Thread: FF LODD reports

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    Angry FF LODD reports

    I would like to know if my perspective is jaded or if I'm actually missing something. I welcome your insight. I say this with all due repect to those involved, and I sincerely mean that, especially those who suffered the loss. I continue to read these line of duty death reports and in the analysis are these vague, broad statements offering no detail or insight as to how the failure to do something that is cited, ACTUALLY contributed to the results. It's like they pull out a standards and reccomendations book and analyze the incident and then write down every facet of something that wasn't complied with, as if it's that simple. In the Contra Costa Report published recently there are standards and buzz words listed, the same ones that are listed in every report. I fail to see, for instance, how mistakenly passing command to a later arriving unit that was marked differently than reported, or failing to walk around and do a 360 of the fire building, had anything to do with the engine company, the very individuals who paid with their life, setting the nozzle down at a fire that was apparently not extinguished. Is the fire service placing its emphasis in the wrong area? I don't know how many command posts, safety officers, liasons and RIT teams it takes to safeguard that.
    Last edited by DeltaCreek; 08-27-2008 at 11:06 PM.

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    Quote Originally Posted by DeltaCreek View Post
    I would like to know if my perspective is jaded or if I'm actually missing something. I welcome your insight. I say this with all due repect to those involved, and I sincerely mean that, especially those who suffered the loss. I continue to read these line of duty death reports and in the analysis are these vague, broad statements offering no detail or insight as to how the failure to do something that is cited, ACTUALLY contributed to the results. It's like they pull out a standards and reccomendations book and analyze the incident and then write down every facet of something that wasn't complied with, as if it's that simple. In the Contra Costa Report published recently there are standards and buzz words listed, the same ones that are listed in every report. I fail to see, for instance, how mistakenly passing command to a later arriving unit that was marked differently than reported, or failing to walk around and do a 360 of the fire building, had anything to do with the engine company, the very individuals who paid with their life, setting the nozzle down at a fire that was apparently not extinguished. Is the fire service placing its emphasis in the wrong area? I don't know how many command posts, safety officers, liasons and RIT teams it takes to safeguard that.

    If you are refering to NIOSH reports...they have made some very questionable assements in recent years and the relevant "expereince" possesed by pannel members is virtually ZERO. There is almost NO firefighting expereince among the many people who develop these reports. (and it shows)

    For the most part today I take them and their "recomendations" with a grain of salt.

    FTM-PTB

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    Fred, I take them and throw them in the garbage. With the exception of guys being killed in apparatus accidents or from wildland fire's most LODD's are from things just going bad, nothing else. To say that most would be prevented would also us saying that we should just do exterior operations instead of attempting to save lives.

    One must always be cognizant of their surroundings and experience is the only way that this is accomplished usually through many near miss situations and white faced, draws changing situations.

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    My opnion in this subjectis based on my review of NIOSH reports and reports from the NJ DFS. It also comes from my participation in several LOD incidents.

    I disagree completely that they are garbage. Until you get to the "Recommendations" section, what you get is usually a very detailed description of the incident. This has great value, I think, in training sessions in the fire house.

    Where the wheels come off the track is when we get to the "Recommendations". These governmental agencies are loathe to actually lay blame at the feet of those responsible. In most of these cases, things did go wrong. But there is a REASON they went wrong and there is usually SOMEONE responsible for them going wrong. Sometimes it is the IC, sometimes it is a non-fire service person, sometimes it is the dead member themselves. But these reports never call a spade a spade and say "(X) SCREWED UP"!

    Of course the reason for this is to keep the governmental agencies out of civil court. But in the process, they diminish the value of these reports.

    The second thing wrong with these reports is the time it takes to issue them. There are some important cases involving LODD that take over a year to get a report issued. I fullyunderstand that the reason they take so long is NOT the investigators fault. It is the fault of bureaucrats who are looking to cover their collective asses. These reports are reviweed and revised over and over bypeople with zero experience n fire fighting. And that is not a good thing.

    Int he case of NJDFS, they have some highly qualified people involved in the investigation and they bring much to the table. NIOSH, howevr, is a different story. We spoke on here about a year ago that NIOSH was hiring investigators for this program. The job announcement required experience in engineering and occupational safety and health. The woreds "fire fighter", "fire officer" or "fire investigator" did not appear in the announcement. That's like having aircraft accidents investigated by people with no background in aviation.

