By studying the responses of the past, both incidents that went well along with incidents that have had tragic endings, we can become safer, more efficient, and wiser.
A great and insightful cartoon strip by the name of "Calvin and Hobbes" ran its course and ended a while back but not before it dispensed a great deal of wisdom. A notable entry that applied to us first responders had the usually ignorant young boy named Calvin ranting incessantly to the great listener and realistic stuffed-tiger sidekick named Hobbes. Their exchange went like this;
The first frame had Hobbes pushing Calvin in a small wagon.
Calvin: It's true Hobbes, ignorance is bliss!
Once you know things you start seeing problems everywhere...
and once you see problems you feel like you ought to try to fix them...
and fixing problems always seems to require personal change...
and change means doing things that aren't fun! I say phooey to that!
Next frame, Calvin and Hobbes are now both in the wagon and flying downhill on a path.
Calvin: But if you're willfully stupid, you don't know any better, so you can keep doing whatever you like!
The secret to happiness is short-term, stupid self-interest!
Next frame, Calvin and Hobbes are now out of control.
Hobbes: We're heading for that cliff!
Calvin: (With hands covering face), I don't want to know about it!
Both: (As they go over the cliff) Waaaugghhh!
The last frame, Calvin and Hobbes have crash landed onto the ground and are laying there injured.
Hobbes: I'm not sure I can stand so much bliss.
Calvin: Careful! We don't want to learn anything from this.
The sarcastic humor is pure genius by the cartoonist Bill Watterson and, it is easy to see that his cartoon is a metaphor for life and an important point for all of us. The paramount lesson is that we need to learn from our mistakes in order to avoid them in the future. This sentiment was perhaps best communicated by the Spanish philosopher, George Santayana, who in his 1905 book, Life of Reason, wrote "Those who cannot remember the past are condemned to repeat it". So, it behooves all of us to review responses within our industry and in fact many national standards and regulations require incident reviews. Hazwoper, for instance, found in 29 CFR 1910.120-paragraph q, requires a formal critique of all hazardous materials responses.
The power of vicarious learning is self-evident. There is just no way any of us can know everything that is required in the business of firefighting or hazardous materials response on our own. There is simply not enough time for us to make all of the mistakes that have been made. That is the value of learning from case studies! By studying the responses of the past, both incidents that went well along with incidents that have had tragic endings, we can become safer, more efficient, and wiser. We can indeed learn to avoid pitfalls along with better techniques in handling tomorrow's emergencies.
The tried and true method of trial and error can also work to our benefit by studying the past. Who can deny the powerful lessons and historic precedents of; " the incident at a cold storage facility where an ammonia environment ignited claiming the life of a hazmat team member and severely burning another? " the incident at a tank farm where a flammable liquid vapor cloud ignited explosively killing one responder and injuring several others? " the incident at a manufacturing facility where a water-reactive, flammable solid exploded severely burning numerous responders and leaving them with impaired hearing? The study of these incidents should be required of any serious student of hazmat response. It would also seem reasonable to state that ignorance of these events would be an insult to the memory of the victims of the above tragedies. Learn what happened to them and apply the lessons on your own responses.
It simply behooves all of us to devote time in our training to case study review and reinforce generic hazmat response concepts such as;
- Employ full team operations
- Complete Incident Action Plans (IAP) and Site Safety Plans (SSP)
- Assure communication systems are working correctly
- Assure proper PPE
- Assure pre and post entry medical checks
- Utilize air monitoring instruments and properly interpret data
- Avoid entering product leaks or spills
- Do not enter visible vapor clouds!
- Consider ventilation of IDLH and/or flammable atmospheres
- Practice decontamination at every incident
- Remember limitations
- Remember resources
- The need for specific training and proper protective equipment to complete assignment safely
In this age of the world-wide-web the sources for case studies are abundant. Absent good website addresses, a search engine and a few key words can provide numerous sources to pursue. Below is listed several sources for research into both firefighting and hazardous materials case studies. Look these incidents up and find out what happened in order to learn how to better respond in the future. It is amazing how much good information, along with images and footage, is available for these lessons.
Ignorance is bliss? Hopefully, you'll agree that being willfully stupid is simply not the way to go. That is, if you want to retire healthy. Last thing!; share this information with your brothers and sisters. That is the ultimate responsibility we all have to each other! Be careful out there!
