Chief Reason Art » niosh

Most Influential LODD Report-Submission for Blog Carnival

chiefreason — Wed, 28 Apr 2010 02:25:07 +0000

We should take something from every LODD report that we read.

We should take the time to read them, if for no other reason than to honor the fallen firefighter(s) and their families.

Over the years, I have read several LODD reports that have had a profound influence, but there is one that affected me more deeply than the others and changed ME with regards to how we should conduct ourselves in a leadership role, remind us how important safety is while conducting our business, to train our departments to recognized standards and to NEVER use the term “volunteer” as an excuse to be less than professional.

The LODD of Bradley Golden was one of the most tragic examples of the stigma that is carried by the volunteer fire service with regards to officer qualifications, leadership skills, training and standards/compliance.

In short; Bradley Golden’s Line-of-Duty-Death was the result of colossal failures from the top down and affects me so deeply because it was so preventable.

According to the NIOSH LODD report http://www.cdc.gov/niosh/fire/reports/face200138.html, on September 25, 2001, Firefighter Bradley Golden of the Lairdsville, NY Fire Department died from asphyxia due to smoke inhalation during a live-burn training exercise. Firefighter Bradley Golden was just 19 years old and had been a member of the department for THREE weeks!

In addition, Adam Croman and Benjamin Morris were seriously injured during the same training exercise.

For a complete story that goes well beyond the NIOSH LODD report, go to http://chiefreasonart.com/brads-page/ .

On October 31, 2002, the final “Death in the Line of Duty” report was published by the National Institute of Occupational Safety and Health (NIOSH) http://www.cdc.gov/niosh/fire/reports/face200138.html.

The following recommendations were made:

1) Fire departments should ensure that no one plays the role of victim inside the structure during live-burn training. (NFPA 1403, 2-4.13)

2) Fire departments should ensure that a certified instructor is in charge of the live-burn training and that a separate safety officer is appointed and has the authority to intervene and control any aspect of the operation. (NFPA 1403, NFPA 1041)

3) Fire departments should ensure that only one training fire is ignited at a time by a designated ignition officer and that a charged hose line is present while igniting the fire.

4) Fire departments should ensure that Standard Operating Procedures (SOPs) are developed and followed.

5) Fire departments should ensure that all firefighters participating in live-burn training have achieved a minimum level of basic training. (NFPA 1403, 2-1.2)

6) Fire departments should ensure that before conducting live-burn training, a pre-burn briefing session is conducted and an evacuation plan and signal are established for all participants.

7) Fire departments should ensure that fires used for live-burn training are not located in any designated exit paths.

8) Fire departments should ensure that the fuels used in the live-burn training have known burning characteristics and the structure is inspected for possible environmental hazards. (NFPA 1403, 2-2.10)

9) States should develop a permitting procedure for live-burn training to be conducted at acquired structures. States should ensure that all requirements of NFPA 1403 have been met before issuing the permit.

As I said, the LODD report does not tell the whole story. See http://chiefreasonart.com/brads-page/.

In the aftermath of Bradley’s tragic death, Assistant Chief Alan Baird III was convicted of criminally negligent homicide. The parents of Bradley Golden filed a lawsuit against the fire department.

On July 17, 2003, “Bradley’s Law” was signed by NY Governor George Pataki. The law makes it illegal for people to pose as victims during live-burn training.

And I will always remember Firefighter Bradley Golden, tragically killed while in the prime of his youth by those sworn to protect him.

TCSS.

Can You Answer My Question?

chiefreason — Thu, 18 Mar 2010 15:38:57 +0000

Do you hear that?

That is the sound of despair, hopelessness and fear. It is your victim.

They can’t get out without your help. The few minutes that have passed has emptied them of any hope that they will get out alive.

Blinding smoke, searing heat…what they are drowning in is what we flourish in; it ignites us and excites us, not because we want it to, but because Fire forces so many conditioned responses and extraordinary actions and tests our most primal instincts. We must rescue our fellow humans AND survive while doing it.

There is no “fight or flight”. It is more like “stay and pray”.

Your victim doesn’t want to die alone, but they don’t want anyone else to die like that, either. They are hoping that, if they are not rescued in time, then at least, in their final moments, they will hear the soothing voice of their God whispering forgiveness into their ear and then open the gate to their eternal peace.

You will move swiftly, stopping for a split second to gauge your own mortality and then push forward, because you have seen the face of your victim. You have looked into their eyes; the windows into their soul and the pain and anguish that you see is the fuel that you use to give you strength.

Their face could be your face or the face of someone that you know. It matters not, because they are a victim. You HAVE to get to them in time. Otherwise; you can only hope that they slip into an unconsciousness that will numb their senses to the horrific effects that only Fire can produce.

You cannot bear that thought. You have made your decision. You have committed your team. You have not only trained for this moment, but you have lived for this moment; a moment in which you could die!

You may hear the roar of the fire over the pounding of your heart. You will hear the water shooting from the nozzle and splashing against the walls and ceiling with terrific force. If you close your eyes, it almost sounds like you’re taking your car through the automatic spray carwash.

You will hear every step, every breath, the sound of the vent saw, a ladder hitting the side of the house, the sound of glass breaking and the radio chatter over the PA speaker on the engine.

There could be several endings to this, but one thing is certain; risk a lot to save a life is in our mission.

This is a scenario that has played out in our heads and in our communities for decades.

No nobler profession than that of firefighter!

The desperation, contemplation, exhilaration, extrication, celebration; it’s a roller coaster ride of emotion for victim and rescuer.

So, my question to you is this: why would you risk it all on an abandoned, unoccupied, vacant, dilapidated, dangerous piece of property that has no soul, no heart, no gratitude and only hate and contempt for those who dare to enter? See: http://www.cdc.gov/niosh/fire/reports/face200837.html.

Or would you?

TCSS.

The article is protected by federal copyright law under The Adventures of Jake and Vinnie© umbrella. It is written and submitted by Art Goodrich a.k.a. ChiefReason. This article or any other article submitted under The Adventures of Jake and Vinnie© umbrella cannot be reproduced in ANY form without the expressed, written permission of the author. Violations are punishable by applicable laws.

Please visit: www.fireemsblogs.com and my blog www.chiefreasonart.com.

Colorado – Engine Rollover LODD NIOSH Final Report

chiefreason — Wed, 03 Mar 2010 22:36:21 +0000

The website article can be read here: http://www.firefighternation.com/forum/topics/niosh-investigation-report-26

I just finished reading the NIOSH report on the February 23, 2008 apparatus rollover that took the life of 33 year-old Shane Stewart of the Ault-Pierce, Colorado Fire Protection District. The NIOSH report can be read here: http://www.cdc.gov/niosh/fire/reports/face200805.html.

The report states that Captain Shane Stewart died after being ejected from the cab and was then rolled over by the apparatus. He was declared dead from multiple traumatic injuries at the scene.

Though it is true that the failure to wear the seat belt was front and center stage in this report, it also raised an issue that I had not seen or even considered before I read this report. There was an issue with the cab compartment “layout”.

It appears that the driver of this unit could NOT reach the mobile radio unit from the drivers’ seat with the seatbelt on! If this were common knowledge, then the experienced driver might not bother to put the seatbelt on at all and the less experienced might attempt to unbelt while enroot to the scene, if he wanted to talk on the unit’s mobile radio. (It should be noted that investigators conducted several tests, using several different drivers to reach these conclusions.)

When going to an incident scene, an apparatus driver should just drive; right?

The second person in the cab should be operating the radio; right?

How many departments have ever called back to the station to request another rig, knowing that it would come with just a driver, even though your SOP may state “a minimum of two per unit” or whatever that minimum is?

A straight stretch of road in good weather conditions and travelling at approximately 45 mph in a tanker is NOT a recipe for an accident.

In this incident, it appears that things went terribly wrong when the driver attempted to reach towards the radio to change to the fire ground frequency. Even with a hands-free system, changing channels would require the radio operator to reach.

So, the location of the mobile radio in the cab becomes very important.

Anything that distracts the driver from his primary duty of driving is cause for concern, but, as the sole occupant as in this case, you still need to communicate.

