By Terry Ritter
Fire and emergency service departments are high-reliability organizations (HROs) in that there are inherent risks and vulnerabilities.
Our job as fire officers is to help keep our personnel safe by identifying those risks and taking measures to reduce vulnerabilities. An HRO is any organization where there is an emphasis on people, process, and priorities working and safety is a concern. Improvements are gained and risks minimized through factual and complete data being collected, whereas factors and sequencing may be flawed as well as measures of prevention without root cause analysis.1
Crash Data Tools
To help our emergency vehicle operators improve, we can collect and assess emergency vehicle crashes with a more detailed and personal approach using different tools. One, a crash data collection tool, was adapted from the Model Minimum Uniform Crash Criteria2 and can be filled out as soon as possible after an emergency vehicle crash as an incident report form. It addresses human, vehicle, and physical environmental features. Meanwhile, a crash data analysis tool, when applied, analyzes the human, vehicle, physical, and psychosocial environment prior to a crash, at the time of the crash, and post crash.
Consider the following: An apparatus engineer (AE) wakes at 0330 for an alarm call and reports with a crew to the apparatus and goes en route. The crew departs the fire station at 0331, and the AE pulls into the roadway and abruptly comes to a halt as a burning order is noted. Emergency lights are activated, but the fire engine is struck by an oncoming car.
To use a data collection tool, the officer would simply pull out the crash data collection tool and mark the appropriate boxes regarding the driver, vehicle, and physical environment. The tool is designed to collect descriptors of events that can be drawn from with interviews to portray the event. Then, through use of the crash data analysis tool and interviews, you may find out the following:
■ Prior to the event, the AE had not slept for nearly 40 hours.
■ The AE takes medications where heavy machinery should not be operated.
■ The vehicle had brake work performed fewer than 12 hours earlier.
■ The AE reported to the officer that the vehicle did not seem to be operating or braking as it usually did.
■ The maintenance division had not been notified of any difficulties by the officer.
■ The AE advised the officer at 1900 the previous evening that a “check engine” light appeared.
■ Immediately after the incident, the AE stepped away from the apparatus, throwing tools and equipment and cursing at the officer.
■ The roadway at the scene of the crash had been closed to allow one lane of traffic at 0200 on that date.
Using a crash data analysis tool with root cause questioning and continuing to ask “why” can help identify true primary causative factors such as:
■ Creating a policy addressing limited sleep or length of work hours.
■ Defining proper training, skills, and experience for emergency vehicle operators.
■ Working with the human resource department to determine best practices to follow with employees taking medications. See 29 CFR Parts: 825.312 and 1630.
■ Practices to ensure proper equipment maintenance is performed and recorded.
■ Practices to communicate changes to emergency response roadways or environments.
■ Ensuring the maintenance staff is properly trained to perform work and has the appropriate equipment to do so.
■ Creating an employee improvement plan for the officer, AE, and maintenance staff.
Using crash data collection and analysis tools in this manner will identify risks, reduce vulnerabilities, and help improve the quality of our emergency vehicle operations.
Consider the model standard operating guideline (see sidebar) for implementation along with these tools. These records should be retained for trend analysis as well. If trends are found, perhaps the cause may be found in industry, organizational, cultural, or other individual resources beyond the practices and standards set forth in your department. The National Fire Protection Association and the International Fire Service Training Association address some of the above factors. Systems, processes, and priorities that can be addressed before they arise can be found in the U.S. Fire Administration Traffic Incident Management Systems FA-330/March 2012, the International Association of Fire Fighter’s Emergency Vehicle Safety program, and the Federal Motor Carrier Safety Administration (FMCSA).
The U.S. Department of Transportation’s FMCSA’s primary goal is crash reduction and safety. The Manila Consulting Group, Inc. has published opinions of an expert panel indicating that certain personality traits, symptoms, and disorders are associated with an increased crash risk as are psychological symptoms such as anxiety, depression, and psychosis.3 If concern or evidence arises regarding personality, psychiatric disorders, or medications for treatment, it is very important to work through these issues with your human resources, risk managers, or department attorneys as federal laws come into consideration.
Using uniform data collection and analysis methods can help our industry compare and improve collectively through sharing resources. Our goal must be to reduce crashes, organizational embarrassment, financial loss, civil liability, and loss of life through professional review and improvement methods.
1. National Aeronautics and Space Administration (NASA) Office of Safety & Mission Assurance Chief Engineers Office. (Electronic communication. June 26, 2003. Encl. to RootCause. Memo.doc.ppt) Retrieved January 16, 2015 from: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf.
2. Bragan, T. (2012). The Model Minimum Uniform Crash Criteria (MMUCC) Guideline 4th edition. Retrieved January 4, 2015 from: http://mmucc.us/sites/default/files/MMUCC_4th_Ed.pdf.
3. Manila Consulting Group, Inc. (2009). Opinions of Expert Panel—Psychiatric Disorders.
TERRY RITTER is a lieutenant with the Madison (WI) Fire Department and has worked in protective services (law enforcement, fire, and EMS) for more than 30 years. He has created many grass roots initiatives from community policing to tactical EMS.
Draft Standard Operating Guideline Apparatus Accident Reporting, Investigation, and Review