Identifying the risk-taking firefighter

Posted on April 13, 2012 by Bill Gabbert

When we’re talking about firefighter safety and preventing injuries, fatalities, or escaped prescribed fires, we often fall back on the hundreds of rules, regulations, standards, orders, lists, watch-outs, manuals, red books, 40-page Incident Action Plans or Prescribed Fire Plans….. the list is endless. While I would never say those resources are worthless, perhaps a deeper root cause of accidents on the fireline are the ingrained human behavior traits welded into our DNA or learned through years of exposure to a workplace culture. Some people are hard-wired to accept a level of risk others would not, or they may think their innate intelligence will enable them to outsmart a fire, or be able to successfully handle any unexpected emergency that is presented to them.

The most successful firefighters are not those who religiously follow every written rule to the letter, but those who recognize, accurately, their own skills and limitations. They take advantage of what they can do well, and mitigate the traits that could lead to an undesirable outcome. But not everyone is self-aware to that level.

The most dangerous firefighters are those who do not know what they don’t know. When they were teenagers, they thought they were 10 feet tall, bulletproof, and knew everything. Now after fighting fire a little here and there, and taking some stupid risks without getting seriously injured or at times not even knowing they were taking risks, they think it can continue, which puts themselves, and if they are a supervisor, those around them in precarious situations.

Bill Belichick

Bill Belichick, head coach of the New England Patriots, is often described as one of the best, or the best, football coaches of all time. He does many things well, of course, but one of his most interesting traits is accurately recognizing the skills and limitations of his players, and then modifying and customizing the game plan, putting his men in situations where they are likely to succeed. For example, after the New York Jets allowed Danny Woodhead, the little 5-foot 8-inch running back, to languish on the sidelines, Mr. Belicheck hired him and now successfully uses him in specific plays and situations that take advantage of his skills. Mr. Woodhead was one of the stars in last season’s Superbowl.

Is it possible to learn something from Mr. Belicheck and apply it to firefighting? What if we could identify the person who does not know what he or she does not know, or the over the top risk taker, and use them in positions where they can succeed without putting themselves or others at risk? Instead of using them in fireline positions, maybe they could succeed as a Ground Support Unit Leader. Or maybe they should not be promoted into a position where they would put firefighters at risk.

Neil LaRubbio recently wrote an article titled “Dead man working”. Here is an excerpt:

…From 1980 to 2010, an average of 17 firefighters died nationally each year, the majority in Western forests, six more on average than during the previous 30 years. Yet, no fire manager would say that safety awareness has become lax. No matter the agency’s culture, getting these roughnecks to act right in desperate situations can be the most maddening variable of all.

[...]

What kind of worker is most likely to choose risk over reason? Researchers at the University of Montana’s Department of Health and Human Performance have come to some conclusions. They found that 20 percent of wildland firefighters demonstrate symptoms of attention deficit-hyperactivity disorder, compared to a national average of 9 percent. The researchers discovered similar statistics in miners, suggesting that people with ADHD gravitate toward high-risk jobs. Research like this may help industry mold environments that accommodate the risky ways in which some people unconsciously approach dangerous work. For example, according to the University of Montana study, individuals with ADHD show higher rates of substance abuse, which may explain the unsparing quantities of alcohol my fire crew in Montana consumed, or the fairytale levels of meth that are said to circulate among oil field, short-haul truckers.

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You might also enjoy an article I wrote in May, 2010: “Stupid people are confident, while the intelligent are doubtful“.

Unlearned lessons in Nebraska

Posted on January 10, 2012 by Bill Gabbert

When we report on serious accidents or fatalities on wildfires, we always try to obtain a copy of the official investigation report from the jurisdiction involved. But for the incidents on federal land at least, and on other lands in most of the western states, the responsible organizations almost always make the report available freely and conveniently, usually on the internet.

