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Examining the role of culture in firefighter deaths

Can NIOSH capture the impact of department culture rooted in unsafe actions?


Champaign firefighters use toy fire apparatus and other props that allow us to simulate various events for training purposes.

Photo/Gary Ludwig

I am a student of reading the National Institute for Occupational Safety and Health (NIOSH) Firefighter Fatality Investigation and Prevention Program investigations of firefighter line-of-duty deaths (LODDs). The investigators do an outstanding job of examining the events that occurred and developing recommendations to prevent future firefighter deaths. From time-to-time, I am asked to review the draft document and make recommendations – an assignment I feel honored to complete.

I find the reports valuable in our efforts to understand the factors involved in firefighter fatalities so I can consider their relation to my own department and whether there are similar issues that we need to address. During my department’s leadership academy, I usually assign a company officer the task of developing a presentation based on a NIOSH investigation that includes factors that our department may also encounter.

One presentation focused on reports involving firefighters getting killed on highways, as Champaign, Illinois, has three major interstates that traverse the city. The review of these firefighter fatalities has led us to provide more comprehensive training on traffic incident management, including the use of Champaign firefighters surrounding a large 8 x 4 board simulating roadways and highways, and using toy fire apparatus, ambulances, police cars, cones, highway maintenance trucks, and other props that allow us to simulate various events for training purposes. The training has proven invaluable with the effort to keep our firefighters safe on the highways.

Company officers have also presented on firefighters who died during training events, falls from roofs during ventilation, and the collapse of an apartment’s second-floor walkway that killed a fire captain in Columbia, Missouri, home of the University of Missouri. Champaign is the home of the University of Illinois, with some 55,000 students, and has very similar structures for student housing.

NIOSH Five: Top factors involved in firefighter deaths and injuries

NIOSH reports prove instrumental when it comes to efforts to prevent future firefighter deaths. One of the takeaways from all the NIOSH reports is the “NIOSH Five.” NIOSH has identified the top five casual factors of firefighter deaths and injuries on the fireground:

  1. Improper Risk Assessment
  2. Lack of Incident Command
  3. Lack of Accountability
  4. Inadequate Communications
  5. Lack of SOPs or failure to follow established SOPs

While the NIOSH Five is an area of concentration to prevent future firefighter deaths, one area that does not seem to be addressed is the fire department culture. I wish NIOSH could somehow evaluate the culture of the fire department to determine its role in firefighter LODDs. I believe that in many cases, the NIOSH Five could be the NIOSH Six, considering the vital role of department culture in firefighter safety.

A culture of unsafe actions leads to firefighter fatalities

My observations from traveling the country is that culture will vary from one department to the next, and it is also regional. The cultures of a department in the Northeast will certainly differ from those of a department in the Northwest.

A fire department’s culture may not be easy to define, but there are certainly elements of fire service culture that are extremely positive. We have proud traditions, many of which should never change, like honor, courage and public service. We also believe in the brother and sisterhood. And we believe in our fire department family, regardless of sex, race or religion.

But some fire departments embrace cultures that are inherently negative and behaviors that are pervasively unsafe. Allowing firefighters not to wear seatbelts and not be in proper PPE on the fireground are just some common examples of fire department culture that can lead to firefighter deaths.

Another example is the lack of a proper 360-degree walkaround of the building by the first company officer on the scene. If the company officer fails to report what they see over the radio for other companies who are en route, then they are adding to an unsafe fireground condition – one that could lead to firefighter deaths.

Why does this matter? Project Mayday has 5,102 documented maydays in its database from 2015 to 2018. Out of those 5,102 maydays, 59% of reports had no 360-degree size-up of the building, and 17% of the 360s were incomplete. Only 24% had a completed 360 of the building completed by the first-arriving company officer.

When you consider that one of the NIOSH Five is “Improper Risk Assessment,” it is no wonder that the lack of or improper 360s can lead to a mayday and/or firefighter deaths. Unfortunately, there are fire departments that accept a culture of allowing firefighters to advance into a building with no or a limited size-up, among other unsafe practices on the fireground.

The impact of the normalization of deviance

Too many fire departments allow unsafe practices that then become common practice – and continue to foster a culture of unsafe actions. This is called a “normalization of deviance,” and it is the same problem that lead to the Challenger Explosion in 1986 and that can lead to firefighter deaths and injuries.

Consider this: A fire department that does not maintain their portable radio batteries in excellent working order so that they hold the maximum charge and allow firefighters just to swap out the battery when it chirps is creating a “normalization of deviance.” Firefighters operating on any incident should have excellent working portable radios; the question of whether the battery will die when firefighters are deep inside a structure should not be an issue. But when you foster a culture of unsafe actions, a simple action that should be a non-issue becomes a significant factor in a life-or-death situation.

Cultural change starts with leadership

Changing the culture in any fire department requires changing behaviors. For a firefighter to change their behavior, they have to believe in the change, and that change starts at the top of the organization. That’s right, cultural change starts with the leadership! If leadership allows a culture of unsafe practices without intervention, it sends a message to subordinates that the behaviors are permissible.

Leadership needs to set the example through practice and action, not just saying so. Leadership needs to set the direction, not by asking what firefighters do on the fireground by why they do it. There can be a thin line between being overly aggressive (and even heroic) and downright unsafe. The firefighter who is always looking to put another medal on their chest at the next award ceremony is also probably willing to make poor decisions on the fireground. This is the type of mentality that must be addressed at all levels of the organization, starting at the top.

Culture is not something that is easily measured, but it is certainly something that needs to be examined when it comes to firefighter safety. I hope the NIOSH investigators can someday capture department culture as part of its evaluation of incidents to determine if culture-based changes are in order to prevent future LODDs.

Gary Ludwig
Gary Ludwig

Gary Ludwig is the former fire chief of the ISO Class 1 Champaign (Illinois) Fire Department. He is past president of the International Association of Fire Chiefs, having concluded his term in August 2020. Ludwig started his career with the City of St. Louis at age 18, rising through the ranks and retiring as the chief paramedic of the St. Louis Fire Department after 25 years of service. He has also served 10 years as a deputy fire chief for the Memphis Fire Department. Ludwig previously served on the EMS Executive Board for the IAFC for 22 years, with six years as chair. He has a master’s degree in business and management, and has been a licensed paramedic for over 39 years. Ludwig has written over 500 articles for almost every professional publication in the fire and EMS profession. He has also been invited to speak at over 250 professional EMS and fire conferences or seminars. His latest book is titled “Fully Involved Leadership.” Ludwig has won numerous awards, including those for heroism, the James O. Page EMS Leadership Award (2014) and the IAFC EMS Section’s James O. Page Achievement Award (2018). He is a member of the FireRescue1 Editorial Advisory Board. Connect with Ludwig on LinkedIn, Facebook and Twitter.