Saturday, May 29, 2010
On May 20, 2010 an Anchorage Fire Department (AK) truck company experienced a brake failure while during non-emergent driving conditions. The apparatus was approaching a large, busy intersection and the brakes failed as they apparatus operator attempted to stop for the red signal. The apparatus, unable to stop, proceeded through the intersection against the red light. Fortunately all cross traffic yielded to the emergency unit and no collision occurred. Immediately following the incident the apparatus operator pulled to the side of the road and refused to drive any further. Fire Department mechanics responded to the scene and found the brake system to be in serious disrepair. The unit was placed on a flat bed trailer and transported to the fleet maintenance shop for further evaluation and repair. Inspection revealed that 4 of the 6 brake sets on the apparatus were non-functioning. The 2 remaining brakes were extremely worn and inadequate to stop the apparatus in a reasonable distance. The unit that experienced the failure is a reserve unit that is 25 years old with 63,688 miles last gross weight was 63,600 pounds. This unit was refurbished with new engine, transmission, cab enclosure and other minor upgrades in 2007. The unit had numerous work requests for air leaks and other issues but no related brake problems were noted. The unit was 600 miles beyond its scheduled periodic maintenance interval. Following this event the department held a safety stand down for all three shifts to inform and instruct its members on the event and to refresh on apparatus inspection procedures. As a result of this refresher, another truck company was taken out of service with mechanical problems similar to the unit that experienced the failure. We at the AFD have been extremely lucky to have experienced this event without any negative long term consequences. This event could have been far more serious resulting in damage, serious injury or even death of both FD members and civilians. It is extremely disappointing that our experience comes so soon after the tragic death of Lt Kelly in Boston as the circumstances are very similar. This event was preventable and concerted efforts are being made to ensure it will never happen again. Please use Lt Kelly’s tragic death and our experience as the catalyst to ensure your crews are safe and equipment is being properly cared for and checked.
LESSONS LEARNED:
Routine apparatus inspections are vitally important for crew and public safety
Apparatus operators must be adequately trained and refreshed in apparatus inspections, specifically inspecting mechanical safety systems such as brakes
Any deficiency in safety systems must be immediately addressed when identified
Drift or lowered expectations routine apparatus inspections are vitally important for crew and public safety
Drift or Lowered Expectations cannot be permitted when transferring into reserve apparatus
All reserve apparatus should undergo inspections and have maintenance schedules revisited
Unaddressed maintenance requests that involve safety systems should constitute removal of the unit from service
Apparatus operators and company officers should be reminded of their obligation and empowerment to halt ANY unsafe action or remove unsafe equipment from service
Maintenance personnel and apparatus operators must understand the team approach to ensuring apparatus operability and crew safety
Reductions in staffing in our maintenance division has resulted in a higher likelihood that maintenance issues may be missed
Reduction in the training division has resulted in fewer training sessions and less apparatus operator specific training sessions has resulted in a higher likelihood those important knowledge skills and abilities may be lost from this group
Biannual apparatus operator / drivers training academies should be reinstated and budgets adjusted to reflect their importance
A more dependable process for reporting safety issues should be developed to ensure issues such as this cannot be overlooked again
Sentinel events such as these must not be overlooked cannot be permitted when transferring into reserve apparatus