Petie's Picks for Case Studies
For firefighting case studies the following are good sources;
- NIOSH Firefighter Fatality Reports at http://www.cdc.gov/niosh/fire/
For hazardous materials case studies;
- Minot, North Dakota, January 18, 2002, Canadian Pacific Rail Incident; http://www.mda.state.mn.us/spills/ammonia/minotstories.pdf and http://www.ntsb.gov/publictn/2004/RAR0401.htm (92 page report with images and diagrams)
- Minnesota incidents; http://www.mda.state.mn.us/spills/ammonia/summaries.htm, case studies from MN
- Ammonia contamination of Propane, October 21, 1999, Minnesota http://www.mda.state.mn.us/appd/nh3/aa_prop.pdf
- Nurse Tank Rupture, June 6, 2005, Minnesota; http://www.mda.state.mn.us/spills/ammonia/nursetankrupture.pdf
- Iowa incidents; http://www.ntsb.gov/publictn/2004/HZM0401.pdf, nurse tank release in Iowa
- Massive Chlorine leak, May 6, 1991, Henderson, Nevada http://www.interfire.org/res_file/pdf/Tr-052.pdf (30 pages with diagrams.)
- Festus, Missouri, August 14, 2002 http://www.csb.gov/completed_investigations/docs/CSB_DPCFinalDigest.pdf
- Final Report: http://www.csb.gov/completed_investigations/docs/DPC-IR_053003.pdf, (99 pages with images and diagrams)
- Aiken County, S.C., January 6, 2005, train derailment with chlorine release in Graniteville. http://www.ens-newswire.com/ens/jan2005/2005-01-10-04.asp; http://www.fireworld.com/ifw_articles/green_cloud.php and http://www.ntsb.gov/Events/2005/Graniteville/survival_factors.pdf
- Herrig Brothers Propane Tank Explosion, April 9, 1998, Albert City, Iowa, (66 pages with images and diagrams) http://www.csb.gov/completed_investigations/docs/Final%20Herrig.pdf
- Weyauwega, Wisconsin, March 4, 1996, Train derailment and propane fire http://en.wikipedia.org/wiki/Weyauwega_derailment http://www.postcrescent.com/specials/assets/APCweyauweatrain/default.htm
BLEVE Case Studies;
- http://ncsp.tamu.edu/reports/NFPA/vapor_explosion.htm, fact sheet on BLEVE
- http://me.queensu.ca/people/birk/research/thermalHazards/bleve/, BLEVE research
- http://www.chemaxx.com/explosion18a.htm" bobtail BLEVE case study
- International Association of Fire Fighters at www.iaff.org/academy/content/fro2/index.html
- National Transportation Safety Board at http://www.ntsb.gov Hundreds of hazmat reports from 1969, many with images and diagrams. Electronic reports since 1998.
- U.S. Chemical Safety and Hazard Investigation Board (more than 40 reports) http://www.csb.gov/index.cfm?folder=completed_investigations&page=index and http://www.csb.gov, go to "completed investigations".
- Combustible Dust Hazards http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=53, 118-page report with images and diagrams from 3 states with explosions that killed 14 people.
- Ethylene Oxide http://www.csb.gov/completed_investigations/docs/CSBSterigenicsFinalReport.pdf, 59-page report of a EO explosion in California.
- Methyl mercaptan release and fire, http://www.ntsb.gov/publictn/2002/HZM0201.pdf
- Hydrogen tube trailer fire, http://www.ntsb.gov/publictn/2002/HZM0202.pdf
- http://www.interfire.org/res_file/pdf/Tr-021.pdf, USFA REPORT
- See David Peterson Live at Firehouse Expo: David Peterson will be presenting "The Fire Service Food Chain; Critical Leadership at all Levels" at Firehouse Expo in July.
David is a 26 year fire service veteran who serves as an officer on Ladder 6 in Madison, Wisconsin, and as the Operations and Training Director for the department's regional Level A hazmat team. David founded the Wisconsin Association of Hazardous Materials Responders, Inc. and served as the first president. Additionally, David teaches, presents, and authors articles for websites and trade magazines on a wide variety of hazmat topics. David is also a National Fire Academy instructor of chemistry and a Master Instructor for the International Association of Fire Fighters HazMat and Terrorism training programs.