Near-Miss Case Study: Sense-Making

In July's article, we reviewed close calls and how they relate to a risk/benefit assessment and failure of firefighters or leaders to comprehend an incident's complexity. Critical thinking is imperative to decision-making, sense-making and situational awareness. In this article, let's explore sense-making and situational awareness in more detail, using wind-driven fires as the muse.

Sense-making is giving meaning to experience. All our relative experiences, education, memory, positive and negative career reinforcements, job knowledge and culture contribute to how an individual interprets a given situation, thus sense-making. This plays a part in interpreting fire conditions, assessing victim survivability and conducting risk/benefit assessments.

Situational awareness is a constant size-up of the environment around you. Firefighters and especially company and command officers need to

  • Read smoke for direction, intensity, color
  • Watch flame spread for direction and intensity
  • Observe for signs of flashover
  • Look for traditional signs of potential collapse

If conditions aren't improving, they're getting worse.

Wind-driven fires can change the dynamic of an interior firefight in an instant. Some organizations define an interior wind-driven fire as those with a wind speed of 20 MPH or more through a windward-side opening in a structure. Some research suggests that wind speeds of less than 20 MPH may still compromise or render positive-pressure ventilation devices ineffective when located on the leeward side.

These three elements and their relationship may contribute to, or conversely prevent, firefighter close calls and line-of-duty deaths. Consider the following scenario.

Crew A is a relatively inexperienced company first due on a single-family residential structure fire. On arrival, a single room-and-contents fire is transmitted on size-up. Wind speeds are light, windward side is the Charlie side.

A typical reaction might be to pull a preconnected hose line and advance through the alpha side, or front door. Wind speed accelerates and turns a simple room-and-contents fire into an untenable situation; escape is cut off and a mayday is transmitted.

Certainly not all variables are provided, but the scenario is plausible and included in various close calls. What are the potential points of failure? What is the fire chief's responsibility in helping to minimize the risk?

Understanding sense-making and situational awareness and accepting the phenomenon of wind influencing fire behavior inside buildings provide a foundation for reducing the likelihood of a bad outcome.

In this scenario, the crew is a relatively inexperienced crew. This potential exists in every fire department: ambitious firefighters promote with limited time in the fire service and exposure to actual firefighting may be limited. These firefighters and company officer also have unique perceptions on the job, interpretation of past policy and training, physical ability, cognitive ability to quickly process information and a wealth of personal history that is constantly influencing behavior.

All these elements contribute to an individual's sense-making ability. These variables influence a firefighter's ability to process information and make a determination on how to approach a scenario or respond to a changing environment.

Consider this same crew as they relate to situational awareness. Once committed to an interior structural firefight, this same crew becomes focused on the task of extinguishment. The culture of the fire service is typically to hunker down and aggressively fight the fire.

Due to elements identified in sense-making, firefighters may become oblivious to what's happening around them. They fail to recognize or fail to acknowledge that despite putting water on the fire, conditions are still deteriorating. Instead of withdrawing, streams are changed from 30° fog pattern to straight stream or some combination thereof based on department practice. Additional hand lines are requested. More resources are called for instead of evaluating what's happening and what's likely to happen.

Interior structure fires are influenced by wind. Many tactical errors are committed by failing to recognize the influence of wind on an interior structural firefight. Tenable situations quickly become untenable with uncoordinated ventilation or opening windward areas without consideration of wind travel through a structure, or when wind speeds suddenly increase. Failure to amend tactics accordingly can prove costly. Prudent organizations develop policy on managing wind-driven fires and train to that policy.

Many firefighter close calls are repetitive and predictive. To successfully affect change in the fire service and reduce close calls, line-of-duty deaths and firefighter injury, the fire chief, chief officers, company officers and leaders need to venture beyond traditional corrective actions. They must answer the outstanding questions: What's the root cause of these events? Why do they keep happening?

These questions must be addressed holistically, and every fire serve leader must continue to ask them until we find the answer.

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