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“Learning from Near-Miss Incidents”
Initiative for the Bulk Power System
This concept paper is prepared by an industry task group of experts led by Robert Schwermann, Senior
Operations Specialist - Human Performance, Electric Transmission Operations, Pacific Gas & Electric Co.
and Chair of the Western Electricity Coordinating Council Human Performance Working Group. The
paper provides a synopsis of a proposed initiative that could be undertaken by the North American
electric power industry to develop a database of lessons learned from “near-miss” incidents. The
objective and broad concepts of the proposed initiative are outlined in this document to seek broad
industry comments and support for the initiative.
The database would be designed to capture and analyze near-miss incidents and develop information
that could be used by the industry to learn safe operating practices, improve understanding of human
performance factors, and identify and address issues that can potentially enhance bulk power system
(BPS) reliability. In addition, the information is expected to be useful in identifying human performance
and technical processes and issues that require further investigation for research and development
(R&D) entities to pursue. The proposed database would be designed to maintain strict confidentiality
and anonymity for those entering the information. It would be voluntary but accessible to all interested
North American entities. Full success of the initiative depends heavily on an industry-wide coordinated
effort that requires support from stakeholders such as asset owners, operators, and employee unions,
to name just a few. The database development efforts could draw heavily upon similar, successful
endeavors by the national aviation and firefighters’ groups, who both have useful and informative
industry databases.
The next step in this initiative includes disseminating this paper to the U.S. electric utility industry
stakeholders to seek comments and support for the initiative. If the industry moves forward with the
initiative, the subsequent step will include seeking funding for the development of this database and for
the ongoing efforts to collect near-miss incident data, analyze the data, and maintain the database. For
this important step, an industry consensus will be sought to identify appropriate entities such as NATF,
EPRI or others for a collaborative effort.
Background
A mature organization consistently draws lessons from experience to improve procedures and the
overall process. It is the logical use of data that enables organizations to determine corrective actions
and the adjustment or sustainment of an effective process. The bulk power industry has a multitude of
processes that allow for the collection and analysis of data from relevant industry activities and
incidents and the subsequent dissemination of valuable lessons learned from such evaluation. This vital
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information, which is used across the industry, leads to many lessons that help maintain personnel
safety and keep the BPS resilient. Most of this information is the result of detailed analysis of events that
have been elevated to the awareness of others. Further success requires a system that can focus on
precursor incidents that, in different circumstances, may lead to larger events—particularly those that
could affect the safety and human performance of industry practitioners and the reliability of the BPS.
The industry needs a method that can identify precursor incidents and allow cooperative, crossfunctional problem solving for the industry.
What Is a “Near-Miss” Incident?
A common definition of a near-miss or close-call incident is one in which no injury, property damage, or
system reliability lapse occurred, but in which such an outcome could have occurred as a result of an
unsafe act, an unsafe condition, defective equipment, or human error. In other words, “You got lucky.”
These near misses provide an opportunity to learn lessons on personnel safety, human performance
aspects, and BPS reliability issues for a proactive stance on safety and reliability.
Currently, no nationwide database of near-miss incidents exists. Limited databases exist within some
utilities across the U.S. power system, but comments have surfaced that efforts to populate and analyze
the information, which would allow derivation of more general conclusions and lessons learned, are
lacking. Consequently, such uncoordinated information seems to have provided little value to the
industry as a whole. A North America-wide database is necessary for gathering sufficiently general and
contextually valuable information to facilitate improvements in personnel safety, human performance
factors and reliability of power system operation. There are entities that have had internal programs
that are marginally successful due to many factors, such as limited scope, lack of anonymity, limited
resources, and lack of organizational support.
Proposal
This proposal is to create an industry-wide “Learning from Near-Miss Incidents” database. It will consist
of:
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A reporting system to enter near-miss incidents
A process to review and polish the entered data to ensure anonymity and value proposition, and
to remove any grievance-type language that does not serve the intended purpose
A framework to analyze the reported incidents from which to draw learning
A repository to assimilate and broadcast the lessons learned to the entire industry
The database will be designed to allow voluntary and confidential submission of near-miss incidents by
reliability coordinators, balancing authorities, asset owners and asset operators. Reports submitted to
the system may describe a variety of issues, such as unsafe occurrences, process missteps, faulty
equipment, and hazardous situations that could affect personnel safety and the reliability of the BPS.
