Near-Miss Case Study: Research. Amend. Share.

As I review firefighter safety literature, I'm encouraged by the volume of information and anecdotes related to firefighter life safety. Clearly, the message is being received by a significant number of fire service leaders and firefighters. In fact, some numbers may indicate a downward trend in LODD and injury, but time will ultimately separate fact from anomaly.

While I'm reviewing the literature, I theorize that the fire service is becoming more defined as a profession as well. Many definitions of profession include the idea of containing an element of science or research and development.

The Institute of Certified Service Managers defines a profession as having a code of ethics, a body of knowledge, research, credentials, continuous professional development, individuals who consider the profession their lifelong occupation and external recognition as such.

We now have a body of knowledge, research and continuous professional development. We're taking note of firefighter fatality, injury and close-call events. These events must be studied and discussed and changes implemented to make our environment safer. Talk with no defined action items does little to influence change.

With this body of knowledge, we can better forecast future events and take action to influence their impact.

Recently, my department experienced a near miss involving a natural gas explosion in a single-family residential structure. Lightning struck the house or very nearby. Visible fire was extinguished using conventional means, but when an examination hole was opened in the wall, an explosion blew out sheetrock and ceiling. One firefighter received minor burns to his face; all firefighters successfully exited the structure.

I was briefed about the frequency of lightning-related structure fires in our area. I was also briefed about a phenomenon experienced in many of these fires as well—a failure of the natural-gas delivery line.

A careful after-action review was conducted to determine the cause of the explosion and if any operating policies should be amended. The likely cause of the explosion was due to an accumulation of natural gas in the void space, which resulted from a failure of the corrugated stainless steel tubing (CSST) after the lightning strike.

CSST is used to transport natural gas throughout a residential structure. The introduction of air after opening the examination hole placed the gas concentration within the explosive limits; the mixture reached an ignition source and caused the explosion.

A panel of experts assembled to review the data included plumbers, city development services, ATF and firefighters not immediately involved in the event. The results were shared with the fire service.

My department was fortunate: There was no smoke inside the residence and all visible fire was extinguished. However, though our firefighters were in complete PPE including SCBA, the facemask was not donned.

Several elements must be explored:

  • Research about the product involved—frequency, location, installation, history—and the event, including actions taken.
  • Continuous training: Department procedures when opening examination holes and department actions following a significant event, such as evacuation procedures, accountability and incident management.
  • Knowledge: Share the data with others.

Research: Become a Sponge

A review of the product involved identified potential avenues of failure if it isn't properly installed. A literature review also discovered questions about safety even if it is properly installed.

In our case, we identified areas where this product is located. Local building ordinances were amended to enhance safety where it's installed.

Building materials and construction methods change frequently. Learn as much as possible about these types of products and their potential impact if they fail.

Continuous Training: Amend Tactics

Armed with the knowledge of experience, tactics were amended. Utility control is imperative and immediate. Firefighters must don complete PPE with SCBA and facemask when opening examination holes. Thermal imaging and other technology is utilized as appropriate.

A review was conducted on emergency evacuation, mayday, accountability and incident management procedures as well.

Knowledge: Share Data

Information was shared with the fire service; this is imperative. A fire chief once shared, "Had I known what happened in Texas (with an LODD), (I) would have altered our policies and (potentially) prevented our fatality."

I'm encouraged with the fire service's direction and I'm excited to be part of its development. We're a profession—not because we self-proclaim but because we satisfy similar elements of other professions. In becoming more professional, we're influencing the safety culture of the fire service.

Let's learn what's injuring and killing firefighters. Let's amend our practices but base alterations on science and best practice. Let's share data and learn from each other.

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