ISO 16 Postincident Responsibilities and Mishap Investigations

■ Initiating Stress Exposure Support

As mentioned, everyone reacts to incident-related stress differently, and the methods used to address the stress must also be varied. One size does not fit all. Establishing a department protocol for addressing ASE issues is encouraged and should guide the ISO's actions. A sample protocol is available for fire departments through the National Fallen Firefighters Foundation's Everyone Goes Home website. Relevant details are filed under Firefighter Life Safety Initiative 13, "Psychological Support." The new model for addressing ASE exposure is tiered and relies on a team approach that includes access to trained behavioral health professionals. The ISO's role in supporting an ASE exposure program has to do with initiating stress exposure protocols, facilitating a "time-out" defusing, and encouraging responders to use stress first aid measures. 1. Initiating stress exposure protocols. At an incident, the ISO considers the incident circumstances and responder signs and symptoms to make a judgment regarding the need to initiate the exposure protocol. When in doubt, lean toward initiation. Confer with the IC to begin the process. 2. Facilitate a time-out defusing. The time-out concept is borrowed from the military as part of the "hot-wash" after-action review model. Basically, the responders take a time-out to gather and briefly review what actually happened, what went well, and what could be improved. Participants are encouraged to share what they felt and what they are currently feeling. This process is similar to the informal PIA but also allows an opportunity to put the event into perspective and to relieve anxiety and uncertainty from a peer-to-peer perspective. The intent is to provide a safe opportunity for responders to discuss any emotional impacts of the event. The savvy ISO uses the time-out defusing not only to gauge the signs and symptoms of stress but to start formulating input for any upcoming PIA (or accident investigation). 3. First aid for stress. Once the ASE is over and crews are released, a method of ongoing awareness and action is needed. In the peer-to-peer model of stress first aid, peers are encouraged to initiate further interventions when they observe a change in functioning, hear statements of internal stress, and perceive a need to help with an individual's sense of confidence or competence following an ASE. Stress first aid can include many measures, including further peer defusing, debriefing, and access to organizational support such as a trauma screening questionnaire that may indicate the need for further assessment and treatment. The terms defusing and debriefing are used often when discussing incident stress programs. The two are different, and the ISO should be aware of those differences. Defusing (as mentioned in the time-out defusing above) refers to a gathering during or immediately after the incident and is characterized by an informal, peer-to-peer discussion format designed to share observations, actions, and feelings. For some, the defusing is all that is needed and they are mentally prepared to move on. A debriefing is typically a scheduled event and is characterized by a more formal agenda designed to promote healing or closure and to outline the process or options for accessing more assistance. To this point, we have looked at the ISO's approach to dealing with potential stress-related issues associated with incident handling. Although it is past the scope of this chapter, some mention needs to be made of the fire department's organizational approach to member assistance and the resources available for those in need. Ideally, the fire department has created a behavioral health assistance program, as required by NFPA 1500 (2013 edition, Chapter 11). The program should include the capability to provide clinical assessments, basic counseling, and stress-crisis intervention as well as processes to address drug and alcohol abuse, depression, and other personal problems that can adversely affect fire department work performance. Where no program is defined, individual responders (and ISOs) should be aware of the many resources available to assist with issues associated with occupational stress. Many of these resources are no-cost. They include, but are not limited to: ■ County health services ■ Department chaplain or other clergy ■ The National Institute of Mental Health (http://www.nimh.nih.gov/index.shtml) ■ The Firefighter Behavioral Health Alliance (http://www.ffbha.org/) ■ PTSD Support Services (http://www.ptsdsupport.net/)

Postincident Analysis NEW SECTION

"Tailgate talk," "after-action review," "critique," "slam session," "incident review," and "Monday morning quarterbacking" are all labels the fire service has applied to the PIA. The PIA is a formal and/or informal reflective discussion that fire departments use to summarize the successes and the areas requiring improvement discovered from a given incident. Successful fire officers learn something from every working incident they are involved in. Each and every firefighter involved in an incident has a viewpoint or an opinion regarding specific circumstances or the general outcome of an operation, and these are important. The IC and the ISO bring perspectives to the incident overview. In fact, the ISO should contribute—officially—to the PIA. NFPA 1500 requires that the ISO be involved with the PIA. NFPA 1521 lists several job performance requirements (JPRs) that the ISO needs to meet in order to maximize his or her PIA involvement (listed in the Knowledge/Skills Objectives at the beginning of this chapter). To maximize the effect of safety-related input on a PIA, the ISO must understand the essential philosophy of PIA as well as ISO issues surrounding PIAs. This section contains a simple process to ensure that the ISO covers the appropriate information for the PIA.

