Before I begin this month’s opinion piece, I’d like to say how delighted I am to have the opportunity to share some of my thoughts with you in the pages of Fire Apparatus and Emergency Equipment magazine, and, as its new editorial director, how pleased I am to be associated with this staff of talented individuals dedicated to informing and improving the fire service through the pages of this publication.
For me, this new association has been like “coming home again.” In a publishing world littered with corporate spreadsheets and quarterly financial reviews, it’s rare and downright refreshing to find a group of individuals who haven’t lost sight of the real reason for doing this – and that reason is you, the reader.
Fire Apparatus is a homegrown magazine, a labor of love, and I’m blessed to have been invited to be a part of it and help it along on its journey to serve you.
Those of you who know me from my years of fire service writing, editing and conferencing will recognize a familiar editorial ring in this column. Those of you who are “meeting” me for the first time through this column will hear it soon enough.
My goal is to connect national, political fire service issues with the working end of the business in ways that provoke thought and induce action, to create a dialogue that will help benefit Number One – the firefighters doing the heavy lifting – in your ability to do your job safer and more effectively. I won’t be shy and I won’t pull punches (much). If you agree, fine. If you don’t, all the better. Let me hear why not!
I’ll be sharing this last page space on a rotating basis with Alan Saulsbury, one of the giants in the fire industry, well-known and greatly respected for his innovative and important work in apparatus manufacturing and safety. He, too, has never been at a loss for an opinion!
Onward!
When fire departments purchase firefighter personal protective equipment, and when firefighters don it, they do so with trust in the manufacturer who built it, the committee that created the standards for it, and the company that listed or certified it.
The Real Test
The real test is performance under real conditions. Firefighters provide valuable feedback from the field to conscientious manufacturers and standards committees who improve products and increase our level of protection.
But when firefighters fall in the line of duty and can no longer tell us what, if anything, went wrong with their gear, it’s up to investigators to put the pieces of the puzzle together and inform the fire community of potential problems that could compromise firefighter survivability. In that regard, as far as National Institute for Occupational Safety and Health (NIOSH) fire investigations go, the fire service should be very, very concerned.
NIOSH is a non-regulatory federal agency tasked with researching and investigating workplace injuries and illnesses and making recommendations for their prevention. Congress established the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) in 1998. The program was placed under a supervision of an epidemiologist renowned for her work in child labor injuries.
FFFIPP investigators are predominantly degreed occupational safety and health specialists provided with, as a NIOSH spokesperson put it, “specialized training on firefighting strategies, tactics, and safety and health, through the U.S. Fire Academy [sic] and other fire service training organizations.”
300 Investigations
I’ll bet you won’t soon find the National Transportation Safety Board hiring fire investigators with a few hours of flight school under their belts to examine air crash incidents.
Since its inception, NIOSH has conducted more than 300 firefighter fatality investigations. Its documentation of firefighter fatalities and its interface with the firefighting community undoubtedly have benefited fire service safety dialogue.
Maybe that’s why some of us have been inclined to overlook the somewhat generic, superficial, and less-than-scientifically-rigorous nature of the investigative reports. Or that NIOSH has yet to create a data base of its fatal incident findings, as Congress directed. But, as safety demands it, we shall overlook no more.
In early 2000, while analyzing evidence at the Keokuk, Iowa, fatal fire, where three career firefighters died in December 1999, FFFIPP investigators discovered that the Personal Alert Safety System (PASS) alarms they were wearing didn’t activate.
One investigator, a firefighter and professional engineer, considered this a “sentinel event” – that is, an urgent signal warranting further investigative response.
He included this information, along with other potentially contributory factors, in a detailed event matrix – a common investigative tool used to create a time line and substantiate investigative conclusions.
This matrix, with its red flag for an intensive follow-up on the PASS alarm issue, was glossed over in the final report on the Keokuk fire. The report noted that the victims’ manual PASS devices were damaged by the fire, but still in working condition.
The report stated, “It is undetermined why the victims’ integrated and manual PASS devices were not heard sounding in this incident” and “Extreme heat and direct flame impingement may have affected the operation of the integrated PASS devices.”
But the report issued no recommendations regarding the PASS devices, beyond cautioning about the need to wear and use them, implying that the fault was human error, not a technical one.