Could the driver have used Dispatch as a relay to the fire ground, which, in this case, was a medical call requesting a landing zone set up for a med-evac helicopter, instead of attempting to change channels while enroot?

I don’t have the answer for that.

Could the driver have used a portable radio with lapel mike instead of the mobile radio? I don’t know what type of radio system they have, so I can’t answer it.

Does driving and shifting gears with a floor-mounted shifter create a distraction that is different than driving and changing channels or even talking on a radio? The report would lead us to believe that a second person in the cab should handle all non-driving tasks.

So, if some believe that a driver should keep both hands on the steering wheels at all times, then all trucks will have to be built with automatic transmissions.

Would a hard-fast SOP that requires two persons minimum per rig be a solution? I would have to say “yes”, because, if you have a driver who is driving AND shifting gears; then add to that, the radio tasks, then I believe that the drivers’ focus would be diminished.

Would you locate the radio in closer proximity to the driver? Would you have it done professionally or would you do it yourselves to save money? Are you aware that even though you do the work that you must still be in compliance with NFPA 1901?

Would you consider hands-free, voice activated headsets with a radio frequency protocol that allows for apparatus drivers to communicate without switching channels while driving?

My final point is that we have to make sure that apparatus drivers are trained and tested at least twice a year in the apparatus that they will be expected to operate and done in accordance with NFPA 1002, 1451, 1500 and 1901.

The Federal Motor Carrier Safety Administration exempts the occupants of fire trucks and rescue vehicles from wearing seatbelts when moving and I believe that this goes back to the days when we could ride on the tailboards and in open cabs, so that law needs changed so that it parallels the many initiatives by our national organizations to get everyone to buckle up.

Everyone who spoke of Captain Shane Stewart said that he wore his seatbelt religiously. See news article here: http://www.greeleytribune.com/article/20080223/NEWS/866066115.

He left behind a wife and two small children.

Let’s honor him and his family by learning from him.

TCSS.

This article is protected by federal copyright laws and cannot be reproduced in any form without the expressed permission of the author or his legal representative.

Please visit: www.fireemsblogs.com and my blog at: www.chiefreasonart.com.

Take a Moment With Paul Grimwood

chiefreason — Sat, 19 Dec 2009 19:22:43 +0000

Author’s Note: I am so proud and so pleased with this interview that I had the privilege of conducting with one of the storied international firefighters of our time. As you read Paul’s biography and his replies to my questions, there is no doubt to the volume of knowledge that my friend possesses.

So, pull up a chair, grab your favorite beverage and enjoy this unique learning experience. And when you are finished, drop Paul a line. He would love to hear from you. Thank you.

Biography

The biography of Paul Grimwood appears in his latest book ‘Euro FireFighter©’, published in 2008.

Paul Grimwood is a thirty-five year veteran of the British Fire Service, having served most of his time as firefighter in London Fire Brigade’s busy West End district. In the mid 1970s he also served an eighteen-month detachment into New York’s South Bronx 7^th Division, during the busiest period in FDNY’s history. From 1976-77 he further served as a volunteer firefighter/EMT on Long Island’s south shore.

For more than thirty years Paul has been undertaking global research into structural firefighting strategy and tactics and has contributed in excess of 200 technical articles since 1979, in an effort to advance firefighter safety. During this time he has served and responded out of more 100 fire stations around the world, working alongside some of the finest firefighters you could ever wish to meet. He has also presented papers on fire service operations at international conferences in several countries since 1993.

His other books include ‘Fog Attack©’ (1992) and ‘3D Firefighting©’ (2005), the latter of which he joint authored with firefighting colleagues Battalion Chief Ed Hartin (USA), and Station Officers John McDonough and Shan Raffel (Australia).

From 1984 he served eleven years as a London Fire Brigade fire investigator and was part of the six-person team that investigated the tragic King’s Cross fire in 1987 where thirty-one lives were lost, including a colleague ( Station Officer Colin Townsley) from London’s Soho fire station.

He is a trained USAR instructor (EMT) and was deployed on operational disaster relief assignments into Iraq (1991) and Bosnia (1993). He is also a CFBT and tactical ventilation specialist (1984-2008) and a Tactical Deployment (command and control) and High-rise Firefighting instructor.

Paul is the founder and principal of Firetactics.com®, a website which has provided in excess of 14,000 pages of structural firefighting SOGs in six languages FREE to over 2.5 million visitors from more than seventy countries since July 1999 (source: Webstat.com).

He is an advisor to several UK Government Task Groups including ODPM Compartment Fire Behavior Training; BDAG High-rise Firefighting; CLG High-rise Firefighting, as well as an editorial reviewer for the Fire Safety Journal (the official journal of the International Association of Fire Safety Science). He is also an established ‘expert’ technical witness and advisor in fire service operations, having worked on several high-profile cases in the USA and Europe.

In 2008 Paul was awarded the Institute of Fire Engineers’ (IFE) highest academic status (FIFireE) in recognition of his thirty-year professional commitment to firefighter safety.

Update: Paul is now retired from Ops but working as a Fire Safety Engineer and High-rise Training Instructor for Kent Fire & Rescue in the UK, an active fire department of 66 fire stations that adjoins London Fire Brigade to the SE.

The Interview

CR: Paul; first of all, thank you very much for taking the time for this interview. You know; we still haven’t had that beer together yet?

PG: Art we have been friends for so many years and I can’t believe we haven’t had the opportunity to share that cold one together! Let it be soon!

CR: We all know when you started your career, but at what age did you start looking at a career in the fire service? What were your early influences?

PG: I wanted to be a firefighter from the age of fifteen. I hung around firehouses and made a nuisance of myself. I eventually got hired the day after my 18^th birthday and became London’s youngest ever professional firefighter in 1971.

CR: Please name and describe some of your mentors.

PG: I saw good things in many role models through the 1970s. There were several fire chiefs in London of that era who I just have to mention, Roy Baldwin; Tony Wilmott and Tom Stanton who were legends in their time. In the USA I read everything FDNY’s Bill Clarke ever wrote as well as Frank Brannigan and who’s that guy … oh yeah Mittendorf in LA. There was also great advice coming from Leo Stapleton in Boston. I had the opportunity of spending an hour with Commissioner Stapleton in his office just before he went on the golf course, what a great guy.

CR: When you started in the fire service, what were the goals that you set for yourself?

PG: I wanted to be the best at what I did and I wanted to serve with the busiest. When I was initially assigned to London’s busiest of their 114 fire stations – Paddington – in London’s west end district I just couldn’t believe my luck. We picked up many serious working fires mainly in hotels during the early part of the 1970s. There were also streets full of vacants that became my learning ground as they burned on a nightly basis.

CR: Was it ever your plan that “student” would become “teacher”?

PG: No that was never my plan Art. I never even considered it, as I couldn’t imagine leaving station life. But then one day a 35 years veteran firefighter, Bill Willis, retired. His experience was going to be greatly missed when he got off the engine for the last time, I just didn’t know how we would cope. The things he told us about getting in and staying there weren’t written down anywhere. I though ‘ I just have to get this stuff down on paper for future generations of firefighters’. That became my first book – Fog Attack.

CR: You have worked for two of the most storied fire departments in the world. Was FDNY just a “ride-along” that lasted almost two years or what? Why would you leave London, England for FDNY?

PG: You know I was very lucky. I met a guy in London in 1974 and we became great friends. Bill Bohner was a giant of a man and as the Deputy Chief in charge of the FDNY’s (then) 7^th Division (South Bronx) he arranged a long-term detachment into New York City from London for me. I had to return to UK at the end of it but it had been an amazing experience to work with the bravest during the busiest period in their history. Yes I guess it was a ‘ride along’ because I was not qualified to wear a mask in the city but we still got in some pretty good scrapes! After all, the masks were nearly always left on the engine!

CR: Would you discuss the cultural differences (USA/Great Britain) not only in general terms, but also in terms of the fire service? Are the political issues that affect the fire service the same, similar or different?