    (Yeah. I appliaed for the NIOSH job and was classified as "Qualified but not considered". That was laughable.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    George, I agree with your position that the reports are excellent in event detail, especially the one I cited and the one recently released by Prince William County, Va. Those two reports were internally generated and offered tremendous detail, and their analytical value does suit an excellent purpose in the firehouse.

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    Sometimes (most times) internally generated reports are far more critical and far more factual than the reports generated by governmetal agencies. Although there are debatable flaws in the Charleston report, it is a very insightful look into the incident and the causes of the ensuing disaster. The NIOSH report will not come anywhere near this in its detail.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    Besides the Prince William report, there are the recent ones from Texas and California that are thorough and informative considering the circumstances. The reports with the hose line layouts and last FF positions should be looked at and learned from, not trashed.
    To me, the reports are depressing reading. But, forcing through to the end wakes me up to my own personel and department shortcomings.
    Read them with respect and an open mind.

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    When our legal system quits punishing people for being people, you will see a willingness to admit mistakes. The purpose of investigations is to try and deny benefits. Any learning from them is collateral damage.
    Logic and proportion have fallen sloppy dead.

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    Default Useful Information

    I believe that the information provided in LODD reports is critical! Accidents do not just happen because "things went bad". Things usually go bad due to a series of complex and interconnected events and actions.

    As noted in one of the earlier posts, NIOSH investigators are not fire service professionals (this is intentional, to try and avoid our biases). However, after a public meeting two years ago, they have instituted a review of draft reports by fire service members in an attempt to address these issues.

    I use these reports regularly, but generally will delete the recommendations before presenting the case. This gets people to look at the information (and consider that this is not the whole story) and think about what happened.

    Department reports or reports done by state investigative agencies (e.g., Texas State Fire Marshal) are also an excellent source of information. As with NIOSH reports there are often conclusions and recommendations that I would not agree with. This does not reduce their value, but simply means that we have to examine the information and reach our own conclusions.

    We have it much better than some other countries where information in held extremely close regarding LODD out of concern for criminal prosecution of Chief Officers (e.g., UK). I understand the reasons, given the judicial and political considerations, but this makes it much more difficult to learn from these events. While we have a litigious socienty, information is much more readily available and can serve as a valuable tool for firefighter safety.

    Cheers,
    Ed Hartin, MS, EFO, MIFireE

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    Quote Originally Posted by johnny46 View Post
    When our legal system quits punishing people for being people, you will see a willingness to admit mistakes. The purpose of investigations is to try and deny benefits. Any learning from them is collateral damage.
    Nothing could be further from the truth. I have conducted three of these investigations. An investigation is based on fact. My investigations are conducted free of any bias that would be interjected if the investigative team were concerned with whether benefits were going to be paid. Facts are facts.

    What you are seeing with the Hometown Heroes Act fiasco is higher level bureaucrats with a bug up their *** about FF. They are making unilateral decisions disregarding facts and the law.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    As noted in one of the earlier posts, NIOSH investigators are not fire service professionals (this is intentional, to try and avoid our biases). However, after a public meeting two years ago, they have instituted a review of draft reports by fire service members in an attempt to address these issues.
    Two things;

    1. It is intentional, but it is intentional because they do not care. FF do not fit into the geek mold of an occupational safety engineer.

    2. The IAAI has a rep on this committee. The committee has NEVER met. Not once.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    The recommendations provided in the NIOSH reports should be taken with a grain of salt.
    However, I believe that the reports are very good at providing the facts about an incident. It provides the size of the structure, location and extent of fire, as well as the location or incident that claimed a life.

    It also provides or has input from witnesses, other firefighters, etc... I guess I look at that information as being invaluable.

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    Quote Originally Posted by johnny46 View Post
    When our legal system quits punishing people for being people, you will see a willingness to admit mistakes. The purpose of investigations is to try and deny benefits. Any learning from them is collateral damage.
    Nothing could be further from the truth. I have conducted three of these investigations. An investigation is based on fact. My investigations are conducted free of any bias that would be interjected if the investigative team were concerned with whether benefits were going to be paid. Facts are facts.

