BY STEVE PRZIBOROWSKI
This article is not meant to second-guess, question, or challenge anything that has gone on in the past or will go on in the future. It is meant to honor those who have paid the ultimate sacrifice by attempting to learn from the mistakes that may have been made or that were cited in official documentation, investigative reports, after-action-reports, and line-of-duty death (LODD) reports available to the public. If we truly want to honor our fallen brothers and sisters, we must do our best to learn from history to ensure that history doesn’t repeat itself.
It pains me every time I read an official, unbiased after-action or investigative report after an LODD, primarily because it looks like almost any other recent LODD report; only the names of the firefighters and fire departments involved are different. Notice that I used the words “official” and “unbiased.” Today, thanks to the Internet and social media, it is not uncommon to have numerous unofficial and biased reports published almost instantaneously, many times before the facts are known and a full investigation has been completed. Many unofficial and biased reports circulate, and fingers are pointing everywhere except where they need to be pointed. Often, the reports are based on emotion and usually are quite different from the official, unbiased report.
That is the reason when an LODD or a serious injury occurs and others begin to make assumptions and ask for my opinion, I say something to the effect that although I am saddened by the tragedy, I will do my best not to make any assumptions until the official, unbiased report comes out (usually in about a year or so). Anyone who wants the facts and answers days or weeks after a tragedy has never conducted an official investigation. The last thing an investigator (or agency) wants to do is provide information that may taint the investigation or cite what may seem to be a contributing factor early on but turns out not to be the case after the investigation has been completed.
Looking at the actions that led up to or contributed to some LODDs, the lessons learned, or the recommendations that would help prevent similar incidents in the future, you often get the sense of déjà vu: Whether the LODD occurred last month, five years ago, 10 years ago, or 20 years ago or more, many of the same contributing factors are involved. Granted, some of the recommended actions commonly made in today’s after-action reports were not available options 20 or more years ago. Examples include using a thermal imaging camera, ensuring that each member has a portable radio, and adopting/following National Fire Protection Association (NFPA) standards such as 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations and Special Operations to the Public by Career Fire Departments.
Almost everyone in the fire service over the course of their career will say those feel-good or politically correct phrases such as “be safe,” “never forget,” “everyone goes home,” “nobody gets left behind,” or something similar, but do they really mean them? More importantly, do they practice what they preach? They probably mean what they say when they say it; however, their disconnect begins when it comes time to practice what they preach and walk the walk. Too many times, we give lip service to safety, something I know I’ve been guilty of over the course of my career at least once-not on purpose, obviously, but just because it is something that happens when we start believing the hype or believing that tragedy can’t strike me or my department or the brothers and sisters I love and respect. Well, tragedy can and does strike us-and more so than we want to believe or acknowledge.
We need to stop giving lip service to safety and start learning from past mistakes. It’s not easy. Anyone can read recommendations and lessons learned and say they won’t do the same thing while they are in command or on the fireground. It is easier said than done. I know. I’ve experienced it. On the fireground, many times we have to make split-second decisions and do not have time to think about our actions. There are going to be situations we may not be able to prevent. Not every firefighter LODD is preventable. Sometimes, firefighters will suffer an LODD for doing the right thing at the wrong time.
Every firefighter, career and volunteer, takes an oath knowing he may suffer serious injury or death in the course of their duties. Based on the law of averages and the situations to which we respond, LODDs will occur. The key is to try to reduce the numbers each year and to see if we can avoid putting our personnel in those situations that are avoidable. The toughest job on the fireground has to be that of the first-arriving company officer who can set the incident up for success or failure, depending on his action or nonaction. The next toughest job on the fireground is that of the first-arriving chief officer, who has to pick up the ball thrown by the first-arriving officer. If the first-arriving officer did not cover all the bases that should have been covered, it’s up to the first-arriving chief officer to immediately recognize what was done incorrectly or not done at all and to make sure those things start to occur or are corrected.
