Most Impactful Near Misses from 2019

Major maydays and line-of-duty deaths that hit national news outlets capture our attention.  Rightly so, we review these articles for lessons learned with hopes to prevent similar instances in the future.  However, these reports are written by third party individuals, that were not on the scene.  We can learn so much more from these events when we hear from those who were there and experienced the event.

We are highlighting some of the most viewed near-misses on the Firefighter near-miss Reporting System closing out 2019, and the takeaways that are shared by the submitter.  The advantage of these reports is the first-person perspective from fire service professionals that were there.  Hear from the actual firefighters that lived through these events and what they took away from their experience. 

Continual Size-up and Good Communication During Fire Attack 

This near-miss was published in April and highlights how we can learn from things that go right, not necessary, from things that go wrong.  Fire crews responded to a two-story single-family home with a basement and suspected fire on the second division. The 360 found smoke coming from “every opening” and was unable to locate any exterior basement access.

The first line was stretched to the Alpha side through the first-floor entrance, assuming the stairs would be inside the front door and allow them to stretch to the second floor for interior fire attack.  Several other units were arriving, including two other trucks and a command unit.
Moments later, the attack crew relayed a priority message that a hole was in the floor inside the front entrance (on division one), and the fire was located in the basement.  The command unit pulled all units back and regrouped.

The decision was made to redirect attack companies to the delta side, where firefighters were able to descend into the basement and suppress the fire.

Lessons Learned from the Report

• Overall, units did an excellent job of communicating and adjusting to the situation presented to avoid a potentially negative outcome. Size-up is critical to identifying a basement fire and, when one is indicated, every effort should be given to make fire attack directly into the basement to avoid a situation similar to what occurred on this incident. That being said, there was little to no indication of a working basement fire during the early stages of this incident.
• Given the time of day and the fact that no occupants were home, it is believed the fire had significant burn time before the fire department was dispatched. This true ordinary construction home was built in 1948, with interior framing of dimensional lumber. While houses of this construction type and era are typically very stable under fire conditions, with the extended burn time, significant portions of structural floor members were either partially or wholly burned away, leading to the hole on the first floor.

near-misses often will reinforce why we do what we do. We don’t have to wait for mistakes or bad things to happen to provide teaching points to our firefighters.  This near-miss is an excellent example of that.

Read the full report here. 

Overturned Butane Highway Cargo Truck Puts Crew At Risk

This report was published in December last year but received over 350 views in 2019. The near-miss discusses the importance of a good working relationship at the command post where the incident commander and hazmat team supervisor were not in agreement in the best strategy.
An MC 331 overturned near an off-ramp. There was no release from the Butane cargo tank; however, approximately 150 gallons of diesel spilled from the saddle tanks of the truck.  The driver was uninjured, and the first companies on the scene requested their hazmat team to respond.

On arrival of the hazmat team, they conducted a damage assessment, and the decision to offload the product before righting the vehicle was made.  Two hours into the incident, a nurse truck arrived, and the off-load began.

Unfortunately, a hydraulic hose ruptured on the nurse tank, and less than 10% of the product was transferred.  Bad weather was in the area, and the incident commander felt pressure to go forward with righting and removing the vehicle despite the hazmat branch director insisting the truck should not be moved without completion of offloading the product.  There was no way to assess the damage to the tank thoroughly, and the decision to right the vehicle was risky.

The truck was righted, and luckily, no product was released despite catastrophic failure being likely.

Lessons Learned from the Report

• High-risk, low-frequency events often involve several SMEs, especially in a Unified Command. The Hazmat team erred on the side of safety and voiced that a longer and safer approach was best. Other on-site SMEs felt the tank would "likely" hold. Catastrophic failure was not an acceptable outcome for the Hazmat team.
• However, they were overruled. Preparations for catastrophic container failure were made. Airspace was cleared, neighborhoods were evacuated, and highways were closed. Minimal personnel worked in the hot zone (equipment operators only).