    What you are seeing with the Hometown Heroes Act fiasco is higher level bureaucrats with a bug up their *** about FF. They are making unilateral decisions disregarding facts and the law.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    In addition to many of the valid points raised, I think some of this can be contributed to the standard Management and PR technique of "Staying on message".

    Just like in any day-to-day OSHA or Risk Management role, you are constantly trying to remind folks of the "Best Practices" for safety. I suspect many of the folks who write these reports feel like regardeless of the actual implications of the action, they must highlight these reccuring issues to keep them at the fore front.

    You are right that it often acts oppositely, and causes us to groan and say "Not this crap again", but how many of us can name off these recurring "reccomendations" by heart. Does this not mean the messaging is working to some extent?
    Never argue with an Idiot. They drag you down to their level, and then beat you with experience!

    IACOJ

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    The problem is that we tend to be halfway decent telling when smoke is being blow up our *****es. We read decent fact gathering in the report which is then blown away by recommendations written by the occupational safety engineers who don't know anything about actual firefighting. After reading a few of these and seeing the same recommendations (some may hold water while others don't) we tend to toss them aside and seek reports written by those whose opinion we respect. They probably could be more valuable if the left their recommendations out and stuck to the fact gathering.

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    Quote Originally Posted by RFDACM02 View Post
    The problem is that we tend to be halfway decent telling when smoke is being blow up our *****es. We read decent fact gathering in the report which is then blown away by recommendations written by the occupational safety engineers who don't know anything about actual firefighting. After reading a few of these and seeing the same recommendations (some may hold water while others don't) we tend to toss them aside and seek reports written by those whose opinion we respect. They probably could be more valuable if the left their recommendations out and stuck to the fact gathering.
    While some of the recommendations can seem a little impractical depending upon where you work or volunteer, I disagree with the idea that these reports would be better without them.

    If you feel that the recommendations have no merit, or dont offer concrete, practical real world solutions for your department, then treat them as such.

    The fact of the matter is, the report is issued following the death of a firefighter. And in many cases, following just ONE of the recommendations offered could have prevented the loss of life.

    Lets not push for less information and less recommendations. Lets push for more, and then be responsible professionals with the information to make changes when and where they are necessary.

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    Having been involved in an incident that was evaluated by NIOSH, I agree with FFred.....factually acturate??? Not in this case......anything but.

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    Quote Originally Posted by MattyJ View Post
    Having been involved in an incident that was evaluated by NIOSH, I agree with FFred.....factually acturate??? Not in this case......anything but.
    Not putting words in his mouth, but...Fred didn't say they were not factually accurate. He was saying that their recommendations were being made by non-fire suppression personnel and were suspect because of that. That is entirely different.

    Can you cite a specific instance where a NIOSH report was factually inaccurate? One of their problems (and not saying it happened in your situation, because I am not familiar with this incident) is that sometimes the involved FD's are more concerned with protecting their asses instead of cooperating in the investigation.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    [QUOTE=GeorgeWendtCFI;980675]Not putting words in his mouth, but...Fred didn't say they were not factually accurate. He was saying that their recommendations were being made by non-fire suppression personnel and were suspect because of that. That is entirely different.

    Can you cite a specific instance where a NIOSH report was factually inaccurate? One of their problems (and not saying it happened in your situation, because I am not familiar with this incident) is that sometimes the involved FD's are more concerned with protecting their asses instead of cooperating in the investigation.[/QUOTE

    All I'm going to say on this, is there was relevent information not included in the report, and false information reported as fact. I'm not going into details on an internet board. The point is the reports might not always be factually accurate. As far as those on my job conducting a separate investigation, I found them very thorough, very concerned with finding out the facts....their report was competely accurate.

    I agree with FFred regarding the recomendations....I was not impressed by the credentials of those offering their recommendations, or making the report.
    Last edited by MattyJ; 08-22-2008 at 05:12 PM.

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    [QUOTE=MattyJ;980698]
    Quote Originally Posted by GeorgeWendtCFI View Post
    Not putting words in his mouth, but...Fred didn't say they were not factually accurate. He was saying that their recommendations were being made by non-fire suppression personnel and were suspect because of that. That is entirely different.

