First and foremost, as the Deputy Fire Chief & Operations Officer for this fire department is was my responsibility to ensure that this event did not happen and to that end I take full responsibility for not using all of my knowledge, skills, and abilities to prevent this incident. I cannot stress the need that agencies working together or collaboratively on joint response groups must understand the need for clear, unilateral communication. Furthermore, we must be willing to be part of a system that creates opportunities to build and strengthen relationships and create awareness and accountability to the standards and guidelines that have been adopted by the fire service and similar response agencies. This incident has opened our eyes to our personal failures and we were fortunate enough to have only incurred a minor injury, but still this is unacceptable.
The Specific Incident:
A T-COM 13H Mobile Air Support Unit was returned to our fire department after undergoing a retrofit of the breathing air cylinders from DOT to ASME. In conjunction with this retrofit, purifying cartridges, associated hardware, and air fittings were replaced. All of the aforementioned work was performed by an individual who possessed no formal education, training, or certification from the manufacturer of the air trailer (Failure #1). As the Deputy Fire Chief in charge of Operations, I ordered the on-duty crew to perform a thorough return to service inspection and operational test of the air trailer. I stressed the importance of utilizing all appropriate safety equipment given the circumstances of the retrofit. Prior to the beginning of the return to service procedures, crews had refueled the diesel tank as this unit has the ability to operate from electric supply or an onboard diesel engine with generator. No problems were encountered during the refueling process. An initial visual inspection of the air trailer was conducted and several nuts, washers, and bolts were found lying inside the pan of the air trailer. Personnel were unable to specifically locate where the parts may have originated from, however, many areas exist within the trailer that make visual inspection difficult (Failure #2). Upon completion of the visual inspection, a firefighter began filling the four air cylinders. The first cylinder was full and transition to filling the second cylinder began when the firefighter heard an air leak (Failure #3). The firefighter suspected the air leak to be emanating from a possible open valve that he felt he may have missed during the pre-start checks. This firefighter was also unaware of a prior existing issue with an in-line check valve that leaked and needed to be repaired (Failure #4). The firefighter began a series of checks on valves and made contact with cylinder #1’s moisture drain valve assembly. Upon contact with the valve handle, the assembly separated from the cylinder, striking the operator in the hand with the force of 6000psi compressed air. The firefighter was not wearing any type of hand protection (Failure #5). This cylinder was filled when the valve struck the firefighter, however, the possibility exists that due to the firefighter’s hand being so close to the valve assembly, the object did not gain much momentum and the injury to firefighter was minor. The firefighter was working alone (Failure #6). A subsequent large air release occurred from the system and was heard by myself and other members inside the fire station. We rushed to the apparatus bay to find the injured firefighter and the air trailer free-flowing air. I placed the firefighter on administrative leave and sent him to the hospital with another firefighter to be evaluated and treated for his injuries. He returned to work later that evening, sore, upset, but healthy. His injuries were minor in comparison to the potential danger that existed.
The air trailer and compressor system were secured, rendered safe, and all air cylinders and system were purged. The fire chief was notified of the occurrence and injury. An investigation began to identify to root cause of the failure. Photographs and written statements were collected from on duty personnel. Once the valve assembly was located, examination of the valve assembly revealed that the components, specifically the compression fittings were not properly installed and tightened, the stainless steel tubing was not flared, air cylinders were misaligned, and after-market parts not included with the upgrade kit were used. Further investigation found that all air cylinders drain port was not properly aligned and perpendicular to the floor surface and questionable usage of Teflon tape. All initial findings were forwarded to the fire chief, city administrator, city attorney, and risk manager for discussion and further action.
The Department:
We are a combination department with new chief officers and are recovering from a period of frequent leadership changes during the course of the last six years. We are a small city fire department with members who care greatly about their community, but also are passionate about their service as a firefighter. Our fire department participates in a Regional Response Team for Hazardous Materials and as such was assigned several pieces of equipment from the Bureau of Homeland Security. Prior to the arrival of the current Fire Chief and Deputy Fire Chief an unclear methodology existed with regards to the daily, weekly and ongoing apparatus checks and maintenance regiments. After my initial indoctrination and communication with the fire chief, I realized that some assessments and observations needed to occur to accurately understand the environment and culture. I immediately made notice to and vigorously attempted to create awareness of several issues regarding un-serviced equipment, expired products, and undocumented maintenance records of equipment assigned to the fire department and to the regional response team. I felt strongly of the importance of creating a transparent form of communication and establishing a concept of teamwork we felt was extremely important so that a personal level of ownership would occur, not only with our own members, but with other departments participating in the regional response team.