The long-term goal is to develop and maintain an industry-wide database that will be widely regarded as
one of the world’s largest sources of information on personnel safety, BPS reliability, and human
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performance. Sharing across the U.S., and eventually across North America, will allow entities to share
their experiences and formulate lessons that can strengthen the entire grid, making everyone more
successful in the pursuit of improving safety and reliability.
Implementation
The overall goal of this effort is to illicit participation from all North American entities that contribute to
or have an interest in maintaining a safe and reliable BPS. Support will be sought from the entire
spectrum of organizations: asset owners and operators and employee unions, and industry practitioners
such as senior management, system operators, and field personnel. Participation can be encouraged by
industry-wide announcements from industry leaders, technical press and communication channels of
various entities.
The database will be designed to minimize the efforts of those reporting the incidents such as reliability
coordinators, balancing authorities, asset owners and asset operators. Depending upon industry
feedback and agreed-upon implementation parameters, the database could also allow individuals, such
as field personnel, switchmen or control room operators, to submit narrative reports in complete
confidentiality.
This would allow for an increased depth of reporting by field personnel. Other near-miss incident
reporting systems, such as the Aviation Safety Reporting System (ASRS) maintained by NASA, and the
National Firefighter Near-Miss Reporting System developed by the Association of Fire Chiefs (IAFC), have
found narrative stories beneficial for grasping the essence of an incident. (Note: reports that do not
contain useful information or contain only expressions of discontentment would be archived and not
processed further). In addition, this proposal suggests that material submitted be categorized using, for
example, the NERC Cause Code Assignment Process (CCAP). See Appendix A for the codes.
Further analysis of each report will be performed to derive learning from the incident from the safety,
human performance, and BPS reliability perspectives. The findings from the analysis of the reported
incidents will be promulgated throughout the industry by means such as trade organization newsletters,
Web postings, etc.
Funding
Once the industry moves forward with this proposed initiative, a proposal will be prepared by the task
group or identified entities to seek U.S. Department of Energy funding for development and
implementation of the database during the first two years, and for ongoing database maintenance costs.
Confidentiality
The task group recognizes that the confidential and independent nature of the ASRS is the key to the
success of the system, since reporters do not have to worry about any possible negative consequences
of coming forward with safety problems. The success of a strictly confidential system serves as a positive
example that is often used as a model by other industries seeking to make improvements, such as the
National Firefighters Association (NFA) and the Federal Railway Administration (FRA).
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Who Will Benefit from the BPS Near-Miss Database?
The Near-Miss Database allows the general public to benefit from a more reliable electrical grid that is
operated and maintained by managers, operators, and field crews who learning from their shared
experiences.
How It Will Be Managed
The near-miss reporting system would receive voluntarily submitted reports (whether or not the
activities reported result in any “incident”), “sanitize” them by removing information that could identify
the entity submitting the reports, process and analyze the reports, and post them on a publicly
accessible site. These tasks could be assigned to a group to be identified at a future date. To preserve
confidentiality and avoid the perception of punitive risks in case the reports imply compliance
infractions, regulatory agencies will be requested to agree to remain at arm’s length and will not receive
or request original reports or any information that could help identify the person or entity submitting
the report.
Database Model: How Are Others Facing the Same Challenges?
Depending upon industry consensus, a set of general specifications will be prepared for the
development, structure and maintenance of the near-miss database. Based on these specifications,
appropriate elements of the existing near-miss databases of other industries will be adopted as
appropriate.
Examples of successful near-miss databases of other industries include those of the aviation and the
firefighting industries. The aviation industry has been gathering and assessing this type of information
for over three decades. Through the Aviation Safety Reporting System (ASRS), pilots and other airplane
crew members confidentially report near-miss and close-call incidents in the interest of improving air
safety and reliability. The ASRS collects voluntarily submitted aviation safety incident/situation reports
from pilots, controllers, and others (including support functions like baggage handlers and on-site
caterers), analyzes the reports, and responds to them in order to lessen the likelihood of aviation
accidents. The ASRS is an important facet of the continuing effort by the government, industry, and
individuals to maintain and improve aviation safety.
Reports submitted to ASRS may describe both unsafe occurrences and hazardous situations. ASRS’s
particular concern is the quality of human performance in the aviation system. ASRS data are used to:
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Identify deficiencies and discrepancies in the National Aviation System (NAS) so that they can be
remedied by appropriate authorities.
