Close Calls: Fire Captain Falls Through Roof

Nov. 1, 2016
In Part 2 of the series, Billy Goldfeder explains how reviewing tragic incidents can help departments better evaluate the reality of their policies.

On March 29, 2015, while performing vertical ventilation on a residential garage fire, Fresno Fire Department Truck Company Captain Pete Dern fell into the well-involved fire compartment, due to penetration of “roof decking burn-through” with direct fire impingement of the lightweight truss. 

Captain Dern sustained critical burn injuries, but fortunately survived. The details of this event are available both in last month’s issue of Firehouse Magazine as well as on Firehouse.com and the Fresno Fire Department website.

Risk assessment

As I worked through this close call event, I tried to focus on how we can deliver the most applicable and usable information to you, the reader, regardless of what rank you hold. As such, I have taken some of the most critical aspects of the incident and the report to create a checklist for determining your department’s level of risk for a similar incident. 

To be clear, this isn't the only way to review this incident and compare it to your own department. There are several available resources, tools, programs or datasets covering a variety of information:

  • NIOSH reports
  • NFFF Vulnerability Assessment Project (VAP)
  • CPSE fire accreditation
  • ISO evaluations
  • IAFC Rules of Engagement
  • IAFF Risk Matrix
  • Recognition-primed decision-making (RPDM)
  • Modern fire behavior research from organizations like UL

These tools and resources can help address those go/no-go options so you can better analyze your risk, and ultimately do what’s best for those having the fire—and the firefighters operating at the fire. 

A key part of the assessment process is conducting a policy determination verification (PDV). A PDV involves an organization determining—in a clear and concise manner—how its policies and guidelines reflect how the department actually operates versus how the leadership wants the department to operate.

With surgical precision, evaluate the department to determine if its day-to-day operations reflect the department’s SOPs, SOGs, etc., and if the SOPs direct personnel on how they are expected to operate. Honest, open and realistic communication is critical, with input at all levels. If the chief thinks that companies operate a certain way based upon SOPs, but the reality is that they almost never operate that way, someone better break that news to the chief.  

Developing SOPs is a process as well. Some departments choose to use policies from other fire departments and just “white out” the names and replace with their own names. Others develop their own SOPs from scratch. And still others have none. And quite honestly, a department with no guidelines is just as unprepared for operations as a department that has policies but fails to follow them.

Here’s a way to test perception vs. reality: Pick a subject, any subject. Now ask five different firefighters for the department’s policy on that subject to see what lines up. If their responses are different, there’s a disconnect.

Another tip: Do the words “shall,” “will” and “may” appear in your policies? Do you—and all the firefighters—understand the very real difference among these words in the day-to-day reality of operations?

Checklist time

The following checklist can be used to help develop policies and guidelines related to department operations:

  • Determine the need for a certain policy.
  • Determine if that policy can be duplicated from another source, such as another fire department or a manufacturer of a specific tool or piece of equipment.
  • If not, develop your own by using leadership in the department as well as those who will be impacted by the policy. For example, if you are developing a first-due engine operator policy, you would be smart to have apparatus drivers involved in the process.
  • Once you have a draft, it’s time for your legal folks to take a look and make sure you haven't gone crazy.
  • Send the draft to an appropriate sampling of department membership (labor, associations, additional leadership if necessary) for review, and provide a clear time when you expect the comments to be back.
  • Take and review changes, and make them or not, depending on legal and realistic parameters.
  • Now develop your final draft.
  • Start the training process on the policy. Yep, training. Do NOT just post a new policy and expect that to be your process. Naturally, training varies based upon the specific policy, but a guideline would include:

o   Classroom training on the policy with videos, slides, Q&A, etc.

o   Hands-on training so that everyone knows how to do the skill/operation/etc. proficiently

o   Testing through written and hands-on observed verification that the department has fairly and properly trained their personnel

  • Institute the policy and follow it.
  • Officers oversee and continue training personnel daily on the policies as well as enforcement as required.
  • Review the policies on annual basis for applicability and change as needed. 

The process can be as simple or as complicated as is required for the specific behavior, training or action. Some departments manage these processes themselves and others use computer-based systems, such as Gordon Graham’s unique Lexipol fire policy program, to provide the needed foundation and training. Either way, pay close attention to your policies, procedures and guidelines to make absolute sure they are a “living” part of how the department operates.  

Lessons from Fresno

Let’s return to the Fresno Fire Department and review some of the lessons learned from the Cortland Incident—lessons that all of us can use as a template when considering if “that” could happen to us. In other words, could this happen at our departments and, if so, what actions will we take to prevent the same tragedy?