In addition, company officers and chief officers must contend with people screaming at them to save their occupant relatives as well as contend with crews on the radio asking for their assignments. Granted, most incidents are not major and can usually be handled by the first-arriving company. We are talking about those major incidents where split-second decisions must be made quickly and a 360˚ hot lap around the structure is needed; when the officer must determine whether the interior environment is survivable and whether to undertake a rescue or launch an offensive fire attack, determine which point of entry is best for the first hoseline, establish positions for the second and third hoselines, and decide whether to request additional resources-and, if so, which ones. The list goes on.
If you’ve been around the fire service long enough, you have probably heard such risk management statements as the one on the Phoenix (AZ) Fire Department Web site:
“We will begin our response on the assumption that we can protect lives and property;
We will risk our lives a lot, if necessary, to protect savable lives;
We will risk our lives a little, and in a calculated manner, to protect savable property; and
We will not risk our lives at all to protect lives or property that is already lost.”
Similar statements can be found on fire department Web sites and on fire station walls. But, do we practice it? I have heard from some firefighters, as strange as this may seem, that their department says that they are only to cover their rears and protect the department from getting sued.
I don’t know of anyone who wishes to have a firefighter under his command or with whom he is acquainted die in the line of duty. Talk to any supervising firefighter who had one of his personnel die in the line of duty. You, no doubt, would hear statements like the following:
- I didn’t want that to happen.
- I wish I would have done this or that to not let him be in the position in the first place.
- I wish we would not have gone inside that structure.
- I wish I would have trained myself more to prevent such situations.
- I wish I would have trained my personnel more to prevent such situations.
- If only I could take back what was done or not done.
- I’ll never forget this tragedy.
- We will never forget what happened.
- We will do our best to learn from this tragedy to ensure it doesn’t happen again.
Firefighter LODDs are equal opportunities for firefighters of all ranks (from volunteer firefighter all the way up to chief) and from all types of departments (career, combination, volunteer, structure, wildland, and so on). Firefighters are dying in all types of situations, in all types of buildings, and in all types of incidents-and for many different but very similar reasons.
If you’ve been in the fire service for any number of years, you have heard the term “never forget”-343 firefighters lost from the Fire Department of New York on 9/11/01; 27 firefighters lost in Texas City, Texas, on 04/16/47; 19 firefighters lost in Prescott, Arizona, on 06/30/13; nine firefighters lost in Charleston, South Carolina, on 06/18/07; six firefighters lost in Worcester, Massachusetts, on 12/04/99-the list goes on and on. These incidents are only some of the more significant losses the fire service has faced.
The fire service is still averaging 100 firefighter LODDs per year; the number ebbs and flows but remains pretty constant.
I don’t believe we need any more committees or work groups to tell us how to save firefighter lives or determine why there continues to be such a high rate of firefighter LODDs. We need firefighters, company officers, and chief officers to start reviewing what is killing and injuring firefighters, to train on the recommendations and lessons learned contained in the fatality reports, and ultimately practice what they preach on the fireground. Train as you want to act or perform on the fireground. That is the only way to increase your odds of survival on the fireground.
Unfortunately, too many times personnel don’t want to train (it’s too hot, it’s too cold, it’s too wet, the football game is on, the baseball game is on, the hockey game is on, the tennis game is on, it’s a day that ends in “y,” we already know how to throw a ladder, and so on). Anyone who has been a supervisor has probably heard these excuses and more. Well, company officers and chief officers, if you care about your personnel and want to ensure they go home safely to their families, it’s up to you to stir up the hornet’s nest and get your personnel out there to train more than they probably want to and probably more than you want to. Nobody said leadership was easy.
Culture
We hear a lot about culture and how it can contribute to LODDs. There are many definitions of culture and opinions of how it relates to the fire service. One definition that really hits home is the following:
There is no greater influence of change in the fire service than the LODD of a firefighter. Yet, there is no greater tragedy than that of a fallen firefighter whose death prompted the passage of a safety policy which may have prevented his or her own death.
