On Nov. 19, 2016, a firefighter from the Poudre Fire Authority (PFA) in Fort Collins, CO, lost consciousness during a confined-space/high-angle rescue training scenario. The firefighter was playing the role of a confined-space victim who was to be rescued using a haul system rigged from a high point off Tower 1. During the raising operation, the firefighter’s harness shifted upward to his neck, and his head made contact with a cross member. The firefighter lost consciousness. He was immediately lowered back into the confined space, where there were rescuers to assist, and he regained consciousness.
Planning the event
This confined-space/high-angle training was an A-shift event that had been scheduled for a couple of weeks, and was discussed during the A-shift conference call on the morning of the incident.
The crews of Tower 1 (four personnel), Ladder 5 (four personnel) and Engine 7 (three personnel) were scheduled to attend the training. Neither the A-shift battalion chiefs nor the shift safety officer were in attendance during the training scenario. Additionally, the north battalion chief had requested that one truck crew stay in service during the training.
The training site
The training was conducted at a construction site for the Greeley Water Pipeline Project. The confined space used for the training was a dry 60-inch water pipe situated in the middle of a shored, cylinder-shaped construction pit that was 30 feet wide and 40 feet deep. The pipe had a vertical component approximately 20 feet that gradually turned 90 degrees to a horizontal component that lead to the same size opening 800 feet away on the west side of the Poudre River. The construction pit contained ground water approximately 20 deep that came within two feet of the top of the entry point.
There were access ladders on site for construction company employees. One ladder went from above the construction pit shores to the ground in the water, and a smaller ladder was placed horizontally from the ground ladder to the top of the confined-space access point (above the water). Another ground ladder, placed after the training began, was secured inside the 60-inch water pipe just below the top of the access point and sat on the bottom of the pipe.
Approximately 8 feet below the confined space access there were wood 4-inch x 4-inch braces spanning the opening in an X pattern. The ladder placed in the confined space passed through one of the quadrants in the X pattern. The vertical opening was straight with no other obstructions.
The training evolution
The training scenario involved a single victim—played by a firefighter from Engine 7, herein called “victim”—with a leg injury sustained in a fall from a ladder, requiring a confined-space rescue followed by a high-angle rescue.
Eight of the crewmembers present were NPFA-certified rope rescue technicians, and one was an NFPA-certified confined-space technician. The positions of incident commander (IC), safety, control, air monitoring, rescuers, backup rescuers, rescuer communications, belay attendant, mainline haul crew and victim were assigned.
The bucket of Tower 1 was centered over the access point and used as the high anchor point for the 4:1 hauling system. The Tower 1 captain served as the IC, and the captain of Engine 7 served as safety for the scenario. The main and belay lines were rigged, secured and checked by NPFA 1670-certified rope rescue technicians. The supplied air breathing apparatus (SABA) lines and system were set up and checked by an NFPA-certified confined-space technician.
The victim was fitted in a Class III rescue harness and attached to the main and belay lines. The victim was wearing bunker pants, a sweatshirt and a helmet without SCBA. When all personnel were ready, the victim was lowered with an air monitor into position through the X bracing and to the bottom of the vertical pipe. He then left the monitor at the base of the vertical opening and walked 25 feet to the west, remaining in his Class III harness.
With the victim in place, a scenario and safety briefing was held, and strategy and tactics for the training scenario were discussed. The briefing was followed by a discussion on the details of the Confined Space Entry Permit, which was not filled out.
Using the existing ladders, the captain from Engine 7 (Safety) climbed down to the level of the water and crossed to the confined-space entry access point. The captain initially sat at the opening to the confined space, serving in the safety capacity. Once the victim and the first two rescuers were lowered into the confined space, the Engine 7 captain returned to the ground-level access point.