The primary reason to distribute accident reports as widely as possible is to reduce the chance of similar accidents. We call these “lessons learned”. There are entire organizations and web sites devoted to this concept, such as the Wildland Fire Lessons Learned Center, the U.S. Army’s Center for Army Lessons Learned, and the Department of Homeland Security’s Lessons Learned Information Sharing site. We put together the document titled Infamous Wildland Fires Around the World, which is a partial list, by date of the year, of some of the more famous, or infamous, multiple fatality wildland fires around the world over the last 150 years. We hope that firefighters will remember these accidents and the lessons learned from them.

But it is much more likely that mistakes made on fires in Nebraska will be repeated.

When we searched for an official report about the triple fatality on the April 28, 2011 prescribed fire near Trenton, Nebraska, we came up with nothing. We linked to a pretty good newspaper report, and asked if our readers were aware of an official report on the incident. One them told us that there was a multi-step process that involved many exchanges via snail mail to get a copy of a fire accident report in Nebraska. And it usually takes about a month, they said.

We called Jim Heine, the Assistant Fire Marshal in Nebraska and asked him how to obtain a copy of a report. He said it was a “simple one-step process”. But it turns out that there are ~~five~~ six steps.

Complete an application form to request the report. The form can be downloaded from the Fire Marshal’s web site, printed, and completed by hand.
Send it to the Fire Marshal’s office by fax or by snail mail.
The agency’s legal counsel reviews the request. If it is approved….
The Fire Marshal’s office sends you an invoice.
You send the Fire Marshal’s office the payment for the report (a typical fee is $3.50).
The Fire Marshal’s office snail mails you the report.

We asked Mr. Heine why the reports were not available on the internet. He said “If you had a family member who died on a fire would you want the report to be public?”

We have heard of many family members who had loved ones that died on a fire who are vehement that the circumstances and lessons learned become public. They would like to prevent other families from losing a loved one and going through the same pain and suffering. Two recent examples that come to mind are the CR 337 fire in Texas last year and the Carson Helicopter crash in 2008 on the Iron Complex fire near Weaverville, California.

Lynette Hamm’s son, Caleb Hamm, passed away on the CR 337 fire in Texas last July. When told about Nebraska’s policy on accident reports, she said:

I can only surmise Mr. Heine has never lost a loved one before. If so, I believe he would want to get to the bottom of it, however it happened, and have those findings available for future training. If the firefighting community really wants to learn from past mistakes/accidents, wouldn’t we want those reports to be made available to everyone in the hopes of preventing another occurrence? I would think so.

Nina Charlson’s son, Scott Charlson, died along with eight other firefighters and air crew members in a helicopter crash on the Iron Complex (or Iron 44) fire in 2008. Ms. Charlson has been very active in following up on the investigations of the accident. When she and family members of other firefighters attended a National Transportation Safety Board forum in November, she released a statement that included the following:

…We cannot bring our loved ones back but if we can stand up for safety changes for future passengers – that is what we want to do.

When told about Nebraska’s policy, she replied in part:

I think it is reasonable that if the victims families did not want to have details made public (maybe their firefighter made a stupid mistake) they could request it – but still firefighters should have the information for future safety measures.

The purpose for any future actions of the Iron 44 families part is definitely for the purpose of safety.

Fuel in a bladder bag

Posted on December 21, 2011 by Bill Gabbert

Maybe I led a sheltered life as a firefighter, or perhaps I just worked around people who made safety number one, but until today I had never heard of filling a bladder bag (backpack pump) with a mixture of gasoline and diesel fuel and using it to apply the burn mix onto brush or slash piles that were to be burned, or were presently burning. But apparently it is a common practice on some U.S. Forest Service districts, according to a recently released “Lessons Learned” document. Below is an excerpt; the entire document is HERE. After the reported near miss, those practices may change.

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I was walking down the hall of the district office with one of the district staff when we stepped into a conversation some of the crew leaders and assistant crew leaders where having about a near miss on some pile burning operations the previously day. There had been a flashback of flame toward one of firefighters while using a Fedco five gallon with fuel mix (piss bag/ bladder bag) to fuel the ignition on one of the piles. Some of the group was thinking it was no was big deal, some were trying to defend the action of using the Fedco as a firing tool, some were not sure and others thought it was not the right tool for the job. One individual said “we used to use them in region “X” and on my old forest all time in pile burning no big deal you have to just be careful with the flashback”.

