The "Direct Hit Reporting System"

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?” 

EGH