While the catastrophe was averted, fortune was on the responders’ side.  This event could have had a very different outcome that could have led to a disaster of epic proportions.

Communication and Accountability Issues Cause Confusion 

Communication is one of the leading contributing factors listed in near-miss reports.  This near-miss was highlighted in a Report of the Week, which led to over 300 views of this report this year. 

An engine company responded to a mutual aid fire to support operations as a RIC.  The fire was in the attic of a single-family bi-level home.  The mutual aid agreement was relatively new, so there had not been a lot of training with the agencies yet, and the engine company was unfamiliar with the organization's operating policies and procedures.

As luck would have it, a MAYDAY was transmitted after their arrival.  It was unsure if the IC heard the MAYDAY as no radio communication acknowledging the MAYDAY occurred.  Long airhorn blasts were initiated by a heads up engineer, and the RIC began reacting but had no idea on the accountability of interior crews.  The accountability tactics were different between the two organizations.

The RIC also had a delay due to some master stream operations occurring around another portion of the home (not endangering interior crews).  The truck company operating that stream was unsure why they were being asked to shut down their operations due to the lack of communication of the MAYDAY.

Fortunately, the MAYDAY was cleared after interior crews self-rescued and exited the structure.

Lessons Learned from the Report

• It is helpful for the IC to have an aide, so there is more than one set of ears listening to the radio. It is helpful for mutual aid departments to train together so they know each other’s on-scene processes. The RIC needs to be actively involved in accountability. A RIC group supervisor could be a helpful go-between for the RIC and the IC and can also function as an IC aide since it helps the RIC maintain situational awareness by being near the IC and assisting.
• Place a RIC member at the door to count the number of people entering and exiting when operating with a department that assigns tasks by individuals instead of by crew number.
• Establish a RIC group supervisor to assist the IC and help the RIC group maintain situational awareness.
• Repeat the Mayday announcement on the radio, so everyone on the scene is aware of it.  Clear the Mayday on the radio, so all units are aware that it has been solved.

It is very easy to lose span of control and for communications to be hindered in a high-stress MAYDAY incident.  Luckily, this one had a positive outcome with no injuries or fatalities.  The organizations can use this event to improve upon in the future at little or no cost.

Read the full report here. 

Chief Sends Two Firefighters to Handle Chlorine Incident 

This report was published in 2016 but also was a highlight for Report of the Week this year, leading to over 250 views as well.  Hazmat incidents are extremely risky, and it is paramount that you understand the limitations in knowledge, skills, and abilities of your firefighters before sending them in harm’s way.

A business called the fire department’s non-emergency business line to report a chemical leak at their facility.  The fire chief who fielded the call sent two hazmat awareness level firefighters in a tanker to investigate.  

On their arrival, they confirmed a chlorine tank was leaking from a two-inch line that could be controlled by throwing a quarter-turn valve.  The fire chief, via cell phone, directed the firefighters to don full structural turnout gear with SCBA and shut the valve to control the leak.
Later that afternoon, the firefighter began complaining of rashes on their skin and soar throats.  The firefighters’ gear also showed signs of damage with signs of corrosion on the metal snaps and buckles.  The turnout gear and SCBA were removed from service.

The EPA and LECP became involved, and both the company and fire department were under investigation by OSHA of the event due to failing to report or handle the spill appropriately.  The fire chief resigned shortly after the incident.

Lessons Learned from the Report

• This was a training issue on the chief’s part and the firefighters.
• The department has learned a valuable lesson. There is no substitute for training. We must handle Hazmat by the book.
• Do not ask firefighters to perform tasks that they are not trained to do. Report hazmat releases as required by law. No command was ever on the scene. 

The report also describes a lack of leadership.  However, another critical takeaway to this report is to work within your scope of training.  If you’re given directions that are outside of your training or expertise, you are obligated to inform your company officer or IC of your concerns. 

