Lessons remain unlearned

22 Mar Lessons remain unlearned

Officials from America’s National Institute for Occupational Safety and Health have spent the past twenty years recording details of not only the physical cause of firefighter fatalities but also whether they were as a result of firefighters deciding themselves to take risks to protect lives and property or whether their commanders had failed to adequately assess the dangers posed at a fire scene.

However, following the deaths of two Kansas firefighters, Larry Leggio and John Mesh in October 2015 a team of Kansas Star newspaper journalists not only reported on the official reaction to the fatalities but also scrutinised whether they could have been avoided if lessons learned from previous fires had been heeded.

Over a year the team, led by reporter Mike Hendricks, analysed all of the Institute’s files and calculated that in the case of 57 percent of the firefighter fire deaths the reports concluded there had been commanders’ failure to adequately evaluate the scene and consider the risks before committing to a plan of attack to extinguish the blaze. In the reports there were also incidents identified where firefighters had died because risks had not been weighed against positive outcomes either by the commanders, or the victims.

Likewise Hendricks discovered that many of the reports contained similar causes of deaths over the years.

Furthermore recommendations about safety procedures and equipment management to prevent the same incidents happening time again had not been read or adhered to by fire commanders because of the lack of an Americanwide firefighting strategy or a national system to check that certain policies are adopted by all forces.

Both Leggio, aged 43, and 39-year-old Mesh were experienced Kansas firefighters when they were part of a team sent to the city’s Independence Avenue to fight a fire and when they arrived found heavy smoke coming from the rear of the building.

Crews rescued at least two occupants and went inside looking for the origin of the fire, but they had difficulty finding its source and as the fierce blaze intensified commanders ordered everyone to evacuate. Several firefighters told investigators that conditions inside had become so untenable because of the heat that they “were nearly at mayday conditions”… A mayday is a plea for help when firefighters fear their lives are in danger.

They all got out safely, and a collapse zone was declared as firefighters continued to pour water on the building from outside with hoses and aerial streams. But a pump truck was put at risk, when flames shot out nearby and its exit was blocked. At that point a division chief radioed his decision to send firefighters into the collapse zone to protect the apparatus. The incident commander did not acknowledge the decision. Two minutes later, the wall fell.

Prior to the collapse, the building’s east side was not seen as an immediate danger by firefighters, including Leggio and Mesh who continued to use it as their primary route between the front and the back of the building. However, according to the report when the commander realised the danger he began radio traffic to remove all the firefighters from the alley but before the communication could be completed the wall collapsed.

What was remarkable about their deaths is how tragically unremarkable they were. The Institute’s report showed that many other firefighters had died before them in similar fashion while operating within a “collapse zone,” an area considered too dangerous to enter because of the risk of structural failure.

Hendricks’ research revealed that a federal workplace safety agency had investigated many of those cases and consequently recommended nearly twenty years ago that every fire department adopt a written collapse zone policy. Yet the Kansas City Fire Department did not institute its policy until after the deaths of Mesh and Leggio, which Hendricks described as “not atypical for a dangerous profession that is more reactive than proactive when it concerns safety.”

When the Kansas Star asked Tim Merinar, who has led a federal investigation unit since the 1990s, why he thought firefighters had continued to die in frustratingly similar ways year after year he said that, in part, it was due to training gaps. He pointed out that a recent study showed only half of America’s 30,000 fire departments have all personnel trained to fight structure fires and that at some smaller volunteer departments firefighters sometimes get no formal training at all.

“A lot of the smaller departments across the country don’t fight a lot of fires,” Merinar said. “Even though a firefighter may have X number of years of experience as a firefighter, he may have very limited actual structural firefighting experience.

As a consequence we’re seeing line officers, company officers and chief officers who have limited hands-on firefighting experience.” The investigation did identify the three most common causes of firefighter deaths in America. They are standing under fragile walls that would soon collapse, entering burning buildings without a hose to protect them and rushing into unstable and unoccupied structures.

“You see the same things over and over again,” said Merinar.Brian Kazmierzak, a safety office from Indiana added “We are our own worst enemies in a lot of ways.”

And Kevin Kalmus, a fire captain in Austin, Texas commented, “ We are sadly unoriginal. We allow the same events to occur year after year that lead to firefighter fatalities.”

These lapses occurred, fire investigators and safety experts say, despite many science-based safety recommendations that have been widely circulated to the thousands of fire departments across the country.

However, no single explanation accounts for why best practices are often not followed. A perplexed U.S. Congress authorised a $1.2 million study in late 2012 to find an answer, but then neglected to provide the money to see it through. And as his report in the Kansas Star was published Hendricks said: “ Fire chiefs and many others – leaders in the fire service wish that fire departments would take safety more seriously than they do.

“There are a number of firefighters out there who believe that they should risk their lives to save property, and the fire departments say that’s not acceptable. “There’s a slogan in the fire service ‘ Risk a lot to save a lot; risk a little to save a little; risk nothing to save nothing’.

No building is worth a firefighter’s life.

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