Support policy formulation, planning, and improvements the NAS.
Strengthen the foundation of aviation human factors safety research. This is particularly important
since it is generally conceded that over two-thirds of all aviation accidents and incidents have their
roots in human performance errors.
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The ASRS acts on the information contained in these reports. It identifies system deficiencies and issues
alerts to persons in a position to correct them. It educates through its newsletter CALLBACK and its
journal ASRS Directline, and through its research studies. Its database is a public repository that serves
the FAA and NASA’s needs and those of other organizations world-wide that are engaged in research
and the promotion of aviation safety.
The National Firefighter Near-Miss Reporting System was developed in 2005 by the International
Association of Fire Chiefs (IAFC). The National Firefighter Near-Miss Reporting System aims to prevent
injuries and save lives of other firefighters by collecting, sharing and analyzing near-miss experiences.
The experiences are collected by firefighters who voluntarily submit them; the reports are confidential,
non-punitive, and secure. After the reports are compiled, they are posted to the IAFC Web site, where
firefighters can access them and learn from each other’s real-life experiences. Overall these reports help
to formulate strategies, reduce firefighter injuries and fatalities, and enhance the safety culture of the
fire service. The program is based on the Aviation Safety Reporting System (ASRS), which has been
gathering reports of close calls from pilots, flight attendants, and air traffic controllers since 1976. The
reporting system is funded by the U.S. Department of Homeland Security’s Assistance to Firefighters
Grant Program. The program was originally funded by DHS and Fireman’s Fund Insurance Company.
Also, the Federal Railroad Administration (FRA) has developed the FRA Confidential Close Call Reporting
System (C3RS), a voluntary, confidential demonstration program for railroad carriers and their
employees to report close calls without receiving disciplinary action. The broad goals of the C3RS project
are: preventing accidents, saving lives, uncovering hidden, at-risk conditions not previously exposed
from analysis of reportable accidents and incidents, and identifying and managing risk through proactive
analysis to identify trends or patterns before safety is compromised. Parties involved include the Federal
Railroad Administration (FRA), Bureau of Transportation Statistics (BTS), National Aeronautics and Space
Administration (NASA), railroad carriers, carrier employees, labor organizations, and peer review teams.
At this time, the C3RS is accepting close-call reports only from Union Pacific (UP) Railroad North Platte
Service Unit, Canadian Pacific (CP) Railway Chicago Area, New Jersey Transit, and Amtrak with the intent
of expanding when possible.
Appendix B includes examples of reports available on the ASRS, National Firefighter Near-Miss Reporting
System and C3RS sites.
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Appendix A: NERC CCAP (Cause Code
Assignment Process)
Click on page below to view all two pages.
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Appendix B: Examples of Reports
Available on the ASRS, National
Firefighter Near-Miss Reporting System
And C3RS Sites.
The reports included in this Appendix were downloaded from the respective websites. They were
slightly re-formatted to legibility, but were not edited in any other way.
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Examples of Three ASRS Reports
ACN: 984272
Time / Day
Date : 201112
Local Time Of Day : 0601-1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Environment
Light : Daylight
Aircraft
Reference : X
Make Model Name : Cessna 340/340A
Mission : Personal
Flight Phase : Parked
Maintenance Status.Released For Service : N
Maintenance Status.Maintenance Type : Unscheduled Maintenance
Maintenance Status.Maintenance Items Involved : Repair
Maintenance Status.Maintenance Items Involved : Work Cards
Maintenance Status.Maintenance Items Involved : Installation
Component : 1
Aircraft Component : Exhaust Pipe
Aircraft Reference : X
Problem : Malfunctioning
Component : 2
Aircraft Component : Exhaust Manifold
Aircraft Reference : X
Person
Reference : 1
Location Of Person : Hangar / Base
Reporter Organization : Personal
Function.Maintenance : Lead Technician
Qualification.Maintenance : Inspection Authority
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Qualification.Maintenance : Airframe
Qualification.Maintenance : Powerplant
Experience.Maintenance.Lead Technician : 12
Experience.Maintenance.Technician : 15
ASRS Report Number.Accession Number : 984272
Human Factors : Other / Unknown
Human Factors : Fatigue
Human Factors : Situational Awareness
Human Factors : Communication Breakdown
Communication Breakdown.Party1 : Maintenance
Communication Breakdown.Party2 : Maintenance
Analyst Callback : Completed
