officer on scene in command for a face-to-face transfer of command. The chief was 250 feet away. The company officer appropriately told the chief that he was going in for rescue with his crew. He could not afford to make the 500-foot round trip to the incident command post (ICP) for a command transfer. He then masked up and went in. The chief attempted several times to contact the company officer, who was now inside the building on his self-contained breathing apparatus. The company officer never responded.
Fortunately, all civilian victims were successfully rescued. No firefighters were injured. Since then, this has become a case study in communications, auditory exclusion, tunnel vision, and the physiological impact of a high-stress environment. Countless firefighters have learned how communications can break down quickly from this successful rescue.
In addition, the importance of a rapid transfer of command is now emphasized in training. Rather than relying on a (habitual) face-to-face transfer when conditions are rapidly escalating, a streamlined command transfer over the radio, often including assigning the initial incident commander (IC) to a tactical supervisor position, has been established. This minimizes radio traffic and prevents a lull at the ICP, allowing companies to outpace the incident. The IC can then remain ahead of the curve without bogging down operations with unnecessary radio traffic.
(2) The second-arriving chief officer is moved forward to work as a division supervisor.
Accountability
Companies were operating at a multiple-alarm fire downtown. The IC had T-cards (index cards with company identifiers) established for accountability with several companies shown as assigned to divisions. Some of the companies had been released for more than 10 to 20 minutes yet were still shown as operating on the fire. The IC was behind the power curve.
In another case, an accountability officer was assigned to a multiple-alarm apartment fire, assigned to collect the Fireground Accountability Tracking System (FATS) tags from the companies. Several were inaccurate, and by the time they were all collected, many companies had changed assignments or had been released from the incident.
The region with both incidents renewed its efforts on accountability and changed the SOP on accountability. Division and group supervisors were given a greater role in accounting for crews, decentralizing accountability to the area where the work is being done in the tactical space. Rather than a centralized “accountability officer,” who often arrives later and can only be in one area at a time, multiple division/group supervisors can simultaneously have hands-on, eyes-on active accountability in real time.
Incident Command
A two-alarm garden apartment fire was underway on a hot day. The IC had a 10:1 span of control, with more companies arriving. The third chief (on the second alarm) arrived and was assigned to be a safety officer. This meant the IC now had an 11:1 span of control, which had a ripple effect on all the other factors (risk assessment, communications, accountability, and so on).
The third chief respectfully said, “I recommend that you make the second chief Division C in the rear, and I will take Division A. That will take your span of control from 11:1 down to 2:1, reduce radio traffic, and increase active accountability. We (the two division supervisors) will be the safety officers for our respective divisions until you get more overhead.” The IC looked up and said, “OK!”
The problem was identified as a lack of incident command system (ICS) usage on smaller structure fires, which led to not using ICS on larger fires, when the span of control gets overwhelming quickly. Through honest after-action reporting and analysis and training, the department used ICS more frequently and consistently before getting overwhelmed.
SOPs
A county with several fire agencies recognized that they all had different SOPs, and this created conflict on automatic- and mutual-aid fires. One issue was that rapid intervention and two-in/two-out were extremely inconsistent on structure fires, since each department had different interpretations of CFR 1910.134. No one was hurt as a result of this inconsistency, yet the potential was recognized beforehand, and the county developed several common SOPs.
Since then, there have been Maydays in the county, yet the rapid intervention team (RIT) operated seamlessly, even during automatic-aid fires. There are three levels of RIT that progress from a single engine to an engine, truck, heavy rescue, and battalion chief. Terminology and application of RIT vs. two-in/two-out is now much more consistent. Regional training has codified the SOP.
From Reactive to Proactive
The original source of the NIOSH 5 is LODD reports and the identification of where the negatives of the NIOSH 5 led to a negative outcome. Two negatives do not make a positive. If we as fire service leaders continue to maintain a narrow view of the NIOSH 5 by seeking to identify where “lack of” or “improper” led to accident/injury/fatality, we will only improve our ability to see and correct the point where things are going wrong. With this, our vision becomes trained toward failures and avoiding negative.
The benefit of having such a well-defined collection of predictable problems as the NIOSH 5 is that we conversely have a well-defined collection of solutions. This presents us with an opportunity to transition from identifying negative impacts on operations to evaluating areas of opportunity for developing and reinforcing positive/proactive operations. When we clarify what success looks like, our vision becomes trained on executing the positive.
As we attempt to avoid the NIOSH 5, we should simultaneously be working toward achieving their counterpoints. If the negatives of the NIOSH 5 cause a dysfunctional fireground, then we can consider the positives to contribute to a functional fireground. Those are discovered simply by replacing “lack of” with “adequate” and “improper” with “proper.”
- Adequate and ongoing risk assessment.
- Clear, concise, and consistent communications.
- Proper command, company, and personal accountability.
- Proper ICS, scope, and function.
- Adequate SOPs in place and proper adherence or variance.
Risk Assessment
Adequate and ongoing risk assessment is more than just an arrival report or size-up. Many individual officers and chiefs have developed a personal risk assessment process or model through time and experience. These may be successful day in and day out, but they are personal and not always organizationally instituted. It is important that organizations clarify, communicate, and practice a consistent risk assessment process. Developed in the 1950s by Lloyd Layman, the FPODP (see below) serves as a sound foundation.