PG: Cultural differences? Well in the UK we are sadly losing the tradition that stays with the job in the US, for example where there is often a strong family link in the fire service, sometimes through several generations of firefighters. I think it’s important that this tradition remains strong; I also think that US firefighters are way ahead on the moustache! This was a ‘must have’ here in the 1930s and some of the old time pictures hanging the walls of some fire stations in the UK show some real hairy droopers! We’ve lost that cultural identity! The political issues are exactly the same – cuts in public services are now an annual event and I just don’t know how much smaller our fire service can get! You can do a lot with a ‘little’ but the day comes when ‘little’ does a whole lot more to you!

CR: Compartment Fire Behavior Training (CFBT) has come to define you. Can you describe how it evolved in theory and then into practice?

PG: It was the late 1970s and I had not long returned from the FDNY detachment, I was busy putting all the things I had learned in the US into published articles. ‘Smoke detectors in homes’; ‘Arson Task Forces’; ‘Medically trained First Responders on Engines’ and ‘Structural Venting tactics’ etc. Then I met some Swedish firefighters who told me about some stuff going on in Stockholm. It wasn’t until 1984 that I came to fully appreciate the strategy the Swedes termed ‘offensive firefighting’ where they were directing short sharp bursts of water-fog into the fire gases to get some ‘steam free’ cooling! I was fortunate enough to get on the nozzle at our next fire one night and guess what …. It was a stair-shaft fire …. Four floors alight and then more! We took the entire fire with a 40GPM flow-rate off of a booster line! Now let me tell you, the stair-shaft fire is the ideal scenario for such tactics because any super-hot water vapor just heads on upwards on the thermal draft and this takes out a whole lot more fire as it rises. I was sold on the Swedish tactics. We used this approach on ‘real’ fires many times over the next few years with some wins and a few losses. It was critical to realize the limitations of this method because if there was one thing the FDNY had taught me, it was to flow big water when it was really needed, or the fire was going to come back and get you. CFBT was a derivative of nozzle bursting tactics. You have the Swede Survival cans in the US but we developed the originals with the Swedes and believe me, it’s a very scientific training experience if these training tools are used correctly. You can learn a lot about fire behavior in these facilities (there is a range of simulators based on varied design principles) but you can also become over confident about ‘real’ fires – these are not ‘real’ fires but simply one-third scale fires that burn solely in the gas-phase. Lots of flaming combustion but no real fire base to hit. You need a good instructor to get the best out of these systems and in the US, Chief Ed Hartin is the best! (www.cfbt-us.com).

CR: Tell us how you developed and nurtured this “amalgamation” of the Swedish tactics of bursting water with anti-ventilation tactics versus your higher nozzle flow rates combined with tactical ventilation.

PG: Until the 1990s, venting structures was pretty alien to us! We would keep the fire area closed down inside our brick construction and go find it. As we developed our venting strategy we found we would get a better result by nozzle bursting the interior gases prior to creating openings. Now don’t think for one minute we were boiling trapped occupants or pushing fire around! This strategy demands precision that can only be learned on the live fire. The nozzle applications and fog patterns are carefully applied so as to remain in control of the thermal layering. As I said, sometimes the conditions are just too over-powering for this approach! I remember one fire we had on a Christmas day where black boiling smoke was emerging from all openings at ground level of a store with apartments above. We used two hose-lines from the street entrance doorways, nozzle bursting with alternate three-second hits into the smoke. It worked for us! We were patient and within four to five minutes we vented the windows and there was no backdraft. The fire was out pretty quick on this occasion.

CR: Your tactics weren’t embraced right away, were they? In fact; it took high profile firefighter deaths before you saw the change.

PG: It was tragic as it took three firefighter deaths in two days in February 1996 before the realization dawned that our firefighters knew very little about fire behavior and the hazards associated with ‘rapid fire’ phenomena. It was decided nationally, despite my twelve years of campaigning prior to these two tragedies, that the time had come to develop CFBT (live fire behavior training) for the UK’s 36,000 firefighters.

CR: Even then, CFBT wasn’t translating well to the fire-ground. What were the obstacles?

PG: There was no standard approach; the training objectives were inappropriate; and the training impact was totally missed! An opportunity went astray for several years as we failed to define the limitations of this approach. The concept of CFBT is to teach firefighters how a fire develops from an incipient fire to flashover. It is not a joy ride! It is not a means of teaching how every fire should be fought. It is very easy to become macho and over confident about the learning experience in these things (cans). You have to have a scientific head on to appreciate the learning objectives. You have to train with precision, controlling fire loading and venting parameters in order to give each student the same learning experience. It is not a real fire experience but believe me, it is as close as you need to get outside of the real thing.

CR: I’m sure that you have seen and probably discussed the “great debate”-fog vs. straight stream. What are you thoughts on that?

PG: Never has there been a more lively debate! For me there is no preference. I can extinguish a lot of fire using differing techniques with either a smoothbore or a fog nozzle. What I will say is that high water content in the stream is absolutely critical when the fire has spread beyond the compartment or room of origin!

CR: Paul; I can’t continue without offering you my platitudes for your book Euro FireFighter©. What was appealing to me was how you choreographed your steps towards incident CONTROL. Granted, the book almost overflows with an abundance of great information, but it all comes together as a perfect blueprint for fire officers in the end. How did you manage such a clear focus of what would become this book?

PG: Well thanks for those comments and that view Art. I always intended this book to be an instructor manual. I wanted the reader to take each and every bullet point and prompt debate from students. I found this a great way to develop learning and simply by taking a power-point and going through the bullet points as statements, we can all follow the debate with our own experiences. The incident command modules are logical processes based on the ‘error chains’ so often thrown up where tragedies occur.

CR: NIOSH. You used several reports in Euro FireFighter©. When you review them, are you looking for lessons learned and the critical information that might be a teachable moment down the road?

Does it concern you that we seem to repeat our mistakes in some cases? Do you think that it’s a fallacy that NIOSH uses templates, because their reports’ recommendations are very similar? I believe that they are similar because the incidents’ end results are very similar, as in repeating our mistakes. What say you?

PG: Any time we review reports of past fires we only get a small portion of what really happened. I know from several personal experiences that if you weren’t on the job yourself then any Monday morning quarterbacking is likely to be worthless. Or is it? The fact is that we are not there to criticize the actions of others but more so to immerse ourselves in the ‘error chain’, or any part of it even if we only get one or two links right, then we are right on the money! Wherever there is a fire where things went wrong it is usually the case that a chain of events unfolded, perhaps during the first five minutes following arrival on scene that set up irreversible circumstances leading to tragedy. In fact, we need to look for the point of ‘no return’ in each error chain and learn for ourselves that there IS in fact a point where we may reverse the situation and alter the outcome. Things happen fast and you may or may not be aware the chain is forming right there in front of you until it is too late. Its so important that fire commanders take a step back, take a breath and take it in. Pay close attention to what is occurring in front of you and don’t hesitate to take instant action that might save lives, even if it means pulling out.

Yes we are all guilty of repeating our mistakes. The thing is we get away with them for so long and they don’t take a bite out of us. It’s when we see several of these errors come together in a few short minutes. In each tragedy you will usually note 4-7 links in the chain that evolved early in the fire. I’ll tell you, the biggest omission from the NIOSH LODD reports is any information concerning fire behavior. We have spoke with them about this before but honestly, I just don’t think they understand fire behavior from a practical perspective and they miss obvious indicators and clear warning signs that might serve as good teaching points. Having said that, the NIOSH database of past reports serves as a critical learning tool. There are always things there to discuss, debate and learn from.

CR: At FDIC 2008, Lt. Ray McCormack delivered “the speech” heard around the world. You and I came out on our blogs with comments on his remarks. What did you get out of it?

PG: You know something? I really did get a feel for Ray’s message. I have to saagain that the way he came over was always going to draw responses in opposition from those of us who see the safety of firefighters as a priority. But he does have a point in some situations and I am seeing it more and more every day. In some areas we are going too far down ‘safety alley’. In my area we are given a directive to lay out three charged hose-lines on the upper floors of a high-rise before our firefighters can access the fire-involved area. Now for one thing that virtually writes off any chances of survival of remaining occupants. It also allows the fire to develop and grow bigger. No Ray, you had a good point and made it well in that your words reached out to millions! But you just have to take a step back and see the damage that might occur. You are a unique role model and some young firefighters will take your words as gospel. In the end, whichever side of the equation we originate from, we just need to meet in the middle and that’s all about getting the right balance between ‘risk versus gain’.