For the first scenario, two firefighters served as the rescuers. They were secured to the main and belay lines, as well as the SABA line and the tagline, and lowered into the confined space one at a time. The victim was secured in a rescue harness over his original Class III harness, bunker pants and sweatshirt. The victim already had on the helmet he wore when initially lowered. The victim recalls telling the rescuers that the rescue harness was on too tight, and that one of the rescuer told him that it was the way he was trained to secure it. The victim was removed from the rescue harness and remained in position as the two firefighter rescuers were raised out of the confined space.
For the second scenario, the same two firefighters served as the rescuers. They were secured to the main and belay lines, the SABA line and the tagline, and lowered into the confined space one at a time. They remained connected to and breathing from the SABA lines. The last rescuer down remained connected to the main and belay lines. The victim was secured in the rescue harness over his original Class III harness, bunker pants and sweatshirt. The victim recalls telling the rescuer that the rescue harness was too tight across his chest.
The victim was moved horizontally to the raising system position. After one of the rescuers disconnected from the main and belay systems, the victim was connected to the belay line at the front lower D attachment on the Class III harness, and the main line was attached to the top attachment on rescue harness. The victim recalls the rescue harness being tightened again. A tagline was also attached. The patient packaging and attachment points were checked while the victim was in a horizontal position and again once he was vertical. Rescuers report that the victim gave the rescue team a “thumbs up” before the raising operation initiated. The victim recalls that he was struggling to breathe and communicated this to the rescuers by saying twice, “You’re cutting me off.” The rescuers do not recall seeing or hearing this.
After a roll call for operational readiness, the operation began. The victim was raised utilizing a 4:1 mechanical advantage system, meaning the victim moved at a speed equal to one-fourth of the speed of the haul team. The haul team was positioned by the main line anchor, which was attached to Tower 1.
As the victim was being raised from the vertical pipe, the SABA lines from the rescuers interfered with his path. The rescuers communicated this with the victim and asked him to manage the SABA line, which he was able to do. As the victim approached the X bracing, he was looking down, and the rescuers advised him to look up to avoid contact with the X bracing.
The victim looked up momentarily, then put his head back down. The victim did not respond to the rescuers’ commands to “look up” again, and his helmet came into contact with the X bracing. At this time, the victim would not respond verbally and became “uncommunicative” with the rescue team.
The rescue team called for a “stop” and hauling efforts were immediately ceased. The team then called “down” for a lower. The haul team managed the main line as the victim was lowered to the rescuers. As soon as the victim’s weight was off the system, he was laid flat and the straps around his chest were loosened, at which point he regained consciousness. The rescue team estimated that the victim was unresponsive for approximately one minute.
After assessing the victim, the rescuers stated he said he was fine, told the rescue team that the harness was too tight and asked them to loosen it and raise him again. The victim recalls that he asked them to remove the rescue harness. After the rescue harness was removed, the victim was raised using the Class III harness. The victim was raised to the access point of the vertical pipe and effectively communicated with the rescuers during the raising operation.
As the victim approached the opening, the lifting line, tag line and SABA lines became twisted so that he could not be lifted out onto the ground. He was assisted across the horizontal ladder to the vertical ladder and out of the construction pit.
The IC called for an ambulance to respond Code 2 to evaluate a firefighter who momentarily lost consciousness during a training event. The victim removed his helmet and harness, got something to drink and put on a sweatshirt.
Ambulance personnel arrived on scene and evaluated the victim. The victim recalls telling the paramedics that he had been unconscious due to being choked, that he had a very bad headache and that his neck hurt. After evaluation, the paramedics released the victim.
The north battalion chief was advised of the event and contacted the operations chief, who requested that the victim be taken to the emergency room. The Engine 7 crew then transported the victim to Poudre Valley Hospital ER for further evaluation. The operations chief also requested that this incident be investigated. The request went to the north battalion chief and the shift safety officer.
Patient outcome
The injured firefighter suffered strangulation-type injuries resulting in continual missed work since the writing of this report. He continues to be off shift, with attempts at modified duty as he is able.