Facts: What are the things that are known for sure about the incident? A well-involved garage fire in a two-story wood-frame single-family dwelling at 4:30 p.m. on a weekday.
Probabilities: What is the incident potential or hazard potential? A high victim profile, after school time of day, and a single-family dwelling. Extension and exposure potential is also high. Incident escalation regarding life hazard and property damage is high so quick engagement is required.
Own Situation: What are the resources you have on the ground and on the way? First-arriving engine with 500-gallon tank, second engine pulling down the block with truck company behind it and balance of first alarm within minutes.
Decision: What is your choice of strategy? Offensive.
Plan: What are the operational tactics and assignments needed to support the chosen strategy? Initiate fire attack, have a second engine bypass the hydrant to perform tank transfer and initiate search. Passing command to the truck captain and requesting vent-enter-search from his crew.
Communication
Communication issues hamper nearly every fireground, yet it is rarely a technology or hardware problem like a radio; it is most often the human side of sender and receiver. Well-defined communication types and times set expectations, formats, and a common language. Some of the critical communication types and times that should be defined for all members include the following.
Preincident
- Incident dispatch.
- Updates and upgrades.
Incident
- Arrival reports.
- Command transfers.
- Conditions, Actions, Needs (CAN) reports.
- Benchmarks completed.
- Urgent traffic.
- Mayday.
Clearer definitions of communication create greater discipline in communication. To send or receive information, there has to be an opportunity to broadcast. Quality radio traffic reduces the quantity of radio traffic.
Accountability
(3) A division supervisor has face-to-face communication and hands-on eyes on accountability with a newly assigned company.
Accountability is not just equipment like tags and roll sheets. Accountability is a hands-on, eyes-on, continuous, active, and anticipatory process. An active IC has considered where the fire was, where it is, and where it is going. These same questions and considerations become the accountability cadence for division/group supervisors: Where were my people, where do I have them now, and where are they going or needed next?
Incident Command
Incident command is not a one-person show. A first-arriving officer going to work cannot be expected to immediately address an escalating problem and coordinate the arrival of the balance of an alarm, and a single battalion chief cannot manage being both the single point of contact for five fire companies or more, an EMS unit, and dispatch on two radio channels while trying to evaluate and coordinate a working incident.
Modern incident command is a team sport. This is accomplished through division of labor, manageable spans of control, and tactical coordination. It is with purposeful intent that following 9/11 there was a shift in terminology from incident command to incident management. As our people and organizations have professionalized through training, education, and experience, there is greater potential at subordinate levels. With that, the modern approach to handling dynamic incidents quicker and more efficiently is when the chain of command places greater attention and value on coordination and management of subordinate actions over control and direction.
Proper use of the ICS keeps us ahead of the incident power curve. For too long, the fire service has had an almost egotistical, low-trust view of ICS. The traditional model is centralized command, and most often in practice traditional ICS is deployed with limited delegation at the upper limits of span and control. Systems under stress and tension during a normal load will fail when the force of a victim being located, water supply lost, or Mayday is added to it. It is much easier to initiate actions and tactics, supported and supervised by divisions and groups early, than it is to offload and reassign working companies to reduce span of control on the fly while evaluating a new incident within and incident that has disrupted the scene and initial incident action plan.
SOPs
Having adequate SOPs in place and proper adherence or variance to them is truly the basis on which everything is built. All the aforementioned functional fireground factors are institutionalized through your organization’s SOPs. Clear preincident and organizational guidelines are expectations of performance that create direction and accountability. We know that there will never be enough paper to cover all that we encounter, so we must allow for “loyal” disobedience and clearly spell out the path and boundaries for working outside of SOPs.
. . .
Through great strides in many areas, we are seeing a steady decline in fireground LODDs. Although this is excellent progress for our profession, it is just one of many goals. Even if we reach a point where we are celebrating consecutive years without a fireground LODD and no reports to identify the NIOSH 5, we should not stop working toward limiting the factors we know cause fireground dysfunction and leveraging points that lead to functional firegrounds.
Like everything we do, training is the key. All these factors are derivatives of incident command. Simulations are not enough. Hands-on, realistic, multicompany drills in which division and group supervisors are rapidly deployed will create a proactive stance and response to incident management, thereby creating experience in a realistic environment. Only then can we address all the NIOSH 5 to have a proactive attitude toward incident command and management, have functional fireground operations, save more lives, and prevent losses.
BRIAN BRUSH is a 26-year veteran of the fire service. His experience spans from rural volunteer to metro-sized departments. Brush is the training chief for the Midwest City (OK) Fire Department. A contributor to Fire Engineering, he is a on the FDIC International advisory board and has been an FDIC International H.O.T. and classroom instructor for more than 10 years. He has a master’s degree from Oklahoma State University School of Fire Protection and Emergency Management and is a graduate of the National Fire Academy’s Executive Fire Officer Program.
ANTHONY KASTROS is a 33-year fire service veteran. He is the author of the Fire Engineering book and video series Mastering the Fire Service Assessment Center–2nd Edition and Mastering Fireground Command–Calm the Chaos! Kastros received the 2019 Fire Engineering/ISFSI George D. Post Instructor of the Year Award. He is the founder of Trainfirefighters.com, teaching command, tactics, and officer development throughout America.
