‘I can’t believe I’m alive': Dramatic near misses from 2019

By John Russ

Major maydays and line-of-duty deaths (LODDs) that hit national news outlets capture our attention. Rightly so, we review these pieces for lessons learned with hopes to prevent similar instances in the future.

While NIOSH Firefighter Fatality Investigation and Prevention reports and similar documents are vital to study, they don’t capture the first-person perspective. We can’t analyze the decision-making of the individual who experienced the event. We may even read a report and wonder, “What were they thinking?”

The Firefighter Near Miss Reporting System captures the thought processes and decision-making within near-miss events. We can ask the question posed above, not in a derogatory way, but rather an inquisitive manner to better understand the actions that led to the event – and what we can learn from it. We can see how, when the bias of hindsight is removed, the actions may seem very plausible. It could even be something that you would do under similar circumstances.

As 2019 comes to a close, we highlight five dramatic near misses that could have led to an LODD. Hear from the firefighters who lived through these “I can’t believe I’m alive” moments, and put yourself in their shoes to consider how you would have handled the same situations.

1. “There was a loud noise, and we were hit with broken glass”

In the near-miss report Basement Fire Smoke Explosion, the department arrived on scene to a two-story, wood-frame single-family home with smoke showing from the eaves. The initial company officer conducted a 360 and found a basement fire, apparent from flames showing in the basement windows. A command officer arrived and transferred command, assigning the first engine company to fire attack. Other units arrived and were assigned various roles to include search, rapid intervention, and ventilation.

Fire attack made entry on the delta side, thinking the stairs would be right there, but soon radioed that they had difficulty finding the fire. Another company on the Charlie side reported stairs in the rear with easy access. Fire attack exited and moved around to the back to redeploy with the companies on the Charlie side.

As this occurred, the incident commander (IC) was briefing the next in battalion chief, assigned to safety, and then heard a loud noise: “There was a loud noise, and we were hit with broken glass. I turned to look at the building and saw the first floor on fire. I radioed dispatch that we had a smoke explosion and to sound the evacuation tones. Fire attack radioed they needed an ambulance in the rear of the structure. I requested ALS through dispatch, and the injured firefighter was brought out front. I had Safety perform a personnel accountability report (PAR) over the radio, and I did a face to face with all crews as they exited.”

A smoke explosion had occurred. The report submitter described the impact: “The officer that was injured was standing in the rear about to click his regulator into his mask when there was an explosion, and he was engulfed in smoke. He had trouble breathing due to smoke inhalation. A rescue crew who had been assigned to search had exited the building before the explosion, and the other rescue crew performing search was thrown down the stairs from the second floor, with no injuries.”

Lessons learned

The near-miss report submitter noted the following lessons learned from the incident:

• Reset basement fires before entering. We teach this, but it is hard to break from what we were always taught.
• Pay closer attention to conditions, and make a radio call if you feel something is not right.
• Search needs to use the same entrance as the fire attack, we had too many doors open.
• Review basement fire standard operating guidelines (SOGs) and make sure to use SLICE-RS tactics for initial-arriving officers.

The submitter also noted that best practices were hampered by difficulty in initially determining the fire location and flow path.

Resetting a fire, also known as conducting a transitional attack or quick hit, allows time to gather necessary resources, find the best path to the seat of the fire, and to move interior safely and efficiently. Putting water on the fire as early as possible improves the chances for victims and reduces the potential for dangerous fire behavior.

Read the full report: Basement Fire Smoke Explosion

2. “All I saw was the muzzle blast and heard the loud crack”

Our more dangerous calls are probably our most frequent. When we respond to structure fires, hazmat releases or car accidents, we can conduct scene size-ups that identify most of the risks. When we walk into a medical emergency, we have way to know the intentions of the patients or family members. The human element is the most diverse risk, and we have little or no indicators of things going bad when we first arrive on scene.

In the near-miss report Fall Patient Brandishes Pistol, an engine company responded to a 71-year-old male patient who sustained injuries from a fall. On arrival, family members were present, and the patient was found on the floor just inside the hallway past a sofa in the living room.

After assessing for injuries and finding none, the crew helped the fall victim up and assisted him to the bed, located in the living room just past the sofa where family members were located.

The patient was slightly confused and had picked up his pace, walking faster and getting slightly ahead of the crew assisting. As he was getting into his bed, he made a reaching movement, but one of the firefighters grabbed his shoulders, moving him, so he was lying on his back. No one noticed what he was reaching for.

The medic was talking with family members to get a history, and responders were beside the bed. As vitals were being assessed, the patient’s arm stiffened, and the patient brandished a gun. The patient was only able to move his arm below the elbow as the responders initially only had control of his upper arm.