■ Chemical Imbalance

A successful rehabilitation program prevents firefighters from experiencing fatigue and mental drain. Nevertheless, some may not have benefitted from rehab, or the incident was simply draining due to the duration or demand of the incident; the human form can only do so much. Even with effective rehab, the end of an incident, especially one requiring significant physical output, can cause chemical imbalance. With the end of an incident comes the relaxation of the firefighters' minds and the shutoff of protective chemicals that stimulate performance. The adrenaline rush is over and the firefighters' metabolisms return to a "repair" state; this reaction also causes a mental slowdown that can lead to unclear thinking and injuries. Another way to see the chemical (and mind) imbalance is to look at a firefighter's tools from a layperson's point of view. Laypersons have to concentrate on carrying an axe, pike-pole, chainsaw, roof ladder, or hose length in order to not cause harm to themselves or anyone around them. Put them in bulky, restrictive, sweat-soaked clothing and heavy boots, and you can see that they would probably get hurt doing almost any task. The firefighter performs these tasks after incredible energy bursts under frightening conditions. Familiarity may help ensure some degree of safety, but concentration is still required. The combination of fatigue and the signal to relax (because the incident is "over") creates the imbalance. Yet the concentration requirement remains the same, and the potential for injury rises. FIGURE 16-2 Calling a huddle before incident pick-up creates an opportunity to remind firefighters of lingering injury threats. Whether the issue is chemical imbalance or postincident thought patterns, the ISO must stay alert, pick up signs of potential injury, and take steps to remind crews of that potential. The ISO may also consider asking the IC for a fresh crew to respond and assist with pick-up when the ISO feels that crews are at risk of injury due to their exhaustion.

■ The Accident Chain

Accidents are the result of a series of conditions and events that lead to an unsafe situation that result in injury and/or property damage. Many call this series of conditions and events the accident chain. The accident chain is a "sequence of events" model derived from The Domino Theory of Accident Causation developed by H.W. Heinrich (1931). The investigation of an accident is actually the discovery and evaluation of the accident chain, which has five components FIGURE 16-5: ■ Environment. The physical surroundings, such as weather, surface conditions, access, lighting, and barriers ■ Human factors. The components of human (or social) behavior—training, the use of or failure to use recognized practices and procedures, fatigue, fitness, and attitudes ■ Equipment (including PPE). Limitations and restrictions of equipment, its maintenance and serviceability, the appropriateness of its application, and, some may argue, its misuse (a human factor) ■ Event. A scenario that brings the first three accident chain components together in such a way as to create an unsafe or unfavorable condition ■ Injury. The injury or property damage associated with the accident (Because a near miss or close call is an accident without physical injury, for the sake of the accident chain, the injury can be supposed.) Ideally, the ISO should be able to stop a potential accident by eliminating one or more of the elements in the chain during the incident or by creating barriers between the elements (recall hazard MEDIC). FIGURE 16-5 Accident investigation is the discovery and linking of the accident chain.

Postincident Activities NEW SECTION

Accurate data are spotty, but many injuries seem to occur while crews are packing up to leave an incident. Common postincident injuries include strains, sprains, and being struck by objects. Postincident injuries seem ironic in a profession whose hallmark is aggressive and calculated risk-taking. For each cause of postincident injuries, the ISO can take preventive steps to reduce their likelihood of happening. Typical causes of postincident injuries are usually tied to postincident thought patterns and chemical imbalance.

Accident Investigation NEW SECTION

An accident investigation is a critical step in avoiding future injuries and deaths. Often, the results of the investigation can lead to changes in SOPs, unsafe situations, habits, or equipment not only for the originating department but for departments nationwide. This vicarious learning is essential. The Sofa Super Store tragedy (June 2008) in Charleston, South Carolina, is a perfect example. In Charleston, the fire department responded to a fire in the rear loading dock area of a large furniture store. Initial control efforts were not successful and the fire spread into a warehouse as well as the showroom. The conditions in the showroom deteriorated quickly, leading to firefighter Mayday situations and the eventual ignition of all the smoke in the showroom (approximately 33,000 square feet [3,065 m2] of floor space). Nine firefighters were unable to make it out and perished. The incident led to several investigative and technical reports that are now being used to help change fire department procedures, training, and tactical operations. Further, the reports have become an impetus for sprinkler ordinances, building inspection programs, and community fire protection planning around the country. Close calls or near misses should also be investigated. Technically speaking, the phrases "close call" and "near miss" are interchangeable. Anecdotally, the phrase "near miss" can be regarded as a near hit. Regardless, we must learn from these events to prevent future injuries. Although the notion of a close call or near miss is subjective, it can be loosely defined as an unintentional, unsafe occurrence that could have produced an injury, fatality, or property damage; only a fortunate break in the chain of events prevented the undesirable outcome. An open, nonjudgmental attitude toward close calls can help a fire department realize the many warning signs, situational occurrences, and contributing factors that precede an injury. Often, the person to begin an accident investigation following a close call, firefighter injury, fatality, or equipment mishap is the ISO, given the nature of his or her assignment as a command staff member. NFPA 1561 specifically requires the ISO to "investigate accidents that have occurred within the incident area" as a major responsibility.2 For most accident investigative purposes (property or bodily harm), the ISO is well positioned for this function as a result of 360-degree scene monitoring. To prepare for accident investigations, the ISO needs to understand the components of the accident chain, issues that create a conflict of interest, types of mishaps that require investigation, and the general steps to conducting an investigation.