I decided to bring it forward to the group that this is something we need to talk about, some were a little reluctant but everybody joined in. I had someone inform the rest of the folks waiting to go out pile burning that we all needed to talk about this issue and that “the piles would wait”. Someone pointed out “have you ever seen a dry piss bag on a fire and did you think there was fuel on the outside of the bag”?

The employee who had the near miss said his fire shirt had fuel on it. We talked how the drip torch had a spark arrest in it, and you are creating a fine mist at the nozzle when you pump the bladder bag which is also creating flumes which comes back and creates the flash that becomes a very unsafe operation.

The subject came up how to carry 5 gallon of fuel mix up the hill as the gas cans weight down on the arm. We asked those that did not think this was the right device to use, why did they not say anything. They felt that they were not going to use it and the person who filled it up was the senior leader of the group.

“What if this had not been a near miss but more serious we should have spoken up or at least talked about it.” We discussed, both as a group and one-on-one, the actions, planning and proper tools to use. We all need to have more training and discussions of proper tools, safety, and minimizing risks.

Wildland firefighters: rhabdomyolysis or “rhabdo” can be extremely serious

Posted on November 16, 2011 by Bill Gabbert

From the FLA. Employee's left leg after 5 surgeries

I will have to admit that when the National Wildfire Coordinating Group’s Risk Management Committee distributed some information earlier this year about rhabdomyolysis, which is frequently referred to as “rhabdo”, I didn’t pay much attention. But today when the Wildfire Lessons Learned Center announced that a Facilitated Learning Analysis (FLA) for a severe case of rhabdo was available, I read it carefully and am now converted. The injury in the FLA occurred September 21, 2011 while a firefighter was taking the Work Capacity Test, or “pack test”. I have seen the light and realize how serious this condition can be.

Left untreated, or if not treated early enough, rhabdo can lead to irreversible muscle damage, permanent disability, kidney failure possibly requiring lifelong dialysis, and even death. Up to 8% of cases of rhabdomyolysis are fatal according to a NIOSH report. And all of this can be the result of exercising hard or engaging in a strenuous fire assignment if other risk factors are also present.

Rhabdomyolysis is the breakdown of muscle fibers resulting in the release of muscle contents (myoglobin) into the bloodstream which are harmful to the kidneys and may lead to kidney failure.

The link between rhabdo and “compartment syndrome”, the condition that is emphasized in the FLA, is certain, but it is not clear to me, having much more fire training than medical training, if compartment syndrome leads to rhabdo or vice versa, and my research found conflicting information. But that is not really important, in that both conditions are similar in that they are caused by damaged muscle tissue. Compartment syndrome occurs when the damaged muscle is inside an enclosed compartment in a fibrous sheath with other muscles, as is found in the arms and legs. Rhabdo can occur with any muscles, but both can lead to the same outcome, including death.

I was disappointed that the recently released FLA did not state the cause of the injured employee’s compartment syndrome/rhabdo, nor did it provide much useful information about how to prevent a similar occurrence, other than to “prioritize staying physically fit”, and the “incorporation of healthy lifestyle choices and better nutrition”. So I attempted to gather some information here in one place that will hopefully be useful for wildland firefighters, to increase their chances of avoiding rhambdo, or diagnosing it if it occurs.
Continue reading →

The myth of drinking water

Posted on October 27, 2011 by Bill Gabbert

Firefighter on the Shep Canyon fire in South Dakota, September 6, 2011. Photo: Bill Gabbert/Wildfire Today

