The need to conduct a thorough investigation of every firefighter fatality, injury or near-miss is one of the 16 firefighter life-safety initiatives intended to significantly reduce the number of line-of-duty deaths and injuries that occur each year. The investigation is a vital part of the process that allows us to learn from each negative experience, then identify and implement the necessary corrective actions to ensure that the experience isn't repeated. While the concept is simple and unquestionably important, in far too many cases the investigation is overlooked, delayed or conducted in a manner that fails to capture the critical information or to implement the corrective action.

The investigation of every accident and injury, no matter how minor, is listed as a supervisory responsibility in virtually every organizational health and safety program ever documented. Thousands of quickly produced reports are created and filed away every day in fire departments and other organizations, and in most cases, the great majority of those reports are never studied or analyzed to determine how the information could be translated into preventive programs and strategies. The investigation process only takes center stage after a fatality or serious injury.

The great majority of serious accidents are both predictable and preventable, and predictability is directly related to experience. Most fatal incidents and serious injuries can be traced to a series of contributing factors that come together to produce a highly undesirable outcome. Those individual contributing factors make themselves evident over a period of time through minor mishaps and near-miss incidents that should, in an ideal world, cause fire chiefs and safety officers to identify problems and implement corrective actions. For every tragic outcome there could be 10 or 100 warning events.

The importance of looking closely at minor incidents and near-misses is beginning to be recognized within the fire service. For example, www.firefighternearmiss.com includes an advanced interactive system to accumulate and share valuable experience-based safety information. The system also provides links to resources that should help identify the appropriate intervention strategies once a problem has been identified.

Every fire department should be taking advantage of this new resource, as well as www.firefighterclosecalls.com. Both sites provide a valuable resource for fire service safety professionals and rank-and-file members who are committed to safety, allowing us to share experience and identify corrective actions on a national and international level.

The ability to predict avoidable situations requires a commitment to conscientiously investigating occurrences, even minor events, and then analyzing the information. The system won't function if no one's paying attention. In far too many cases we don't notice that no one is conducting appropriate investigations, analyzing the information or conducting safety audits until we're faced with a tragic outcome. After a fatality has occurred, we're often forced to look closely at our past performance — or some other organization comes in to do it. At that point it's too late to go back; however, it's absolutely essential to look forward and ensure that we learn the lessons and never make the same mistakes again.

Major safety investigations

The investigation of a line-of-duty death or a serious firefighter injury is among the most important and difficult tasks that any fire chief will ever have to face. It's an unfortunate reality that the most painful and difficult situations also present the most immediate and critical need for a very thorough and intensive analysis. A thorough and conscientious investigation is an essential first step in ensuring that our worst days do not repeat themselves.

When we experience the loss of a life or a serious injury, it is usually only a matter of minutes before someone (usually a reporter) starts asking what went wrong. The reflex reaction to such questions is often, “We did everything by the book. If we had it all to do over again, we wouldn't do it any differently.” This response is comforting and possibly reassuring to those involved, but it's also a denial of the very obvious fact that something must have gone seriously wrong or we wouldn't have anything to talk about. This response also establishes a defensive posture for every subsequent question, conversation or revelation about what happened.

We should be saying, “We're not sure what went wrong at this point, but we are going to conduct a very thorough investigation and make every effort to ensure it doesn't happen again.” From the very beginning the emphasis has to be placed on determining what went wrong, what we can learn from the experience and how we can implement those lessons to prevent future occurrences. This process is seldom simple or easy, and it can be extremely painful, but it's also essential to keep firefighters from being killed or injured in the future for the same reasons.

Major investigations become highly visible events. Every individual or organization that has any relationship to the event will have an interest and often a bias when it comes to identifying the cause. The news media, in many cases, would be thrilled to be able to report that some individual was found to be negligent or held legally responsible, because those stories produce headlines that sell newspapers and attract viewers. Attaching blame to one individual or organization is simple, sensational, and relieves everyone else of any responsibility. In real life, things are seldom that simple.

On the opposite side of the equation, in many cases there's a reluctance to examine circumstances too closely in case they show that the victim was in some way negligent or contributed to the situation. There is a concern that we would dishonor a fallen firefighter by discovering that he or she made an error that contributed to his or her own death. As caring and sentimental as we may be, it would be foolish and professionally negligent to ignore facts and fail to learn the lessons from any unfortunate situation. The protective reflex also could apply to shielding other individuals or the fire department itself from critical examination.

