Having been involved in the fire service for almost 30 years, I have read and discussed firefighter deaths, as well as listen to many fire service intellectuals espouse their opinions on our fatality rate compared to other occupations, risk vs. gain, community expectations, etc.

What I have found is that there are TWO, distinctly separate camps, where it comes to what is “acceptable” and what is not. That is; there are those who believe that an average of 100 deaths a year isn’t bad, when you consider the “dangers” that we face and then there is the other side who believes that ONE is too many, if it could be prevented and that 100 deaths a year are UNACCEPTABLE.

Personally, I wish that we could put jealousies and egos aside and get crackin’ on a truly productive effort to bring down the line of duty deaths from firefighting activities. If you haven’t noticed, we are killing ourselves the majority of the time because, though being what we are and doing what we do beats strongly in our hearts, our hearts have been weakened by poor diet, lack of exercise and the stressors of the job, causing fatal heart attacks.

We are also killing ourselves going to and from the scene and killing others as well. Apparatus accidents and POV accidents are increasing at an alarming rate and we still have those that STILL refuse to buckle their seatbelt.

Approximately 20 percent of LODDs are the result of injuries incurred during actual fire suppression operations and this is the statistic that is favored by the first camp and that would be all well and good were it not for the issues that were involved in contributing/causing the death (s).

And when guys like me want to step back and look at the “big” picture in the hopes of peeling back the lessons learned/the takeaways, we are called “armchair and Monday morning quarterbacks, Safety Sallies, gutless, ball-less, embarrassment to the profession” and my favorite- “too safe”; just to name a few. I am well past getting upset about it anymore.

Firefighting is a risk-based business-we HAVE to take risks or we’re not doing our jobs.

Really?

Well then; we are going to look at a double LODD from West Virginia and then you tell me if you still feel that we should trade our firefighters-our precious resources-for a tin can.

In Grimwood’s book Euro Firefighter©, Paul describes the “error chain”. In the error chain, Grimwood states:

The ‘error chain’ is a concept that describes human error accidents as the results of a sequence of events that culminates in death or serious injury. Typically, there is usually a chain of mistakes, or omissions, inactions, or failings, that all contribute to the final outcome…

Familiarizing firefighters with the concept of recognizing and eliminating the error chain can prevent an accident before it can occur…

There are some critical clues to identifying links in the error chain. They are divided into: Operational factors and Human Behavior factors…

The presence of any one factor (or more) does not mean that an accident will occur. Rather, it indicates rising risk levels in field operations and that firefighters and fire officers must maintain control through effective management of both risk and resources, in order to eliminate unsafe acts, unsafe conditions and unsafe behavior.

On Thursday, February 19, 2009, Craigsville-Beaver-Cottle Fire Department in Nicholas County, West Virginia lost Lt. Johnnie Howard Hammons and FF Timothy Allen Nicholas during fire suppressions operations. Both were experienced firefighters, according to records ( http://www.register-herald.com/archivesearch/local_story_051234439.html ).

According to the NIOSH report ( http://www.cdc.gov/niosh/fire/reports/face200907.html ), Victim #1 (Hammons) and Victim #2 (Nicholas) entered the front door of the mobile home trailer with a charged 1-1/2 inch hose line. Within 5 to 10 minutes of them entering, the pump operator sounded the evacuation alarm when he noticed that his tank water was low. The victims did not evacuate from the structure. Firefighters on scene attempted to contact them via radio and by yelling into the mobile home. The fire chief and a firefighter tugged on the hoseline several times with no response. They then pulled on the hoseline and it came freely from the mobile home. Both victims were found in the front room, several feet from the front door.*

*Names of victims were added by author. Names of victims are not contained in NIOSH reports.

Using Grimwood’s template for the ‘error chain’, we will dissect the investigation report of NIOSH.

Text from the NIOSH report will appear in italics.

From the NIOSH Summary:

Their facepieces were not on when they were found…

According to the medical examiner’s office, the victims died from smoke inhalation and thermal inhalation. The carboxyhemoglobin (carbon monoxide poisoning) levels were 63% in Victim #1 and 64% in Victim #2. The toxicology reports for both victims showed lethal doses of cyanide in their systems.

It is hypothesized that based on injuries, positions of the bodies when found and the condition in which the victims were found leads investigators to believe that the victims did not enter the structure on air. Masks were found hanging unattached to either victims’ face. Entering into an IDLH atmosphere without proper PPE greatly compromises the safety of entrants. Obvious are the breach in the Human Behavior factors in the ‘error chain’; however, several Operational factors were present, including but not limited to:

- Lack of SCBA maintenance program.

- SCBAs not equipped with PASS alarms.

- Incident Command directly involved with fire ground activities.

