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NIOSH Investigations Can Help Prevent Future LODDs

NIOSH Investigations Can Help Prevent Future LODDs

Wednesday, 08 June 2011

The National Volunteer Fire Council (NVFC) is committed to protecting first responders and reducing the number of line-of-duty deaths and injuries. Many fatalities can be prevented by learning from previous tragedies, understanding why they happened, and avoiding similar mistakes that may have been made. The National Institute for Occupational Safety and Health (NIOSH) provides a critical program that is designed to help the fire service do just that.

The NIOSH Fire Fighter Fatality Investigation and Prevention Program is a federal program under the Centers for Disease Control and Prevention (CDC) which conducts independent investigations of firefighter line-of-duty deaths. The fatality reports summarize the circumstances and events leading to the tragic event and provide recommendations to prevent future firefighter injury and death. Although NIOSH is a research and education agency and does not have regulatory authority, the investigative reports often drive local and national regulation and policy. Published reports are available for free on the NIOSH web site at  www.cdc.gov/niosh/fire/.

The reports do not place blame on an individual or department, but rather they focus on the situational facts leading up to and during an event that impacted the outcome. The format of the reports has recently been updated to provide a quick one or two page snapshot of the recommendations found in addition to the full report.

Investigation Process

Although each investigation proceeds differently, the general process is as follows:

NIOSH receives a notice of a LODD and uses prioritization criteria to decide if it will be investigated. This prioritization occurs mainly due to their limited resources and the average 100 LODDs each year. Prioritization factors for traumatic injuries include: multiple death incidents, structure fires, vehicular accidents involving fire apparatus, emerging safety issues, and unique incidents.  Priorities for cardiovascular medical LODDs include hyper and hypothermia, seizures, diabetes, medical overdoses, CVD events during training and CVD events on the fireground.  The NIOSH investigation prioritization flowchart can be viewed on the web site at www.cdc.gov/niosh/fire/pdfs/FFFIP_DecisionChart.pdf.

Types of incidents that are not investigated (or have not been in quite a few years) include volunteer LODDs responding in personal vehicles, wildland LODDs, and aircraft incidents (partially based on the fact that the National Transportation Safety Board conducts investigations for the latter two).

Once the NIOSH Fire Fatality Investigation Team decides to investigate the incident, they reach out to the fire department Chief or designated point of contact soon after the event. This outreach allows NIOSH to express interest in the incident and clarify that they are a non-regulatory agency and are not interested in finding fault or blame.  Historically, this outreach has resulted in a very high level of cooperation and involvement by the effected department. At this time, NIOSH confirms with the department the schedule that will work for them. Often the department will elect to initiate the investigation after the memorial service has been completed.

The investigation team conducts a sit-down meeting with the fire department to identify the people and agencies involved that the team might want to talk to. Outside of the fire department members, interviews may be conducted with building code officials, water department, law enforcement, any local investigation team, and other participatory parties. Data is also collected from sources such as the dispatch recordings; apparatus, equipment, or air pack maintenance logs; medical and training records;  fire department standard operating procedures and policies, radio transcripts, and pictures, among others. Following the field investigation, the team begins drafting the report.

The draft report is first circulated internally among NIOSH team members and then sent to the department (minus the final recommendations to ensure focus of editing by responding agencies remains on the factual situation depicted)  for input and confirmation of the operational action descriptions. NIOSH works to resolve discrepancies identified by the fire department to ensure all information is accurate prior to release as a public document.

Drafts of the report are then sent to a third party subject matter expert for review and feedback. These subject matter experts are recognized leaders in the field with a background of published documents, training curriculum, or mastery of technical operations and command.

After final revisions, the report is released and posted on the NIOSH web site. Due to funding, printed reports are no longer disseminated to departments following the release. However, once a year, NIOSH will send out a mass mailing to all departments in the U.S. of four to six reports that focus on key issues identified over the past year.   All reports and publications are made available for downloading from the Fire Fighter Fatality Investigation and Prevention Program web site. 

Investigative Team Members

The Firefighter Fatality Investigative Team consists of 10 individuals: two medical investigators located in Cincinnati, and seven traumatic injury investigators and an information technology specialist located in Morgantown, WV. All team members are trained in occupational health and safety and are an extension of the CDC’s occupational fatality investigative team. Half of the investigators have a fire/EMS background and all have some combination of training or expertise in fire industry training, safety officer, fire behavior, building construction, standards and codes, and physiological/medical conditions.

NIOSH Funding

Funding comes through the Department of Health and Human Services to the Public Health Service, Centers for Disease Control and Prevention, and then NIOSH. The Firefighter Investigative Program contains 10 of the 800 staff members that work for NIOSH.

Reporting

Following suggestions from the field, NIOSH updated the reporting format to make it more accessible. The format now includes a two-page summary that contains a brief executive summary, contributing factors, and key recommendations. This overview of the findings is designed to make it easier for individuals that don’t have time to read through the full report.   All NIOSH LODD investigation reports can be found on the program web site at www.cdc.gov/niosh/fire/.

The NVFC and NIOSH

NIOSH has begun notifying the NVFC when they initiate an investigation with a volunteer or combination department. The NVFC historically sends condolences to each department following a loss and will now be able to support the department through the NIOSH reporting initiative. The NVFC will serve as a liaison between the department and NIOSH, showing support for the non-regulatory nature of the investigation and reporting.

The NVFC will disseminate the NIOSH reports through its health and safety communication channels. This includes distributing the two-page summary containing the contributing factors and key recommendations through various outreach methods. The NVFC’s B.E.S.T. Practices for health and safety serve as a close link to the reported findings and lessons learned from each report. Visit www.nvfc.org/health_safety to find tools and resources that address safety and health initiatives to combat line-of-duty injury and death.

The NVFC strongly supports the efforts of NIOSH and encourages departments and individuals to use the reports as learning tools.