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I recently sat in on a brief on the new Near Miss Reporting System.  I’ve always been a strong advocate of the Near Miss System since its inception and have used it many times when preparing to teach various topics.  It has a strong history of collecting and providing valuable information to the fire service.  And I’m glad to report that the new reporting system is better, stronger and faster than ever before.  But something struck me during the presentation on the new near-miss system.  If we are tracking the near misses, how are we tracking the “hits?”  

We have a system that collects anonymous data on the “misses,” that we share globally in an effort to prevent it from happening again.  But when it comes to actual fatalities, things get a little sketchy.  We have NIOSH reports that typically follow a death.  But I have come to realize from my own experience that those can be significantly edited.  I certainly do not mean to diminish the great work that the NIOSH staff does, it is just part of the process.  On rare occasion, a department will release an in-depth review that provides good information on the details of a death.  I also realize that there is a heap of legal filtering when a line of duty death occurs.  Many who would have information to share are not permitted due to legal constraints. 

To my point, I’m starting to pick up a potential epidemic on the fire ground and I don’t readily see a mechanism to measure the potential significance. How many firefighters have died in the last 20 years as a result of being caught in a unidirectional flow path?  I’ve done a little digging to see what data exists, and the data is very scattered and inconsistent.  Just looking at the obvious incidents, we quickly see that unidirectional flow paths can develop rapidly, and seriously injure or kill multiple firefighters at a time.  And yet, honestly, I did not have a working knowledge of the concept until a couple of years ago.  And I pay attention, or at least try to be current on the latest in our business.  To me, that is scary.  

I know what the “stakeholders” will say; we can’t or we don’t want to measure specific data on line of duty deaths.  To the “stakeholders,” I say that’s not good enough!  I know it will be complicated and difficult, but figure it out anyway.  We have to find a way to capture accurate cause-and-effect data related to line of duty deaths.  In many of these line-of-duty-death cases, it wasn’t the plumber, or the welder, or even the construction that killed our brothers and sisters.  It was the tactics we used to manage the situation.  We put our selves in positions where we shouldn’t have been, most often in the flow path.  We failed to control the building using proper tactics, which obviously requires staffing.  It is important to note that in most cases, the firefighters on scene were doing exactly what they were trained to do, so I certainly don’t fault them, or even think about playing “Monday-morning Quarterback.” They did what they believed was the right thing to do.  That is all anyone can ask and we should forever honor and remember their sacrifice.   

But the facts and lessons of these incidents are lost in the political correctness and positioning that occurs after a serious incident.  We have to find a way around that.  We have to find a way to learn and update our tactics.  We’ve made tremendous progress with the latest fire dynamics research.  The next challenge now is to incorporate systematic learning and improvement from experience during application.  We currently lack the infrastructure to effectively do that.  I know achieving such a goal is a deep, political and legal process, but why not get started now? 

To the departments who have openly shared such information, thank you.  We appreciate your courage to put it all out there so we can learn from these tragedies and hopefully prevent them from happening again.  To the “stakeholders,” you have a lot of work to do.  If I have offended anyone, it is certainly not my intention.  My only intent is find the information we need to do our job as safely as we reasonably can.  

Again, I’m a big fan of the Near Miss Reporting System.  I’m glad we’ve been able to keep it alive.  I would simply like similar data on cases where we unfortunately had a “hit.”  Maybe we need the “Direct Hit Reporting System too?” 


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Comment by Bobby Halton on April 23, 2014 at 12:12pm


Great post and I think what we need to look at when we talk about flow paths or air tracks are akin to what we think about when we talk about rivers. Currents move water and air, branches can occur and then you have mutile flow paths where you can push fire. But if you have an unidirectional flow path STAY out of the exhuast flow! Especially when were talking about a unidirectional flow path situtation.

I think besides the deaths that have occurred when we were caught between the inlet and the exhaust openings of the unidirectional flow path we also need to look at when firefighters were caught in the change of a flow path from bidirectional to unidirectional. For example when we take a door initially cooler gravity currents are rushing in low and heat is rushing out over our heads often times the fire that intensifies so that that bidirectional flow path becomes so small that it's not a tenable environment for us and the flow is now so energy intensive that it is in essance unidirectional. I think that is another flow path issue we need to look at. And far more common than say the tragic Cherry Road example or the Montgomery example.

As regards your direct hits thoughts I think it's a great idea but I think also interesting is the fact that unless there is a significant loss of life or tremendous injury we hear little about most near misses. We tend to focus on the line of duty deaths especially multiple line of duty deaths but we forget about capturing lessons learned that are happening far more often where we are able to avoid significant injury. Were starting to be more data-driven and were starting to do a much better job of capturing information which will help us be smarter faster and better in the future.

Lets keep the discussion going! Bobby

Comment by Michael Teague on April 22, 2014 at 5:47pm

We need something like the Wildland Fire Lessons Learned Center. There are many well written reports about LODD/Injuries and Near Misses that are much more detailed than Near Miss Reports and NIOSH reports but there is no one single repository for the reports making it difficult to perform research on the incidents. 

Eddie please contact me. 

Comment by Bill Carey on April 22, 2014 at 4:23pm

"Statistically Relevant" is a key concept that NIOSH and Near-Miss need to grasp ahold of. How often do you see the sharing, even on anniversaries, of fireground LODD reports and yet hardly any from other activity type. That is part of the responsibility we as stakeholders, and for some of us, as members of the the various service and business related organizations some of us are a part of need to realize and correct. "Flowpath" is a popular word right now, and with good cause given the latest research, but to date we have more firefighters dying outside of the fire building or away from the fire scene than inside a smoke hallway or a room of origin.

There is value in looking at data from 20 years ago but we should be cautious in thinking that applying new information from the past two, three years could of made a significant difference. That is similar to thinking the steamer engineer from the 1900's could have delivered water better if only he know how to use a humat valve.

In 2012 deaths that were a result of vehicle crashes increased fourfold, yet when was the last time you saw as much a push about safe response equal to safe fireground operations?

Data, like a statistic, is tricky to use when we don't make it statistically relevant. Eddie's post should challenge all of us to be across the board in sharing tragic and near-tragic lessons learned, regardless of where they occurred, and to be uniform in reducing all line of duty deaths, not just the ones which are wrapped up in neat presentation with glossy photos, videos and audio from the scene.

Comment by Richard Jordan on April 22, 2014 at 1:29pm

Great article Chief. The devil is in the details but most often never fully revealed .

Comment by Eddie Buchanan on April 21, 2014 at 2:18pm

No sooner than I post this, and Billy sends out the CDC map.  75 burn related deaths since 2000, but the data still leaves out any indication of tactics. But progress! 

Comment by Grant Schwalbe on April 21, 2014 at 2:11pm

That would be great if we could narrow down the tactics used at these incidents.  20 or so categories that could narrow down the near misses or hits that you want to look at.  Should we consider that all tactics in some way are "contributing factors"?  I think so!

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