The Dirty Dozen of Swiftwater Rescue

BY GREG MERRELL

Swiftwater rescue is one of the most dangerous rescues first responders may face in their careers. Many factors lead to the danger—the risks of moving water, hypothermia, the dynamic environment, lack of training, and lack of appropriate personal protective equipment (PPE). Most of these factors are beyond first responders’ control. We mitigate the hazards we can control; identify those we can’t; and work around them to perform a safe, successful rescue. Our risk/benefit analysis in water rescue must ensure we avoid the “Dirty Dozen” human factors that can decrease our rescue capabilities and lead to rescuer injury and possible rescue failure.

• Fundamentals of Open Water Rescue
• Swiftwater Rescue: Are We Ready?
• Dramatic Swiftwater Escape, Passaic, New Jersey
• SWIFTWATER RESCUE TACTICS, Part 1 | Part 2

The Dirty Dozen was developed in the aviation maintenance community in 1993 by Gordon Dupont of Transport Canada. They are the 12 most common human error conditions that may precede accidents, the elements that can lead to mistakes. The aviation industry has adopted the Dirty Dozen; by focusing on avoiding these human factors, it has since reduced the number of errors. Most accidents are not caused by one major mistake but rather a series of events of lesser severity; most are tied to human factors. Often, seemingly insignificant omissions have led to tragedy. The Dirty Dozen applies to first responders in swiftwater rescue. It is imperative that we avoid each of the 12 during preparation, en route, at scene size-up, and during a water rescue. The water rescue environment is dangerous; we must avoid human factors that can lead rescuers to making mistakes and causing injury to themselves, their crew, and the victim.

Lack of Communication.Often, this is the number one contributing factor to failed rescues and rescuer injuries. Communication is important in both training and at the rescue scene. A proper crew briefing will avoid a communication failure. All personnel on scene must understand the rescue plan and have an opportunity to ask questions on any issues they do not understand or point out a safety issue that has been overlooked in the briefing. A briefing checklist ensures important details are not missed, such as identifying safety issues, the hydrology affecting rescue, allocating resources for upstream spotters and downstream safeties, what rescue techniques will be used, a review of hand/whistle signals, and contingency and emergency plans. Ensure all rescue personnel know their roles and understand their job functions as part of the rescue.

Complacency. This is a feeling of self-satisfaction accompanied by a loss of awareness of potential dangers. Rescuers become overconfident because of their familiarity with completing a task regularly in either training or in actual rescues. Water rescue is dynamic and conditions change rapidly, so you must avoid complacency. Not all rescues are the same. For example, you may have multiple vehicles in high water during a flood that are simple wade-out rescues in knee-high water and you just walk the vehicle occupants to dry land. If you do not take the time to look at the hydrology, use a walking stick, or wear proper PPE, the next rescue attempt can lead to tragedy. Although you may make multiple “easy” rescues, treat each one independently and do not let complacency cause a failed rescue and possibly a rescuer tragedy. Continually challenge yourself and your team in training to avoid complacency; bring a multitude of scenarios to your training to better prepare your team.

In aviation, the most complacent personnel are the “5–15-year” pilots. This can be true in rescuers. Often, the newer rescuer (with one to five years of experience) is more cautious and diligent in following the proper steps; the senior rescuer (with 15 to 25 years of experience) has seen a lot of his own or others’ mistakes and anticipates problems early and can avoid them. The overconfidence of the mid-level rescuer (with five to 15 years of experience) can lead to failure. The mid-level rescuer sees himself as bulletproof; he can overcome mistakes with sheer strength, skill, and power. Team leaders must ensure this attitude does not overtake rescue team members.

Lack of Knowledge. Training is paramount in water rescue—the initial training as outlined in the standards but also the refresher and continual training. Teams must look for training opportunities within and outside their organization. Technical rescue continues to progress with new tactics, techniques, and equipment that make rescues safer and easier. It is imperative that rescuers learn and understand the rescue techniques that are within their scope and training level. The time to learn is not at the emergency scene; rescuers must have the knowledge of their own and their team’s capabilities and limitations based on their training, their abilities, and their PPE. Knowledge also includes knowing your mutual-aid organizations’ capabilities, their response times, and who to contact when needed.