CR: You have a compatriot in the United States. Please tell us about Ed Hartin, since he had such nice things to say about you!

PG: Chief Ed Hartin is certainly one of the most outstanding firefighters I have ever met. His constant efforts to improve the education of firefighters and his unique ability to impart a message are typical of Ed’s mission in life. He continues to help firefighters in all parts of the world and I consider myself very fortunate to have met and worked with him because he has made me better at the things I try to do in life. Ed – thanks brother.

CR: Your website www.firetactics.com is extremely popular worldwide. Has it exceeded your expectations? How has technology driven and/or expanded your mission?

PG: You just have to love the worldwide web and yet we now take it for granted. In 1989 when I wrote my first book about international fire-fighting tactics (Fog Attack) I had to type every word without cut and paste. I did tear up a lot of paper! I also had to write to firefighters in several countries and you know, it took two to three weeks to get replies, just for me to write back to them again for more information! It was never ending.

When I managed to get Firetactics.com online I was blessed with a most generous offer from Task Force Tips to host it for me for free and they have done this ever since it first went online in July 1999. Its been a wonderful experience for me and before Firefighter Nation, Firehouse.com or Fire Engineering, ‘Firetactics’ was actually the most searched firefighting website on the web. It brought together firefighters from over 70 nations and I made many great friends through this route. The message was always about safety and firefighting innovations. I want to thank every single one of you who clicked on Firetactics.com in those early years because it told me that the world was full of firefighters that were looking for the very same answers as I was. I hope you found them.

CR: Can you talk about your charities?

PG: There have been many over the years. Lets just hope that some burn victims in the UK, USA and Australia have benefited somewhat from the proceeds. RAFT in the UK is my big one and thanks to the excellent first year sales of EuroFirefighter, the NYC Burns Foundation is about to get a nice check.

CR: Do you get any downtime? Any “Me” time, Paul?

PG: Sure! I love my family and we spend some great times together. But my weeks are getting more full with work as I get older!

CR: Please know that, in the world community known as the brotherhood/sisterhood, you are truly one of the brightest beacons that floods our senses with critical safety and survival techniques that will save our lives. What is next for the enterprise known as Paul Grimwood?

PG: Chief Art – it is you who shines as a beacon. If you only knew how your steadying influence and great words have spread out into the global firefighting brotherhood. You always know how to break things down to simple logic and speak to people in a firm but civil manner in a way that people really listen. I always say that when the going gets really rough Art will be there to take control. I would have loved to have served with you brother.

CR: When are we having that beer together?

PG: When those Yankees pick up the next World Series brother! Oh I’m sorry you’re a football fan!

CR: As is my custom, I always give my guest the last word along with my deep gratitude for their thoughts. Thank you so very much, Paul and you have the floor.

PG: This interview is a true honor for me so thanks Art. I want to thank everyone who has taken any interest in my work and who has taken the time to email me. It is truly gratifying to hear from firefighters how they think something I once wrote might have made their approach safer in a fire. Your personal friendships and lifelong dedication within the profession constantly inspires me to remain working well into my fourth decade. You are all very special people and it has been my great fortune to know you all.

I received an award when working in Malaysia from their Fire Commissioner. It is a lovely golden crested plaque with a red seal of authority. The words on the plaque are so true; it went like this;

‘We must learn to trust our men (and women) who fire fight in the front, they are closest to the dangers and the hazards, therefore that is where real wisdom is’.

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.

Be Honest; Call It Bureaucratic Bulls**t!

chiefreason — Wed, 18 Nov 2009 21:35:54 +0000

I will provide the pertinent links at the end of this blog. But first…the blog.

On February 9, 2007, a terrible tragedy occurred in Baltimore, MD.

Fire Cadet Racheal Wilson died during a live burn training exercise at an abandoned row house. Her death lit up the fire service discussion boards across this country over a multiplex of issues. The incident brought swift and sweeping changes within the Baltimore City Fire Department; most notably the removal of the Director of Training and the resignation of Chief William Goodwin.

Despite our opinions for some of the many issues involved in this tragedy, it cannot be refuted or disputed that Fire Cadet, Firefighter Apprentice, Firefighter Candidate, Firefighter Trainee, Probationary Firefighter* Racheal Wilson was employed by the City of Baltimore and more precisely, by the Baltimore City Fire Department at the time of her death.

*(There was some confusion over the proper terminology with regards to a firefighter in the process of completing their training)

Who can argue that Cadet Wilson was not an employee of the fire department? It would seem pretty obvious. The NIOSH LODD report (http://www.cdc.gov/niosh/fire/reports/face200709.html ) states in its opening sentence, On February 9, 2007, a 29-year-old female, career probationary firefighter died…

Pretty specific, wouldn’t you say? So; what could be the issue?

Fire Cadet Wilson was at work on February 9, 2007, was involved in a training exercise as part of her final phase of training, died while training at work for her employer and at the time of her death, engaged in tasks that were required as part of her job as an employee of the Baltimore City Fire Department for the City of Baltimore.

Therefore, under the Public Safety Officers Benefits (PSOB) program, Fire Cadet Wilson’s surviving family members-in this case, her two children-should receive a lump sum pay out of PSOBs in the amount of $295,194.

Nope!

The U.S. Department of Justice (DOJ), at least for the moment, is DENYING THIS CLAIM submitted on behalf of the children by their father.

The reason (because there is ALWAYS a reason)?

According to sources, it is because the Baltimore City Fire Department failed to submit paperwork establishing her eligibility for the funds.

WTF? (This means, “What did I just read/hear”)

Now; I have two questions to ask: 1) WHERE IS THE NATIONAL OUTRAGE OVER THIS BUREAUCRATIC NONSENSE? And 2) Why wouldn’t the application for PSOBs be included in everyone’s insurance packets, post employment paperwork or beneficiary designation documents, as part of their Human Resources employee management tools?

It is strange that we will bust our asses to get the all-important exit interview from some bottom-feeding under-achiever, but we can’t insure that death benefits are properly AND promptly paid? (Hey; HR gurus…write PPP on your whiteboards. If you can remember what SHRM means, you should be able to decipher Properly Promptly Paid death benefits.)

Trading Precious Resources for TIN!

chiefreason — Mon, 16 Nov 2009 03:53:34 +0000

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.

Can We Put Risk Out of Business?

chiefreason — Tue, 17 Feb 2009 03:50:18 +0000

In the NIOSH Alert Preventing Deaths and Injuries of Firefighters When Fighting Fires in Unoccupied Structures (http://www.cdc.gov/niosh/review/public/141/pdfs/DraftAlertUnoccupiedStructures.pdf), there are several references made to risk assessment, developing and enforcing risk management plans and then training the firefighters, safety officers and incident commanders to the plan.

This is accomplished by creating SOPs/SOGs specific to risk management.

What I want to point out straight off the git go is that every incident is going to be different in some ways, but your process for assessing risk should be the same every time. It is not one of those “if you don’t see this, then skip steps 3 and 4”. No; you should measure risk the same way every time and THAT, along with a proper size up will determine your tactics.

In Paul Grimwood’s latest book, Euro Firefighter, he discusses risk management at length.

I believe that it is by design that it appears in the very beginning of the book to underscore its importance to a successful outcome.

A clear distinction is drawn between what is a size up and what is risk assessment, because they are NOT one and the same.

According to Grimwood: The purpose of size up is to efficiently deploy my forces to achieve life and property protection and to have sufficient resources on-scene.

The purpose of risk assessment is to establish the level and types of exposure to risk that personnel may encounter and to decide how these hazards might be managed, controlled, prevented or ‘balanced against the potential for gains’.

When you look at common factors associated with firefighter deaths, is it any wonder that more focus and a sense of urgency is placed upon properly assessing risk?