    Can you cite a specific instance where a NIOSH report was factually inaccurate? One of their problems (and not saying it happened in your situation, because I am not familiar with this incident) is that sometimes the involved FD's are more concerned with protecting their asses instead of cooperating in the investigation.[/QUOTE

    All I'm going to say on this, is there was relevent information not included in the report, and false information reported as fact. I'm not going into details on an internet board. The point is the reports might not always be factually accurate. As far as those on my job conducting a separate investigation, I found them very thorough, very concerned with finding out the facts....their report was competely accurate.

    I agree with FFred regarding the recomendations....I was not impressed by the credentials of those offering their recommendations, or making the report.
    You missed my point. I'll use a case I am familiar with to explain.

    I am aware of a FF LODD in an urban city. Career FD. FF was killed during fire suppression activities.

    (In this state, it is a requirement for PEOSHA to investigate every FF LODD and issue a report).

    When the investigative team went to the Fire Directors Office to initiate their investigation, they were handed a copy of the press release issued by the FD and told that this was all the information the FD was going to give them. They were denied access to everything except the investigation conducted by the county authorities.This report dealt mainly with the origin and cause.

    This PEOSHA agency had to threaten to go to court. They were then provided with redacted reports. They also were able to conduct some interviews with the assistance of the union.

    There was a tremendous amount of political interference by city/state officials in this case that resulted in an almost 18 month delay before the very watered down report was released to the public. When the report was released, the FD was not placed in a good light. The FD then had the audacity to hold a press conference blasting the PEOSHA for issuing a report containing numerous errors. This was despite the fact that they refused to cooperate in the investigation and make it factually accurate.

    I have heard anecdotes of this happening in other cases. It's kind of like the "garbage in - garbage out" theory. See what I'm driving at? It's not a question of whether the internal investigation is accurate. Under normal circumstances, they have access to information that nobody else does. The information is also fresher and more reliable. It stands to reason that the internal investigation is going to be a higher quality than the outside agencies's reports if there is no interagency cooperation.

    I have participated in three of these investigations. I can tell you without exception that our state DFS was brought into the investigation on Day One and was provided access to every piece of info we had. The result was a high quality, factually accurate report.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    [QUOTE=MattyJ;980698]
    Quote Originally Posted by GeorgeWendtCFI View Post
    Not putting words in his mouth, but...Fred didn't say they were not factually accurate. He was saying that their recommendations were being made by non-fire suppression personnel and were suspect because of that. That is entirely different.

    Can you cite a specific instance where a NIOSH report was factually inaccurate? One of their problems (and not saying it happened in your situation, because I am not familiar with this incident) is that sometimes the involved FD's are more concerned with protecting their asses instead of cooperating in the investigation.[/QUOTE

    All I'm going to say on this, is there was relevent information not included in the report, and false information reported as fact. I'm not going into details on an internet board. The point is the reports might not always be factually accurate. As far as those on my job conducting a separate investigation, I found them very thorough, very concerned with finding out the facts....their report was competely accurate.

    I agree with FFred regarding the recomendations....I was not impressed by the credentials of those offering their recommendations, or making the report.
    One other thing that is right on the money. The qualifications of the NIOSH folks are highly suspect when it comes to FF LODD investigations. If NIOSH has nothing but non-fire fighters conducting their investigations, it is not their fault. It is OUR fault. There are no non-LEO's conducting investigations into their LODD's, I guarantee you that.

    It has always boggled my mind why the USFA or NIST hasn't jumped into this and formed a GO-team to investigate these incidents. Of course, they would also be denied access by the FD's afraid of shining a light on the truth, but at least it would take the non-FF issue off the table.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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    Quote Originally Posted by GeorgeWendtCFI View Post
    Nothing could be further from the truth. I have conducted three of these investigations. An investigation is based on fact. My investigations are conducted free of any bias that would be interjected if the investigative team were concerned with whether benefits were going to be paid. Facts are facts.

    What you are seeing with the Hometown Heroes Act fiasco is higher level bureaucrats with a bug up their *** about FF. They are making unilateral decisions disregarding facts and the law.
    I believe you do your best and I think you're an honest fellow.
    Logic and proportion have fallen sloppy dead.

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    Default NIOSH Recruitment

    May of this year was the latest time that NIOSH recruited a "Safety and Occupational Health Specialist" for the Fatality Investigations Team, Firefighter Fatality Invetsigation and Prevention Program. This position is out of the Division of Safety Research, NIOSH, the CDC and DHHS respectively.

