After studying near-miss injury and line-of-duty death reports, Retired Fire Chief Rich Gasaway identified 10 leading mistakes that contributed to death and injury on the fireground. Before a packed room at FRI in Denver, Chief Gasaway hit on five of those mistakes and their solutions.
"I've spent a lot of time in the trenches of firefighter near misses and line of duty deaths in the process of doing my doctoral research," Chief Gasaway said. "I realized there were some themes, commonalities that just kept happening over and over. When firefighters do bad things, I look at it and ask why did that make sense to them at that time."
1. High risk, low staff
A critical mistake is trying to perform high-risk activities on the fireground without ample staff. Most fireground deaths occur within the first 12 minutes when there are eight or fewer firefighters on scene, before full support is available.
It usually takes 15 to 20 firefighters to accomplish all of the tasks at a residential structure fire.
"They are trying to do all of the tasks of 20 firefighters with six or 10 firefighters," Chief Gasaway said. "The priorities get a little out of kilter. You can't assign all of the tasks to one company."
One way to ensure proper staffing is to be quick to call for mutual aid or additional units. This won't put a full staff on scene at the same time, but will greatly reduce the amount of time when the scene is understaffed.
"We also have to change the expectations for outcomes with less staff," Chief Gasaway said.
When conducting live-fire training, begin with partial staffing and gradually increase the personnel actively fighting the fire, he said. This will replicate real fire scenarios, as opposed to having the entire crew begin its attack at the same time.
2. Hands-on commander
Having an incident commander who is actively fighting the fire reduces the amount of attention the commander can give to situational awareness. It is often tempting for the commander to get in the mix of it.
"When you are multi-tasking with physical activity and perform command duties, (the brain) gets overwhelmed," Chief Gasaway said. "You are watching the big picture of a dynamically changing event. And as soon as you go look at the pump panel, all the clues that form your situational awareness have all been changing while you are looking at the pump panel."
Another common problem is not doing a full 360-degree size-up. This is the first and best opportunity to capture clues about the fire.
"The size-up is your opportunity to capture the clues or puzzle pieces to put them together and figure out what is going on," Chief Gasaway said. "By not going around the structure, you are taking puzzle pieces away and there is a big hole in the middle of your picture."
Part of solving this problem is not just doing the size-up to capture those clues, but knowing ahead of time what clues are important. The commander needs to think about what clues to look for before the fire incident.
It is also important to sift through competing clues, as there is much noise on the fireground. Likewise, the absence of clues is important.
4. Getting defensive
Failure to know when to switch from an offensive to defensive attack is another component to firefighters getting hurt or killed.
"We do that because we are firefighters," Chief Gasaway said. "We're aggressive, competitive, don't like to lose, Type-A personalities."
But the window to safely and effectively knock down the fire has closed by the time they arrive and start their attack, Chief Gasaway said.
The key to avoiding this pitfall is a good risk vs. benefit assessment. Part of that is knowing what a "no go" situation looks like and what to do in that situation.
It is important to teach firefighters not only how not to go in, but what to do when they don't go in.
"We have to have this discussion in training, not on scene; it is too emotional." Chief Gasaway said.
5. Train not to fail
Short cuts in training is another major factor in firefighter injuries and deaths. A lot of the seemingly stupid things firefighters do is really them doing exactly what they were trained to do.
Instructors, Chief Gasaway said, are also under time constraints and train the best that they can. Yet, the training is often misguided. "I fully admit it; I have trained firefighters to fail," he said. "I didn't know it at the time. I thought I was being a good trainer."
One example of bad training is not training firefighters to get out. The blacked-out mask evolution almost always involves them going in and doing search and rescue. More effective would be to send them in with good visibility, black out the mask and make them find their way out.
This replicates entering a structure and having the conditions change for the worse.
"In those conditions, we want to be outward moving and survival focused," he said. "Those firefighters being trained to go in in zero visibility are being trained to fail.
"You know how many times I have seen fatality reports where conditions went bad and firefighters kept going, just like they were trained to do."
Chief Gasaway said departments should re-evaluate all training programs for ways to improve them, and to be sure they duplicate stress as our brains behave differently under stress.
It is also important to have realism, repetitiveness and emotion in training, he said — all of which help train the mind and body to remember what to do.