Comments from Chief Tom DeMint
At the time of the accident, I requested the division chief of operations to immediately begin an investigation of the incident internally and to explore the possibilities of including an outside investigator to verify and validate our findings.
An investigation was launched, and the equipment in question was immediately removed from service. We also simultaneously implemented a confined-space training/safety stand-down until the report was completed and changes could be implemented. PFA’s Health and Safety Officer was assigned to lead the internal investigation.
The division chief of operations was tasked with coordinating an outside review of the investigation. Mike Roop, an experienced industrial accident investigator with confined-space expertise, came to our community in April 2017 in order to ensure that all employees involved in the incident were available for interview. Roop reported to PFA staff that the initial internal investigation and report were thorough and some of the best internal work he has experienced as an investigator. He stated that the report was accurate, detailed and provided appropriate recommendations. He used the internal investigation report as a basis for his final report.
The highest priority for the PFA is the safety of our employees and the public. I want to emphasize that training is an ongoing and continually evolving process. As new procedures and best practices come out, we constantly evaluate and update training techniques related to all aspects of Authority employees’ work. We take very seriously any aspect of training that could be improved.
Internal investigation
During the investigation, several findings came to light that PFA should take action to correct. The findings that follow are defined in two categories—injury-specific and overall/related. The injury-specific findings directly contributed to the injury in this Close Call, whereas the overall/related findings had little or no bearing on the actual injury but had the potential for further injury or have the potential for injury at future events.
Injury-specific findings
According to the report, it appears that the victim was having problems during the ascent with the underlying Class III harness being too tight and also riding up on his neck, which may have restricted blood and/or oxygen flow to his head.
When he was nearing the cross beam in the vertical shaft, the victim was unable to raise his head and avoid the beam due to the forward tilt of the rescue system, and he may have already been experiencing some restricted breathing and hypoxia.
During the hauling process, the victim’s head made contact with the cross beam, it forced his head forward and down, with the Class III harness potentially cutting off either the blood supply, air supply or both, resulting in “strangulation” (ER doctor’s diagnosis post-incident). Due to lifting by hand and the victim out of direct sight, it could not be accurately determined how hard or for how long the force was applied while his head was in this position.
At the time of the incident, the victim was wearing boots, bunker pants, a hooded sweatshirt and a Class III harness underneath the rescue harness. The Class III harness interfered with the victim’s neck as it as it “rode up.” The bunker pants may have added weight and also padded his legs, causing him to sink further into the rescue harness.
These factors may have caused the rescue harness to shift, tighten and tilt forward his center of gravity, putting extra constriction from the Class III on his chest, neck and throat. The forward tilt also restricted him from raising his head far enough to avoid having it pushed forward and down into his chest.
The manufacturer of the rescue harness stated that the nature of the product does indeed tilt a victim forward (head positive) about 5–10 degrees. The company offers (and the product is now not sold without) a “bridle” system that attaches to the front of the product and the dorsal hauling rope, which brings the victim into a complete upright position, and can be tilted back (head negative, body positive), thereby relieving the extra pressure on the front of the chest and neck, and putting the weight back onto the upper legs and seat area where it belongs.
The rescue crew, by staying in verbal contact with the victim, was able to quickly determine that there was an issue and order the lowering of the victim. By staying in verbal contact, the crews addressed this situation quickly and correctly, helping to reduce the severity of the injury.
Overall/related
In this situation, on-duty crews had initiated, scheduled and performed their own training event. Although the training was identified in the training calendar and discussed on the shift’s morning conference call, the specifics of the training were not known by the shift battalion chiefs or shift safety officer. The north battalion chief had requested that one truck crew stay available for response. The shift safety officer had no direction/expectation of which crew-initiated training events should be attended. Crew self-initiated training is common throughout PFA, including those that could be considered high risk.
The training site was selected by the on-duty crews in attendance. Some of the crews on scene had familiarity with this training site and had prior visits to the site to meet with the water project construction personnel.