■ Atypical Stressful Events

An atypical stressful event (ASE) is an incident that presents mental or emotional pressure or strain circumstances that are outside the ordinary experience of the responders. Some refer to an ASE as a potentially traumatic event (PTE). Examples of an ASE/PTE might include: ■ Mass-casualty incident ■ Firefighter LODD ■ Witnessing of a coworker's suicide ■ An unusually difficult or long-duration rescue or recovery effort with gruesome circumstances ■ A death caused by the responders Some may regard ASE and PTE as fancy terms to describe what used to be called a critical incident that triggered the use of critical incident stress management (CISM) teams and debriefings (CISDs). Although CISM teams and CISDs have been used for decades, research has shown that they don't necessarily prevent behavioral issues and, in some cases, inhibit natural recovery. Using ASE or PTE recognizes that responders have different resiliency levels toward stress and marks a new approach and model to help with firefighter behavioral health. We will use ASE in our discussion.

■ ISO PIA Contributions

By monitoring an incident for potentially unsafe situations, the ISO brings many valuable observations to the PIA. The functional areas addressed in the hazard MEDIC approach to ISO duties (monitor, evaluate, develop measures, intervene, and communicate) are also of worth to the PIA effort. Nevertheless, the PIA is a time for crews to share and reflect and take home a message. A long dissertation from the ISO can easily negate any such message. However, the ISO should comment on some key issues, including the following: ■ General risk profile of the incident. The ISO can share the overall picture from a risk management point of view. Items such as risk/benefit, pace, and impressions about appropriateness of the risks taken can be discussed. If a situation developed that placed a crew at risk, the ISO may find it valuable to call on the crew to relay his or her thoughts or perceptions. These observations may have to be built on so that everyone takes away some value. ■ Effectiveness of crew accountability. The ISO can yield to an accountability system manager for some of this type of information. Observations about crew freelancing (working in conflict with the action plan), individual freelancing (working without a partner), and reinforcement about successful tracking and communication should be shared. ■ Rehab effectiveness. Even though they should be, ISOs are seldom "processed" through rehab. How then can the ISO comment on the effectiveness of rehab? The ISO can share observations of the pace, energy, and focus trends throughout the incident, as well as the duration or rotation of work efforts. If injuries resulted during the incident, an investigation is likely. But for postincident purposes, some exploration of rehab as a contributing factor may be discussed. ■ Personal protective equipment (PPE) use. Although the ISO normally defers individual PPE concerns to the company officer or crew leader, ongoing PPE issues can be addressed by the ISO. As an example, the choice to do overhaul at an incident without self-contained breathing apparatus (SCBA) may have been premature. Likewise, a four-gas monitor may have been used to make the decision to go "packs off" and use simple dust masks. These decisions can be discussed and reinforced as appropriate. ■ Close calls. The circumstances surrounding a near injury should be detailed from all participants' points of view. The ISO should minimize his or her contributions to close-call events and reserve judgment because an actual investigation may be warranted. In some cases, a close-call event may be an invaluable lesson to share with others. Several fire service organizations have joined to create a near-miss reporting system to help share experiences with other firefighters (see the Fire Marks box). ■ Injury status. If no injuries have been reported, this positive outcome should be reinforced. Most likely, good practice and procedure led to no injuries. If this belief is not shared by all, then the role of "luck" should be discussed; this can very well raise safety awareness for the next incident. If a firefighter injury required transporting someone to a medical facility, firefighters will want an update FIGURE 16-4. The ISO should be cautious. Issues of medical confidentiality, investigative needs, and other ramifications may limit the amount of information that can be shared. In these cases, the ISO should keep the discussion centered on the efforts under way to care for the injured. If a firefighter injury was significant, or if a firefighter fatality occurred, the ISO should use any initial PIA session as a tool to listen to firefighters (there will likely be a more formal PIA in the future, once the investigation and written report are finished). While listening, try to keep an open mind. Often, firefighters may appear to be blaming when, in reality, they are venting, displacing stress, or even grieving. These reactions are normal.

Introduction: Paying It Forward NEW SECTION

For every 1 serious firefighter injury, over 600 near misses or close calls could easily have been serious.1 Firefighters sometimes wear a close call as a badge of courage and use exaggerated tales to fuel firehouse coffee talk. Firefighters involved with a close call may trivialize or minimize the brush with injury or death. Often, the closer firefighters come to serious injury, the more they minimize the storytelling, perhaps indicating that the event really got their attention. At what point does the incident safety officer (ISO) need to follow up on a near miss and work toward the prevention of a similar event that may not have such a "lucky" outcome? Ideally, the lessons learned from any close call should be folded into training and used for ongoing efforts to avoid similar situations in the future. In other words, pay it forward. Often, the war stories that arise from close calls are invaluable tools in the teaching of new firefighters in academies nationwide. The key to making the lessons productive is an accurate portrayal of the facts and actions. Collecting information quickly and from multiple sources will help to ensure that information is captured accurately. The reconnaissance responsibility places the ISO in the best position to capture and document incident activities for a postincident analysis (PIA), critique, or after-action review. Further, the ISO can use the information to begin an investigative process if an injury or fatality has occurred. Paying it forward also helps those who are dealing with any psychological imprint that may have occurred as the result of an unusual, emotionally draining, or especially gruesome incident—those atypical events. This chapter explores the responsibilities and duties of the ISO for postincident activities, PIAs, atypical events, and accident investigations.

