Common Cause Failures- What side of the Curve are you on?

New NIOSH Report Issued: On February 29, 2008, a 21-year old male volunteer fire fighter (the victim) and a 33-year old volunteer Lieutenant were injured during a structural fire. The fire fighters were attempting to locate and rescue a 44-year old female resident from a burning duplex.

The fire fighters became trapped on the second floor when fire conditions deteriorated. The victim was rescued by the rapid intervention team (RIT) and both the victim and injured Lieutenant were transported to the hospital. The victim remained in critical condition for several days in the burn unit before succumbing to his injuries on March 5, 2008. The female resident of the structure did not survive the fire.

Key contributing factors identified in this investigation include;
the lack of water supply,
fire fighters advancing within the burning structure without the protection of a charged hoseline, inadequate training in defensive search tactics,
non-utilization of thermal imaging camera by the search crew,
lack of coordinated ventilation,
size-up information about the structure was not relayed to fire fighters, and
interior reports were not relayed to the incident commander.
NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should:

be prepared to use alternative water supplies during cold temperatures in areas where hydrants are prone to freezing

ensure that search and rescue crews advance or are protected with a charged hoseline

ensure fire fighters are trained in the tactics of a defensive search

ensure that fire fighters conducting an interior search have a thermal imaging camera

ensure ventilation is coordinated with interior fireground operations

ensure that Mayday protocols are developed and followed

ensure the Incident Commander receives pertinent information during the size-up (i.e., type of structure, number of occupants in the structure, etc.) from occupants on scene and that information is relayed to crews upon arrival

ensure that fire fighters communicate interior conditions and progress reports to the Incident Commander

develop, implement, and enforce written standard operating procedures (SOPs) for fireground operations

Additionally;
fire departments and municipalities should ensure that citizens are provided information on fire prevention and the need to report emergencies immediately

building owners and occupants should install smoke detectors and ensure that they are operating properly

CONTRIBUTING FACTORS
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that ultimately led to the fatality:

Inadequate water supply. Two hydrants in the vicinity of the burning structure were frozen from the cold weather.

The victim and injured Lieutenant did not have the protection of a charged hoseline during their search for the trapped occupant.

Inadequate training in defensive search tactics.

Non-use of a thermal imaging camera which may have allowed the search and rescue crew to advance more quickly through the structure.

Ventilation was not coordinated with the interior search.

Size-up information about the structure was not relayed to the interior search crew. The interior crew was searching in the wrong duplex for the trapped occupant and did not realize they were in a duplex.

The incident commander was unaware of the search crew’s location in the building. He did not receive any interior reports and was concentrating on resolving water supply issues.


There are a number of basic factors presented within this report that are not only common to many other NIOSH LODD reports, but also present at best common shortcomings in the way many fire departments operate or practice. After reading the report and the apparent cause and contributing factors, provide some insights as to how we can overcome similar issues affecting incident command, operational deficiencies and tactical failures. What are we missing? How does your department stack up?

Have you had similar "operational issues" such as these; the lack of water supply, fire fighters advancing within the burning structure without the protection of a charged hoseline, inadequate training in defensive search tactics, non-utilization of thermal imaging camera by the search crew, lack of coordinated ventilation, size-up information about the structure was not relayed to fire fighters, and interior reports were not relayed to the incident commander.