It’s Time to Hold Chief Officers Accountable for Line-of-Duty Deaths

Whenever a fire department suffers a line-of-duty fatality, it is a time of great sorrow and grief. After the pipers have left and the visitors have gone back to their own lives, it becomes time to try to prevent this tragedy from occurring again...


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Whenever a fire department suffers a line-of-duty fatality, it is a time of great sorrow and grief. After the pipers have left and the visitors have gone back to their own lives, it becomes time to try to prevent this tragedy from occurring again.

Whenever I have been called upon to assist in an after-action investigation, it has not been a pleasant task. What most members of the fire service don't want to realize is that this is not an exercise to find blame, but rather to prevent it from occurring again. Most members believe that any fault will only increase the department's exposure to litigation or that somehow the spouse and children won't receive their benefits. This simply is not true. The exposure for litigation remains constant and the benefits always seem to be paid.

After the smoke has cleared and the victims have been buried, most departments try to resume their activities as before the disaster. The person who is usually overlooked during this time is the incident commander at the time of the disaster. After I have interviewed as many witnesses as possible, including the fireground commander, I ask to look at the department's accident and injury reports for the previous three years. What does this have to do with the incident?

Back in the 1990s, Gordon Graham, a California Highway Patrol officer and lawyer, gave me a gift: the "Triangle of Potential" theory. It contends that for every 300 incidents at which members do not follow standard operating procedures (SOPs)/standard operating guidelines (SOGs), fail to follow safe practices or disobey orders, and this is not corrected, 30 "close calls" will occur. If still not corrected, one major hospitalization or fatality will occur. I usually find the affected departments will follow this formula. What is not surprising is to find the name of the fireground commanders either as commanders of the transgressors or as the transgressors themselves.

Fireground disasters are not acts of God nor are they unpreventable. Front-line firefighters will go into hell if they are allowed. This activity is justified by the premise of search and rescue. However, what is missed is that human skin fails at 124 degrees Fahrenheit and that an environment with less than 19% oxygen causes death. Too often, brave but misguided troops head into an ambush that needs to be stopped by the responsible commander.

How do we ensure that competent commanders are leading the fire service? Don't get me wrong, it is important to be a people person around the station, but only one person is responsible for all activities on the scene. Command on the fireground is a dictatorship the same as on any battleground. I believe that credentialing is a start. A combination of experience and education is the key to get into the exam process. For those who feel experience is all that is necessary, consider this: the intended candidate is the most experienced room-and-contents firefighter who ever held a hoseline, but today is to command a fire in a warehouse that is 60 by 100 feet with about 10% involvement on arrival. Too many commanders try to make every scenario fit their own limited portfolios. They may get away with this 99 times, but at the 100th fire they get caught and people get killed. Too many commanders don't follow safe practices; for example, if you are short staffed, then limit your operations to meet what you have. Too many commanders are preoccupied with filling in boxes on a command chart; and too many are no more than spectators — while listening to tapes of the disaster, the only responses from the commander appear to be "OK" or "Acknowledged."

Commanders need the experience, knowledge and courage to predict outcomes and pull out troops if the danger exceeds the capabilities. People have asked me during assessment centers about priorities. When I became a boss, I learned two key things: first, my only job was to ensure that my troops went home after a shift; and, second, "don't ever forget where you came from, but realize that you can never go back."

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