- Wind conditions pushing smoke though the mobile home (horizontal chimney effect).

- Anchor for strap on SCBA mask missing, compromising a positive seal.

- No radio carried by interior crew.

- Incident Commander did not take command by naming incident, designating command post and did not give initial report on conditions.

- Incident Commander was initially helping with traffic control, pulling electrical meter and helping with pump operations.

By performing these tasks, the Incident Commander lost control of initial firefighting activities of the victims, firefighting activities of other fire suppression teams and the search and rescue of firefighters.

In addition, changing fire conditions were not monitored or communicated and fire suppression efforts were not coordinated.

A Personal Accountability Report (PAR) is essential to an accountability system. It was known that two firefighters were missing, but their names were unknown at the scene. A call back to the fire station had to be made to determine the names of the missing.

Furthermore, no Incident Safety Officer (ISO) was established to assist the Incident Commander with accountability, firefighter safety or ensuring the donning of PPE.

Would a properly trained ISO have allowed entry into the structure at all and if so, without firefighters being properly attired in PPE, including SCBA and on air?

No Rapid Intervention Team (RIT) was staged and prepared to respond to a firefighter emergency. No one trained in RIT was on scene that day, so the Incident Commander chose them based on experience once he realized that he had a firefighter emergency.

Mobile homes are unlike common residential homes in that they act as a horizontal chimney, because of their narrow width with narrow hallways. It was reported that a hose team using a 2-1/2 inch diameter hose was working at the opposite end of the trailer from the victims. Once inside, they switched from straight stream to fog, changing the thermal balance by introducing more air flow due to the nozzle setting. As the rescue team on the A-side of the trailer was conducting their search for the victims, they reported very hot, smoky conditions from the D-side, where the other hose team was operating. The D-side team only stopped when they ran low on air and exited the structure, taking their hose to the A-side. The Incident Commander took the hose on fog and aimed it through the front door, immediately dissipating the smoke and heat and allowing the rescue team to find the victims.

The department Standard Operating Guidelines (SOGs) were “out-dated” and were in the process of being updated. It was noted by investigators that the SOGs were mostly administrative in nature and lacked detailed fire ground operations.

Both victims had their Nomex® hoods rolled down on their necks. Victim #1’s helmet was found on the couch…as if it had been taken off and laid there. Both victims’ facepieces were found hanging at waist level with their regulators attached, possibly indicating that they were stored in this manner.

It was noted that the department was using both low pressure tanks and high pressure tanks. Some had integrated PASS alarms, some had stand-alone PASS devices and some without any PASS device. Soot was found inside and outside of the facepieces of the victims; another indication that the facepieces were not being worn by the victims.

Facepieces had not been flow tested since March of 2002. Investigators also determined that SCBA bottles had not been recently hydro-statically tested.

Firefighters did not have personal facepieces, but instead, shared them. Questions of proper fit-testing procedures and medical evaluations for respirators were raised. It was noted that many fire department members, including Victim #1 had excessive facial hair and beards.

During the initial phases of the incident, E32 could not pump water, because the truck was in the wrong gear. It was corrected by the Incident Commander and water was then available from E32.

Wind conditions at the time of the call were steady at 15 miles per hour with gusts up to 24 miles per hour. It was reported that weather conditions were not properly considered when employing fire suppression operations.

The structure’s integrity after having been under heavy fire load contributed to a firefighter falling through the floor during interior fire suppression operations. Fortunately, he continued to spray water and was successfully extricated without injury.

This is a very tragic incident that cost two men their lives and their families will be without them forever more.

The problems with the investigative materials that come out after we have laid fallen firefighters to rest is that they are not lauded for their critical review of the available evidence, but instead are seen as criticisms.

When we look at what leads to or contributes to the deaths of our brothers and sisters, we have to set aside our emotions, maintain an open mind, fully digest and process the information so that we can learn from it.

In this case, we have to understand that fighting fires in mobile homes presents unusual challenges and cannot be treated with the same tactics employed at a wood framed, light-weight constructed residence. If you don’t remember anything else, remember “horizontal chimney”.

And to firmly grasp the concept and the evolution of the “error chain” as defined by Grimwood, I recommend that you read this NIOSH report.

If you find any similarities to your department, I strongly urge you to change it NOW. We owe it to Lt. Johnnie Howard Hammons and Firefighter Timothy Allen Nicholas.

If we don’t change it now, we will continue to trade firefighters-precious resources-for tin.

TCSS.

The article as submitted is published under The Adventures of Jake and Vinnie© umbrella and is the intellectual property of Art Goodrich a.k.a. ChiefReason. It is protected by federal copyright laws and cannot be re-printed in any form without expressed permission from the author. You may read other works by the author at www.chiefreasonart.com.