Distractions. Anything that draws a rescuer’s attention away from the task he is assigned is a distraction. Some you can’t avoid at a rescue scene—e.g., bystanders, weather conditions, and noise from water flow. Rescuers must not let these distractions keep them from doing their job. The rescue itself can be a distraction when one is assigned the seemingly unglamorous role as an upstream spotter or downstream safety. A rescuer may begin to lose focus on the importance of his specific job and focus on what others are doing. Hence, he isn’t prepared when his role becomes necessary. Many psychologists attribute distraction as the number one cause of forgetting things. Forgetting your assignment and role in the rescue can be devastating on the rescue scene. Leaders must continuously ensure that all rescue team members remain focused on their individual assignments and safety check all equipment and rigging. Distractions are hard to train for; however, rescue team members must remember to concentrate on the task at hand and not let outside distractions affect their job performance.

Lack of Teamwork. As first responders, we must work together to accomplish a safe water rescue. Each person has a role in the rescue; if he does not understand and perform his assigned task correctly, we are setting ourselves up for failure. A strong command presence is necessary to ensure that each rescuer understands the rescue plan. Yes, our ultimate goal is rescue; however, the incident commander (IC)must clearly outline the tactics and techniques to accomplish each rescue through a thorough crew brief. This avoids duplication and ensures important assignments are not missed. Working together effectively and efficiently leads to successful rescues and mission accomplishment. A team’s effectiveness depends on the selection of its members; a rescue team should have a broad range of experience and skills. Some teams are made up of personnel from neighboring communities and may only link up on actual rescues. Training together is essential to develop cohesiveness; it allows members to learn from each other and develop trust in each other.

Fatigue. Prolonged physical and mental stress results in fatigue, which reduces a rescuer’s ability to concentrate, remember, and make decisions effectively. This can lead to distraction and limited situational awareness. Often, flooding requires multiple rescues, which can fatigue rescuers as they make one rescue after another. Team members must keep one another alert and identify safety issues that may occur because of errors caused by fatigue. To enhance their focus during prolonged events, rescuers should include fatigue factors in training. They should not only practice skills in training when they are well rested. Safety is paramount and must not be overlooked in actual rescues or during training. A well-rested training/safety officer should always be part of training. A training idea to simulate fatigue factors is to have team members perform strenuous physical fitness activity, then immediately move to a water rescue skill that requires dexterity and skill comprehension—e.g., rigging of anchors, setting up a tension diagonal, identifying hydrology features, backing a boat trailer, or doing a crew brief on a simulated rescue. Such training increases the physical fitness of the team, brings teammates together to increase team effectiveness, and adds simulated stress and fatigue to improve team skills.

Lack of Resources. An ineffective rescue and possible accidents can result from rescuers working outside their scope of training. The tripod of safe rescue consists of teams that have proper training, effective personnel, and proper equipment. If one of these is missing, we may lack the resources necessary for a safe, successful rescue. If your organization lacks one of the three legs of the rescue team tripod, look to mutual-aid companies. Many agencies may not have the financial resources or personnel to staff a stand-alone water rescue team. However, they can work with neighboring organizations to combine assets and personnel to develop a countywide or regional rescue team. Resources are a determining factor in the type of rescues a team may perform. Water rescue team leaders and members must understand their capabilities and recognize their limitations based on their training, their personnel, and their equipment.

Pressure. You can expect pressure whenever performing a water rescue; part of a first responder’s job description is performing skills under pressure. However, when pressure affects the ability to complete tasks correctly, rescuers may get hurt, and the rescue can fail. Pressure can be from a lack of resources and training and outside factors such as bystanders and family members expecting the rescue to take place immediately without a proper briefing. At times, rescuers feel an obligation to act beyond their level of training or the level of PPE on hand because of the pressure of the situation. First responders must find calmness in the chaos of the water rescue scene and make decisions with their heads, not their hearts. This pressure can overwhelm rescuers in a small community because of the high probability of knowing the victim or the victim’s family. In training scenarios, incorporate pressures similar to those of an actual scene to assist with recognition primed decision making to allow rescuers to make the right decisions based on the situation rather than outside pressures. The pressure of the situation should never be an excuse for shortcuts. Never sacrifice safety for speed!