When you place your people inside a structure with radios that don’t work, radios that might be on the wrong channel or worse, no radio at all, then you haven’t properly assessed risk.

If you have anyone at the incident and PASS devices have not been activated, then your risk management plan has failed, because training your department in the proper use and maintenance of their personal protective equipment is also a part of that plan.

When you think about the goal of the incident commander, it is to get the job done and get it done safely. Conversely, the goal of the safety officer is to do it safely and to still get the job done. Firefighters should be empowered to communicate any condition that compromises their safety.

Recently, I read an excellent article on risk assessment in Professional Safety magazine, a monthly magazine published by the American Society of Safety Engineers. The article was written by Jerry D. Loghry and Chad B. Veach.

What caught my attention was a part of the article that discussed “probability of loss”. It stated that probability is measured as the number of times in which a particular event can result from a certain activity, divided by the number of all outcomes occurring from that activity.

I realize that it is a mathematical calculation, but think about it. If we are looking for empirical data that will ease our conscience and help to flush the bitter taste from our mouths because we would not take unnecessary risks with an unoccupied structure, then “probability of loss” is it!

If it sounds too “theoretical”, then think about this; Loghry and Veach also state a more basic concept, which is: The more ways an event can occur in given circumstances, the greater the probability that it will occur…The frequency of previous event occurrences can indicate a strong probability of future recurrences.

Does that make sense; the frequency of injuries at vacant/unoccupied structures can predict a strong probability that it will happen again?

Let’s look at a study that was done at Flint, MI in 2007. From Grimwood’s Euro Firefighter: Out of 767 total structure fires dispatched, 443 resulted in a report of actual structure fire. The 443 structure fires involved 264 occupied structures and 179 vacant structures. Vacant structure fires represented 40% of the department’s structure fire call volume.

The department’s injury rate at vacant structure fires is more than TRIPLE the national average reported by the NFPA.

62% of the department’s fire-ground injuries occurred at vacant structure fires.

79% of the cost from fire-ground injuries resulted from fires at vacant structures.

93% of the cost of injuries at fires in vacant structures occurred in buildings that were unsecured when firefighters arrived.

Fire-ground operations produced (21) injuries at vacant buildings.

(13) injuries occurred during fires at occupied buildings-whilst most injuries were minor by nature, the potential for serious injury or LODD clearly exists.

If THAT doesn’t get your attention, I don’t know what will.

My conclusion? The NIOSH Alert Preventing Deaths and Injuries of Firefighters When Fighting Fires in Unoccupied Structures (http://www.cdc.gov/niosh/review/public/141/pdfs/DraftAlertUnoccupiedStructures.pdf) must be taken seriously by every fire department in our country.

Drawing up a risk assessment plan with detailed SOPs/SOGs should start NOW!

If you would like to comment to NIOSH about the alert, please go to http://www.cdc.gov/niosh/review/public/141/comments.html.

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. xchief22 and 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.

Baptism By Fire Or Death By Diversity?

chiefreason — Tue, 13 Jan 2009 01:38:14 +0000

We use the term “baptism by fire” in the fire service to measure that milestone that we achieve with our first big fire; our first true test as a firefighter. The “baptism” welcomes us into a world where ranks are closed very tightly and bonds are never to be broken. And when one dies, the aggrieved mourns the loss, but it is the fire department that captures all of the attention.

This blog is done with respect to and in honor of Fire Paramedic Apprentice (FPA) Rachel Wilson of the Baltimore City Fire Department, who died during a training exercise on February 9, 2007.

The intent of this blog is to examine pre-incident issues, post-incident issues, recommendations that were made post-incident and corrective measures taken to date. Comments are welcome, but they will be respectful, thoughtful and most of all, civil. I expect there to be differences of opinions, but again; they will be respectful replies.

Because of the many issues involved, I believe that it is important that a dissection of available information takes place and we intake them as lessons learned.

First of all, I know very little about the “inner” workings of one of our storied fire departments in this country; Balitmore City Fire Department. After all, they were the backdrop for the feature film “Ladder 49”.

However; though I may not know how BCFD fulfills their mission statement, I know how it should work at ANY fire department, because firefighters are NOT supposed to die during their training. They are supposed to be learning the skills that will keep them alive!

I will tell you that, based on the information circulated after the death of FPA Rachel Wilson and since, it appears that this tragic incident has become a political football and though inappropriate, it is the exclamation point to a series of decisions that may have been made for the wrong reasons that culminated in the death of a 29 year old mother of two small children.

After I read the NIOSH report for this LODD, I was reminded of a training death that occurred on September 25, 2001. Bradley Golden died during a training exercise in Lairdsville, NY.

I was reminded because, in my opinion in both cases, leadership failed. Those who were charged with protecting these new probationary firefighters, failed to do so. Make no mistake; that “protection” begins from the selection process through the rest of their tenure with the fire department.

They are similar incidents because, in both cases, national standards that could have protected them were either violated or ignored. They certainly were not followed. As an example; in both cases, more than ONE fire was set and materials containing petro-chemical components were used as fuel for the training fires.

The other, obvious similarity between the two was that; post-incident, no one was willing to accept responsibility for their actions/inactions. Baltimore Mayor Dixon wasn’t accepting responsibility for Rachel Wilson’s death, even though she pushed for diversity for city employees.

BCFD Chief Goodwin fired three officers because he wasn’t accepting responsibility for Wilson’s training death, even though it was his personal pick heading up the training academy.

In the Lairdsville, NY case, at least the person who refused to take responsibility for his actions was arrested, charged, tried and convicted of contributing to the death of Bradley Golden.

FPA Rachel Wilson was described in the NIOSH report as a 29 year old female, who stood 5’ 4” tall and weighed 192 pounds. According to the CDC Body Mass Index Calculator, Wilson’s BMI was 33; considered to be “obese”. A weight of 110 – 140 pounds for that height would produce a “normal” range BMI stat. This could have been a factor with Wilson’s inability to self-evacuate through a window with a 41” high sill.

Furthermore, there were accusations made early on in the investigation that diversity was a key consideration in Wilson’s hiring. In addition, at the time of FPA Wilson’s training death, the fire department did not have any physical fitness requirements. In other words, NO CPAT (Candidate Physical Ability Test)!

During the post-incident investigation, all fire department officers interviewed, stated that the “city had removed physical fitness requirements” some years before, in an “attempt to recruit a more diversified work force”. The fire department had a physical agility test that lacked national consensus and it relied on “self-elimination” of candidates. The environment at the fire academy was to pressure the less qualified recruits to drop out,” according to interviews.

So; if a candidate made a poor decision to apply, what are the chances that they will make the decision to “self-eliminate”? It is common during the agility portion of a CPAT certified course to FAIL. This tells that applicant: (a) better luck next time and (b) go get into better physical shape and come back. BUT; you don’t get hired until you can pass and damn the diversity initiatives, because being fit for the job has NOTHING to do with race, gender or religion.

Without knowing BCFD’s complete testing process, reports stated that FPA Wilson experienced “mask claustrophobia” during previous training evolutions. Additionally, Wilson had not met the minimum time of the physical agility test. It was reported that Wilson tested again just prior to the live burn and produced a slower time than her initial test time.

So; it is clear that FPA Rachel Wilson’s firefighter skill sets were being brought into question, but only after her death.

Reports were saying that certified fire instructors in Maryland were in short supply. Plus, it was costly to schedule and hire them for training, so, under the watchful eye of Chief Goodwin, the fire department was going to save money by hiring “adjunct” instructors and pay them with more time off, which simply means that he was going to use HIS people and instead of paying them overtime, they would be given more Kelly days. But, wouldn’t someone have to cover them in the rotation and wouldn’t they be paid overtime to do it?

It was reported that, on the day of Wilson’s death, none of the adjunct instructors participating had any training as a fire instructor. Also reported was that the adjunct instructor in FPA Wilson’s squad was doing so for the FIRST time.

