CARLA FIREY
Firehouse.Com News
Photo Courtesy NIOSH
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When six firefighters were killed in a Worcester, MA warehouse fire on
December 3, 1999, a team from the National Institute For Occupational Safety
and Health (NIOSH) faced one of their most challenging investigations.
Indeed, on the first trip to Massachusetts the investigators remained in the
background, offering assistance when requested but refraining from
conducting interviews. "We kind of stayed in the background and watched the
recovery process," said Frank Washenitz, a member of the NIOSH team. "We
offered any information we could provide, and tried to have a support role."
In 1998, Congress commissioned NIOSH to examine the deaths of firefighters
in work related incidents. Using the same methodology and policy as FACE
(Fatality Assessment and Control Evaluation Program), NIOSH created the Fire
Fighter Fatality Investigation and Prevention Program.
FACE is a NIOSH research program used for the identification and
investigation of fatal occupational injuries. The goal of FACE is to
collect information on factors that may have contributed to an occupational
fatality, and to develop recommendations for the prevention of similar
incidents.
The Worcester interviews themselves, which the team initiated on the second
trip to the scene, were awash with emotion. "In any situation like this,"
Washenitz said, "you have a close-knit, brotherhood setting. Emotions are
one thing that’s consistent."
For the investigators, conducting interviews and examining the scene can be
a difficult task. "It’s tough to go out and see people in an event of life
where they’re taking it hard," said Thomas Mezzanotte, investigator for
NIOSH. "We have to make people relive the event, and that can be draining."
NIOSH’s Fire Fighter Fatality
Investigation and Prevention Program
investigates and reports on approximately 80% of annual firefighter
line-of-duty deaths, said Richard Braddee, team leader of the Morgantown,
West Virginia investigation team. NIOSH investigators prepare reports on
these deaths in an effort to explain the event and prevent future
fatalities.
Photo Courtesy NIOSH
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NIOSH’s two largest firefighter investigation offices are located in Ohio
and West Virginia. The offices in West Virginia oversee the trauma fatality
investigations. They also have a department devoted to SCBA equipment and
maintenance programs, and in-house laboratories for examining equipment.
Ohio offices investigate cardiovascular deaths.
Almost all of the NIOSH investigators are certified firefighters. Those who
aren’t, anticipate completion of the training in the near future. Aside
from giving them a certain amount of credibility, the firefighting training
helps the investigators empathize with the people they must interview. All
of the team members complete Fire & Arson school at the Fire Academy in
Emmitsburg, Maryland.
The trauma team consists of seven people, all located in Morgantown. Of
those, one person is entirely devoted to the examination of SCBA and the
development and evaluation of SCBA maintenance programs. All of the
investigators on the team have college degrees, and most hold post-graduate
degrees. In general, their education and work experiences are related to
occupational safety and safety engineering. Braddee, the team leader,
possesses a Masters degree in Safety and Environmental Management. He is a
certified firefighter and has investigated occupational fatalities for
sixteen years.
The other team members responsible for conducting investigators include
Frank Washenitz, Kim Cortez, Mark McFall, Tom Mezzanotte, Nancy Romano, and
Jay Tarley. Tom McDowell is the team’s physical scientist, and Cathy
Rotunda fills the role of project specialist.
NIOSH usually learns about firefighter fatalities from the USFA or
Firehouse.com. They request initial data and information from the city in
which the incident occurred and the fire department from which the victim
worked. Frequently the fire department, police, and coroner’s office
release their files.
Photo Courtesy NIOSH
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From this initial data the NIOSH team attempts to estimate the number of
on-scene interviews which will be necessary. At some point after the
funeral and memorial services have been completed, depending on the team’s
caseload, NIOSH will send investigators to the scene. The number of
investigators sent to any particular incident varies according to the size
of the fire department involved, the number of fatalities, and the current
caseload of the investigators. In general, no more than four investigators
are sent to one scene.
"We usually wait until after the victim is buried," said Kim Cortez, an
investigator with NIOSH. "We want to be respectful of the families and
their emotions." NIOSH investigators usually arrive on the scene about a
week after the firefighter’s funeral.
Once the team arrives on the scene of the fatality, they work in conjunction
with other investigators. The team frequently interacts with fire marshals,
the fire department, the coroner’s office, and/or the police department.
The team examines the scene of the incident and the large equipment that was
damaged or involved. "Sometimes there’s nothing left to really see," said
Braddee, "but it helps give us a feel for the incident."
The team’s primary method of investigation involves interviewing the people
who were on the fire ground scene. They try to determine the sequence of
events and the various roles of each member of the department. The
interviewers will probe the circumstances and conditions surrounding
training, equipment, SCBA, turnout gear, and communications. Other
questions would include SOPs, RITs, and the incident command system.
