Line-of-duty deaths among U.S. firefighters: An analysis of fatality investigations
Research highlights
▶ NIOSH investigations of LOD medical fatalities have consistently produced two recommendations for improvement: conduct regular pre-placement and annual medical screenings of firefighters, and make participation in wellness/fitness programs mandatory. ▶ Trauma or non-medical fatalities reveal a broader and more complex array of recommendations, but recommendations involving personnel management and planning/incident command account for about 70% of all high frequency recommendations in trauma cases. ▶ Further analysis of these recommendations reveal linkages to four higher order causal factors: under-resourcing, inadequate preparation/anticipation of adverse events during operations, incomplete adoption of incident command procedures, and sub-optimal personnel readiness. ▶ These deficiencies may be symptomatic of the fundamental cultural paradigm of firefighting. ▶ One that accepts and normalizes high levels of personal risk.
Introduction
The United States depends on about 1.1 million career and volunteer firefighters to protect its citizens and property from losses caused by fire. Firefighting is considered to be one of the most stressful and dangerous occupations. Each year more than 100 firefighters die in the line of duty and over 80,000 are injured (Karter and Molis, 2009, United States Fire Administration, 2009). The fatality rate for firefighters is three times worse than for the general working population (International Association of Firefighters, 2001). Advances in technology, personal protective equipment, engineering controls, environmental management, medical care, and safety legislation produced substantial reductions in fatalities during the 1970s and 1980s; however, these numbers have not improved during the past 25 years and have been trending upward for the past decade.
Without question, firefighting is high hazard work, but it is unique beyond this. In most high hazard work situations, the goal is hazard avoidance. In contrast, for firefighting, the principal work activity is hazard engagement, which is usually further complicated by extreme time pressure. The customary safety strategy in many high hazard work situations is to implement multiple safety measures, or what is sometimes referred to as: “defenses in depth” (Rasmussen, 1997, Reason, 1997). That is, several layers of precautions are put in place to protect the workers and the integrity of the overall system, even when components fail or errors occur. There is little protective redundancy in firefighting, and risks to personnel must continually be assessed and reassessed as the fire situation develops and changes, often with little predictability or advanced warning. Most efforts to protect firefighters fall into two general categories: preparative measures and operational measures. Preparative measures encompass actions that prepare the firefighters to do their work in as safe a manner as possible. This would include personnel selection and placement, training, professional socialization, as well as the provision of personal protective equipment (PPE) and other safety devices. Operational measures focus on maintaining an adequate margin of safety during actual firefighting activities. This would include adherence to various standard operating procedures (SOPs), continued monitoring of risk–benefit ratios, communications, staffing, and other command and control activities.
As part of the effort to reduce firefighter line-of-duty fatalities, the United States Fire Administration (USFA) collects and evaluates information regarding line-of-duty (LOD) firefighter fatalities and publishes the data in the annual firefighter fatality reports (e.g., United States Fire Administration, 2009). In 1998, Congress appropriated funding to the National Institute for Occupational Safety and Health (NIOSH) to conduct independent, onsite investigations of firefighter line-of-duty (LOD) deaths (National Institute for Occupational Safety and Health, 2009). The investigations conducted as part of the NIOSH Firefighter Fatality Investigation and Prevention Program (FFFIPP) are voluntary and not all fatalities are investigated. Cases are selected for investigation using a decision algorithm (National Institute for Occupational Safety and Health, 2009), with the primary goal not to find fault or assign blame, but rather to learn from these events and to formulate recommendations directed at preventing future firefighter injuries and deaths.