Personal Protective Equipment (PPE) is a very important component to personal safety and especially to a firefighter. Turnout gear is literally their barrier to extreme heat and death. According to reports, turnout gear was replaced on the “front lines” and the throwaways were taken to the fire academy, where cadets would select their “gear” for training. On February 9, 2007, FPA Wilson was wearing a coat that was 5 years old and was dirty, but within compliance. Her pants, on the other hand, were 10 years old and well past their useful life and beyond repair. The crotch area shows extreme wear and tear and it was reported that the moisture barrier was no longer effective.

Radios, flashlights and SCBAs were provided on an “as needed” basis. Through interviews, it was noted that some of the participants did not have Personal Alert Safety System (PASS) devices and some instructors did not have radios.

One could suppose that poor communication caused NINE (9) fires to be set, with seven (7) of those fires set underneath the “fire floor”; in this case, the third floor, where Wilson’s crew was to extinguish a training fire (s).

For the training fires, according to NIOSH, a mixture of excelsior, wooden pallets, tree branches, an automotive tire, bed mattresses and foam rubber from a chair were used. Anyone with even a tacit knowledge of NFPA 1403 knows that you only use material with “known burn characteristics”.

The fires were arranged in “teepee” and “lean-to” fashion, both acceptable; however, stuffing excelsior into voids and vent areas are not.

Reports (NIOSH) state that FPA Wilson had difficulty controlling the hose line. As the fire that stood in their way on the second floor grew, her instructor took the hose, knocked down the fire on the second floor and then they advanced to the top floor, where conditions soon deteriorated.

Their exit was a window that led to a second story roof top. The window was approximately 28” wide and the window sill was 41” from the floor (see report). FPA Wilson could not self-evacuate through the window with the rest of her crew. It took a valiant effort for crews to push through the second floor and up to the third floor in order to assist with the rescue of FPA Wilson. She was in serious condition, quickly transported to the hospital, where she was pronounced dead from her injuries.

Mayor Dixon expressed outrage in a press release. Chief Goodwin stated that, if policies were violated, people would be held responsible. His recommendations were sent to the mayor for her press release.

An interesting termination occurred with the officer who was in charge of RIT. According to reports, the RIT officer was on “light duty” and could not actively participate. Had NFPA 1403 been followed, the likelihood of activating the team would have been highly unlikely.

On the day of the incident and during the press conference afterwards, Chief Goodwin praised everyone involved for their “valiant efforts” to rescue FPA Rachel Wilson. So; why would the officer in charge of RIT be one of the three terminated from the department? How was this reward for a “valiant effort”?

Why would anyone on “light duty” be involved beyond the planning stage of a live burn exercise? Who made the decision to place a person on light duty at the scene of a live burn and be put in charge of RIT?

Who made the decision to use this three story, dilapidated piece of crap as a live burn training exercise?

Who made the decision to set more than one training fire at a time during the training evolution?

Who allowed materials with known petro-chemical properties to be used as fuel for the training exercise?

And at the very beginning that led to a very sad ending: who made the decision to hire FPA Rachel Wilson?

Was the decision to hire Rachel Wilson made by city hall to achieve diversity? If so, then the mayor should be held accountable.

If Chief Goodwin allowed the culture that ultimately led to the death of Rachel Wilson, then he needed to be held accountable.

Who was accountable for Rachel Wilson on the day she was hired and on the day that she died?

How can the fire service be the face of compassion, if we show little, if any for our own? It becomes increasingly harder to save lives if we kill the ones hired to do that.

And at the end, there is a hypocrisy that allows for a middle aged, out of shape, paperweight to decree CPAT for everyone…else!

That same hypocrisy allows us to spin our information. I applaud BCFD for implementing the corrective actions to the ten (10) NIOSH recommendations. Note that I didn’t say “changes” as Chief Clack did. “Change” is what will occur within the department AFTER the recommendations are implemented.

And if anyone is looking for “justice” out of all of this?

Let’s just say that there must be a “sliding” scale, because in New York, you can go to jail if you don’t protect your people’s safety, but in Maryland? You just move on to bigger and better things.

Here are the links that I promised:

http://www.abc2news.com/news/local/story/Final-Report-On-Firefighter-Death-Critical-Of/6LEmfr4uBEWPXYcEKZzQEA.cspx

http://www.emsnetwork.org/artman/publish/article_25310.shtml

http://www.baltimoresun2.com/talk/showthread.php?t=112618

http://www.cdc.gov/niosh/fire/reports/face200709.html

http://wjz.com/topstories/firefighter.injured.west.2.425362.html

http://www.baltimorecity.gov/news/press/02-22-07StatementonWilsonInvestigation.pdf

http://www.ci.baltimore.md.us/government/fire/downloads/1208/121908%20NIOSH%20Report%202008.pdf

http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm

http://www.citypaper.com/news/story.asp?id=13835

http://www.cdc.gov/niosh/fire/reports/face200138.html

http://media.www.loyolagreyhound.com/media/storage/paper665/news/2007/11/20/News/Baltimore.Fire.Chief.Goodwin.Resigns-3111021.shtml

http://www.cwhms.com/news.php?id=1

http://www.firefighterclosecalls.com/pdf/BaltimoreTrainingLODDFinalReport82307.pdf

TCSS.

This article is protected by federal copyright under The Adventures of Jake and Vinnie© umbrella. It cannot be re-produced in any form without the expressed permission of the original author.

Interview with Chief Mark Wessel of Keokuk, IA FD

chiefreason — Tue, 13 Jan 2009 01:35:48 +0000

Author’s Note: This article first appeared as a “Voice of Reason” article under my pen name ChiefReason in October of 2004 during Fire Prevention Week. I am re-printing it here for several reasons. I do so to honor the memory of Dave McNally, Nathan Tuck and Jason Bitting, the three firefighters who gave the ultimate sacrifice in the performance of their duties. I do so to keep my promise to Chief Wessel to continue to spread his message. And I also want anyone who thinks that they are ready to take the leadership role in their department to read this and then ask themselves if they are ready. I am providing the link to the NIOSH report for those who wish to read a more in-depth account of the events that occurred on December 22, 1999. http://www.cdc.gov/niosh/fire/reports/face200004.html

On December 22, 2007, it will be eight years ago that Keokuk, IA Fire Department suffered its worst firefighter loss of life to a residential fire.

On December 22, 1999, the fire department was decimated by the deaths of Assistant Chief Dave McNally, Firefighter Nathan Tuck and Firefighter Jason Bitting. A young mother lost three of her children. A catastrophe times six!

I believe that the lessons learned from this fire are important to future generations, because it is Middle America and occurred in a town with a population of about 13,000. The demographics of this community could mirror many across our nation.

Keokuk is protected by a career department consisting of 18 firefighters and a chief. A shift is covered by 5-6 firefighters beginning at 7:00 am with a callback system and mutual aid.

I have asked someone who is very close to Mark to introduce this extraordinary gentleman.

So I will defer to none other than Chief Billy Goldfeder, founder of www.firefighterclosecalls.com.

INTRODUCTION:

Chief Mark Wessel is a fire chief like many of us-and like many of us, started off at the bottom rung and worked his way up. He has responded to numerous fires, rescues and related emergencies and has reacted like many of us-from the good to the bad-from the happy to the sad. And like many of us, has tried to do the best he can with what he has to work with-from the budgets to the equipment to the firefighters. Just another hard working fire chief in the USA.

Things changed drastically for Chief Wessel and the members of the Keokuk FD in 1999 when not only were 3 children lost in a fire-but 3 of his firefighters as well. The actual story can be found below. My comments are related from a more personal standpoint as far as the “before and after” of when bad stuff, real bad stuff happens.

So often in the fire service, we never learn. In some cases, even tragic events don’t change the behaviors of a fire department….even when it happens to them! And that only makes the event more tragic. But in recent times, as horrible as some losses have been, there are some leaders that have tried hard all along-but when the bad occurs, have the guts and leadership to effect change-no matter what the barriers. One such excellent example of that is Chief Mark Wessel. Chief Wessel could have taken many “roads” following this tragic event but that’s not the kind of person he is. It is clear to anyone, once they talk to him, that they will understand that he had the courage to MAKE THE CHANGES and will discuss and share what happened in Keokuk with firefighters anywhere so “that” does not happen to them. Kind of a “history repeating itself” prevention officer. He shares what they did wrong, what they did right and how ANY FD can learn from the horror that he and his firefighters went through. His message is clear-this kind of event does NOT have to happen to you and while yes-he has enacted some very radical changes, Mark’s focus is what all of ours should be everyday-that EVERY FIREFIGHTER RETURNS HOME AFTER EVERY ALARM.