Based on previous conversations with project personnel, construction crews perform constant monitoring when they make entries and have not had readings requiring SCBA. Pre-monitoring of the confined space by PFA personnel prior to the training did not occur, and the first monitor into the confined space was attached to the victim.
One PFA member accessed the confined-space opening via the ladders in place and secured by construction crews. This included placing a ladder across to the opening from the inside edge of the shored pit. The crews did not know the depth of the water between the shored pit and the confined-space opening. Neither taglines nor PFDs were utilized by personnel who accessed the opening via this method.
The specifics of a Confined Space Entry Permit were discussed during the training, but no permit was completed.
Internal Recommendations
Recommendation 1: Training should occur in controlled environments to determine the best use of harness attachments when another harness has the potential for connection. The bridle attachment for the rescue harness involved in this incident corrects a forward tilt of the victim that would reduce the chance of this type of injury. In this case, the intent for rescuers to have a redundant harness system may in fact be detrimental, as it could put the victim in a compromising position.
Recommendation 2: During training, the time that personnel are placed in these victim recovery harnesses should not exceed 10 minutes. Use of “rescue dummies” should be utilized for situations where these conditions cannot be attained. If a firefighter is playing the role of victim for any sort of training, it should be ensured that they understand the equipment that will be utilized for the rescue and have an opportunity to view, assemble, get in or learn about the equipment prior to beginning the scenario.
Recommendation 3: Training sites need to allow for a safety officer in the immediate vicinity whenever possible. The site chosen for training was a fairly tight shaft, with no easy way to get a safety person into the immediate area of the accident. This did not allow for effective positioning of a safety officer with a constant visual on the victim.
Recommendation 4: High-risk training of this complexity should have a pre-determined Training Action Plan (TAP) completed and approved prior to the training occurring. PFA Training Division currently uses TAPs for department coordinated training, but PFA has no written direction on when TAPs are needed for self-initiated training, or what the approval process is. High-risk training is currently not defined in writing. As such, PFA should provide direction to crews on what constitutes the need for a TAP, the approval process and what constitutes “high-risk training.”
Recommendation 5: Air monitoring should be performed and recorded prior to entry into a confined space. This should be defined in the TAP for confined-space rescue training. In this training scenario, the firefighter playing the victim was lowered into the space with the initial monitor and no SCBA. Best practice is to monitor ahead of entry. PFA currently has a written expectation for monitoring at a confined-space rescue call. This does not address confined-space rescue training.
Recommendation 6: A Confined Space Entry Permit should be completed on all training confined space entries. This should be identified in the TAP for confined-space rescue training. Although the crews discussed what a permit entails, no permit was filled out for the training entry. PFA currently has a written expectation for completing an entry permit at a confined-space rescue call. This does not address confined-space training, yet OSHA states that all confined-space entries should have a permit.
Recommendation 7: Training events that require a minimum amount of personnel on scene should be identified to determine crew capability/availability to remain available to be pulled away from the training. Minimum amount of personnel in attendance should be identified in the TAP. An event such as this required both trucks to be committed to the event and to be out of service with a potential lengthy response delay. The shift battalion chiefs were not aware of the specifics of the training and only requested the crews keep a truck crew available for response.
Recommendation 8: Training such as this should have a pre-determined safety component addressing the need for a dedicated safety officer at the event. This need should be pre-determined and identified on the TAP. In this event, the shift safety officer had no expectation of attendance of this training. Due to the complexity of high-risk training events, a safety message can pre-determine the need for a dedicated safety officer.
The PFA’s next steps can be found at firehouse.com/12378824.
Next steps
From the recommendations in the report, certain changes of policies were recommended: Operational Directives, Training Policies and Procedures at PFA. These changes were coordinated through the Operations Division and the Support Division. Chief DeMint also had the appropriate committees codify these changes into the appropriate policy, Operational Directive or Training Policy.