A situation arose regarding our T-COM 13H Mobile Air Support Unit. This piece of equipment is part of the regional response team and is part of the fire department’s inventory. Upon my arrival, I conducted a survey of this piece of equipment and determined that the unit had not been serviced and quarterly air samples had not been drawn and tested. Until this time, this piece of equipment was indeed in service and being used regularly. I informed the fire chief and the unit was immediately removed from service until a course of action could be made. A local repair agency was contacted to complete an annual service, including a subsequent air sample conducted on the air to meet the NFPA standards. The repair agency stated that they were an authorized repair agency, and had the necessary credentials to complete the requested work. It was later determined that the repair agency hired for the annual service may not have been able to adequately complete the repairs in accordance with the manufacturer’s specifications. In addition, the installed DOT cylinders were also found to be out of hydrostatic test dates. The air trailer manufacturer had recommended ASME cylinders, however the purchasing entity selected DOT cylinders in lieu of the ASME cylinders. Several of our contacts regarding the retrofit stated that the course of action was selected due to what was stated as “funding difficulties”. The specific discussion arose due to the extreme labor intensive efforts in order to conduct hydrostatic testing. The unit again was removed from service and parties were notified while we tried to determine a new course of action.
Local politics and culture created a parallel expectation that this air trailer was intended to be used during a regional fire academy and conference. The fire department was unaware that the air trailer would be needed and did not receive advance notification by conference planners. What was clearly understood were phone calls stressing the importance of this unit’s presence during the academy and how significant an impact it would be if the air trailer was not provided. The importance of the air trailer’s presence was the priority not the below standard condition. The fire chief and I struggled with this situation and against their personal experience and judgment allowed the air trailer to be used with a hopeful attitude that this positive participation would gain some much needed favor with local departments. To provide some semblance of firefighter safety an air sample was hand delivered for testing to ensure air quality. No safety incidents associated with the air trailer occurred during the conference..
The Fire Chief and I were again made aware through informal channels that the regional response team executive board had planned to perform a retro-fit on this air trailer. The currently installed and expired DOT cylinders would be removed, and new ASME cylinders would be installed thereby eliminating the need for hydrostatic testing and the subsequent, cumbersome and difficult removal process. At first glance and initial discussion, the proposed changed made sense and seemed to be in line with the mission of the regional response team. A red flag was elevated when we realized that the proposed changes would be performed by an individual who possessed no formal training or certifications from the air trailer manufacturer. My fire chief and I strongly communicated our disapproval for this plan and in turn offered to seek assistance from the manufacturer in determining a more suitable and appropriate course of action. This was communicated to the regional response team executive board; however we were made aware that the purchase of the new ASME cylinders had already been started and shipping was expected to occur within thirty (30) days. The fire chief and I attempted to reason with this executive board unsuccessfully. Several times the financial limitations were expressed to us and how the individual had significant engineering experience and would be more than capable of conducting the work. We were strongly encouraged to not interfere with the proposed plan since leaders from the regional response team had been working on this process for quite some time. The fire chief and I were not satisfied with this course of action, and in turn agreed to identify our own source of funding from within the fire department’s budget in an attempt to keep the process “above board”. Additionally, we cited the health and safety of the members and the longevity of the equipment.
This process incurred several additional obstacles, information brokering, and false presentations which left our fire department “outside the circle”. We were repeatedly assured that the work would have approval from the manufacturer for the individual conducting the work. The chief and I found ourselves exhausted and subsequently allowed work to occur on the air trailer. Having exhausted our alternatives, we marginalized our part in this process by stipulating that work be conducted off-site and the air trailer be returned operational and with certifications. Looking back, I should have not allowed myself or my fire chief to waiver from our stance and instead, presented the facts of our position to someone higher in the chain of command.
While this retro-fit work was occurring on the air trailer, I contacted the air trailer manufacturer to confirm that approval had been granted by them for this retro-fit and that the individual conducting the work did have training from the manufacturer. We received a lack of response to both questions. The fire chief and I found ourselves trying to minimize conflict and reach a consensus decision without critical evaluation of alternative ideas or viewpoints. Ongoing communication since the incident has revealed that additional information brokering and false presentations were occurring to the manufacturer. The manufacturer has agreed to fully assist our fire department in correcting all of the problems created and to restore the air trailer to operational status.
Lessons Learned:
I failed in my primary responsibility to keep the health and wellness of all personnel as my number one priority and to ensure that everyone goes home safely. I allowed myself to be pressured by a broken system which relied upon “we can save a buck” mentality. I failed to create a mindset that I was in a marathon, not a sprint and allowed myself to become exhausted when I needed to have reserve energy. One of my firefighters was injured because I did not do my job.
(Failure #1 & #2) – “All of the aforementioned work was performed by an individual who possessed no formal education, training, or certification from the manufacturer of the air trailer.” “Personnel were unable to specifically locate where the parts may have originated from, however, many areas exist within the trailer that make visual inspection difficult.”
Action – Repairs, alterations, modifications, and maintenance work should only be conducted by approved, certified personnel who have been properly trained in those procedures and routinely perform the aforementioned work to maintain their proficiency and attention to detail. There is no excuse for using lack of funding or financial planning as a basis to shortcut the system when it comes to conducting repairs and keeping fire service equipment in a ready service state.
(Failure #3) – “The first cylinder was full and transition to filling the second cylinder began when the firefighter heard an air leak.”
Action – If we are not familiar with the equipment to diagnose a condition or malfunction, then we must seek guidance from a more experienced individual or professional level assistance.
(Failure #4) “This firefighter was also unaware of a prior existing issue with an in-line check valve that leaked and needed to be repaired.”