■ Postincident Thought Patterns

One cause of postincident injuries has to do with the little-studied concept of postincident thought patterns. Postincident thought patterns are the reflective or introspective mental preoccupations that firefighters experience just after incident control. These thought patterns can lead to inattentiveness and, consequently, injuries. In cases of especially difficult, unusually spectacular, or particularly challenging incidents, firefighters tend to reflect on their actions. The replay of the incident starts almost instantly when the order is given to "pick up." Introspection is normal FIGURE 16-1. The switch from activities requiring mental sharpness and physical effort to an activity that is so rudimentary as to be dull presents a letdown trap. Herein lies the problem. Some incident commanders (ICs) may release the ISO from the event after the "serious stuff" is done. This is an error. After a working incident, the ISO should circulate among those involved in the pick-up and keep an eye out for inattentiveness. Signs may include faraway stares or robot-like actions. Firefighters might stop and look about as if they have forgotten their task. Simple reminders or jocularity can help them regain focus and reduce their injury potential. One method to reduce the effect of postincident thought patterns is to take a brief time-out and have everyone gather for a quick incident summary and safety reminder. These huddles can be effective for all personnel on scene or even small groups FIGURE 16-2. Even a casual coachlike approach that emphasizes the need to stay alert and not fall into an injury trap can be useful. FIGURE 16-1 Postincident introspection is normal but can lead to inattentiveness and injury.

Stressful Events and Trauma Support NEW SECTION

Stress happens—to everyone. For our purposes, stress can be defined as the physical, mental, or emotional tension and strain resulting from a situation in which a person feels pressured or threatened. The year 2015 started off with the job-posting website CareerCast once again listing firefighting as the most stressful job in America. The ranking comes from a scoring system that measures 11 stress factors, including, among others: ■ Physical demands ■ Environmental conditions ■ Hazards encountered ■ Risk to own life ■ Risk to others ■ Time constraints Although some may view the ranking as dubious, it is probably safe to say that most working adults view firefighting as a relatively stressful endeavor. Those same adults also expect firefighters to tolerate the job stress—and for the most part, firefighters do. Accepting the inherent stresses of the job is one thing, managing that stress is another. To manage stress, people find relief in recreation, religion, socializing, family time, and physical fitness regimens, to name but a few outlets. Still others resort to undesirable coping mechanisms such as drug and alcohol abuse. Some say they "have had enough" and choose to leave the profession. At its worst, the short-and long-term effects of stress can lead to behavioral issues, including acute stress disorder (leading to post-traumatic stress disorder) and suicide. The rate of suicides among emergency responders is alarming: The Firefighter Behavioral Health Alliance reports that there were 62 validated responder suicides in 2013.6 The point here is to recognize that the job is stressful and that people react differently to those stresses. Even though we still have much to learn about the behavioral sciences, we do know that stress-related issues can evolve from an unusually traumatic incident (atypical event) and/or repeated exposure (burnout) from more common incidents. Fire departments are encouraged to address both by accessing behavioral health programs and professionals (some available at no cost through county health services). With that said, the ISO does have a role in the recognition of occupational stress. Namely, the ISO must be able to identify the types of incidents that might be atypical, describe some signs and symptoms of occupational stress, and initiate some first aid measures for addressing potential occupational stress issues.

■ PIA Philosophy

The ISO should approach any formal or informal PIA with an attitude of positive reinforcement for safe habits and an honest, open desire to prevent future injuries. In most cases, the PIA is nothing more than a discussion of what went right and what should be different next time. This may sound simple, but it is often hard to achieve, especially in light of a close call or a significant operational mistake that could have easily led to an injury. When an operational mistake has been made, the ISO should first consider the outcome: Did an injury occur or was there reportable property damage? If so, the PIA becomes secondary to accident investigation (covered later in this chapter). If no injury or damage occurred, the stage is set for lesson-learning. To capture the lesson, the ISO should start by employing a philosophy of discovery. The ISO can discover the general feeling of crews by making some inquiries regarding the operational environment, ascertaining the perceptions of crews regarding the seriousness of the mistake, and performing some general fact-finding. The discovery philosophy can also give crews a voice for their concerns and may even assist in getting someone to acknowledge an error. When making inquiries, stay away from questions that can be answered as yes or no. Framing open-ended inquiries is the best approach. For example: ■ "Explain the location in regard to ...." ■ "Describe the conditions you faced." ■ "What was your thought process for ...?" ■ "How do you feel regarding ...?" ■ "How can we proceed/prevent/improve ...?" Occasionally, this approach does not work. Crews may spend great amounts of energy "explaining" their actions in an attempt to justify them. In these cases, the ISO needs to act as a sounding board and not offer judgments. If the discovery process leads to individuals or crews getting overly defensive or emotional with each other (the blame game), it may be best to separate the parties and let them cool off. While the general approach of the PIA is to look back at an incident, the overriding goal is to look forward to the future. Through this process, departments seek to discover what went well (reinforcement) and what didn't (prevention) so that the next incident will have a better outcome.

