"Quid est veritas?"
In this classic scene from ‘A Few Good Men’, Danny Kaffee is questioning Lt. Col Nathan Jessop about the use of a ‘Code Red’ that resulted in the death of a Marine. Colonel Jessop’s line, “You can’t handle the truth” drives to the point that while we may seek answers, we may not always want to hear them.
How does this apply to the Fire Service, well grab a cup off coffee and I will tell you. For every line of duty death that occurs, there are thousands of brothers that offer condolences and stand shoulder to shoulder with those mourning the brother lost. Once the funerals are over, sometimes before, the second guessing begins. People that had no involvement in the incident immediately start offering their opinions as to why the deaths happened, and how they could have been avoided.
Obviously this is inappropriate. If you weren't there, then mind your business until someone that was weighs in. The official investigation should be the defining document, addressing what went right, what went wrong, and how to avoid it in the future.
But does it really do that? Do we really want to know the truth? Can we handle the truth? There are brothers out there that think we should learn from Line of Duty Deaths, without questioning the the actions of the brothers that were there. Explain to me how that is possible? Without asking questions, how do we determine what went on, what decisions were made, and where things went wrong? Without asking questions, how can we possible analyze what happened?
So if we can’t question the actions of the brothers on that fateful day, how do we learn? Do we just look at the end result and say, “wow that was bad, I better be careful that what happened to him doesn’t happen to me.”? If we do that, then we are saying that the events that occurred are just “happenstance”. We are saying that the actions of the Fire Department and the individual had no bearing on the outcome, and are unimportant. We are saying, “Shit Happens.” Now that may be true. The Department may have done everything right, and yet a firefighter was still killed. But the only way we find that out is by investigating and questioning and examining every aspect of the operation. The intent of this investigation is not to criticize. Whatever questioning is done, it should be respectful and truth seeking. It should be with the intent of learning from the event, not prosecuting those involved.
One of the major complaints, from many, is that the NIOSH reports are too vanilla, too boilerplate, and rarely address the real issues. That they don’t go far enough into investigating the root cause of the incident. That they are too generic, “Firefighter #1 from Fire Department A”, that many fail to connect with the event and therefore whatever lessons are contained within are promptly discarded.
But why are the NIOSH reports like that? Is it because NIOSH lacks the ability to properly investigate our incidents? Or is it because we “can’t handle the truth.”? Is because we really cannot honestly look at our events and accept that some things that were done may have been wrong? And we especially cannot handle someone from outside doing that for us, pointing out or mistakes and where we are lacking. Whatever the reason, this is probably why most prefer the internal Department reports to the NIOSH reports. Because the Department’s tend to be a bit more forthright and direct about what happened. It is too bad that we have such a comprehensive Fatality Investigation programs and yet many find the results so disappointing. Maybe we need to look in the mirror to find the reason why that is.
Regardless of who is doing the investigation, we as a service need to be able to handle the tough criticism that goes with working in a life and death environment, otherwise we face the reality that what has happened before will happen again. It is kind of like the definition of insanity, “Doing the same thing over and over and expecting a different result.”
Another aspect of this issue is how prepared is your department? We should prepare, as a department for the mission we face. One aspect of that preparation is being ready to answer the hard questions after an injury or death occurs. In other words, we need to train and prepare like NIOSH will here tomorrow. Are you ready to answer the tough questions? Can you defend your policies, training, and actions?
The Fire Service needs to use these reports as a tool, a tool to show us what can happen and hopefully how to prepare for it and prevent similar outcomes. Much like Hal Moore spent hours reviewing all of the French after action reports, before deploying to Vietnam so he was prepared to fight the enemy he would face. The Fire Service needs to accept that it can learn from the experiences of others, that no one Department has cornered the market on experience or knowhow. We can, and should learn everything we can from the experiences of others. We owe it to those that have made the ultimate sacrifice to learn from their last fire, to make sure it never happens to us.
Below are some examples of some really well written reports, produced by the Departments that had the events.
On April 4, 2008 a fire occurred on Colerain Township, Ohio that resulted in the deaths of Captain Robin Broxterman and Firefighter Brian Schira. “As a result of what occurred that morning, Fire Chief G. Bruce Smith took immediate action and ordered a thorough examination by an internal department fact finding committee of the events, practices, procedures and training that led up to April 4th. On July 11, 2008, the department released its preliminary report that described the events of that fateful morning as they unfolded. Following the issuance of the preliminary report, a subsequent final report committee was appointed and tasked with analyzing the incident in its entirety and producing a more comprehensive report.”
Below are the findings of the Final Report Committee:
The following factors were believed to have directly contributed to the deaths of Captain Broxterman and Firefighter Schira:
• A delayed arrival at the incident scene that allowed the fire to progress significantly;
• A failure to adhere to fundamental firefighting practices; and
• A failure to abide by fundamental firefighter self-rescue and survival concepts.
Although the aforementioned factors were believed to have directly contributed to their deaths, they might have been prevented if:
• Some personnel had not been complacent or apathetic in their initial approach to this incident;
• Some personnel were in a proper state of mind that made them more observant of their surroundings and indicators;
• The initial responding units were provided with all pertinent information in a timely manner relative to the incident;
• Personnel assigned to Engine 102 possessed a comprehensive knowledge of their first-due response area;
A 360-degree size-up of the building accompanied by a risk – benefit analysis was conducted by the company officer prior to initiating interior fire suppression operations;
• Comprehensive standard operating guidelines specifically related to structural firefighting existed within the department;
The communications system users (on-scene firefighters and those monitoring the incident) weren't all vying for limited radio air time;
• The communications equipment and accessories utilized were more appropriate for the firefighting environment;
• Certain tactical-level decisions and actions were based on the specific conditions;
• Personnel had initiated fundamental measures to engage in if they were to become disoriented or trapped inside a burning building; and
• Issued personal protective equipment was utilized in the correct manner.
On April 16, 2007, Technician I Kyle Wilson was killed in a wind driven residential fire at 15474 Marsh Overlook. As a result of the investigation, a comprehensive list of findings and recommendations were made. These findings included building construction, operations, policies and procedures.
On May 25, 2008 a serious fire occurred in Loudoun County, Virginia at 43238 Meadow Court. & Firefighters were injured, including 4 that suffered serious burns. This report and YouTube link represent a comprehensive look at the events that day, and offer recommendations to prevent similar events from happening again.
Dave LeBlanc is a Captain with the Harwich, Massachusetts Fire Department. Dave entered the Fire Service in 1986 as a Call Firefighter with the Dennis Fire Department. He worked full time during the summers in Dennis, while attending the University of New Haven in West Haven, Connecticut. In addition to his regular duties, Dave also manages the Department’s Radio system, is responsible for conducting Fire Investigations, and assists in maintaining the computers systems.