-Theodore Lee Jarboe, 1994
Many times, it’s easy to point fingers at the department’s high-ranking leadership for the lack of training, policies, or direction. Sometimes leadership has been determined to be the cause, given the findings within an official, unbiased after-action report; there has to be some responsibility and accountability at the company officer and battalion chief levels. Solid leadership and changing of culture must begin at the company officer level and at the fire station. Any chief can get up and try to improve the culture of the agency or lead the agency into the future, but if the troops don’t want to follow or don’t agree with the positive changes a chief or the fire service is trying to implement, the ideas and vision will fail. Changing the culture is not easy. A department can change only when enough people want it to change.
Do ego and pride get in the way of safety sometimes? We would be lying if we said they don’t. No one wants to look bad in front of their peers, and egos get in the way regularly. To quote Chief (Ret.) Alan Brunacini, Phoenix (AZ) Fire Department, “Egos eat brains.” They also get firefighters killed or seriously injured if they are not kept in check!
Attitude also comes into play. Some firefighters feel they are invincible, some feel it is okay to die in a structure fire, some feel it won’t or can’t happen to them, some are just oblivious, and some just don’t want to even think about it happening.
Firefighters don’t usually die because of one thing by itself. Read any unbiased after-action or investigative report, especially one from the National Institute for Occupational Safety and Health, and you will usually see that it was a combination of events that led to the firefighter LODD. The majority of time, it seems that one thing by itself (happening or not happening) rarely leads to a firefighter LODD.
As a new firefighter, I remember a senior captain telling me, “Don’t sweat the small stuff.” He was a laid-back captain who said that time and time again to anyone who would listen. There is some value to that statement (meaning keep calm and remain cool under pressure). I think there are also some negative consequences if you take it too literally. Why? Because if you don’t sweat the small things, there is a good chance the small things will lead to bigger things! If you turn a blind eye or disregard those small things that could be considered warning signs, there is a high probability that something bigger and worse will occur at some point in the future.
Everything begins with the first-arriving officer, who is typically the company officer and who can make or break the outcome of the incident. That first-due officer will be the hero or the zero at the end of the incident. It’s as simple as that.
For example, a company officer can do a 360˚ hot lap around a house that is on fire and determine that the interior of the structure is not survivable and that nobody inside is savable. This is not an easy decision to make; you’ve just written off everything inside-life and property.
To complicate matters further, just after you direct your personnel to grab the 2½-inch hoselines, since you are now in defensive mode, you are confronted with a lady screaming that her baby is still inside and that you need to save her baby! What are you going to do?
Obviously, there is no easy or right answer; each choice is filled with consequences. Choose not to change to a rescue mode and ultimately risk the lives of your personnel for what will more than likely be a body recovery (based on your fast, risk-vs.-gain assessment based on your 360˚ lap), and who knows what the lady and any other bystanders will do or say to you now and through their social media outlets? Choose to change to a rescue mode and risk the lives of your personnel for what will more than likely be a body recovery, and there is a good chance you and your personnel may suffer an LODD.
There is no easy answer. Either choice may hang over your head for the rest of your career and life. Welcome to the life of a company or chief officer. This is what you signed up for-making those rare decisions that can have major impacts and consequences. I’m not going to choose the best option for you. You are supposed to do that.
The Role of the Officer in Preventing LODDs
Simply, the fire officer needs to be the designated adult, the one who says “no,” “knock it off,” “back out now,” or “we don’t go into every structure fire.” Ouch, did I just say that? My ears are burning from the comments of those who say I am sacrilegious for saying such a thing. Yes, I’ll go on record that our personnel are more important than a building or a piece of property or a dead body. Did I know it was a dead body? Well, no, but there are no absolutes in life, and the life of a fire officer contains a lot of gray area.
Use the 50.1 percent rule if that helps you make decisions. If there is a reasonable belief (50.1 percent or more) that nobody can survive inside the structure given the conditions and time the fire has been burning, not to mention the condition of the building and other mitigating factors, then I’m sending my personnel on a death mission.