■ Investigation Issues

The ISO should be aware of issues and concerns that arise regarding involvement in accident investigation, one of the biggest of which is liability. Picture this: A firefighter is seriously injured while working a commercial structure fire where an ISO is functioning. In the ensuing investigation, the question arises, if a safety officer was present, should an injury have occurred? The conclusion of some may be that the ISO obviously did not do his or her job; it may lead to doubts about the objectivity of the ISO in investigating the incident. Did the ISO cover up anything in an attempt to deflect blame? This scenario may seem far-fetched, but it is a reality in our litigious society. For this reason, there are circumstances where ISOs should recuse themselves from the investigation process: ■ The ISO is the one injured. ■ The ISO was directly involved in the property damage. ■ An LODD occurred. ■ Multiple, and significant, injuries to firefighters occurred. For significant (or multiple) injuries and death(s), the ISO should request HSO assistance for a simple reason: The role of the ISO is part of the equation that needs to be investigated. More specifically, some may reason that an assigned ISO should have prevented the outcome, and therefore his or her actions should be questioned. In these cases, a conflict of interest exists for the ISO when assigned the function of accident investigation. Outlining fire department procedures that need to be implemented following a fatality (or an injury that may result in a fatality) is beyond the scope of this text. Such information is available through the U.S. Fire Administration, IAFF, and IAFC. How does the ISO perform safety tasks on scene and conduct an honest, meaningful investigation following an accident? The answer is simple: Do both with due diligence. Due diligence is a legal phrase for the effort to act in a reasonable or prudent way, given the circumstances, with due regard to laws, standards, and accepted professional conduct. The ISO who acts in a prudent manner—uses the hazard MEDIC action model, takes steps to eliminate or communicate hazards, and works within established standards (NFPA) and laws (Occupational Safety and Health Administration's [OSHA] Code of Federal Regulations [CFR])—has taken significant steps in reducing liability. Added to this is a long-standing legal principle of discretionary function, which recognizes that certain activities require a value judgment among competing goals and priorities. In these cases, nonliability exists (Nearing v. Weaver).3 Another issue the ISO must be aware of in accident investigation is the involvement of outside agencies with an interest in the accident. State and/or federal OSHA and/or National Institute for Occupational Safety and Health (NIOSH) officials, labor group investigators, insurance investigators, and law enforcement officials are often involved in a significant injury or death investigation. In many cases, these agencies can help the ISO; most likely, however, an investigation that has reached this magnitude signals the end of the ISO's need to lead or even participate in the investigation (the ISO becomes a witness).

Getting the Job Done ISO Documentation Issues

The ISO should get in the habit of documenting his or her actions for all incidents. In some cases, the documentation is mandatory (e.g., hazmat incident, confined space rescue, departmental SOP requirements). The ISO's documentation efforts are beneficial in numerous ways, but they are especially helpful in developing a PIA (formal or informal) and in resolving follow-up inquiries that may not be evident at the time of the incident. In addition to basic incident information (e.g., assigned incident number, location, timeline), the ISO should document the following: 1. Overview of the incident conditions found on arrival and notable changes that occurred 2. Suggested changes to the IAP: What alternatives were proposed, and were they adopted? (If the suggested change is not adopted and the incident goes "sideways" on the IC, how is the ISO to defend his or her suggestions?) 3. Soft interventions, stern advisories, and firm interventions 4. Summary of meetings with the IC 5. Substance of safety briefings delivered to responders 6. Follow-up items that may need to be addressed within the framework of departmental improvement (reoccurring problematic areas like PPE, rehab, or training issues) 7. Unusual or strange events or conditions 8. Other forms or required reporting documents

Fire Marks The National Firefighter Near-Miss System

The National Firefighter Near-Miss System is a voluntary, confidential, nonpunitive, and secure reporting system with the goal of improving firefighter safety. The system is funded by the Assistance to Firefighters Grant Program of the U.S. Department of Homeland Security and is hosted in affiliation with the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC). This web-based system allows individuals to submit a report. An easy-to-follow template helps guide inputs that are used to categorize the incident. Filed reports are reviewed by fire service professionals, and lessons learned are reposted on the website in an anonymous fashion. The system is also designed to generate a database that can be used to spot trends, develop training programs, and offer suggestions. Anyone can access the system to review reports or sign up for a news service that automatically emails the report of the week to subscribers. The system can be accessed at http://www.firefighternearmiss.com.