The Serious Accident Review Team reviewed NIOSH fatality reports involving interior structural firefighting operations to identify common factors. The report identified several common factors, with the numbers in parentheses below representing the number of times that factor was documented in another NIOSH fatality report:

  • Personal Protective Equipment/Safety Gear (16)
  • Independent Action and Freelancing (18)
  • Leadership and Safety (5)
  • Incident Command Post (12)
  • Accountability of Procedures (28)
  • Size-up and 360 (27) 
  • Incident Action Plan (17) 
  • Transfer of Command (15) 
  • OSHA 2-In/2-Out Guidelines (15) 
  • Vertical Ventilation (5) 
  • Organizational Expectations (28) 
  • Risk Management Process (27) 
  • General Safety Guidelines (18) 
  • Recognition of Modern Fire Science (4) 
  • Fire Stream Tactics (11)
  • Training (90) 

This is another example of “us” continuing to make the same mistakes over and over again.

Hard questions

With this in mind, consider the following questions:

What is your department’s policy on reviewing what went right and what went wrong after every fire? Is it done at the scene? Is it done more formally? Is it done at all?

When there is a close call, injury or critical injury, what is your department’s policy? Do you have a safety committee? What is their role? Is it defined by policy?

What is your policy on PPE for members operating in the hazard zone?

What is your residential structural firefighting policy? How are garages factored into the operation? What about modern fire load and construction? What is expected by the first-arriving officer? What does the first-due company do? What is expected by the first-due chief?

What company ensures water supply? What do the other companies do when they arrive? Do they stage? What does the truck company do? Do they always go to the roof? Why? Do they do what they want to do? Do they freelance? Do they do what they do because they have always done that? Be honest! 

What is your size-up and 360 procedure? Is it clearly defined so that no matter who is on duty or responding, the person doing the size-up will always answer the same questions each and every time? Your initial radio transmission should include:

  • Who you are and your arrival on the scene.
  • A clear description of the building. (Note: A 1,000-square-foot, single-family dwelling is large compared to a mobile home but tiny compared to a mansion. How does your department define small, medium and large?)
  • Statement of the problem you are or are not observing (fire, smoke, nothing, etc.).
  • Your incident action plan. Is it an offensive fire (go in) or defensive fire (stay out)?
  • Incident strategy.
  • Name and location of Command.

How do you account for your members on the scene? Does it work or is it just a “pretend” accountability system? At any moment, are there behaviors and procedures in place so the question, “Where are our companies right now?” can always be answered accurately and with confidence?

What is your PAR or role-call procedure? What happens if a company doesn't answer? How are your dispatchers involved in the event companies are not accounted for?

What is your department’s definition of a command post? Is it the incident commander (IC) walking in front of the building? Is it the IC standing at the back of a vehicle in the open air? Is it the IC inside their vehicle, windows rolled up, so they can focus on the incident? Are they outside, appearing to be an “information booth,” with everyone from firefighters to cops to media walking up and talking to them—and distracting them at what may be a critical moment?

What qualifies your ICs to be ICs? You know what qualifies pump operators, and you know what qualifies EMTs, but what qualifies someone to be an IC at your department? And just like you evaluate your personnel for their fire and EMS skills, how often are your ICs evaluated for their job on the fireground?

Does your department have a standard command/tactical worksheet? Do your ICs use paper and pencil or do they have to boot up? Does the worksheet include checklists to make sure all tasks, as defined by policy, are accomplished? Is it on the apparatus and command vehicles?

What is your radio usage policy? Does your fireground sound like truckers watching out for cops on their CB radios? What if there was a mayday? Could your members transmit right now if they are in trouble? What guidelines do you provide your members on when to use the radio? At my department, our chief uses the term “no good news” for this. In other words, he doesn't need to know that we are doing what we are expected to do; he needs to know when we are unable to do so. Another term to remember is DIM-WIT: Does It Matter What I’m Transmitting? If not, keep the air clear. 

What is the rapid-intervention plan at your department? What tools does the RIT crew need? What are their expectations? What should they be doing without orders?

What flow in pressure and gallonage are you getting out of your nozzles? How do you know? What have you done to be sure the flows are what you expect? Better yet, what flows are needed and how do you determine those flows? When or why do you need 200 gpm, and when or why do you need 300 gpm? 

Phew. Sound like a lot? Are you stressed? Need an aspirin after reading that? It is a lot and should force us to think. These are just a few of the items that relate directly or indirectly to the fire that critically burned a Fresno fire captain. 

Fresno takeaways

The Cortland Incident served as a wake up call to the leadership and all levels of the Fresno Fire Department—and many of us outside the department, too. Fortunately, the department’s labor and management did take that wake-up call seriously and have implemented critical changes, while not negatively impacting their aggressive ability to do the job they are expected to do. If anything, the changes they have made—and continue to make—allow the department to better serve their community and their members by being better trained, better skilled and better lead. 

So much of what came out of their report reflects on policy, or the lack thereof, and the importance of our policies being “living” policies that accurately reflect how the leadership expects members to operate each time they roll out the door. In football, the playbook (policy) provides agreed-upon direction, and the coaches (officers) make the adjustments based upon conditions with success being the goal. Obviously in our business, it's hardly a game and the stakes are so much higher—but the success analogy works. 

Our sincere thanks to Chief Kerri Donis, Captain Pete Dern and all those operating that day. Also, our thanks to those who participated in the subsequent investigation and report of this critical incident so that the fire service can learn from it so as to not repeat it.  

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