The fire officer needs to lead by example; he must not accept mediocrity or allow complacency to set in. The fire officer needs to continuously find new and creative ways to train his personnel, even when the personnel don’t want to be trained. If a fire officer is too buddy-buddy with his personnel, he may fall for the excuses to get out of training. Strive for a balance. If the World Series or the Super Bowl is on, for example, work around those events to train-train earlier or later that day. However, when three regular season football games are on in one day (one before noon, one in the afternoon, and one in the evening), we can’t watch all three games live. Tell your crew to pick the one most important to them to watch live; they can watch the others on DVR or TIVO. Training should be a regular part of every day.
The fire officer is in the best position to decrease the number of LODDs. Officers complain about the lack of personnel in their Training Division and don’t recognize they are the training officers for their personnel. If your department has a dedicated training division working a 40-hour (on paper) week, those personnel are usually able to schedule only mandated training and ensure that the most important topics are covered. They may occasionally teach classes, but they tend to be administrators, given their workload. They are also there to ensure resources are being pushed out to the fire officers to ensure they have the best, most up-to-date information to use to train their personnel.
Some basic suggestions for the fire officer in regard to training follow:
- Do what you can to provide a minimum of two hours per day of training. It doesn’t have to be continuous; most likely, it cannot be continuous because of competing time constraints such as emergency responses. Shoot for 15 minutes here, 30 minutes there, 10 minutes here, 45 minutes there; ultimately, just make it happen, and be creative. Use every opportunity to train.
- Be creative. Know what you’re teaching if you are the instructor. No one person is the subject matter expert in everything. However, if you are not the subject matter expert, find out who is and have that person be the lead instructor. It may be someone within your crew, someone working at another fire station, someone at another department, or even someone who is not a member of your fire department.
- Fire officers need to empower their personnel; don’t expect to be the only instructor for every topic. Doing so shortchanges your personnel, especially since nobody is the subject matter expert in every topic. Don’t rely on your department training officer to train you or your personnel! It is your responsibility as a fire officer to be the training officer of your crew.
- There are numerous Internet resources for fire officers. Many offer free e-mail lists so you can stay on top of the fire service and the latest trends:
Fire Engineering–emberly.fireengineering.com
Firefighter Close Calls-www.firefighterclosecalls.com
Everyone Goes Home-www.everyonegoeshome.com
United States Fire Administration-www.usfa.fema.gov
National Institute of Standards and Technology-www.fire.nist.gov
National Institute for Occupational Safety & Health-www.cdc.gov/niosh/fire
Firefighter Near Miss-www.firefighternearmiss.com
- Stay on top of your trade by also subscribing to trade publications. Join fire service associations or organizations that offer newsletters, e-mail blasts, and other sources of information such as the following:
National Fire Protection Association-www.nfpa.org
International Society of Fire Service Instructors-www.isfsi.org
International Association of Fire Fighters-www.iaff.org
International Association of Fire Chiefs (IAFC)-www.iafc.org
Fire Department Safety Officers Association-www.fdsoa.org
IAFC Safety, Health & Survival Section-www.iafcsafety.org
This article is dedicated to Captain Mark McCormack of the Santa Clara County (CA) Fire Department, who lost his life at a structure fire in Los Gatos, California, on February 13, 2005. Captain McCormack, I will do everything in my power to acknowledge and learn from the recommendations and lessons we learned after your death to do what it takes to prevent future LODDs. I challenge all fire officers to show they care about their personnel by not putting them in a position where an LODD is likely to occur.
STEVE PRZIBOROWSKI, a 20-plus year veteran of the fire service, is the deputy chief of administrative services for the Santa Clara County Fire Department in Los Gatos, California, where he has worked since 1995. He is an instructor for the Chabot College (Hayward, CA) Fire Technology Program. He is a state-certified chief officer and master instructor and has Commission on Professional Credentialing chief fire officer designation. He has a master’s degree in emergency services administration and has completed the Executive Fire Officer Program. He is the author of How to Excel at Fire Department Promotional Exams, Reach for the Firefighter Badge, and The Future Firefighter’s Playbook, published in 2013.
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