■ Events Requiring an Investigation

The types of mishaps that should be investigated can be influenced by federal, state, and local laws and by individual department SOPs and insurance carrier requirements. As a guideline, however, events that should be investigated from a prevention (pay-it-forward) perspective include the following: ■ Firefighter injury. The local fire department should have a policy in place regarding the types of injuries that require the ISO to investigate. Minor injuries that don't require medical attention are often documented on simple forms, filled out by the injured person's supervisor, for archive and workers' compensation purposes (most workers' compensation programs require an investigation and documentation before claims can be processed). More serious injuries that require medical attention and have the potential for lost time are likely candidates for an ISO investigation FIGURE 16-6. ■ Firefighter LODD. As stated earlier, a firefighter LODD event will require a comprehensive investigation involving liaison with several agencies. The ISO is likely to start the LODD investigation process (evidence protection, initial documentation) but will likely be recused. The department HSO or other uninvolved officer (preferably a chief officer) should take the investigative lead. ■ Close call. Incidents involving near-injury or near-death circumstances can benefit from an investigation. Events such as flashover, building collapse, firefighter Mayday (no injury), and RIC activation are strong candidates for investigation. ■ Fire department equipment failure. Stuff breaks all the time. The point here is to investigate equipment/apparatus failures that negatively altered the incident outcome. Issues that impact product liability, recall potential, maintenance, or serviceability can benefit from an investigation also. ■ Apparatus mishaps and property damage. Apparatus involved in mishaps are typically required to be investigated by insurance carriers, and the ISO may have to take the lead. Unintentional damage to property, caused by fire department actions, may warrant an investigation. The key word here is unintentional. Firefighter actions often cause damage (cutting a hole in the roof), but that is intentional. Examples of unintentional damage can include water run-off flooding of exposures, collapse of streets/culverts due to apparatus weight, and damage to parked cars when deploying equipment.

■ Signs and Symptoms of Incident-Related Stress

The way responders react to an ASE is diverse and subjective. Reactions to trauma can range from a simple pause to a complete behavioral shutdown. Regardless, the ISO is perhaps the first person to see that an ASE is challenging the emotions of one or more of the responders. Listing signs and symptoms of incident-related stress can be tricky in that some of them are shared with the signs and symptoms that accompany overexertion, postincident thought patterns, and chemical imbalance, including: ■ Far-away stares ■ Task forgetfulness ■ Lethargy ■ Reserved verbal responses to routine conversations On-scene signs and symptoms that are more aligned to an ASE (as opposed to other causes) can include: ■ Outward crying ■ Emotional outbursts of anger and intolerance toward coworkers ■ Total shutdown of interaction with others The signs and symptoms included in these lists may be found at the incident and warrant attention by the ISO. Some responders may not show any indication of incident-related stress but are nonetheless impacted. As days and weeks pass, the internalized stress from the incident may become apparent. Acute stress disorder (ASD) refers to behavioral issues that arise in the days following an ASE. Flashbacks, bad dreams, depression, and worry are common symptoms of ASD. Some recover quickly from ASD with little or no intervention. If symptoms persist for longer than a week or two, or go untreated, the ASD may proceed to post-traumatic stress disorder (PTSD). PTSD is a mental health disorder that can develop in individuals who have experienced a terrifying ordeal that involved physical harm or the threat of harm. PTSD can cause individuals to experience intense, potentially debilitating, emotional distress that can keep an otherwise healthy person from leading a normal life. According to the National Institute of Mental Health, signs and symptoms of PTSD include thought perseveration (reexperiencing of thoughts), avoidance behaviors, and hyper-arousal issues.