“I saw a pistol coming toward me …. It waved toward my face as I reacted and pulled my body and head in a backward motion. As I pulled back, my right-hand pushed the firearm to the left as it went off, just missing my left shoulder about 10 inches from my face. All I saw was the muzzle blast and heard the loud crack. I moved my hand from a pushing motion and immediately grabbed the gun to keep the action from working again. I pressed it down on the bed, pressing the gun next to his head deep into the mattress.

“I grabbed the firearm with both hands, realizing it was a revolver. I yelled, ‘I got the cylinder’ and began to wrestle with the patient. The first responder to my right jumped in to assist with removing his fingers from the gun, but the patient had a death grip on the handle. The paramedic immediately jumped in from the left and gained control of his left arm as we were trying to access the firearm.

“We notified dispatch that shots were fired. Law enforcement arrived within minutes.

“The family was in shock, just as we were …. A few minutes later, the patient was assessed again and was fully alert. He claimed no knowledge of shooting the firearm.”

Lessons learned

The near-miss report submitter noted the following lessons learned from the incident: “There is no such thing as a routine call. We hear this all the time, but what does that really mean? It means to watch our patient’s hands. Even if you’ve responded to the same people three times before, always have extra eyes watching. If the first responder to my right hadn’t gained my attention, the outcome would have been very different. All it took was the time for me to turn on the monitor and apply the BP cuff, 5 seconds max, and I’m fighting for my life at close combat. We had only been in the home for about 7 minutes before the incident occurred.

“We will be paying closer attention to the older male population and have extra eyes to watch hands and scan the area for potential weapons. We will also ask the family members if there are weapons or firearms close by where the patient usually sits or sleeps.”

Weapons and altered mental status are a terrible mix. Situational awareness is key to predicting behavior. As responders, we need to recognize that many patients suffer from dementia or PTSD. Try using techniques that reduce agitation and increase situational awareness.

Read the full report: Fall Patient Brandishes Pistol

3. “My foot landed on an energized power line”

Being notified of hazards when first arriving on a scene is important, but just checking the box of “notification” doesn’t mitigate the risks.

In the near-miss report Officer Steps on Energized Power Line Due to Poor Visibility, firefighters were on the scene of a small single-family home with heavy fire involvement. Their first assignment was to set up a rapid-intervention crew (RIC) on the Bravo side. The RIC officer conducted a 360 and notified all firefighters of a low-hanging clothesline on the Charlie side and that the electrical mast had fallen from the home. Power and cable lines were down in the yard.

As fire operations continued, personnel were removed from the interior, and suppression activities continued only from the outside. The interior crews were recycled to rehab, and the RIC crew was reassigned to fire suppression.

“I walked the 20 to 30 feet away to look down the Delta side of the structure to familiarize myself with the area and see how the conditions could affect our assignment. The house was small, and I was still near my crew. I stepped just to the corner of the house and my foot landed on an energized power line. The power line began to arc, and I felt a vibration under my foot.”

Fortunately, the firefighter was OK. He reported that he did know downed power lines were in the vicinity, but due to poor light conditions and visibility, he never saw them. Luckily, he did not contact the live power lines that were hanging by the fence just a few feet away.

Lessons learned

The near-miss report submitter noted the following lessons learned from the incident: “Make sure to use scene lighting. The downed line was communicated to everyone on the scene, but it was dark in the area where it was located. The crew was given a verbal size-up of the area prior to entering it, but was not shown exactly where the hazard was.”

Visibility and task saturation can easily distract firefighters from hazards that may have been identified during initial 360s. However, it may not be enough. As soon as feasible in fire operations, it is beneficial to mark hazards with traffic cones or caution tape to help jog the memories of firefighters who either arrive later in the incident or who have operated there for some time.

Read the full report: Officer Steps on Energized Power Line Due to Poor Visibility

4. “Every firefighter was close to being burned or killed by the jet’s exhaust”

Near-death can occur at any moment. We expect it on high-risk emergencies, but it can happen when assisting a disabled motorist or during a relatively mundane training drill.

The near-miss from the report Passenger Mode Nearly Kills Seventeen occurred as aircraft rescue firefighting (ARFF) crews were sent to help a disabled plane during an airshow. Seventeen firefighters were on standby during the show. A World War II-era jet propulsion plane had slipped off the runway and was stuck. The pilot enlisted the help of firefighters to push the aircraft back on the runway.

Many of the firefighters didn’t don PPE, as the assumption was that they would push the plane. There was no formalized incident commander, safety officer or incident action plan. While many of us wouldn’t necessarily do these things for assisting a motorist, it proved in this instance that these steps, even in an informal capacity, are paramount.

Photo/Firefighter Near Miss Reporting System

The firefighters were not initially successful at pushing the plane. The ground was soft, and the slight incline made it impossible.

During the second attempt to push the plane, the pilot started the engine and began to throttle up. On ignition, a fireball shot from the jet propulsion, starting a small grass fire.