Be prepared for investigation

There are several reasons why investigations miss the mark; however, the most frequent cause is the lack of a plan to conduct a proper investigation when the situation arises. The death of a firefighter is our worst nightmare. When faced with an intensely personal tragedy and all of the associated activities, few of us are capable of identifying the need for a thorough investigation as a top priority and formulating a rational plan to ensure that it happens.

Unfortunately, in many situations time is of the essence, and a delay in getting the investigation started can result in the loss of critical information. The best way to address this problem is to have a well-defined investigative process ready for immediate implementation when the situation arises. This is a plan that we hope will never have to be used, but if it's needed, the procedure should be predefined and initiated without delay.

Model procedures for conducting major investigations are available from national fire service organizations, and the U.S. Fire Administration publishes a model autopsy protocol. These guides can be obtained easily after a fatality has occurred, but that's too late to develop an effective plan. The procedure should be ready for immediate implementation.

Very few fire departments have the resources to conduct a thorough investigation of a major incident without assistance. This is particularly true when a fatality occurs, because the primary focus of the organization immediately turns to a list of pressing issues that include survivor notifications and assistance, funeral arrangements, critical incident stress debriefings, news media interviews and, in many cases, continuing operations at the incident scene. Other than in metropolitan departments, it's unlikely that the organization itself will be able to immediately assign a full team to begin the essential steps of investigation and documentation.

Some large departments are able to immediately assign a pre-designated investigation team to focus on capturing information and ensuring that the investigation begins without delay. Safety investigation teams have been defined as a standard mutual aid resource in several areas, and the members of a regional or statewide team are prepared to respond immediately and provide assistance to the jurisdiction that has experienced a loss of life or other major mishap. This ensures that trained and qualified individuals will be able to respond very quickly and begin the investigation process. The subsequent steps can be implemented more gradually if the initial priorities have been addressed.

Working with others

In most cases, particularly if there's a fatality involved, there will be other agencies conducting parallel investigations. These usually will include the authorized regulatory agency for occupational safety and health, and the coroner or medical examiner.

In the case of a vehicle accident, police investigators are usually responsible for conducting an inquiry. The police or a designated law enforcement agency is often required to conduct an investigation of any sudden death. The workers compensation insurer also might send an investigator to determine the circumstances. If the incident involved a fire, the fire marshal or fire investigation division will have to conduct a cause and origin investigation to determine how the fire started. If the investigation leads to criminal charges against someone who is responsible for causing the incident, the process will quickly become much more complicated. An arson fire that results in a firefighter fatality will probably become a homicide investigation, with all of the unavoidable legal complications.

All of these agencies generally have the legal responsibility, as well as the authority, to conduct their own investigations, issue reports and take specific actions as a result of their findings. Each investigative agency generally has its own rules and procedures for conducting an investigation, which may or may not include working with the fire department's internal team. Outside efforts are often directed toward finding legal responsibility, in the sense of negligence or a violation of an applicable code, standard or regulation. Depending on the situation, some of these agencies could adopt an adversarial role in which they're investigating the actions and policies of the fire department at the same time the fire department is examining itself.

It is critical for everyone involved to understand the different roles and responsibilities and to cooperate in a responsible manner. The pre-investigation planning process should identify all of the agencies and organizations that are likely to be involved in different situations and establish their various roles and responsibilities. The basic relationship between the firefighter safety investigation and all other investigative agencies must be understood.

Additional organizations, such as the National Institute for Occupational Safety and Health, the National Institute for Standards and Technology, the National Fire Protection Association and the USFA, also will become involved in some investigations as observers and information gatherers. These organizations are interested primarily in obtaining information that will provide educational or research value; however, they also can provide valuable technical assistance to a local investigation team.

Fire department responsibility

The most thorough investigation of any event should always be the fire department's own internal reconstruction and analysis of the occurrence. While other investigations will address a variety of special concerns, the fire department's internal investigation must consider every aspect and potential contributing factor. The mission of the investigation team must be to conduct a thorough and unconstrained analysis of the event and everything related to it, ensuring that the true and complete facts are determined. Corrective action must be based on addressing real problems; not a perception of the problem or part of the problem. The ultimate goal of the internal investigation is to identify corrective actions that will prevent future occurrences of a similar nature.

The results should always be shared with other fire departments and fire service organizations. The lessons, even if they are embarrassing, are much too valuable to be hidden from view. We owe it to our profession to let others learn from our experiences. The detailed fatality investigation reports and subsequent research efforts that have been produced by fire departments such as Phoenix and New York City have provided a wealth of information for the fire service to use. The reports should be studied and their lessons should be implemented by every fire department.

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J. Gordon Routley is a freelance consultant and program director for the Firefighter Life-Safety Initiative, sponsored by the National Fallen Firefighters Foundation.