■ The Investigative Process

Where does the ISO begin to investigate an injury or mishap? Of the many investigative models to choose from, the most common is a simple three-step approach.4 Step 1: Information Collection Numerous sources of information should be collected following an incident. These can be divided into six categories: 1. Incident data. Included is factual information, such as incident number, chronological time of events, weather conditions, apparatus assigned, personnel assigned (by name and assignment), and documented benchmarks (primary search complete, incident under control). 2. Witness statements. Statements may be difficult to gather, and assistance may be required (law enforcement officials can usually help). An attempt is made to gain as many perspectives as possible FIGURE 16-7. While keeping the witness speaking in facts is important, so is gaining a sense of the witness's perspective (see the Getting the Job Done box). Remember that much of what a firefighter does requires rapid judgment and execution. 3. Scene sketches/diagrams. Accuracy is critical: Be as precise as possible. Quick hand sketches work well for apparatus, hose, and crew placement, as long as measured distances are included so that a more precise drawing can be rendered later. 4. Photographs/video. If you noticed video footage being taken during an incident, attempt to gain it from the videographer. Media sources may be helpful as may posts on social networks. Follow-up video or still photography can capture the results of the mishap. FIGURE 16-7 The ISO should support an accident investigation with many witness reports. 5. Physical evidence. Protective equipment, damaged equipment, or other physical forms of evidence should be retained FIGURE 16-8. Once again, law enforcement officials and fire origin/cause investigators are a good source of expertise in the collection and documentation of physical evidence. For serious firefighter injuries and/or LODD, the PPE used by the victim (including SCBA, personal alert safety system [PASS], radio, thermal imaging camera [TIC], and escape devices) should be collected and treated as evidence. EMS personnel and those treating the victim at a medical facility may need a reminder that the PPE and clothing worn by the patient must be retained as evidence and not discarded. 6. Existing records. Equipment maintenance records, policy and procedure manuals, training records, and other documents are useful when it comes time to analyze the factors leading to the accident. At times, the extensive search may require going back many years to make a discovery that may have set the stage for the mishap. Likewise, the research may reveal that the proper maintenance, training, and other conditions were in place. Step 2: Analysis and Reconstruction The ISO reads through the accumulated data and separates facts, perceptions, and unknowns and determines the need for more information. At times, irrelevant data can be discarded. Once the information is analyzed, the ISO can reconstruct the accident. Utilizing the accident chain concept as inputs, the ISO can chart the accident sequence as part of the reconstruction. The reconstruction is designed to find causal factors, which are the events or conditions in the accident sequence that contributed to the unwanted outcome. Causal factors include: ■ Direct cause. The immediate event/condition that caused the accident. ■ Root cause. The factor(s) that, if corrected, would prevent reoccurrence. Root causes are usually high-order, fundamental factors such as training, equipment, and procedures. FIGURE 16-8 Protective equipment and other physical evidence must be retained, marked, tagged, and identified as evidence. ■ Contributing causes. The factors that collectively increased the likelihood of an accident but individually did not cause the accident. Once the causal factors are discovered through deductive reasoning, some attention must be given to barrier analysis. As we know, firefighting is a risky business accomplished in very hazardous environments. We train and equip firefighters to face those risks and hazards using many administrative (SOPs and training) and physical (PPE and equipment) barriers to separate the hazards from the targets (firefighters). The performance and application of these barriers must be analyzed as part of the reconstruction effort. Often, the reconstruction analysis points to an unintended result that occurred during human performance (an error). Human performance errors can be viewed as a mismatch between the human condition and environmental factors at a given moment or during a course of actions. When a human performance error is discovered, the analysis effort should continue to help uncover certain precursors that may have been present. The use of a Task, Work Environment, Individual Capabilities, and Human Nature (TWIN) model can assist as a diagnostic tool for analyzing human error precursors TABLE 16-1.5 Step 3: Recommendations Charting the accident chain and analyzing the causal factors, barriers, and error precursors set the stage for answering two really important questions: What happened, and why did it happen? Recommendations are then developed to keep the what and the why from happening again. Most often, the recommendations fall into the areas of equipment, policy and procedure, or personnel (training, attitude, fitness). There may be a tendency to focus on one solution. Be inventive and force yourself to develop more than one solution. After multiple solutions are developed, evaluate each and focus on the approach that you believe would best prevent a reoccurrence. Nowhere in the accident investigative process are the words "blame" or "discipline" used. This is important. Placing blame or recommending discipline has a tendency to close minds and erect acceptance barriers. If the ISO is to remain effective, it is best to state recommendations in the form of future accident prevention. Upon discovering a case of complete disregard for safe practice (a form of negligence), the ISO should meet with a supervisor or chief officer and allow the department to handle the issue administratively. Although there may be some backlash and tension regarding the ISO's investigative effort, most safety-conscious firefighters and officers will applaud the actions of the department and the ISO. Accident investigation is not a fun task, but it is vital to the reduction of future injuries. If the ISO can demonstrate good intent, the investigation serves as an investment in making a difference and paying it forward.

Key Terms

accident chain A series of conditions and events that lead to an unsafe situation that results in injury and/or property damage. It typically has five components: environment, human factors, equipment, an event, and the injury. acute stress disorder (ASD) The behavioral issues that arise in the days following an atypical stress event (ASE). atypical stressful event (ASE) An incident that presents mental or emotional pressure or strain circumstances that are outside the ordinary experiences of the responders. close call An unintentional, unsafe occurrence that could have produced an injury, fatality, or property damage; only a fortunate break in the chain of events prevented the undesirable outcome. debriefing A scheduled event that is characterized by a formal agenda designed to promote healing or closure and to outline the process or options for accessing more assistance. defusing A gathering during or immediately after the incident that is characterized by an informal, peer-to-peer discussion format designed to share observations, actions, and feelings. due diligence A legal phrase for the effort to act in a reasonable or prudent way, given the circumstances, with due regard to laws, standards, and accepted professional conduct. postincident analysis (PIA) A formal and/or informal reflective discussion that fire departments use to summarize the successes and areas requiring improvement discovered from an incident. postincident thought patterns Reflective or introspective mental preoccupations that firefighters experience just after incident control. post-traumatic stress disorder (PTSD) A mental health disorder that can develop in individuals who have experienced a terrifying ordeal that involved physical harm or the threat of harm.