After reading our excerpt and later the full document from the the Serious Accident Investigation Factual Report for the hyperthemia fatality on the CR 337 fire in Texas, we heard from Dr. Brent Ruby, who has completed studies on this exact issue, even having studied wildland firefighters while they were working on fires. In one of his studies he was monitoring a wildland firefighter outfitted with a core temperature monitor, an ambient temperature sensor, and a special Camelback hydration system that monitored his water intake. This firefighter experienced a heat-related illness, heat exhaustion, and had to be evacuated off the fireline by a helicopter. That was a terrible thing to happen to a firefighter, and I’m sure the researchers thought the same thing, but it was probably a once in a lifetime cornucopia of incredibly useful data. Dr. Ruby sent us this message, reprinted here with his permission:
Continue reading →

NTSB to hold public forum on the oversight of firefighting aircraft

Posted on September 30, 2011 by Bill Gabbert

Sikorsky S-61N helicopter operated by Carson

Following the 2008 crash of the Sikorsky S-61N helicopter operated by Carson on the Iron Complex fire near Weaverville, California in which nine firefighters died, it became clear that the FAA and the U. S. Forest Service had inadequate oversight of the operation of aircraft used for wildland firefighting on federal lands. Here is an excerpt from an article we wrote December 8, 2010 after the NTSB presented their findings from the investigation:

Who regulates wildfire aviation?

The answer is: nobody. The FAA claims they have no authority to regulate the aviation activities of other federal agencies or state and local governments. This authority has to be granted by Congress, which has shown no interest in becoming involved in the aviation safety of firefighters. And the federal agencies, or at least the U.S. Forest Service as proven in this accident, generally do not have the aviation expertise to inspect and regulate their own agency-owned or contracted aircraft. Good luck in trying to not think about this the next time you’re climbing into a helicopter at a fire. (Let’s see – got hard hat, gloves, line gear, tool, life insurance.)

Today the NTSB announced that they will hold a public forum on the oversight of “public aircraft operations”, which includes aircraft used by the federal government on wildland fires. Maybe something good will come out of this, but all they can do is make recommendations, and the FAA sometimes ignores recommendations made by the NTSB. And good luck getting Congress to do anything about anything.

Here is the full text of the NTSB announcement:

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“FOR IMMEDIATE RELEASE: September 30, 2011

NTSB ANNOUNCES PUBLIC AIRCRAFT FORUM

The National Transportation Safety Board will hold a two-day forum on safety issues related to the oversight of public aircraft operations on November 30 and December 1, 2011, in Washington, D.C.

The event, entitled “Public Aircraft Oversight Forum: Ensuring Safety for Critical Missions,” will be chaired by NTSB Chairman Deborah A.P. Hersman and all five Board members will participate.

Public aircraft are operated by a federal, state, or local government for the purpose of fulfilling governmental functions such as national defense, intelligence missions, firefighting, search and rescue, law enforcement, aeronautical research, or biological or resource management. Government organizations conducting public aircraft operations supervise their own flight and maintenance operations without oversight from the Federal Aviation Administration (FAA).

“Our accident investigations have demonstrated the risks of inadequate safety oversight and identified persistent confusion as to the role of the FAA when it comes to public use aircraft,” said Chairman Deborah A.P. Hersman. “During the forum, we will gather information on the roles and responsibilities of the entities engaged in public aircraft operations and hear about methods for ensuring effective safety oversight.”

Recent NTSB investigations of accidents involving public aircraft include:

the August 5, 2008, accident near Weaverville, California, involving a helicopter operated by the U.S. Forest Service on a firefighter transport mission
the September 27, 2008, accident in District Heights, Maryland, involving a helicopter operated by the Maryland State Police as a medical evacuation flight
the June 9, 2009, accident near Santa Fe, New Mexico, involving a helicopter operated by the New Mexico State Police on a search and rescue mission

Panelists participating in the forum will represent federal, state, and local government entities, aviation industry trade associations, and civil operators contracting with government entities. A detailed agenda and list of participants will be released closer to the date of the event.

The forum will be held in the NTSB Board Room and Conference Center, located at 429 L’Enfant Plaza, S.W., Washington, D.C. The public can view the forum in person or by webcast at www.ntsb.gov.”