“Everyone continued to push, mainly on the left wing, as the pilot throttled up ‘a little.’ … As we pushed, the pilot throttled up more than just ‘a little’ and then some more. The plane started to spin around due to it being in dirt and mud. The jet’s exhaust turned toward the firefighters. All 17 personnel on scene let go of the plane and took off running to hide behind a vehicle for protection from the heat shooting out of the jet exhaust!”

If the firefighters had remained in place, especially the ones with no PPE, they would have sustained severe injuries or even death from burns.

Lessons learned

The near-miss report submitter noted the following lessons learned from the incident: “Every firefighter and officer was very close to being burned or killed by the jet’s exhaust. There was never any ICS, command established, safety officer established, divisions, or groups given out. There was never an after-action review (AAR), lessons learned, critique, hot wash or whatever you want to call it.

“In the future, calls like this must have an established command, incident action plan (IAP), thorough risk assessment, safety officer, groups and proper PPE. The pilot gave instructions as to what to do; however, the plane/jet should have never been turned on with personnel near it or pushing it. Using personnel instead of a towing vehicle was unsafe and a result of poor decision-making. Personnel should have been clear of the flames and fireball that shot out of the exhaust when the pilot turned the jet back on. Aviators are supposed to take ‘the most conservative approach’ to a problem. This did not occur.

“Col. Mike Mullane, U.S. Air Force fighter pilot and NASA astronaut, warns firefighters to guard themselves against falling into ‘passenger mode.’ The moment that 17 firefighters decided to go along with the pilot’s plan, without saying a single word, was the moment they stopped contributing as team members. All became victims of groupthink and became passengers. Passenger mode is a killer for teams.”

Read the full report: Passenger Mode Nearly Kills Seventeen

5. “I discovered we were inside the room involved”

Staffing levels, especially in the rural volunteer fire service, sometimes doesn’t allow for the most experienced crew to be the initial decision-makers.

In the near-miss report Flashover Conditions During Attack, a crew of three firefighters was on the scene of a single-wide mobile home with a room-and-contents fire. None of the crewmembers had ever made an interior attack before, but they decided to go interior anyway.

“I stopped my crew midway through the building, as conditions were worsening with higher heat. As I saw little curls of flame lighting off in the smoke above, I instructed the nozzle firefighter to open his nozzle at the ceiling. I knew things were getting worse when no water was falling on us, evaporating in the atmosphere above. I started screaming to flow water. We were fortunate it didn’t flashover.

“We continued down the hallway, as I knew we had to be close to the end of the trailer. The heat started increasing again, and I could hear the fire. I knew something wasn’t right when I saw a yellow speck at the corner of my mask. When I rubbed my hand across my mask, I discovered we were inside the room involved. The smoke was so thick that we couldn’t see through our masks. We were lucky that the conditions didn’t worsen while we were inside.”

Lessons learned

The near-miss report submitter noted the following lessons learned from the incident: “Don’t be complacent; trust your instincts and training. Three inexperienced firefighters got lucky but hopefully learned from the experience.”

After reviewing the report, the near-miss team also provided some additional takeaways to consider: It’s paramount that firefighters understand the importance of flowing water, even when flames may not visible. Also, inexperienced crews that lack appropriate supervision can be a deadly combination. While we want to provide the best service possible, we need to be smart about the decisions we make, taking into consideration our own knowledge, skills and abilities.

Read the full report: Flashover Conditions During Attack

Taking action: Using near-miss reports for enhanced learning

There are several ways that you can be more engaged and learn from near misses.

• Resources to your inbox: First and foremost, sign up for the Firefighter Near Miss Report of the Week. Subject-matter experts review near-miss reports and create a learning platform that includes discussion questions, takeaways, leading practices and other resources. These resources can be used within a company dynamic, during drills at the firehouse or during individual learning sessions. You can also listen to a narrated report of the week.

• Search reports: If you have a specific topic you are interested in and want to review those near misses, you can search over 5,500 near miss reports. The topics range from emergency events, such as structure fires and hazardous materials responses, to non-emergency near misses that occurred at training or during other station duties.
• Share your story: The Firefighter Near Miss Reporting System ensures anonymity, security and no disciplinary action. Reading this article has provided valuable insight into real events where firefighters almost perished. This is not possible without the capability of sharing near miss in a structured manner, then vetted and reviewed for accuracy and dependability.

The challenge has now been passed to you. Share your near misses and lessons learned to protect the next shift.

About the author
John Russ is an 18-year veteran of the fire service, currently working for the Brentwood (Tennessee) Fire & Rescue Department as a lieutenant/paramedic. He has been the program manager for the IAFC’s Firefighter Near Miss Program since January 2016. Russ has also worked for numerous career and voluntary fire and emergency service providers to include prehospital EMS providers, specialized technical rescue organizations, along with risk management and prevention entities. He has a master’s degree from Middle Tennessee State University in professional studies and two bachelor’s degrees from Eastern Kentucky University, one in fire and safety administration and one in prehospital emergency care. Russ is a veteran of the U.S. Marine Corps.