    There was one vacancy. The recruitment period was from 7 May until 21 May.

    Qualifications were at the GS-11 and GS-12 level.

    GS-11:
    One year of specialized experience at least equivalent to GS-09. Experience requirements at GS-11 are met by three full academic years of graduate level education or the successful completion of a Ph.D or equivalent doctoral degree.

    GS-12:
    One year of specialized experience at least equivalent to GS-11. Specilized experience related to the KSAs (Knowledge, Skills, Abilities) include experience in the evaluation of firefighting procedures and techniques in relation to the prevention of traumatic injuries/fatalities through the application of occupational safety and health principles.

    All applicants were evaluated on experience, education, training, self-development and repsonses to asessments and core questions.

    The job description, in part was, "NIOSH conducts independent investigations of line of duty fire fighter fatalities. Investigations are conducted for deaths under a variety of circumstances, including deaths that occur on the fireground, while responding to or from alarms, or while training or performing other non-fire emergency duties. The investigations involve site visits, interviews with fire department personnel, and interviews and meetings with other relevant parties. The program does not seek to determine fault or place blame on fire departments or individual fire fighters, but to identify steps that can be taken across the country to prevent future deaths and injuries. The investigation findings are summarized in an investigative report with recommendations for preventing future similar deaths or injuries. Health communication materials are developed from investigations of similar types of deaths. For example, documents have been developed summarizing findings and prevention recommendations from multiple investigations involving structure fires, and fire fighters working along roadways."

    Starting salary was $54,494 to $84,913.
    "If you put the fire out right in the first place, you won't have to jump out the window."
    Andy Fredericks,
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    Rest in Peace

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    also, the NIOSH report for Contra Costa is still pending.
    Report No. 2007-28

    There are a total of 49 reports pending, one of which is from 2006.
    "If you put the fire out right in the first place, you won't have to jump out the window."
    Andy Fredericks,
    FDNY E.48, SQ.18
    Alexandria, VA F.D.

    Rest in Peace

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    Quote Originally Posted by bcarey View Post
    May of this year was the latest time that NIOSH recruited a "Safety and Occupational Health Specialist" for the Fatality Investigations Team, Firefighter Fatality Invetsigation and Prevention Program. This position is out of the Division of Safety Research, NIOSH, the CDC and DHHS respectively.

    There was one vacancy. The recruitment period was from 7 May until 21 May.

    Qualifications were at the GS-11 and GS-12 level.

    GS-11:
    One year of specialized experience at least equivalent to GS-09. Experience requirements at GS-11 are met by three full academic years of graduate level education or the successful completion of a Ph.D or equivalent doctoral degree.

    GS-12:
    One year of specialized experience at least equivalent to GS-11. Specilized experience related to the KSAs (Knowledge, Skills, Abilities) include experience in the evaluation of firefighting procedures and techniques in relation to the prevention of traumatic injuries/fatalities through the application of occupational safety and health principles.

    All applicants were evaluated on experience, education, training, self-development and repsonses to asessments and core questions.

    The job description, in part was, "NIOSH conducts independent investigations of line of duty fire fighter fatalities. Investigations are conducted for deaths under a variety of circumstances, including deaths that occur on the fireground, while responding to or from alarms, or while training or performing other non-fire emergency duties. The investigations involve site visits, interviews with fire department personnel, and interviews and meetings with other relevant parties. The program does not seek to determine fault or place blame on fire departments or individual fire fighters, but to identify steps that can be taken across the country to prevent future deaths and injuries. The investigation findings are summarized in an investigative report with recommendations for preventing future similar deaths or injuries. Health communication materials are developed from investigations of similar types of deaths. For example, documents have been developed summarizing findings and prevention recommendations from multiple investigations involving structure fires, and fire fighters working along roadways."

    Starting salary was $54,494 to $84,913.
    And who did they hire? I am asking because my information is that the individual had no fire fighting experience.

    Although I would have had to take a pay cut, I applied for the position. I was rated something like "Qualified but not considered" or something like that.
    PROUD, HONORED AND HUMBLED RECIPIENT OF THE PURPLE HYDRANT AWARD - 10/2007.

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