Action – **COMMUNICATION** Personnel, including myself were aware of an unrepaired check valve that was not repaired during a previous service. The problem did not receive proper follow-up and subsequently fell through the cracks and was not communicated to all personnel. Situations like this only further jeopardize the safety and effectiveness or equipment and readiness.
(Failure #5 & #6) – “The firefighter was not wearing any type of hand protection.” “The firefighter was working alone.”
Action – Establish clear safety guidelines and operational procedures to provide for the safety and accountability of personnel working within the department.
(Personal Failure) – I allowed myself to become more concerned about being liked and accepted by the local culture, and I lost sight of my moral and ethical objectives and commitments to my firefighters and the community I serve. I ignored my values and allowed an unsafe set of procedures to occur which allowed a firefighter to be injured.
Action – I make a commitment to exhaust all avenues to affect a process that will allow for the operation of a safe regional response team. My guide will be the minimum, nationally recognized standards, built with a membership committed to not only serving the community and being the best they can be. More importantly, we will now be committed to the health and safety of our responders, and the public we serve.
Dialogue on the Concept of Procedures
Failure to Follow Procedures
When procedures are present, they are documented and available for every detailed action performed. The possibility always exist that an individual follows or does not follow the procedures. Even under the best circumstances of adhering to procedures, technical problems can occur. It might be that an operator does not follow the procedures as they are laid out. There can be several reasons for this:
· The environment was changed at some time in the past, and the procedures were never updated. Now the environment changes again, rendering the operator’s memorized procedure invalid. At this point, even if the procedures were updated the operator will not be aware of it.
· The environment was changed, and no previous procedures exist. This is just a more out-of-control version of the previous situation which is creating a recipe for an injury or unsafe situation.
· The procedures exist and are correct, but the operator will not (or cannot) follow them.
· There are no procedures for unskilled operators to perform technical repairs on specialized equipment.
Depending on the management structure of your fire department or the organization to which you belong or participate, you might not be able to do much more than communicate and document your concerns to the appropriate responsible party. In any case, making yourself available to do what you can to help resolve the problem is the best approach.
Situational Awareness Will Save Lives
The common thread of every configuration change as in a technical retrofit is that some sort of a change is being made. The change may be large, or it may be small. But it is still a change and should be treated with respect and available to open communication.
Many organizations implement some type of change control process. The intent of a process is to help managers, administrators and all parties affected by the change to manage the change and to reduce the organization’s exposure to potential problems.
A change control process normally breaks the change into different steps. Previous experiences have provided the following model for creating a procedure for change:
A. Preliminary Research
a. Preliminary research attempts to clearly define:
i. The nature of the change to take place
ii. Its impact, should the change succeed
iii. A fallback position, should the change fail
iv. An assessment of what types of failures are possible
b. Preliminary research might include testing the proposed change during a scheduled downtime, or it may go so far as to include implementing the change first on a special test environment run on dedicated test hardware.
B. Scheduling
a. The change is examined with an eye toward the actual mechanics of implementation. The scheduling being done includes outlining the sequencing and timing of the change (along with the sequencing and timing of any steps necessary to back the change out should a problem arise), as well as ensuring that the time allotted for the change is sufficient and does not conflict with any other system-level activity.
b. The product of this process is often a checklist of steps for the system administrator to use while making the change. Included with each step are instructions to perform in order to back out the change should the step fail. Estimated times are often included, making it easier for the system administrator to determine whether the work is on schedule or not.
C. Execution
a. At this point, the actual execution of the steps necessary to implement the change should be straightforward and anti-climactic. The change is either implemented, or (if trouble crops up) it is backed out.
D. Monitoring
a. Whether the change is implemented or not, the environment is monitored to make sure that everything is operating as it should.
E. Documenting
a. If the change has been implemented, all existing documentation is updated to reflect the changed configuration.
Obviously, not all changes require this level of detail. Typical, reoccurring actions do not require this level of detail thought. However, as changes become more complex, a more formal change control process becomes necessary.
Conclusion
In some cases where mistakes are made, the mistakes are not realized until the consequences reveal themselves. Best practices would dictate that all methods of testing, repairing, and evaluating corrections are implemented prior to going on-line with a technical piece of equipment. When evaluation and testing are ignored prior to a technical piece of equipment being placed in-service, the best individual will realize that something is wrong and seek assistance. This is where we as supervisors must ALWAYS encourage the people we work with to contact the appropriate people immediately if they suspect something is wrong. Although many firefighters are highly-skilled and able to resolve many problems independently, the fact of the matter is that this is not their job. And a problem that is made worse by a well-meaning firefighter harms both that person’s career and your department’s ability to quickly resolve what might originally have been a small problem.
Please do not allow something like this to occur in your department! The heartache, frustration, and sleepless nights are enough to create chaos, much less having to think about a damaged piece of equipment or more importantly, an injured firefighter. There are no excuses for this event. I can share my experiences and ask every firefighter to stop for a moment and think about what they are doing and I ask every fire chief to lead by example and not allow these sorts of behaviors and actions to reside inside your organization. We have the greatest job in the world and we must take the time to be united on the front of firefighter health and safety.