"We’re occasionally met with a little fear," said Jay Tarley, the team’s
newest investigator. Tarley has a degree in safety engineering and six
years of experience in the industry. "Sometimes people think that we’re
there to place blame. In truth, we only want to help prevent future
fatalities."
Photo Courtesy NIOSH
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NIOSH believes that fatalities and job injuries are typically multi-causal.
"We’re not here to point a finger and blame someone," said Braddee. Once
the investigators explain their role, they usually receive a friendly and
warm welcome.
Nonetheless, other challenges present themselves during the various
interviews the team must conduct. "Sometimes it’s difficult to get them to
talk about it," said investigator Nancy Romano. "A lot of fire departments
have a family atmosphere. Some of them really are family. In some
departments a lot of relatives will work there together."
Tarley said that respect was the best way to deal with the difficult
emotional situations arising from interviews. "It helps to be a people
person," he said, "and to try and sympathize with them."
"Sometimes people just want to talk about the firefighter who died. They
need someone to listen," said Cortez. "It’s hard to emotionally distance
yourself from the victim, but it’s important to concentrate on the actual
event."
The investigators ask about the training, the situation, and the actual
event. Investigators ask everyone on the scene about their role during the
incident. In as much detail as possible, they attempt to recreate the event
on paper. Diagrams and descriptions are used to piece together the
situation. "It’s like putting together a puzzle," said Tarley. "There’s an
overwhelming amount of information."
"A lot of it depends on the situation," said Cortez. "We see all types of
fatalities: propane explosions, drownings, motor vehicle, and falling from
ladders. Firefighters are exposed to so many different hazards."
In some incidents, SCBA may be transported to the NIOSH lab for examination
by engineer Thomas McDowell. McDowell uses six NIOSH certification tests
and one NFPA airflow test in his examination of the SCBA. "Other tests
might also be added, depending on the circumstances," McDowell said.
Unfortunately, the SCBA is often damaged by the time McDowell receives it.
"A lot of damage occurs after a firefighter goes down," he said, "so my
results are sometimes inconclusive." McDowell frequently discovers that the
SCBA was functioning properly during the incident.
Once the investigators complete their interviews, they return to NIOSH
offices to prepare the report. The reports include a summary, detailed
results of their investigation, the cause of death, and recommendations.
"The typical report goes through about fifteen reviews," said Romano.
Reviews are made by fellow team members, editors, and the deputy director of
NIOSH. The fire department, branch chief, and experts may also review the
document. Experts include former Deputy Chief Vincent Dunn of the FDNY and
Frank Brannigan, a Fellow in the Society of Fire Protection Engineers.
The caseload of the investigators, as well as the number of reviews
necessary for a report, determine the time it takes to finalize and publish
a report. "I have about five open cases now," said Romano. In general, it
can take anywhere from 4 months to a year before a report is ready for
publication.
NIOSH also publishes special reports and documents. Hazard IDs describe a
specific hazard, such as propane tank fires, and offer recommendations for
minimizing risk. ALERTs examine more general topics, such as structure
fires or motor vehicular accidents. ALERTs also offer specific case
studies, recommendations, and a summary of precautions. Publication of a
new ALERT is anticipated in 2002, and three new Hazards will probably be
issued in 2001.
Other NIOSH publications include a Public Health Advisory regarding Aluminum
Oxygen Regulators and a Fact Sheet examining exploding flashlights.
Photo Courtesy NIOSH
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Another aspect of the NIOSH Fire Fighter Fatality Investigation and
Prevention Program involves the evaluation of SCBA maintenance programs.
"The biggest problems," said McDowell, "are lack of documentation and SOPs."
McDowell evaluates approximately six maintenance programs in various fire
departments, on-site annually. Most on-site audits are called as a result
of a firefighter fatality.
McDowell also receives about 50 requests a year for his information packet.
The packet contains copies of relevant articles, a fifty-question audit
checklist, and sample SOPs and inspection forms. The audit checklist
includes questions about SCBA training, SOPs, inspection, maintenance, air
quality monitoring, recharging of cylinders, record keeping, and an annual
review.
Any fire department can request this packet, and McDowell believes that most
hear about the program through the NIOSH web site.
"A lot of them want to try and
improve their maintenance programs first," he said, "and then they call and
ask me to do an on-site audit."
The NIOSH Fire Fighter Fatality Investigation and Prevention Program has
completed approximately 140 investigations since inception. About 106 are
available on the web site http://www.cdc.gov/niosh/firehome.html
and the rest are being processed.
Each member of the team agreed; their goal was to inform the industry about
risks and prevent future firefighter fatalities. Cortez said, "Someone lost
their life for this, and you want to do what you can to help prevent this
from happening again."
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