Lack of Assertiveness. Everyone is a safety officer! It’s a great statement, but if people are afraid to speak up, some obvious safety issues may be ignored, and unsafe actions will occur at a water rescue scene. Another issue with lack of assertiveness is not being committed to the chosen rescue technique. We should always be ready to modify the plan and adjust as the situation and conditions change. However, when performing the skill required, the rescuer must commit to performing it properly and aggressively. For example, in doing a tethered swim, on entering the water, the swimmer must swim hard and commit to the proper body positioning for the hydrology to reach the objective. If the swimmer lacks assertiveness, he risks injury and rescue failure resulting from poor technique and lack of commitment to the rescue swim. Lack of assertiveness can also be a shortcoming in after action reviews (AARs) because of fearing to point out instances where the team can perform better. Every rescue and training scenario offers an opportunity for teams to get better and address areas that need improvement. It is important that all team members feel comfortable discussing improvement points within the organization. To assist with assertiveness in AARs, criticism should be directed at actions and their consequences rather than at individuals.

Stress. This can be debilitating to rescuers. Stress can be acute or chronic; both can be dangerous at a water rescue scene. It is important to understand when rescue team members are not themselves and stress is affecting them. Often, it can simply be the stress of the current water rescue situation; this stress level can be reduced through training and anticipating the rescue scene’s hazards. Stress can cause rescuers to make decisions that are unsafe and not according to team skills or standard operating procedures (SOPs).

It is important that rescuers get proper rest, remain physically fit, and are able to discuss personal issues with a trusted team member or trained professionals. Organizations must have a critical incident stress management team and have an employee assistance program to help first responders deal with the stressors of the job, personal life, and outside pressures. Rescuers should find a release for trapped stress to clear their minds and enable them to function at 100% while on the water rescue scene. You can reduce on-scene stress through conducting a proper scene size-up, understanding each scene’s hazards, and having an effective crew briefing to ensure all members are on the same page.

Lack of Awareness. This is the failure to recognize and understand the situation and predict the results of your inaction and inattention to detail. Situational awareness is imperative to provide a safe rescue scene. Many things are going on during a water rescue, so rescuers must avoid tunnel vision. Distraction can result in lack of awareness on scene; don’t allow bystanders and outside distractions to affect your ability to comprehend the entire scene and changing conditions.

Regardless of your assignment, whether you are an upstream spotter, a downstream safety, the IC, the safety officer, or the rescuer, each team member must focus on his job but also be aware of his surroundings and how quickly the situation may change. Maintaining situational awareness allows you to foresee problems affecting the rescue and overcome the issue before it negatively affects the rescue. To compensate for lack of awareness, checklists are important to keep all team members focused on the task at hand. A checklist should include any safety checks prior to taking action; a second set of eyes on a rescue system setup can easily avoid tragedy.

Norms. Based on the workplace culture, these are the expected, unwritten rules of behavior. Norms can be good or bad, safe or unsafe. Rescue teams must identify and eliminate the negative norms, which can often be difficult because of the “That’s how we’ve always done it” attitude. However, this can be overcome through assertiveness and by encouraging all team members to express their opinions. Many cultural norms allow for cutting corners, which leads not only to a failed rescue but also to unnecessary injury to the victim and rescuers. We can overcome the negative norms by using realistic training, rescue AARs, and an analysis of rescue mistakes made by other organizations. Often, rescuers are more lucky than good; this can be very dangerous. A bad habit can become a norm because it worked before. Just because a rescue was successful does not mean that it was done in the most safe and efficient way. Follow SOPs to ensure scene safety. Use checklists and current policies/procedures to properly allocate resources and ensure safe operation at a water rescue scene.

The Dirty Dozen outlines 12 human error factors that can affect the safety of victims and rescuers at a water rescue scene. Team members must identify each of the 12 and avoid them on the rescue scene. Use realistic training scenarios, emphasize teamwork in training, use checklists, follow policies/procedures, and maintain situational awareness at all times.

Leadership is paramount to avoid letting the Dirty Dozen come into play during a water rescue. Safety first! Always let the rescue-related factors dictate the situation’s urgency. Don’t let outside distractions dictate your decision making. Water rescue teams should use proper arrival, continuous scene size-up, appropriate resource allocation, effective communication, quality teamwork, and risk/benefit analysis to determine the necessary actions to ensure the mission is safely and successfully accomplished.

Greg Merrell is a battalion chief with Oklahoma City (OK) Fire Department, where he has served as a technical rescue company officer and has taught swiftwater rescue and boat operations to emergency responders and military personnel nationwide. Merrell is a task force leader with OK-TF 1 US&R team.