The Error Chain
The error chain is a concept that describes human error accidents as the result of a sequence of events that culminates in the death(s) or serious injury(ies) to a fire fighter or a crew of fire fighters. In these situations, there seldom is a single overpowering cause. Typically, there is a number of contributing factors and errors present, thus the use of the term "error chain". The links of these error chains are identifiable by means of ten "clues" divided into operational and human behavioral factors. Recognizing and breaking any one link in the chain increases the potential to break the entire error chain and prevent a resulting incident where fire fighter injuries or fatalities are likely to result.
More than fifty fireground incidents where fire fighter fatalities or serious injuries have occurred have been examined in developing and testing the concept of the "error chain". Each case study was examined from the perspective of: "if this fire crew had been trained to recognize the links in the error chains that were present, would this knowledge increase the probability that it would have caused a different crew response and outcome (specifically to avoid the fatality or serious injury)?" In most of the events considered, the answer was "yes".
The fewest "error chain" links discovered in any one accident was four and the average number was seven. Yet, recognizing and responding to only one link is all that is usually necessary to change a negative outcome. The presence of more than one link serves to enhance the potential for timely recognition of an error chain that is likely to soon occur.
While an error chain might be relatively easy to reconstruct during a deliberate accident investigation, the presence of one may be different for a fire fighter or fire crew to detect as it occurs under stressful circumstances. Familiarizing fire fighters with the concept of recognizing and eliminating the "error chain" can correct a lethal accident before it can occur. Much like our efforts in fire prevention, "the best fire we can respond to is the one that we prevent".
There are ten important 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 fire fighters and fire officers must maintain control through proper management of both risk and resources to eliminate unsafe acts, unsafe conditions and unsafe behaviors.
Mission Critical Operational Factors
1. Failure to Meet Benchmarks, Tactical Objectives, or Targets Failure of fire - rescue personnel to attain or maintain identified benchmarks, tactical objectives, or targets of the overall strategy employed at an incident could prove to be deadly for our members operating at alarms. This includes operational tactics, procedures, or any other goals established by the incident commander for fire fighting resources (fire crews).Example of Tactical Objective Failure: Fire attack has been underway for at least 10 minutes with no discernable reduction in fire volume or change in tactics. Many firefighter lives have been lost to this sucker punch - keep an eye on the integrity of the building all of the time!
2. Use of an Undocumented/Unauthorized Procedure
The use of a procedure or procedures that are not prescribed in approved training manuals or operational safe practices to deal with abnormal or infrequent conditions.
Example: Applying master stream into an occupied structure; or placing an attack line in roof ventilation hole would represent an improper variation from proper procedures.
3. Departure from Standard Operating Procedures (SOP's)
Intentional or inadvertent departure from prescribed standard operating procedure is often the "first link" in the accident chain. Well-defined SOP's are the result of a synergistic approach to problem solving with the influence of time removed. As a result, in different situations Standard Operating Procedures represent an effective means of problem resolution without the sacrifice of time, which is often not available. We are not suggesting that SOP's will resolve all problems. However, following established procedures will typically facilitate safe and effective operations. Failure to follow SOP constitutes a link in the error chain and is a significant indicator of rising risk. If your organization has SOP's, train on them. If you train on SOP's, use them. If you vary from established SOP's have a defendable reason (2in / 2out can be suspended to go to work at an emanate life hazard).
Example: Failing to have a continuous, dependable water supply at a structural fire violates most (hopefully all) SOP's. Make sure to drop a supply line at building fires!
4. Violating Limitations
Violation of defined operating limitations or specifications either intentionally or inadvertently (unintentional), as prescribed by manufacturers, regulations, manuals, or specifications opens the door wide for an accident. This "link" includes equipment specifications, operation limitations, local, state and federal regulations relating to the safe operation and use of all equipment.
Example: About 29% of fire fighter fatalities happen responding to and returning from alarms. More times than not, apparatus is operated outside (beyond) of limitations. Vehicle speed falls under this category, so slow down and arrive alive!
