When PPE Fails, Tell Somebody

The recent nationwide MSNBC story about Personal Alert Safety Systems (PASS) device failure and firefighter Line Of Duty Death (LODD) investigations highlighted yet another issue concerning firefighter safety.

Ordinarily, such a story would have been published only in fire service magazines and Internet sites. With national coverage, however, it captured the spotlight for a brief moment in time and caused us to take notice.

Venom Aimed At NIOSH

Most of the venom in the story was spewed toward the National Institute for Occupational Safety and Health (NIOSH), a division of the Centers for Disease Control and Prevention (CDC). NIOSH has long been the certifying agency for self contained breathing apparatus (SCBA), and in the past eight years it has received congressional endorsement and funding to investigate firefighter line of duty deaths and other incidents of multiple firefighter fatalities.

The original thought behind the LODD investigations was for NIOSH to operate similar to the National Safety Transportation Board’s model for plane crashes and other mass transit accidents. A team of investigators would arrive within hours of the event with authority to investigate and report their findings. NIOSH has never received enough funding to either investigate all LODDs or to respond immediately to an incident.

After eight years, if you have read a half dozen or so of the NIOSH reports, you have pretty much read them all. And that is not a knock on NIOSH. It is just that we keep repeating the same stupid stuff over and over, and all the reports keep repeating the same themes.

Some of those themes include: allowing firefighters to be active when they have pre-existing medical conditions; failure to buckle seatbelts; failure to maintain control of a vehicle; failure to have an effective accountability system; failure to train; failure to have or follow standard operating procedures (SOPs); and risking a lot when there is nothing to save.

Only occasionally do we hear about equipment failure as a contributing factor in a firefighter fatality. Yet, there were at least 15 documented firefighter fatalities during a six-year period (December 1998 to December 2004) where the PASS alarm was not heard. If the alarm had sounded, would all 15 of the firefighters survived? Maybe not all, but certainly some would have.

Were there other factors that contributed to their deaths? Absolutely, but the fact remains, a critical piece of equipment for firefighter survivability did not operate as designed.

Would a record like this be acceptable in the aviation industry? No way.

So, how did all of this happen without us, the fire service, connecting the dots and realizing there was a problem? Apparently, one person in NIOSH picked up on the issue, but was unable to convince his supervisor. It was this conflict that eventually brought the story to the national forefront.

There is something we as the fire service can do to help address the problem – something that has yet to be stated in any of the articles or newscasts. That is departments need to report failures. More about that in a minute.

Calls For Heads To Roll

Almost all of the fire service organizations have encouraged action to improve LODD investigations. There have been calls for heads to roll at NIOSH. Some have called their investigative teams the “No-Go” teams.

There have been suggestions to place investigations under the U.S. Fire Administration (USFA). Even former presidential candidate Sen. John Kerry (D-Mass.) has said he wants the U.S. Department of Health and Human Services to investigate NIOSH.

Having been personally involved in two NIOSH LODD investigations (both medically related), I found the NIOSH investigator, who happened to be a medical doctor, to be very professional. His investigation was thorough, and he kept my department updated on everything he was doing, including reviewing the reports before they were released.

One thing about NIOSH reports is they do not necessarily find fault or lay blame on anyone. They just state the case and recommend actions to prevent future occurrences.

Accountability Lacking

No individual names or fire department names are mentioned in their reports. While you may not agree, I believe it’s a good thing that individuals and departments are not named and embarrassed. It also lessens the appetite for judicial involvement.

On the other hand, it’s bad in that no one is held accountable and bad practices are often allowed to remain in place.

One thing NIOSH should do is revisit previous investigations to see if its recommendations have been implemented. My guess is that far too many departments continue “business as usual” following an incident and investigation.

Now back to the question of how we manage to lose 15 firefighters over six years in part because of PASS device failure. The answer is simple – each event was considered isolated. No connections were made. No patterns followed. That’s because there is no formal process for fire departments to report equipment problems and no central data collection agency to raise concerns of a common problem.

We’ve all probably been involved or heard a story about a fire department reporting equipment problems to a sales person, distributor or manufacturer and be told that we were the only ones having a problem. We then later learn that other departments are having the same problem.

Several months before the MSNBC report, the National Fire Protection Association’s (NFPA) Technical Correlating Committee (TCC), which has oversight for firefighters’ personal protective equipment (PPE), was working on the problem within its scope of influence.

Failures Were Known

In fact, Laura Morrison, widow of St. Louis firefighter Rob Morrison, who died in the line of duty in May 2002, spoke to the TCC at one of its meetings. She very pointedly let us (the committee) know how unacceptable it was for PASS alarms to fail and for no one to know about it.

It was also at this meeting that one of the major U.S. fire departments reported it had discovered its PASS devices would fail under heat and water conditions and its technicians were using hair dryers to dry them out.

After they were dry, they worked fine and were sent back into the field. And they weren’t the only department doing this. The problem was never reported to agencies that could have created permanent solutions to the problem.

From that meeting and others, the NFPA added requirements to PASS devices to make them better able to withstand heat and water.

So, what should you do if your PPE fails? The answer will be detailed in the next revision of NFPA 1851 – Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting, which will be available in July.

The new standard states fire departments must report all serious PPE health and safety concerns to the manufacturer and the certification organization in writing. The fire department must request a written acknowledgement from the manufacturer and certification agency within 30 days.

If an “element” of PPE is NFPA compliant, it will have a third-party certification label affixed to it. The third party has an obligation and must protect its certification label. If this process had occurred with the PASS devices, we would have been able to address the problem much earlier.

A Process That Could Work

You might be wondering what constitutes a serious health and safety concern. There are three major concerns. First is an occurrence that causes loss of life or could cause loss of life. Second is an injury resulting in permanent bodily damage. This can be instantaneous or cause a life limiting disease or disorder eventually resulting in death.

Finally, a serious concern would be an injury necessitating hospitalization, which requires actual medical or surgical procedures likely to cause a loss of work for more than one day.

Until a better solution comes along, this is a process that could work – if used.

Fire departments should not report problems that do not present a danger to health and safety. For example, occasionally there are internal battles in a fire department over the selection of a PPE item. Sometimes there are emotional attachments to a particular brand.

One faction of the department may have wanted brand X while another faction wanted brand Y. If brand X is selected, then the brand Y folks tend to find problems with brand X, and a herd mentality sets in. If you report a problem, be sure you can substantiate it.

Be sure it is not an operational or maintenance problem. That’s the only way the system will work and have credibility.

Only time will tell what the future of firefighter LODD investigations and PPE failure reporting holds.

It’s interesting to note the new chairperson of the previously mentioned TTC is from NIOSH.

Editor’s Note: Robert Tutterow, who has nearly 30 years in the fire service, is the Charlotte (N.C.) Fire Department’s health and safety officer. He is a member of the NFPA’s technical committees on fire apparatus, serving as the chairperson of the group’s safety task force. He is also a member of the NFPA’s structural fire fighting protective clothing and equipment correlating committee.

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