Company Near-Miss Review
Low-occurrence events are a concern for many departments. These calls account for only a small percentage of responses and have the greatest element of uncertainty for our personnel. They fall into the areas that get the most attention during training simply because if not conducted correctly there is a higher possibility for injury. These types of incidents generally require additional technical expertise and use tools that are not as familiar to all personnel. These are calls that involve techniques used for high angle, water rescue, trenches, hazardous material, confined spaces, or others that rarely happen. Because the nature of these techniques involve personal risk, we tend to front load the safety staff in many of our written protocols.
The featured report this month involves a department training with new equipment using a haul system to lower a simulated patient from a building. Once the evolution was completed, the group transitioned to a rappelling exercise using the same haul system from the previous drill. Subsequently, the personnel at the training exercise demonstrated some confusion regarding which tools were to be used. While reading this report, consider how your crew would have approached this exercise. The complete report, Fall During Rope Training, is available at http://firefighternearmiss.com/Reports?id=12788 on the Firefighternearmiss.com Web site.
During rope rescue training, we were practicing with our new Multi-Purpose Device (MPD). The device replaced an older system utilizing numerous working parts, with the intent to make lowering and raising during rope rescue more streamlined and efficient. We were working on the top of the four-story drill tower with a tripod as a high point anchor system. The MPD was being used on the main line with another MPD on the belay to raise and lower a training dummy in the litter basket. Once we completed the initial drill, one of the firefighters asked if he could do some rappelling. This firefighter had not had much exposure to rope rescue, and an opportunity to learn was satisfied.
The training involved the firefighter being lowered over the edge and then locked off with the MPD on the mainline. An overhand knot ensured that the mainline was locked off. During the descent, it was noted that the rope had minor slippage when passing through the MPD. The slippage was more than likely due to the age and wear of the rope. Still in place from the previous exercise, the belay line also used an MPD.
After instruction from the training lead, the firefighter began his descent on the eight plate and had good control for the minimum amount of experience he had on the rope. At this time, while rappelling, another firefighter seemed confused on why the MPD on the mainline was locked off and not being used. The other firefighter decided to untie the mainline and unlock the MPD, as he thought he needed to lower the firefighter to rappel. When he opened the MPD and began to lower the firefighter, the firefighter dropped uncontrollably to the ground. Fortunately, the firefighter on the rope was only about four feet off the ground.
- How do you conduct rope training?
- Is there always a safety briefing prior to beginning an evolution? Are designated personnel on site to maintain safe practices throughout?
- Do you ever use the type of equipment mentioned? Using the gear you have available, demonstrate how your department would rig up this exercise for the rest of the crew. One line for main descent line, and one for secondary belay; how do you ensure adequate fall protection is in place?
- Occasionally, training sessions are as fluid as fire alarms. Given what you know about this event, how would you protect personnel from this unintended situation?
Lessons to Share
From the original report: The firefighter who untied the rope quickly understood the different principles of rappelling with an eight plate and lowering with the MPD. He learned that the eight plate needed a static line. We also discussed the importance of considering any actions, especially during high-risk training, with the rest of the team to ensure appropriate measures. It is never okay to untie any line with another firefighter on it.
Changes implemented due to this event
Communication is vital. We have experienced several near misses when conducting high-risk rope training. When conducting this type of training, it is important that designated safety officers are in place and only utilized in that role. A strong command presence must also be present by those instructing the evolution.
In this report, the human error noted involves a firefighter untying a rope and unlocking a mechanical device while another firefighter is rappelling on the same line. Information available from this report indicated some of the elements involved in the evolution, but each decision point for this near miss are not clear. We can infer the steps as they may have occurred.
Each evolution before this one involved using the multifunction device to raise or lower the training objective. When the static line was untied, the firefighter on the rope immediately fell to the ground. One decision point may have involved a loss of situational awareness by the firefighter who untied the main line. Although the report identified the confusion regarding why the MFD was tied off, it is possible the firefighter was unaware of the change in training objective and may have missed the updated training briefing prior to changing the exercise.
The lessons shared also indicated the need for additional safety monitors for this type of event. This emphasizes the need for front-loading the safety element for any low-occurrence event actual or in training.
Though the report did not indicate a complete absence of familiarization by all concerned, there is a final point to consider. Where the initial objective indicated the crew was training with a new tool, it’s not clear why a Multifunction Device was also utilized on the belay line. With the need for fall protection being absolute, it is ideal to use a proven system until the crew is familiar with the tools.
Changing how we look at each near miss can lead to understanding why the near miss occurred rather than just how. If you have experienced a near miss where the initial indication was human error but additional investigation revealed decision turning points that led it to an unexpected outcome, I would like to read about the event. The International Association of Fire Chiefs hosts the national reporting system at www.Firefighternearmiss.com. Submitting a report only takes a few minutes and could prevent an injury or save a life.
A bit of controversy
Multipurpose Device Simplifies Rope Rescue
NFPA 1983, Standard on Life Safety Rope and Equipment for Emergency Services
Mastering the Solo Rope Rescue Technique: Special Operations
Greg Lindsay, MPA, CFO, has been a member of the Oklahoma City (OK) Fire Department since 1984. He has worked through each level of the operational fire service and has been a battalion chief for the past 15 years. Lindsay has a master’s degree in public administration from the University of Oklahoma and Chief Fire Officer designation from the Center for Public Safety Excellence. He has been with the Firefighter Near Miss reporting team since March 2005. You can reach him at [email protected]