5. No One in Command and/or Free Lancing
No one establishing and monitoring progress of an incident action plan and progress of the operation is perhaps the leading cause of fire fighter death and injuries at all types of emergencies. Further, individuals or crews operating independently (outside) of command is another very dangerous practice. Control of the incident is the highest priority for operational personnel, to ensure our safety and to deliver service to the "Smith family" (our customers). If command of the situation is not strong and obvious, then other important tasks are likely being overlooked as well. In 9 out of 10 NIOSH Firefighter fatality reports, Command was weak or, worse yet, not established.
Example: An arriving company at a multi-alarm fire goes to work without reporting in to command and not under command's direction. Never allow companies to self-deploy (except initial alarm units) without directions / control from the incident commander.
6. No One Is Aware of the Overall Operating Environment / Preoccupation or Distraction
Often referred to as "tunnel vision", it is easy to lose sight of changing conditions. The lack of a careful eye(s) above, around, outside and being aware of what is going on at all times. Tunnel vision leads to a lack of situational awareness thereby, the rising risks to our members. Take steps to ensure that the "command team" (more about teams in Part IV) is paying attention all of the time. Command's attention is focused on any one item or event to the exclusion of all others. This includes any number of distractions that can draw attention away from the progress of the entire operation. Distractions can be the result of stressful operating conditions, high workload, poor equipment, malfunctioning equipment, or just the deteriorating conditions found at most incidents. Distraction may be the result of personal problems, inattention, complacency, fatigue or many other human factor problems.
Example: Companies are allowed to work a defensive fire inside the collapse zone. This is a "widow-maker" waiting for victims. Always pay attention all of the time!
7. Incomplete (Poor) Communication / Information
Incomplete (poor) communication or information is the results of unknown or non-communicated information, events, conditions, situations or questions about the incident. A failure to seek resolution of this confusion or disagreement has cost many fire fighter lives. Part III in the "Crew Resource Management" series will discuss this concern in some detail.
Example: If one fire crew member withholds observations or knowledge of existing hazards from another fire crew member a link in the error chain exists. Complete and effective communications are a must if we are to eliminate fire fighter death and injury someday.
8. Ambiguity / Unresolved Discrepancies
Ambiguity exists any time two or more independent sources of information do not agree. This can include observations, radio reports, people, training manuals, SOP's, senses or expectations that do not correspond with existing conditions. This situation is often overlooked and reappears only after an accident occurs. Failure to resolve conflicts of opinion, information, or changes in conditions, or not raising issues that need to be brought to the attention of command or sector officers generally has very negative consequences.
Example: The driver of a hazardous materials hauler plays down the harmful effects of the spilled product, while the MSDS expresses great concern for caution. Resolve these issues quickly and take a conservative approach, "if you don't know - don't go"!
9. Confusion or Empty Feeling
A sense of uncertainty, anxiety, or bafflement (clueless) about a particular situation. It may be the result of mentally falling behind the pace of operations, a lack of knowledge or experience. Perhaps it is caused by being pushed to the limits of one's training or operational capability or such physiological symptoms and effects as a throbbing temple, headache, stomach discomfort, "gut feeling", or nervous habits (ticks). Human factors researchers suggest that these signals are symptomatic of uneasiness and should be treated as indicators that all may not be right, leading to a potential accident.
Example: The entire operation is moving very rapidly and you are not able to keep up with the pace. Keep in mind that your "street smarts" are likely to lead you to a correct decision, follow them and don't take unnecessary risks. Don't be afraid to ask for help (second opinion) to help you get on the correct "page" of the incident action plan.
