How to lead your department through a LODD

How NIOSH investigators and the department can better understand the LODD and prevent its repeat

By the time a person has struggled to the top firefighter position, that member has managed a lot of issues. It is likely that the fire chief has experienced about everything under the sun.  

Whether managing a complicated administrative process or handling a complex emergency response, the hope is that the chief has been there and done that, at least once.

According to NFPA figures, there were more than 370,000 structural fires in 2011. In addition to fires and rescues, each year career and volunteer fire chiefs oversee some type of budgetary and other administrative processes.

As the chief settles into the "routine of the position" (if there is such a thing), there are not too many surprises happening in the corner office. Then, on the most horrible day of an entire fire service career, the department experiences a line of duty death. 

I don't know anyone who has the experience to be comfortable handling a LODD. After the initial shock and stress of learning that a member's precious life has been lost, time will seem to speed up and the department will be tested to its breaking point.

The organizational leadership team will need to step up to guide the department through this dark period. They will have hopefully participated in one of the many outstanding programs presented by the National Fallen Firefighter Foundation. Even with the proper training under your belt, this is a very difficult and sad assignment to manage. 

The investigation begins

The first phase of leading after a LODD is making sure every detail supporting the grieving family has been handled respectfully and properly. The next phase will be the investigation component. 

Many leaders would say that the focus of the LODD investigation must be on learning the details about the response and never allowing the same situation to occur again. The mantra will sound something like: "If we don't learn, we are destine to repeat history." 

However, when the sleeves are rolled up and the investigation begins, there can be a lot of barriers blocking the investigators from getting to the facts. The same issues may prevent the department from building an effective recovery plan. A recovery plan gives the department a good shot at not repeating the actions that lead to the LODD. 

An investigation will most likely include the National Institute for Occupational Safety and Health's Fire Fighter Fatality Investigation and Prevention Program. NIOSH is the investigative arm for the Centers for Disease Control and Prevention responsible to conduct a voluntary review of firefighter LODDs.


NIOSH's fatality investigation program opened its doors in 1988. During the past 15 years, it has produced hundreds of LODD reports.

Some of those who have an interest in firefighter health and safety issues, say the NIOSH LODD reports need a facelift. They say the NIOSH reports use a lot of the same recommendations from case to case. 

The naysayers will say that the investigators do not go after the actual causal factors. They may go as far as to say that the root causes are covered-up for political reasons or to prevent organizational and personal embarrassment. The LODD final reports use the same boilerplate information and they have very little value, can be heard as well.

One wonders if this criticism is warranted or overstated. After 15 years of service, does NIOSH need to change its investigative process and reporting? 

In 2008, NIOSH began hiring company and chief officers who served in fire suppression or operations in career fire departments to investigate LODD incidents. NIOSH did this in reaction to requests from the fire service for this level of qualification.

Many of the cases NIOSH investigates are in fact similar incidents. Further, there are dozens of documents showing that many of the firefighter fatalities happen in similar ways with similar root causes.

If this is so, then it stands to reason that the factors are very similar and the final report text does appear to be a boilerplate.

For example, many fireground LODDs had no accountability system in use. In some LODD cases, the department doesn't have an accountability policy, system or training. If this is the case, it appears that NIOSH is doing its job and doing it well.

Broader authority

One of the first concerns NIOSH supporters raise is that the agency needs to have broader and better defined authorities to respond to and investigate all line of duty deaths.

To initiate a NIOSH investigation, the department that experienced the fatality must request that NIOSH respond to the event. I wonder how many commercial airlines would call in NTSB to investigate a plane crash, if that was a necessary step? My guess is not many air carriers would call out of fear of increasing the airline's liability and its organizational embarrassment. 

So, the Federal Code of Regulations gives the NTSB the legal authority to respond to all plane crashes that occur in the United States. With that authority and responsibility, NTSB needs the budget to support its mission. Even if it had the authority to respond uninvited to all traumatic (nonmedical) LODDs, it is doubtful that NIOSH has the funding. 

Changing times

If an investigative facelift is necessary, then what would it take for the NIOSH reports to be more valuable in reducing future firefighter fatalities?

First, give NIOSH the authority, responsibility and funding to investigate all traumatic LODDs. Next, NIOSH should share the responsibilities of the preliminary investigation. 

The "go team" model that NTSB uses would be of great value. For example, the crashed Boeing 777 at SFO was still smoldering at the end of the runway when the NTSB go team was packing up to head west. 

The team wastes no time arriving on location to get information at a plane crash, as some information is perishable. Arriving in time to obtain that information and the fresh human data (personal accounts) needs to happen as soon as possible.

To implement the go-team concept, I suggest trained, qualified and well-respected members from two of the top three associations: International Association of Fire Fighters, National Volunteer Fire Council and International Association of Fire Chiefs.

If two qualified investigators were added to each team at no additional federal cost, a lot more could be accomplished when the boots hit the ground. Further, if each group is represented, then there will be a higher level of buy-in, which will lead to more respect and usefulness for the final LODD report.

NIOSH uses expert technical reviewers to ensure accuracy and correctness with each investigation report. NIOSH selects a reviewer based on the type and size of the department involved with the investigation.

This means that a reviewer from a metropolitan fire department would be called on for an incident at another metro department and a volunteer fire officer would be used to review an incident involving a volunteer department. The reviewer must be a fire officer with operational experience, knowledge and skills.

Recovery plan

Once the final report is published, the affected fire department should develop, publish, distribute and follow a comprehensive LODD recovery plan. This is an area where we often fall short. It seems that most fire departments do very little with what the NIOSH investigators provide.

A second go team needs to appear on-site and guide the department in the development of its LODD recovery plan. This continuum of outside efforts could range from handing the entire process to simply observing the department develop its own plan with internal resources. I would think that only one NIOSH official would be needed along with two of the three member associations assisting the recovery plan development.

One of the most comprehensive LODD recovery plans was developed under the direction of Fire Chief Alan Brunacini of the Phoenix Fire Department. This plan, Southwest Supermarket Fire Report, took a year to develop and contains more than 100 pages of text; it is an excellent best-practice guideline.

The elements of the recovery plan must be based on national standards, such as those of NFPA, whenever possible.

How it can work

Here's one way this can work. When command training is needed to be included, use a nationally recognized program such as Blue Card or National Incident Management System in the recovery plan when command failures were listed in the final LODD report.

Next, use the recovery plan to develop a detailed, logical and well-supported action plan to guide the recovery efforts. The action plan can be part of the recovery plan, but must focus on the steps necessary to make the identified changes and organizational improvements. 

The action plan needs to identify the funding source as well as the people responsible to complete the tasks as required. The action plan should contain the person who has the overall responsibility and when progress meetings are to be held to describe successes and point out barriers that must be removed to reach.

The meetings must continue until all of the action steps are completed. This relentless follow-up of the plan is mission-critical.

Finally, if there have been other LODDs or serious near misses in the same department, a gap analysis report should be developed. This report should list all of the previous recommendations and improvements that were documented. 

The status of each recommendation should be reviewed and described. The items that have not been completed should be added to the action plan; this will close the firefighter safety gap from previous investigations and suggestions.

The tone of the investigation and report cannot be accusatory. The focus needs to be on learning and prevention.

Tip of the spear

This column regularly acknowledges fire service leaders who have been on the leading edge of a specific project or fire service improvement. So this month's Tip of The Spear shout out goes to Richard Duffy of the International Association of Fire Fighters.

Duffy was instrumental in bring about the NIOSH investigation process. It is fair to say that without Duffy's leadership the death investigation process would like not exist.  

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