Read the full report here.

Officer Steps on Energized Power Line Due to Poor Visibility

Being notified of hazards when first arriving on a scene is very important, but just checking the box of “notification” doesn’t mitigate the risks.  With this near-miss, the firefighters were notified of a downed power line on initial operations, but later into the event, stepped on the downed lines, causing an arc and electric shock.

The firefighters were on the scene of a small single-family home with heavy fire involvement.  Their first assignment was to set-up RIC on the bravo side.  The RIC officer conducted a 360 and notified all firefighters of a low hanging clothesline on the charlie side and that the electrical mast had fallen from the home.  Power and cable lines were down in the yard.

As fire operations continued, personnel were removed from the interior, and suppression activities continued only from the outside.  The interior crews were recycled to rehab, and the RIC crew was reassigned to fire suppression.

One of the firefighters moved from the RIC staging area to assess the house and conditions before operating one of the exterior hose lines.  As they walked towards the delta side, they stepped on the downed line, which caused an arc.  The firefighter also stated he felt a vibration under his foot.

No injuries occurred, and the firefighter was able to continue suppression activities.  The firefighter did know downed powerlines were in the vicinity, but due to poor light conditions and visibility, he never saw them.  Luckily, he did not contact the live power lines that were hanging by the fence just a few feet away.

Learning from near-misses

There are several ways that you can be more engaged and learn from near-misses. First and foremost, sign-up for the Firefighter near-miss Report of the Week.

This email distribution is different from reading standard submitted reports. Subject Matter Experts review these reports and create a learning platform that includes discussion questions, take-aways, leading practices, and other resources to capture further information. This can be done in a company dynamic or during evening drills at the volunteer firehouse or can be done individually. If you prefer audible books or podcasts, you can also listen to a narrated report of the week.

If you have a specific topic you are interested in and want to review those near-misses; you can browse over 5,500 near-miss reports. The topics range from emergency events such as structure fires and hazardous materials responses to non-emergency near-misses that occurred at training or during other station duties. If you are working on a more substantial research project, we also will collect a grouping of reports for you. Simply contact us and let us know what you are looking for, and we will do the searching for you.

Our reporting system is a national system that ensures anonymity, security, and no disciplinary action. This is accomplished through a stringent review process that vets all information submitted before a report is published. However, some departments are working to develop near-miss systems internally.

We are happy to help. Contact us, and we can provide sample operating guidelines and procedures and also share with you the successes and failures we see other fire departments have when developing a local near-miss program.

Finally, Dr. Rich Gasaway, with SAMatters.com, has been a massive proponent of the Firefighter near-miss Reporting System. He has several podcasts, blogs, and other training material that can promote concepts that address human error and human performance improvement. These concepts can help you prevent near-misses, injuries, and accidents in your department. Visit Dr. Gasaway’s website to find out more.

Share Your Story

Reading this article has provided valuable insight into real events where firefighters almost perished. This is not possible without the capability of sharing their near-miss in a structured manner, then vetted and reviewed for accuracy and dependability. The challenge has now been passed to you. Share your near-miss today, to protect the next shift.

John Russ is an eighteen-year veteran of the fire service, currently working for the Brentwood (TN) Fire & Rescue Department as a Lieutenant/ Paramedic. He has been the Program Manager for the International Association of Fire Chiefs’ Firefighter near-miss Program since January 2016. John has worked in various facets of the Firefighter near-miss Reporting System since its inception in 2005. John also has worked for numerous career and voluntary fire and emergency service providers to include pre-hospital emergency medical service providers, specialized technical rescue organizations, along with risk management and prevention entities. He has a Master’s Degree from Middle Tennessee State University in Professional Studies and two Bachelor’s Degrees from Eastern Kentucky University; one in Fire & Safety Administration and one in Pre-Hospital Emergency Care. John also is a veteran of the United States Marine Corps.