Uncategorized

Rope-Training Exercise Leads to Near-Miss

Issue 5 and Volume 3.

The all-hazards mission of today’s fire and rescue service brings a multitude of responsibilities to fire department members. Rope rescue—a discipline requiring thorough knowledge and constant training in loads, friction, the effects of gravity and mechanical advantage—produces some of the industry’s sharpest mechanical minds. This exceptional mechanical aptitude translates to improved performance in other rescue disciplines as well. No one can acquire competency and confidence in the rope discipline without constant, labor-intensive training.

This month’s report, No. 06-567, describes a near-miss event that occurred during a training exercise. As you read the account, think about your own competency in rope rescue, leadership, risk assessment and drill preparation.

Event Description

“A crew decided to do some rappelling from our six-story training tower. When the crew arrived, it was decided to use a bottom belay for the rappel. The crewmember who set up the training asked who was going to go up to the top of the tower to safety check and assist anyone who may need help with the equipment. At this point, an individual said he would. He said he knew everything about what was going on at the top of the tower. This person was a 6-month rookie. Our department had sent him to a 20-hour rope technician course.

“Once the group was at the top of the tower, they rigged a rope and began rappelling on figure 8s. A few guys went over; at this point all the 8s were on the ground. Somebody said, “Hey, just use the rack.” The safety instructor said OK. He then instructed the firefighter who was about to rappel to only use a couple of bars. He then told him that the brake for this device was just like an 8. He told him to pull down instead of up. After a little investigation, it was found that this firefighter rappelled down from the top of the tower on 2.5 bars on a 6-bar rack.

“When the firefighter broke the edge, he began to fall. The battalion chief who was responsible for the bottom belay was engaged in conversation with the firefighter next to him. Somebody then yelled, ‘Belay! Belay!’

“The firefighter was stopped approximately 7 feet off the ground. He fell about 53 feet before he was stopped. The rope burned all the way through his gloves, causing very large blisters and lacerations all the way across both his hands.”

Lessons Learned

“If you don’t 100-percent know how a piece of equipment works, don’t use it. The world of rope rescue is very dangerous for someone who doesn’t fully understand the outcome of their actions. As for our rookie, he made a huge mistake. He should hold himself accountable for what happened and make sure nothing like this will ever happen again. That being said, I also believe that he was SET UP TO FAIL, first by the instructor who gave him a sheet of paper that said Rope Rescue Technician on it after only 20 hours of instruction. I have more than 800 hours on rope and don’t consider myself a technician.

“He was then set up to fail by our department, because of the decision that was made by an officer in our organization to let him run the operations on top of the tower. It’s important for the leadership within a group to know the capabilities of the individuals whom they lead. I feel that a rookie should not have been put into this situation.

“Communication then became an issue in the incident. The rappellers were not communicating with the bottom belay guys; no commands, such as ‘on rope’ or ‘belay,’ etc., were being used. The bottom belay must pay attention to what’s going on during rope operation. It’s also important to train on equipment that your department has available.

“If you don’t know, ask. It’s like I told my chiefs: Firefighter-so-and-so could be DEAD right now. It’s really that simple. We’ve worked hard to prevent this or anything like it from happening again. We are stressing training and individual knowledge of what is happening around you in all environments.”

Comments

The contributing factors to this near miss read like a case study in a human factors text. Elements of human error in decision making, situational awareness, communication and teamwork are readily apparent, making this report a classic worth studying repeatedly. The reporter also makes a particularly astute observation when he notes that the department has a role in the failure of the rookie. In a safety-based culture, the entire system, not just the individual(s) at the “crash site,” is examined as part of the correction/prevention process. The reporter of No. 06-567 has provided us with an excellent technical rescue near-miss report to use at a safety briefing before a drill and a solid template for approaching error management.

Preparation

  • Technical rope drills require planning and lines of responsibility that are pre-designated and clearly defined.
  • All technical rope drills should include a didactic review of the skill set(s) being reviewed/reinforced.
  • A specific, focused safety message is a must. Personnel attending the drill should be attentive during the safety message. The lead instructor should stop the briefing and enforce attentiveness if members engage in sidebar discussions.
  • At least two of the most experienced members should inspect the equipment. The inspection should be given sufficient time to ensure all equipment gets more than just a cursory look. Lives literally hang in the balance during rope-rescue drills.
  • Set aside time to review the drill’s objectives and reinforce best practices.

Prevention

  • The most significant prevention step: Approach each technical rope drill as if someone can get killed while participating … because they can. A 60′ fall is fatal.
  • Tell participants to be alert for signs of complacency. As team members become more confident in their skills, complacency can (and will) creep in, insidiously undermining performance. If all members aren’t watching for short cuts, the holes (errors) in our defensive layers line up and lead to injury.
  • Newly minted “technicians” should be counseled by more seasoned members regarding the limits of their status. First-level certification training typically provides skill sets that meet minimum standards—not competencies to lead or be left alone at drill sites.
  • Remind all members to speak up if they see something that doesn’t look right. The environment must be open enough to ensure members don’t suppress their concern out of fear of embarrassment.
  • Don’t take short cuts. They eventually lead to oversight. Oversight leads to error. Error leads to disaster.

Conclusion

No one can perform perfectly all the time. Technical rope work, like all fire and emergency service disciplines, is a team effort. Team performance is essential for success. As this report from www.firefighter nearmiss.com reminds us, the lessons we take from others today make us perform better and safer tomorrow.