Wrap-Up Chief Concepts

■ The reconnaissance effort of ISOs places them in a desirable position to help capture and document incident activities for a postincident analysis (PIA). The same information can be used for an accident investigation should one be required. ■ Postincident thought patterns are the reflective or introspective mental preoccupations that firefighters experience just after incident control. These thought patterns can lead to inattentiveness and, consequently, injuries. Chemical imbalance can also impact postincident "pick-up" activities and lead to accidents. For these reasons, an ISO should not be released prematurely from an incident; the ISO should remain and help monitor actions and remind responders to be safe. ■ A PIA is a formal and/or informal reflective discussion that fire departments use to summarize the successes and areas requiring improvement discovered from a given incident. NFPA 1500 requires that the ISO participate in, and contribute to, the PIA. ■ The overriding goal of a PIA is to prevent future injuries or mishaps. The ISO facilitates this outcome by adopting a positive, discovery-oriented philosophy as crews discuss what happened, what went well, and what could be improved. ■ PIAs can be informal, on scene; informal debriefing style; or formal (written). Formal PIAs should be used for incidents involving an LODD, significant apparatus or equipment failure, a Mayday call or RIC activation, large life or property loss, large-scale resources, and specialty teams (technician level). ■ The ISO's involvement with PIAs starts with information collection on scene by visiting with crews and asking simple questions regarding the incident. That is followed up with documentation, which includes observation notes, scene sketches, and a timeline. The ISO is also encouraged to spot trends so that information can be shared with training officers and supervisors in the spirit of improving or correcting developing issues. ■ The ISO should get in the habit of documenting his or her actions and observations of conditions for all incidents, not just those involving a PIA. The documentation can help archive the incident for issues that might arise later. ■ During the actual PIA, the ISO's primary function is to listen to others and encourage their reflection. The ISO should, however, be prepared to comment on issues pertaining to risk-taking, crew accountability, rehab effectiveness, PPE use, and any close calls. For incidents at which a responder injury occurred, the ISO should be cautious and limit input to efforts to help the injured. ■ NFPA 1561 requires the ISO to investigate accidents that have occurred within the incident area. The purpose of the investigation is to prevent future occurrences and is accomplished through a discovery and evaluation of the accident chain. The accident chain has five components: the environment, human factors, equipment, an event or series of events, and the actual injury or mishap. ■ There are times when it is not advisable for the ISO to conduct the accident investigation because a conflict of interest might exist. Those incidents include: • The ISO is the one injured. • The ISO was directly involved in the property damage. • An LODD occurred. • Multiple or significant injuries to a firefighter occurred. In these cases, ISOs should recuse themselves from the investigation and pass the investigation on to the department HSO or other chief officer who was uninvolved with the incident. ■ Mishaps that should be investigated include firefighter injuries, LODDs, close calls, significant equipment failure, and apparatus mishaps or unintentional property damage caused by the fire department. ■ There are many processes that can be used to begin an investigation. A simple three-step process is most common: 1. Collection of information 2. Analysis and reconstruction 3. Recommendations ■ The information that needs be collected includes incident data, witness statements, sketches/diagrams, photographs/video, physical evidence (especially PPE/SCBA), and existing departmental records (like training documentation and SOPs). ■ Witness statements should be obtained using a recognized sequence and effective communication techniques. Law enforcement and fire origin/cause investigators can help obtain witness statements. ■ The analysis and reconstruction step attempts to chart the accident chain and discover causal factors such as the direct cause, root cause, and contributing causes. Once discovered, the ISO needs to also do a barrier analysis, which is an examination of the performance or application of administrative controls (SOPs/training) and physical controls (PPE/equipment) that worked or didn't work. Human performance errors that have been discovered should be further analyzed to help uncover error precursors. Using the Task, Work Environment, Individual Capabilities, and Human Nature (TWIN) matrix can help identify those precursors. ■ The recommendation step should include several solutions designed to prevent an accident reoccurrence. Blame and discipline discussions should be omitted from recommendations. In cases where a complete disregard for safety has been uncovered, the ISO should yield to the department chief or other supervisory officer to handle disciplinary actions. ■ The firefighting job is plenty stressful, and people react differently to those stresses. Even though we still have much to learn about the behavioral sciences, we do know that stress-related issues can evolve from an unusually traumatic incident (atypical event) and/or repeated exposure (burnout) from more common incidents. An atypical stressful event (ASE), sometimes referred to as a potentially traumatic event (PTE), is an incident that presents mental or emotional pressure or strain circumstances that are outside the ordinary experience of the responders. Examples might include mass-casualty incidents, LODDs, witnessing of a coworker's suicide, especially gruesome and prolonged rescue/recovery events, and deaths caused by the actions of responders. ■ Signs and symptoms of incident stress can include task forgetfulness, reserved demeanor, and lethargy. More pronounced signs can include outward crying, emotional outbursts, and total shutdown of interactions with others. ■ The ISO's role in supporting an ASE exposure program has to do with initiating stress exposure protocols, facilitating a "time-out" defusing, and encouraging responders to use stress first aid measures. ■ The terms defusing and debriefing are used often when discussing incident stress programs. Defusing refers to a gathering during or immediately after the incident and is characterized by an informal, peer-to-peer discussion format designed to share observations, actions, and feelings. A debriefing is typically a scheduled event and is characterized by a more formal agenda designed to promote healing or closure and to outline the process or options for accessing more assistance. ■ NFPA 1500 requires fire departments to have a behavioral health assistance program in place to address issues of clinical assessments, basic counseling, and stress-crisis intervention. Individuals are encouraged to access these programs but may also find assistance from county health services, clergy, and several networks, including the Firefighter Behavioral Health Alliance.