The changes include but are not limited to:
- Determine appropriate minimum hours confined space rescue (CSR) training (minimum 24 hours recommended by Roop), identify PFA policy and procedure changes, and determine the appropriate recipients at PFA for CSR training. This shall be accomplished by June 1, 2018.
- By Dec. 31, 2017, PFA shall develop a policy in the use of Training Actions Plans (TAP) to include:
o When TAPs are required, specifically in regards to technical rescue
o Defining what constitutes “high-risk training”
o Minimum number of personnel to conduct a high-risk training exercise
o Identifying the use of rescue mannequins or victims
o Required command and control
o Required permitting page
o An approval process for conducting training
- Develop policy/practice changes to ensure PFA identifies when critical safety training is required prior to implementation of equipment and practices. This shall be accomplished by Dec. 31, 2017.
- Effective immediately, all confined-space training exercises will have confined-space entry permits completed when any personnel will be entering a confined space.
- Effective immediately, anyone entering in potential Immediately dangerous to life and health (IDLH) atmospheres or simulated atmospheres will have air monitoring in place prior to entry.
- Ensure that all certifications are current and referenced to the appropriate standard. Roop did feel that our firefighters were qualified but does report that the certifying agency referenced the wrong NFPA standard. This shall be accomplished by June 1, 2018.
- Ensure that all training exercises are current and referenced to NFPA standards. This shall be accomplished by June 1, 2018.
- Before the equipment in question is placed back into service, the appropriate firefighters will be trained on what has been learned on the use, positioning, attachments and other aspects of the gear.
- Effective immediately, bunker gear and other thermal protection shall not be worn in confined-space rescues or training exercises that require rescue harnesses unless impractical.
- Effective immediately, Permit Required Confined-Space (PRCS)/IDLH entry shall require all entrants to be attached to a retrieval line, and an attendant shall be stationed immediately outside the confined space unless doing so would create a greater hazard to the entrant. The attendant shall be attached to a retrieval line with a separate haul system when in or near an IDLH environment. Each PRCS/IDLH entry shall have a confined space supervisor, attendant, separate haul systems for each retrieval line and backup rescue capabilities.
- Effective immediately, rescue mannequins shall be used as the victim/patient when a training exercise is not in a controlled environment and/or the time personnel are placed in the device exceeds 10 minutes. The use of live victims should only be used in training environments that allow for a limited time while suspended from any harness and quick access to the victim exists should a problem arise.
- Effective immediately, haul systems shall have a “load watch,” with instant communications to the haul team when hauling a human payload.
- Effective immediately, the rescue harness shall be equipped with the bridle attachment for vertical lifts.
- Effective immediately, rescue harness training should be instructed by a subject-matter expert and held in controlled environments.
These are the minimum of the changes that Roop required. As fire chief, I anticipate that coordination between the Operations Division, the Safety Committee, the Training Division, the Operational Directives Committee and others will develop even more recommended policies and procedures. It is important that we learn from what the PFA internal investigators and Roop discovered in their investigations of this incident.
We will focus on these changes and others to make our training and response exercise more effective and safe. It is incumbent upon us, the leaders in safety for the community, to maintain a culture of safety. What’s even more important is our continued support of the injured firefighter and his family during his recovery. Please keep their family in your thoughts and prayers.
External report findings
Roop interviewed or talked to 16 PFA personnel who were either directly involved with the training drill or had useful knowledge about it. Roop found that memories of events among the participants differed quite a bit. Most of the personnel were forthcoming and seemed interested in helping Roop determine the exact cause of the injury. The re-creation exercise was crucial. All the participants in the original event were in attendance. Roop constantly asked the injured firefighter to identify any inconsistencies with packaging and rigging.
The identifiable contributory factors highlighted in the report include:
- Victim-packaging in the rescue harness was a problem because of the bunker pants and a full body harness worn by the simulated victim.
- A vertical lifting bridle was not included by the manufacturer with the purchase of the rescue device and therefore not used, which resulted in the victim’s head pitching forward.
- Insufficient training by the manufacturer about the limitations of the rescue device used.