Once notified of a LOD fatality, usually by the USFA or the fire department, NIOSH starts its investigation by contacting the fire department and conducting a thorough review of all applicable documents (e.g., department policies and procedures, dispatch records, victim's training records, coroner/medical examiner's reports, death certificates, police reports, photographs, and video). NIOSH investigators also interview fire department personnel and firefighters who were on the scene at the time of the incident. Additional expert assistance might be sought for incident reconstruction or fire growth modeling. The entire series of events during the incident is then summarized in a report, which includes recommendations to prevent future deaths and injuries under similar circumstances. Recommendations are made based on established best practices, National Fire Protection Association (NFPA) standards, information from the United States Fire Administration (USFA), and the public health and fire service literatures related to each case. Each report typically addresses multiple contributing factors and contains a number of different recommendations. Reports for all completed investigations are available on the NIOSH website. Since the program's inception, NIOSH has completed over 470 fatality investigations.
There have been several prior efforts to compile and analyze various portions of this accumulated database. Hodous and colleagues (Hodous et al., 2004) reviewed firefighter fatalities from 1998 to 2001 and synthesized NIOSH recommendations for cases involving structural firefighting activities. These researchers identified eight frequently occurring recommendations that highlighted three general areas of concern: (1) use and enforcement of standard operating procedures (SOPs) related to structural firefighting techniques and strategies; (2) adequate staffing and adherence to contemporary incident command practices, and (3) increased attention to communications and personnel accountability and rescue. Peterson and colleagues (Peterson et al., 2006) examined recommendations from the first five years of fatality investigations (1999–2003). Their analysis identified 31 “key” recommendations, 22 involving traumatic injury fatalities and 9 involving cardiovascular fatalities. These were further reduced to 17 sentinel recommendations involving training, standard operating procedures, safety practices, and the safety environment of fire departments. More recently, Ridenour and associates (Ridenour et al., 2008) reviewed all investigations completed between 1998 and 2005. This analysis highlighted ten categories of recommendations, two focusing on medical cases and the other eight focusing on traumatic injuries.
The clear majority of medically-related fatalities involve cardiovascular events and these have produced two predominant recommendations: the need for improvements in medical screening, and the need for wider adoption of fitness/wellness programming for firefighters. These are both preparative measures designed to identify and address cardiovascular risk in operational personnel. Trauma cases, on the other hand, have yielded a much more diverse array of recommendations and a less clear picture of high priority needs. These recommendations address both preparative and operational measures, and cover a broad territory that includes command and control functions, operations and tactics, and equipment and resources.
Section snippets
Purpose
The present study continues this line of inquiry but expands it in several ways. The first objective was to determine the extent to which the incidents investigated by NIOSH are representative of all firefighter LOD fatalities. NIOSH investigations are voluntary on the part of the fallen firefighter's organization and NIOSH does not have sufficient resources to investigate all fatalities. This issue has potentially important implications for the generalizability of any key recommendations
Method
This study reviewed all FFFIPP investigation reports for fatalities occurring between 2004 and 2009 and released by NIOSH on or before August 15, 2010. Reports were accessed from the NIOSH website (www.cdc.gov/niosh/fire). Spreadsheet software (Microsoft Office Excel 2007) and relational database software (Microsoft Office Access 2007) were used to compile the relevant information for each completed investigation. The spreadsheet was configured so that the case file number was linked to the
Results
Table 1 shows the distribution of fatality investigations by category, victim demographic characteristics, and total number of recommendations. During the time period under study, NIOSH completed 189 fatality investigations, involving a total of 213 LOD deaths. Ninety-nine investigations involved medically-related fatalities and 90 involved fatal traumatic injuries. Seventeen investigations involved multiple fatalities; all of these were trauma cases. Of the 213 firefighter deaths: 99 were
Discussion
NIOSH completed 189 fatality investigations, involving 213 firefighter LOD deaths, between 2004 and 2009. These investigations produced a total of 1167 recommendations intended to enhance firefighter safety. The present analysis identified 35 high frequency recommendations: six pertinent to medical cases and 29 pertinent to injury cases.
All six medical recommendations address medical readiness or fitness for duty, and two of these recommendations were especially prominent: (1) the need for
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