It is a pleasure to introduce this interview with my friend and colleague, Chief Mark Wessel.

Btn. Chief Billy Goldfeder, E.F.O.

October 2004

CR: Chief; first of all, thank you for sharing your experiences of this tragic incident. It is a story that I feel needs to be told again and again. The fact that you have traveled this country recounting it is an extraordinary display of humility and strength of character on your part.

CW: Thank you, Chief. This is the only way I can think of that and possibly make something good come out of a very tragic event in our department.

CR: I have heard you speak on three occasions. The first time was at the memorial service on Sunday, December 26, 1999. The second time was at Tazewell County Fire School in East Peoria, IL in April of 2002 and just recently in New Windsor, Il on September 16^th. And all three times, I sat in awe of your composure. Where do you find the emotional strength to relive that tragic day time after time?

CW: Actually, the only way I can describe where the strength comes from is through God and everyone’s prayers. That day was one of the most, if not the most horrible day of my life. The loss of our brothers has been horrible to say the least. The only way I can describe how I am able is simply this: I relive the day in my mind, everyday. I will never forget the horror for the families, the firefighters, the community, and myself. All I have left are opportunities to share the experience in hopes someone, somewhere, will be safer.

CR: You delivered not one, but three eulogies at the memorial service; all the while, looking at the faces of the families of the three, fallen firefighters. Was it surreal? Were you in a state of shock, denial; what?

How did you do it?

CW: To be quite honest, I remember being mostly numb. I felt so humbled and responsible that all I could think about was the fact that no matter what words were said, they were not adequate. The entire ordeal was so far above my ability to comprehend, I just existed through the service. Fortunately, there were so many people that assisted myself, and the department, so that things ran smoothly. I will never be able to express my gratitude enough to all those people.

CR: You did your program at Tazewell on “The Disaster Has Become Personal”. You described the preparation for the memorial, the funeral and arranging for the benefits for the firefighters’ families. You spoke of some battles that you fought during this time. I particularly remember one involving John Buckman, who, I believe, was president of the National Volunteer Fire Council (NFVC) at the time. Can you talk about that?

CW: Actually, Chief Buckman was representing the IAFC. Sometimes people lose perspective of why we were gathered that day. Politics sometimes supersedes common sense. Fortunately, it was not a local issue, but more of a national issue as to who would be allowed to sit on the stage (how many union representatives vs. non-union representatives). Chief Buckman was not the problem. I was able to mitigate the problem and move forward with the program as planned. I would like to clarify that I certainly appreciate Chief Buckman traveling to Keokuk to represent the IAFC. That was the first time I had met Chief Buckman, and all I can say is he has been there for my department and me. I believe we have developed a very good friendship over the past 5 years.

CR: Tell us about the public’s reaction to the overwhelming presence of all of the firefighters at the memorial service.

CW: I believe the general public viewed first hand what we mean when we speak of the brotherhood. The interesting part of the brotherhood in this part of the country is, whether you are paid or volunteer, you belong. Although the Keokuk Fire Department is all career, and has been for 125 years, when we require assistance, it’s the volunteers that we call on. I so much appreciate their help for that time and since.

CR: Governor Tom Vilsack was in attendance. Were you given any private time with him and can you share with us what was said?

CW: There really wasn’t much time. The Governor traveled here that day, spoke some words of regret and encouragement then returned to Des Moines just after the service.

CR: Assistant Chief Dave McNally and you had a relationship before the two of you joined the fire department. Please tell us about your friend.

CW: Dave and I knew each other before we were ever hired onto the department. We weren’t what you would call running buddies, but occasionally would hang out together. Dave and I were hired about a year apart. He more senior to me. I guess to give a perspective of how our careers evolved, I’ll give a quick and dirty. Mid 70’s; both firefighters. Early ’81, Dave became a Lieutenant and I was a firefighter on his shift. In 1983, I became a Lieutenant and we were on different shifts. In 1988, I was promoted to Assistant Chief. Dave was my Lt. In 1995, Dave was appointed Assistant Chief. In 1997, I was appointed Chief. Dave was the best. I would have followed him anywhere.

CR: Nathan Tuck was 39 years old at the time, but had only been on the department 4-1/2 years. Did his desire to join come from his other community involvements?

CW: I think Nate was all about helping. It really didn’t matter what he was doing, just so he could help someone. High school kids seemed to be his passion. His personality was just right for them. Nate was so compassionate. Always encouraging. That can be an elusive trait to find today.

CR: When I see pictures of Jason Bitting, I see youthful exuberance and eyes full of promise. Tell us about Jason.

CW: Jason is kind of hard for me. I think because of the age difference. A big teddy bear! So strong, so willing, so intelligent, yet still remaining naïve enough to have a burning desire to live and to learn. Jason was the kind of person you had to love.

Actually, all three of the guys were so special. I was able to fill the vacant positions, but could never replace those three special firefighters.

CR: Let’s talk about the NIOSH report and especially, the recommendations. Staffing was an issue. It is obvious that your resources were stretched by the MVA and then the report of the residential fire. Is it safe to say that your initial response to the fire was a quint, engine and four personnel. Was this SOP?

CW: Yes; that was the initial response. Whenever you have a total shift of 6 personnel, a 5 man minimum and answer 850 to 900 calls for service a year, you are going to have times when you respond to an emergency with 3, 4, or 5 personnel on the initial response. This is what we learned: It’s not how many you respond with, it’s what you do with them when you arrive. If you lose perspective of the whole picture, it doesn’t matter how many you have.

CR: What do you believe NIOSH considered an appropriate staffing level for a city like Keokuk?

CW: I think this will also better explain the previous question. I don’t think NIOSH actually stated how many personnel would be an appropriate staffing level for a community like Keokuk. If you were to take into consideration NFPA and all of the evolutions that need to be accomplished, I would think that number would be somewhere between 13 and 16 personnel. Now; that would be for a single-family dwelling. Next; take into consideration the age and condition of the community. How about all of the commercial structures in the community? And, the industrial base that Keokuk serves? I guess one might easily estimate the need for 24 to 30 personnel on duty ready to respond. But, the $700 question. How do we pay for it? We don’t. We make due with what we can afford. With that comes responsibility to formulate SOP’s that can be affected safely. If you can’t do that, then stand back and become defensive in your attack of the emergency. It’s much easier to stand in front of the media and say we had to let it burn because we did not have the resources to use a reasonable amount of safety to protect the firefighters than it is to conduct a memorial service. It’s much easier to look at a reporter with rubble in the background than to look into the faces of the grieving family of a firefighter. That I can say with certainty, and anyone reading this should take it to the bank.

CR: The report recommended that the IC does initial size-up before initiating firefighting efforts and then continually evaluating risk versus gain as the incident continues. AC McNally was the highest rank initially. Wouldn’t he have done a size-up before starting search-and-rescue? And would you not take command once on scene under “normal” circumstances?

CW: Under normal circumstances, yes. TUNNEL VISION played a huge role in the way that fire was approached. Mother, with a 4 year old in hand, screaming, “MY BABIES ARE INSIDE” was key to the deviation from normal operations. I believe being keyed up from the MVA that morning just prior to the call-in fact they were called off of that incident to this one-played a part in the initial operation. Having no medical transport available played a key role. One might say that this fire was routine. ROUTINE is no longer a word in our vocabulary. Other than pulling into the fire scene and seeing smoke from a residential structure, there was nothing else routine about it. There was nothing normal about that day.

CR: Do you think too much emphasis or not enough is put on an ICS? What would it have done for you on this day? You had to get the kids out. In retrospect, break the incident down to what might have been done differently.