- The forehead and chin straps to hold the head upright were not used.
- The rescue harness is a useful and valuable tool; however; its use should include both proper warnings and training.
There are also unverifiable contributory factors that Roop was unable to confirm. The victim firefighter strongly asserts that the training event was flawed in its organization and that the two rescuers who packaged him on two successive occasions overly tightened the device to the point of compromising his breathing and blood flow.
The victim further claims that the rescuers did not check on his breathing and were unresponsive to his distress. The rescue harness video advises securing the patient with its straps “snug, but not restricting” and to use the “two-finger” method under each strap to ensure that it is not tight/restrictive.
The rescuers in question denied the specific victim claims. Roop’s investigation of the incident could find no specific evidence verifying either the victim’s or the rescuers’ assertions, but the identifiable contributory factors do reveal that there were issues with patient packaging in the rescue harness during the training event.
Final Comments from Chief Goldfeder
With the recent loss of Chief Alan Brunacini, I could not help but be reminded of him when I was working on this particular Close Call. There was a time in our country where little, if anything, was shared when a firefighter was injured or killed. While I always acknowledge the IAFF in pushing the need for facts—and they have for decades—Chief Bruno always stands out in my mind as the individual chief who set that example.
Specifically, in 1984, Phoenix Firefighter Ricky Pearce died in the line of duty. I distinctly remember how Chief Bruno shared with the world what the Phoenix Fire Department could improve upon following that tragic loss. Sharing the truth wasn’t exactly common back then.
Unfortunately, in some areas, the facts are still not shared, but that’s not the case with Chief DeMint and the PFA. As you read, every detail of this event was investigated both internally AND externally. Using an outside subject-matter expert is so important when getting to the bottom of why things go wrong.
The incident details and recommendations have already been well covered, but I would like to highlight one important, but general, point related to communication and policy.
From my perspective (which, admittedly, is more often from a chief/supervisor’s view vs, a firefighter’s view, although I try hard to maintain equal perspective), I cannot emphasize enough the importance of communication. If your crew is going out for training or a drill, make sure that is fully communicated to and approved by your on-duty chief or duty officer. And if you are using a rarely used tool or device, ensure that you are fully trained and initially qualified on it.
What is the best way to accomplish this? Policy.
Now is the time to consider several questions related to your agency’s policies to determine what is expected when a company officer wants to conduct a hands-on field drill:
- What does your department POLICY state?
- What steps must be taken prior to initiating a drill?
- Who is to be notified?
- Who approves the training?
- Who is responsible?
- What backup plans are in place?
- What standards apply to the drill?
This may seem like a whole lot when your company simply wants to hit the streets and do some realistic training, but by having a clear policy that specifically outlines who, what, where, why, etc., you can avoid injury—or worse. In this case, so much of what can be considered for your department’s related training policy has already been done for you by the PFA.
As risk management expert Gordon Graham—my longtime partner at FireFighterCloseCalls.com—reminds us, “If It’s Predictable, It’s Preventable.”
Our sincere thanks to Chief Tom DeMint of the Poudre Fire Authority for sharing this Close Call with Firehouse.
Sidebar: About the Poudre Fire Authority
The Poudre Fire Authority provides fire/rescue services across approximately 235 square miles, including the City of Fort Collins, CO, and the Poudre Valley Fire Protection District. The district has a population of approximately 206,000 people and an estimated property value in excess of $29 billion. Its 210 career employees, 25 volunteer firefighters and six volunteer support members staff 13 fire stations, a training center/warehouse/emergency management complex and administration facility that includes Headquarters and Community Safety Services divisions.
A five-person board of directors appointed by the Fort Collins City Council and Poudre Valley District Board governs PFA. Its members include two city council members and two district board members. The fifth member is chosen jointly by these four and has historically been the Fort Collins city manager. The board appoints Poudre Fire Authority’s fire chief, a title currently held by Chief Tom Demint.