Shortly after that report was released, the investigator who characterized the PASS alarm failure as a sentinel event was terminated, in part, gleaning from documents obtained, because he was working too slowly (or thoroughly) on gathering evidence his supervisor considered of dubious value. In a letter explaining her rationale for terminating the employee, the supervisor wrote:
The Matrix
“The matrix included information from the transcribed interview tapes, reordered in an approximate time line. This matrix appears to have required substantial amounts of …time. The utility and necessity of such a matrix is not clear, however. It is not clear that this matrix is necessary … in identifying contributory factors for the purposes of developing recommendations to prevent future events….
“It is not possible to assess … whether the employee has minimized his fact gathering, per my written guidance, to those pieces of information which are needed to summarize the chain of events …, or that have direct implications for prevention recommendations.”
Shortly after his dismissal, the employee – again, himself a firefighter – sent a letter to the director outlining his concerns that sentinel events were being disregarded at the possible expense of firefighter safety. He wrote, “This is only one example where the managers of this Program … repeatedly instruct staff to omit critical facts because of ‘potential liability to the program.'”
A NIOSH supervisor denied that charge. And a NIOSH spokesperson wrote, “Our investigators routinely identify, examine, and report on PPE used by firefighters in cases that we investigate ….When warranted by the investigation, or when requested by the fire department, we conduct further testing on these devices.” Apparently, further testing to discover a cause for PASS alarm failures isn’t “warranted” until it happens at least five times.
Barely Audible
In four subsequent investigations of structure fires occurring from 2001 through 2004 in which firefighters died, NIOSH noted in its reports that PASS alarms didn’t activate or were barely audible to rescuing firefighters but that it was “unable” to determine why.
Was NIOSH “unable,” or was it unwilling to treat the occurrences as sentinel events and take the next step by adding some real science to the investigative equation?
Was it “unable” or simply too careless to establish and follow protocols and procedures consistent with recognized investigative standards?
According to the NIOSH spokesperson: “The program does not have formal criteria for identifying sentinel events. We use our extensive knowledge and expertise about firefighter safety and health, and our experience in conducting investigations, to identify circumstances or events that may be unique. We are always on the lookout for something that may be an unrecognized or under-recognized problem.”
For these ever-vigilant experts, however, the idea of a solution for non-working PASS devices was for five years to blame the fallen firefighters for not properly using their devices and then blame manufacturers and researchers for not developing new and better downed firefighter location technology.
It wasn’t until January 2005 that NIOSH took action on the PASS alarm issue by verbally contacting the chairman of the Technical Committee for the National Fire Protection Association’s NFPA 1982, Standard on Personal Alert Safety Systems.
In April 2005, NIOSH formalized the contact in a letter to NFPA. Eventually, this set into motion a series of initial tests conducted by the National Institute of Standards and Technology, which found, as stated in an April 2006 NFPA news release, that “Exposure to high temperature environments may cause the loudness of PASS alarm signals to be reduced…[National Institute of Standards and Technology NIST] has shown this sound reduction may begin to occur at temperatures as low as 300 degrees F.”
The NFPA 1982 technical committee intends to revise the standard based on further testing by NIST. A timetable has not been publicly released, but the standard is scheduled for revision in 2007.
Nothing To Do But Wait
What are fire departments to do? As far as the PASS devices are concerned, there’s nothing you can do, except wait. You’ve waited five or six years for NIOSH to treat your last resource for survival as being important enough to be seriously addressed.
You’ll have to wait now until the standard is revised and new units manufactured. Maybe you can buy them with your diminishing FIRE Act grant money.
Members of the entire fire community should contact congressional representatives and advise them of the problem and their duty to correct it.
What you can do is actually read the reports and call out NIOSH when it ascribes the ubiquitous “undetermined cause” to equipment failures at fatal fires.
What you can do is encourage your fire service organizations – the “stakeholders” – to call on the director of NIOSH to raise its bar. And our NFPA technical committee members need to keep a close eye on NIOSH reports for red flags.
At the recent NIOSH stakeholders meeting, an overhaul of the current FFFIPP process wasn’t on the agenda, but that’s what needs to happen. NIOSH must elevate FFFIPP to a “gold standard” within the epidemiological and research communities, wherein research is independently verified, written investigative procedures followed, sentinel events recognized and communicated in a timely manner, the best qualified and knowledgeable investigators assigned, forensic science utilized whenever required, and the whole truth exposed.
The fire service deserves nothing less than “gold standard.” And if NIOSH can’t provide it, Congress should find another agency or group that will.
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