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Learning from Tragedy Lesson One Preparation

This Monday, December 8th. an F/A-18D returning to Miramar Naval Air station from the USS Abraham Lincoln off the coast of San Diego encountered some type of engine problem forcing the pilot to eject seconds before the jet slammed into a neighborhood just outside the airbase. The resulting explosion destroyed two homes and damaged three more. The most tragic result was the death of four members of one family who were home unfortunately at the time. An additional 20 homes in the area were evacuated to the smoke and heat.

What struck me as interesting was a comment made by a politician shortly after the crash that he wanted to conduct an investigation to ensure that this type of incident would never happen again. This type of comment, although understandable, clearly illustrates the lack of understanding of the general public to the dangers involved in high risk occupations. We know that United States Navy and Marine Corps provide excellent training, excellent maintenance and demand all of their pilots undergo the most rigorous training of all pilots flying today. All of this notwithstanding the United States Navy and Marine Corps understand that failures will occur.

No system, no machine, no individual is perfect and so one must anticipate the occasional failure, the occasional accident and the consequences. The consequences are what must be mitigated. Now if this particular politician is going to ensure that no Navy jets ever fly again over a neighborhood in San Diego then he can in fact have his dream. But barring a complete and total ban of naval aircraft and the San Diego civilian airspace no one guarantee there won't be another accident.

What can happen is that the United States Navy and Marine Corps need to investigate this incident and look at all the systemic issues that came together tragically to cause this accident. We would hope that now with all we understand about the systemic nature of accidents that the pilot is not identified as the cause. Unfortunately commonly in air related events this is all too often the finding. This represents the easiest way out and therefore the most common way out by some unmotivated investigator who is all too happy to say it was simply human error. Any event, especially transportation accidents that involve human beings as operators, pilots or engineers generally gets labeled as human error.

In order to understand how errors occur, how failures happen and what really causes an accident we need to let go of what Prof. Sidney Dekker PhD calls the old view. We must adopt what Prof. Dekker calls a new view of human error then and only then we recognize that the accident in this case a tragic plane crash is enmeshed in almost spiderweb of complex interconnected and yet independent causes. There is no root cause, there is no primal cause, it was not just human error it was clearly a systemic failure.

What we take away from these types of studies for our profession, for the fire service. In these events we are the first to be called and we must be ready. From the firefighter perspective it's our job to be prepared for these events and not to assume that we can make them all go away. In that regard I would suggest that you read the drill on military aircraft located at this web link
http://www.fireengineering.com/display_article/213203/25/none/none/...
Hold the drill this week connect the drill in context to this tragic event have your folks read the article in fire engineering have them look at the video which is still available in our video section from the ABC news report bring this event alive in your training. Just because you do not happen to live underneath and airbase does not mean that you should not be prepared. These events can happen anywhere the United States Air Force, Navy, Marine Corps, and Army as well as our close friends the US Coast Guard fly over every state in the union. You owe it to your residences in your town and you owe it to the outstanding pilots of those fine aircraft to be prepared to respond when they need you. Don't think about it, do it. To quote Adm. Rickover it's easy to talk about doing things its a whole a other matter to get them done. Firefighters get it done.

If you want to really do more to get prepared is a great article by John Carr and Les Omans titled responding to commercial aircraft hazmat incidents in this article they do address some of the issues with military aircraft. http://www.fireengineering.com/display_article/128427/25/none/none/...

Just a few things to keep in the back of your mind when you're dealing with a downed military aircraft stay away anything painted yellow and black. Remember these aircraft carry ordnance, weapons and oftentimes have secure systems. If you have a military base near your fire department requests training as to what to do and who to contact in the event of a downed military aircraft. During my time at the Albuquerque fire Department the members of the Kirkland Air Force Base were always more than willing to put on classes for us at any time as to what to do if one of their aircraft were compromised or had to make an emergency landing.

The fire service is all about relationships, we need to continue to foster good relationships with our partners particularly with the military bases in our first due. For more good reading on aircraft emergencies like to recommend fire Department response to helicopter emergencies by Jerry Knapp Christopher Flatley and Wayne Sutherland available here at this link
http://www.fireengineering.com/display_article/251463/25/none/none/...My thoughts and prayers go out to the family and friends of the family who lost their lives on Monday. My thoughts and prayers and deepest condolences also bought the brave Marine pilot when sure did everything he could to direct that aircraft away from any homes prior to ejecting. Until next time stay safe and remember be careful out there.