CW: I truly feel ICS is the most important aspect of firefighter safety we can have on the emergency scene. Good command should reflect control, coordination, goals and communication. I guess I could beat myself up indefinitely over the operation. Some may even say I should. Trust me; I have. Through this I have gained nothing. What has been most effective is dissecting the incident into pieces small enough to calculate. Also, dissecting the department so that the task is not so overwhelming in the development of good SOP’s, SOG’s.

CR: “Defensive search” was mentioned. I don’t mind telling you that it put a silly look on my face. The only thing that I could think that it meant was to take a long stick and poke it through a window and maybe someone would grab it. How close am I?

CW: Actually Chief, you’re not to far off. What defensive search actually refers to is the idea of not over committing. Do not place yourself in a position that you might become part of the problem. I know we train to rescue people. I know we all have learned the right hand rule and left hand rule on primary search and rescue. Let me just say this: If you have firefighters who have not had this training, they should not be your rescue team. If you are a firefighter who has not had this training, then you should refuse to perform interior search and rescue. I was teaching a basic breathing apparatus class and was asked the question about CEU’s for HAZMAT Tech. I asked if the student was a Tech and he replied “yes”. This particular student had never worn breathing apparatus. Maybe over the years things have changed that much, but I always thought you needed to wear breathing apparatus to train to the HAZMAT Tech level. Don’t put yourself or your people in an over committed environment. When and if other resources arrive, then and only then might you consider further commitment? Stay next to a door or window to do your search. Do not commit further than your resources or training allow for a reasonable amount of safety.

CR: “maintains close accountability for all personnel at the fire scene”. This would suggest that you didn’t know where your FIVE people were, when it is painfully clear that you knew exactly where they were and what they were doing. Was this meant to address communications issues? Who had radios that day?

CW: I did in fact know that they were performing rescue operations on the interior of the structure. When you have this few personnel on the scene, you can track everyone without too many problems. As the incident grows, you must then utilize a formal accountability system to track all the operations that are simultaneously occurring. Having a good accountability of your personnel will help to stabilize a scene, reduce freelancing and provide a safer more proficient operation. Having an established accountability program will reduce the impact of Murphy’s Law.

CR: NIOSH addressed communications. Were there difficulties with radio transmissions, radio equipment, and no back-up channels? What caused your radios to be a focus for their review?

CW: At the time of this fire, only the officers had portable radios. Today, all personnel carry radios. There was very little communications occurring at the scene that morning. In fact, it would be reasonable to say little or none, except for initial communications with dispatch. I think NIOSH focused on this mainly because communications seems to be a common denominator in LODD’s. It would seem to me that whenever a team is focused on search for a known victim, the radio’s become very quiet. We have worked on our communications quite a lot. We continue to have a long way to go. With radio communications there is always room for improvement. I think for me the lesson in emergency scene communications was not what was communicated but more of what was not communicated.

CR: RIT is a biggie. A lot of discussion over the years. At what point in this incident did you actually have enough manpower to assign RIT? And honestly? Knowing Iowa OSHA like I do, I would have bet on a citation for violating two in/two out. Was RIT part of the equation early into this incident?

CW: No, RIT really wasn’t a consideration. Actually the 2 in 2 out rule is negated in Iowa if a known rescue is in progress. 2 in 2 out never played a role in any of the investigation. My only observation towards 2 in 2 out is; Why is it OK in OSHA’s eyes to perform a rescue with only one person if you know someone is trapped than it is if you are assuming someone may be trapped? I thought OSHA was about employee safety. If that is the case, even they make an exception to the rules (SOP’s).

CR: The last NIOSH recommendation addresses PASS devices. Your firefighters each wore two; one integrated into the SCBA and the other attached to their coats. Yet, no one could recall hearing any audible alarms from any of the stricken firefighters. Could it be speculated that a thermal event inside the structure rendered the devices inoperable?

CW: The third party testing revealed that, due to the extreme thermal event, the electronics failed in all the audible devices. One more lesson; if it is man made, it can and most probably will fail at the worst time.

CR: Could you talk about relationships and their importance when dealing with a traumatic event?

CW: Considering I’ve been fortunate to have not had prior experience with a LODD, I would say we had to learn how to deal with the trauma. Fortunately, the firefighters respected each other through the entire ordeal. There were so many different emotions being experienced, you just had to wonder how the department would make it. I guess the Good Lord stayed with us through to the end. Although I’m sure we remain far from the end. Each person experiences grief in a different way and at different times. Knowing that you are going to have all these different emotions occurring, you have to stay on top of the game. We were able to come through this with little animosity and hurt feelings. It’s all about RESPECT.

CR: The last time you and I spoke, you told me about the McNally boys and I saw that gleam in your eye and that smile stretch across your face. Tell our readers about them.

CW: All three of our men had kids at home. Some were rather young and would need to analyze all of this at a later age. Some were older and could, for as well as can be expected, experience the pain and suffering of the loss of their father immediately. I really could not relate to them very well as I had never experienced a loss of this type. All I could do is sit back and pray that the children could rationalize the loss and continue to move forward. Fortunately, to the best of my knowledge, all has gone well. As for the McNally boys; they are doing well. Pat, the oldest son of Dave, was in college working towards a degree in law enforcement. He wised up, changed his mind and moved towards an education in fire science. Pat decided he wanted to be a firefighter. Of course, I was pleased with his decision. Any father would be excited about his son or daughter following in his footsteps. The difference is, Pat had experienced the worst of times. Then Pat came to my office and said he wanted to be a firefighter in Keokuk. Well, you can imagine the mixed emotions I had. We talked quite extensively regarding the reasons he wanted to be a firefighter. Pat had the right answers, the right attitude. Pat has been with the department for over a year now, and is doing very well. I just see so much of his father in him, sometimes he’ll do something or the look on his face will remind me of Dave, and I have to walk away. Usually with tears moving down my cheeks. Pat’s desire to be a firefighter in Keokuk also in some way makes me feel very good inside. Dave’s youngest son has also expressed an interest in the fire service, and he too would like to be a firefighter in Keokuk. I only hope I have the opportunity to make that a reality for him also.

CR: That is a fitting ending to this interview, but your story of that day will continue, won’t it? You have such a passion for this that I can tell that you never want anyone else, be it firefighter, family or friend to have to experience it. Your final thoughts, please, Mark.

CW: As it is written in Job, “Should we accept the good that is given and not accept the bad?” Life sometimes throws a curve and we take it on the chin. I knew even as a firefighter I had a responsibility to others. My partner was relying on me for his safety. Then as I was promoted, others were relying on me as well. Eventually the department became my responsibility, and things went bad. I had always thought that I operated safely.

Sometimes your eyes get opened unexpectedly. You don’t have to experience what Keokuk experienced. Why is it, we all know if we are punched in the nose, it is going to hurt like hell? Yet some of us still have to pick a fight to believe it. Let Keokuk be your punch in the nose. Let our incident be your incident. Study it. Pick it apart. Plug it into your operating procedures. Not just what is written, but how you actually operate on the scene. For most, you will probably find there are some major discrepancies in your written procedures and your everyday, take it for granted, on scene operations. You have the ability to “Make The Changes”. Do you have the desire? If not let someone else lead. From the bottom to the top, you must be willing to step forward. Not stand back, not stand still. This is not a social club. If you think it is, ask your family if the social pleasure is worth the risk? If you are not willing to train, then get out. Fishing is much more relaxing, but learn to swim first.

Many people have touched my life and supported my department and me through this tragedy. I can only say “Thank You” to all of them. To the Firefighters of Keokuk, my hat is off to them. They exemplify the definition of firefighter. They have supported me through this, when often lines are drawn in the sand.

As long as my mind, body and soul can summon the strength, I will continue to carry the message of firefighter safety. Listen to my pain and understand how important it is for “Everyone to go Home”. Keep that thought in the forefront of all you do. Do not buckle to the pressures of peers or politicians. If you can do this, you may just find yourself sleeping better at night. Stay Safe.

First published 10/05/04

An Interview With Chief Mark Wessel of Keokuk, IA FD is the intellectual property of Art Goodrich a.k.a. xchief22 and is protected by copyright. It cannot be re-printed in any form without expressed permission of the author.