10. Belief of Invulnerability
Perhaps the most dangerous of human factors is the one of feeling that, "I won't get hurt, that only happens to you". Whether willed into complacency by "years of experience" of running into burning buildings or driven by the psychological effects of the adrenaline rush, this is a "killer" felling. This factor is often times the foundation and precursor to additional "error chain links" which increase the risk and likelihood of a serious accident occurring. Individuals predisposed to this link are oftentimes prone to engaging in other high-risk off-duty activities, such as sky diving, racing (vehicles, boats), among many others, which fit the widely held "macho" perception and image of the fire fighter (they seem to spend a lot of time on "light duty").
Example: The young (physically or mentally) fire fighter that firmly believes that the job must be painful and accidents are the "nature of the beast", believes that they are indestructible. Find this guy / gal a day-work slot on the light wagon!
Environmental Factors
In addition to the previously listed ten clues which influence the occurrence or non-occurrence of a serious injury or fatality there are six additional factors which play a role in the quality of decision-making that fire fighters make at every incident. These additional environmental factors include:
1. Training The extent and quality of basic and continuing education / training will directly influence the quality of the decision making process of the individual. The world that the fire fighter operates in, is constantly changing and is very challenging to keep abreast of all possible hazards, new systems, methods, new technology, and risk limitations.
2. Experience
The typical fire fighter today has less experience than his/her counterpart of 25 years ago. Experience is a nondescript term of "knowledge gained" as the average fire fighter will operate (work at alarms) in only a few different types of occupancies in a whole career. There is an old adage "25 years experience or one year of experience repeated 25 times over?"
Experience may be counter-productive to improved safety if a fire fighter has engaged in a high-risk/low-frequency critical operation that did not result in a serious accident the situation may have been a "near-miss", leaving the member with a false sense of security. Statistically you can play Russian Roulette and 83% of the time nothing will happen. But, eventually you will die if you get enough "experience."
3. Attitude
"Attitude is everything" as the saying goes. The fire fighters' attitude will play a significant role in the mental aspects of an entire operation, and for that matter, their entire career.
4. Complacency
Sometimes seen as an outgrowth of "experience", this will typically manifest itself in operations that are performed by rote habit. For instance, pulling an undersized line at a large fire out of habit, because "that's what we've always done before". This is a large factor that leads to accidents and is difficult to overcome until after it is too late.
5. Health
Another major factor is the physical, mental, and emotional health of the fire fighter. It is important to the quality of decisions that will be made, or the actions that will be taken. Work or home problems will impact the timeliness and quality of critical decisions that are made (Part VI will discuss critical decision making).
6. Peer Pressure
Peer pressure may be the most influential environmental factor in the fire fighters decision-making process. The quality, timeliness, and correctness of the actions of the fire fighter may be significantly complicated by how the fire fighter perceives what others will say about their operational actions. The culture of some fire departments is so strong in this area, that fire fighters will not call for help in situations where they are confronted with life-threatening hazards or where they are not trained or equipped to overcome the situation they face on their own.
Conclusion
The combined fire service experience over the past 25 years has indicated that fire fighter fatality rates have not dropped. Over that same time period significant effort has been expended to impact the technology, protective clothing, and equipment used in fire fighting to make the job safer and reduce injuries and fatalities. The fire service is slowly awakening to the concept that technology cannot overcome bad incident management practices. Fire fighter deaths over the past two years, seem to indicate the situation could get much worse before we truly lower the high rate of injuries and fatalities. In order to make substantial progress in lowering these appalling statistics we need to recognize that bad decisions lead to bad actions that result in bad situations.
The presence of one or more of these clues means that an "error chain" might be in progress and that appropriate caution / corrective actions are advisable. Recognition of the presence of "error chain links" provides response crews with another tool to appropriately manage risks associated with emergency operations.
It is important to point out that identifying the presence of an "error chain" does not, in and of itself, eliminate the risk of a serious injury or fatality. Instead, it serves as a warning to the fire fighters that they must take appropriate action to manage the outcome of the incident operation in the face of rising risk, and that all personnel must maintain proper control of the incident through proper management of personnel and equipment. Tune in for Part III, when we take a detailed look at improving your incident critical communications. Until next time, be safe out there!
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