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Comment by Marty Mayes on December 16, 2008 at 1:44pm
Thanks for the reply, all good stuff. Have a great holiday season.
Comment by Chris Fleming on December 16, 2008 at 10:49am
Thanks for the comment, Marty. I hear you on "training the brain". I agree, that we have to have strong basic skills to be able to think on the fire ground. If you have to think about which end of a halligan to put into the door frame, you probably aren't thinking about conditions on the other side of the door. As far as my comment on the "broken system" what I meant was that an emergency or fire is what happens when something has gone wrong for someone else. Nobody designs a building to burn. Your are right that we are not a part of the broken system, but we can't expect a building on fire to behave the way it would under non-fire conditions. We are not part of the broken system, but we are definitely inserting ourselves into something gone wrong. As a friend of mine says, "noone calls us when they do something right!" Thanks again, and stay safe.
Comment by Marty Mayes on December 15, 2008 at 5:22am
Chris, I found your views on this subject very interesting. You are right, the investigative part of any post incident review is based on blame. We are a country filled with attorneys who basically lend themselves to becoming our politicians. They in-turn manufacture the very laws and review boards we must deal with. Lawyers are only post incident and consequence based in thier approach to any system failure. By understanding this sytem we only find ways to cover up mistakes, not truly address systemic failures. As for us, a pre-incident plan is a solid tactic to address systems and evaluate what failures are likley. Now as for the next part we are probably only disagreeing over the particular vocabulary we use personally. I feel we cannot expect the unexpected, by true definition the un-expected is always an unknown. I feel if we train such a mindset we are selling our guys short. We are not training the brain to be able to deal with the dynamic world of firefighting. The truth is our job remains a bit of an inigma, meaning there are jobs we simply cannot train for or plan. We must strive to train our firefighters how to use thier natural instincts.How to make sound and prudent judgements at these times.If you take a solid and experienced company officer, give him a well trained crew, I bet he can make a good decision. Even if he is faced with unknown varibles when he left the house. To accomlish this he and his crew must have a great mastery of the basic skills needed for self survival. They must be skilled tactically as well. When the brain can fire through all of the day to day skills needed for this job, it can focus more space on instinctual based decision making. I am not sure I agree with the statement, we are already responding to a broken system, secondary to the fire or emergency. While I certainly see where you are coming from, I feel our response(or system) is not a component of a failure. I tend to look at this job and how we perform it's assigned duties as work. It is what we do. I train simply to do better job. As long as humans design and implement systems, there will be failure at some and maybe all levels. How we respond to these failures is what makes us brothers. Now back to agreeing with you! I tell my guys this alot,
"We must effect a change in fire behaviour, not fire affecting our behaviour." Like you said, accept what is and work the fire given. Thanks Chris.
Comment by Chris Fleming on December 12, 2008 at 11:09am
The simple answer in any investigation into accidents or errors is usually bent on placing blame on an individual or individuals. What is more important in preventing reoccurences is studying the system. That brave Marine pilot did not get into the cockpit expecting a crash, the same way no firefighter goes to a call expecting to be injured or killed. Perhaps there is a new way of looking at training that says "Expect the unexpected." I think the military spends a lot of time doing that type of training, as is evident by the pilot being able to eject from the aircraft before impact. The fire service is coming around to this type of training with the emphasis on "Get Out Alive" and R.I.T. training, but we still have work to do. We need to take our thought process back to the preincident plan. When there is a fire or emergency the system is already broken! We show up trying to fix the broken system or mitigate the damage. We need to start approaching fires with a different mindset. Currently, most aggressive firefighters roll out the door thinking offensive/ interior attack and THEN if that's failing we retreat and go defensive. Maybe we should repond with the attitude that our initial attack will be defensive then, if conditions allow we go to an offensive attack. To apply what we do to the pilot scenario, we are getting in the cockpit as the plane is malfuctioning! To expect the plane (fire ground) to be functioning as expected when we show up is like throwing ourselves in front of the train with no brakes. I am not suggesting that interior, aggressive firefighting be abandoned but we need to recognize that we can't undo what has been done when a system has experienced catastrophic failure.

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