Company Near-Miss Review: Tactical Changes for Flow Path Management

Issue 1 and Volume 15.

Jobs on the fire scene can vary in intensity. Primary jobs for most incidents include fire attack, search, ventilation, salvage, rapid intervention to protect the interior crews, overall command, and incident safety. Unique circumstances can require other specific tasks but covering the broad strokes of these primary assignments can give us a foothold on the incident. Consider, when the science of fighting a fire changes, the tactics we were taught may also have to change.

The current model for attacking a structure fire addresses managing the ventilation flow path. Controlling how the smoke and gases exhaust from the building and where any oxygen enters can give us insight for beginning to control the fire. Reading the smoke, understanding the ventilation exit thermal planes, and coordinating ventilation with the other assignments on the scene are assignments for a veteran firefighter. The incident commander should carefully select the person assigned to coordinate these responsibilities.

The featured report, Roof Ventilation Drops Ceiling Onto Interior Crews, published 5/30/2018, is available at http://firefighternearmiss.com/Reports?id=12789. The report identifies communication and situational awareness as the most significant contributing factors for the injuries sustained by the two firefighters. As you read the report, consider the ways you would manage this task.

Event Case Study

The crew was dispatched to a working structure fire. While working on overhaul in a stairwell, two firefighters received minor injuries when ceiling and roofing materials fell on them. When the incident occurred, the firefighters were working under the direction of a division supervisor. The firefighters were pulling ceiling and wallboard to check for extension of a deep-seated fire that was difficult to locate. Smoke was coming from the roof area and exterior walls as well as the interior wall area. The division supervisor requested a vent hole in the roof area above the stairwell to assist in locating the fire extension. The inspection hole was cut, and the roof crews punched through the ceiling, causing construction material to fall on the firefighters below. The firefighters were knocked to the floor. One was treated at a local hospital and released. The other firefighter was treated on the scene.

Lesson to Share

What recommendations do you have to prevent a similar occurrence? Situational awareness is not only the responsibility of those in command and other supervisory roles; it is the responsibility of everyone. We all have the responsibility of watching out for the overall safety of one another. Roof crews were not coordinating with interior crews.

Managing this task consists of a series of crew functions. The roof crews have to work in a blind situation that makes it impossible to work without a coordinator. Consider the following points in discussion with your company members. • When you work inside a structure fire, how do you coordinate with crews working in other areas of the building?

• Keeping the flow path manageable in a structure requires a sharp eye and vigilance. What tactics do you use to keep this under control?

• When looking at a floor plan, it’s possible to identify how to use doors and openings to direct smoke and air movement through a structure. Discuss how sequentially opening doors and windows can aid in managing the path smoke flows from a structure.

• Attic spaces typically lack compartmentalization in single-family residences. Tactically, is it best for the roof crew to breach the ceiling during ventilation, or would it be better to leave the placement of the ceiling breach to an interior crew? Just a few feet off target in the attic can force heat and smoke to migrate through a hallway to another part of the structure.

The critical elements associated with this report are coordinating the tactics during this event and maintaining situational awareness. I notice that both are “human” related elements. Because the author identified why this happened rather than who was responsible, we can learn more about the causal factors that contributed to the event. Focusing on each element will help explain the pieces of this puzzle and relate the learning steps for other firefighters.

Working backward from the incident, it is possible the roof crew completed their task without knowing firefighters were directly below. Other factors can include the structural material degraded during the fire, allowing more than the sheetrock to fall when breached. In addition, when you look down through the smoke, it can be difficult to see what obstacles or conditions are present. More information from the roof crew could provide specifics critical to their decision process.

Since the overhaul crew had been hooking sheetrock before the vent hole was cut, it is understandable that they continued to work systematically investigating the heat sources located in the area and did not expect a breach from the top. It also is understandable that the roof crew breached the ceiling because that is how they were taught to provide ventilation.

A modest change in ventilation tactics can provide safety for crews working interior. When you decide to ventilate vertically, consider using the vent crew to provide openings only in the roofing material while also requiring the interior crews to breach the ceiling. Giving the interior crew decision-making responsibility for where the ceiling is breached will allow more control of the ventilation flow path and will protect them from unexpected falling ceiling materials. This tactic works very well for me and can mean the difference in reducing migrating smoke and fire damage to other parts of the building. The science associated with this information is leading this change in practice.

Coordinating tactical elements on the fireground has always been a concern for firefighters. Sharing your experiences can reach farther than you might know. The National Firefighter Nearmiss Reporting system, hosted by the International Association of Fire Chiefs, is supported by firefighter organizations (paid, volunteer, and combination) and can be found at www.Firefighternearmiss.com. Because of the recognition of these organizations, the reach of these reports is international in scope. Any lesson you share is available free of charge for anyone wanting to learn about firefighter-related events.


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]