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Anomaly.Deviation - Procedural : Maintenance
Anomaly.Deviation - Procedural : FAR
Detector.Person : Maintenance
Were Passengers Involved In Event : N
When Detected.Other
Result.General : Maintenance Action
Assessments
Contributing Factors / Situations : Procedure
Contributing Factors / Situations : Logbook Entry
Contributing Factors / Situations : Manuals
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors
Narrative: 1
I worked with another Airframe/Powerplant (A/P) and Inspection Authorized (I/A) Mechanic installing
an overhauled engine. When the aircraft came in for an oil change seventy-five hours after the engine
[was] installed, another Maintenance facility discovered the exhaust system was leaking. They stated a
gasket was missing from the ‘Y’ pipe and the exhaust [manifold] was misaligned with the brackets
which support it. During the investigation to how this occurred, it was discovered I failed to follow FAR
43.9(3) by [not] providing the name of the person I was working with. This failure of an incorrect
installation was due to lack of experience of the installer and failure to follow the steps provided in a
Service Bulletin on how to assemble the [exhaust] system. Though the service instructions were
available and the parts were too, we as a team failed to go step-by-step on these instructions which
resulted in the exhaust leak. Failure to identify this hazard could have resulted in an in-flight fire. I also
believe this is a violation of FAR 43.13 Performance Rules, because we failed to use the methods
prescribed in current manufacturer’s Maintenance manuals.
Callback: 1
Reporter stated he failed to include the other Mechanic’s name in the C-340’s logbook sign-off for the
engine overhaul and installation because he normally signs-off for all the work.
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Synopsis
A Lead Mechanic with an Inspection Authorization (I/A) rating reports that he failed to include another
Mechanic’s name in the logbook sign-off associated with a Cessna C-340 aircraft engine overhaul and
installation. The aircraft was also found to have an exhaust gasket missing and the exhaust manifold
misaligned, contributing to a potential inflight fire condition.
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ACN: 984126
Time / Day
Date : 201112
Local Time Of Day : 1801-2400
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Environment
Light : Night
Aircraft
Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Air Carrier
Make Model Name : Regional Jet 200 ER/LR (CRJ200)
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Plan : IFR
Flight Phase : Descent
Airspace.Class E : ZZZ
Component
Aircraft Component : Turbine Engine
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Pilot Not Flying
Function.Flight Crew : First Officer
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 984126
Human Factors : Fatigue
Human Factors : Workload
Events
Anomaly.Aircraft Equipment Problem : Critical
Detector.Person : Flight Crew
Were Passengers Involved In Event : N
When Detected : In-flight
Result.General : Declared Emergency
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Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : MEL
Primary Problem : Aircraft
Narrative: 1
While enroute a moderate vibration developed and was felt in the airframe and the control yoke.
Thrust and airspeed were reduced to 250 KTS and the vibration subsided. We advised Approach of our
condition and he vectored us for an approach to Runway 02. We declared an emergency and landed
safely without incident. Contributing factors [and considerations for the emergency declaration]
included: Imminent engine shut down, possible flight control failure, IMC conditions, aircraft control,
deviation to another airport facility for better emergency handling, heavy fatigue on this leg seven and
extremely long day with multiple aircraft swaps and multiple deferments on equipment throughout
the day on every leg.
Synopsis
A CRJ flight crew experienced apparent engine vibration just prior to descent for landing. They
declared an emergency and landed without incident. Factors contributing to the flight crew’s ordeal
included: fatigue, multiple legs; and multiple aircraft swaps each with deferred maintenance items.
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ACN: 984026
Time / Day
Date : 201111
Local Time Of Day : 1201-1800
Place
Locale Reference.ATC Facility : ZAB.ARTCC
State Reference : NM
Altitude.MSL.Single Value : 22000
Environment
Flight Conditions : VMC
Light : Dusk
Aircraft
Reference : X
ATC / Advisory.Center : ZAB
Aircraft Operator : Air Carrier
Make Model Name : B737-300
Crew Size.Number Of Crew : 2
Operating Under FAR Part : Part 121
Flight Phase : Descent
Airspace.Class A : ZAB
Component
Aircraft Component : FMS/FMC
Aircraft Reference : X
Problem : Malfunctioning
Person
Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Air Carrier
Function.Flight Crew : Captain
Function.Flight Crew : Pilot Not Flying
Qualification.Flight Crew : Air Transport Pilot (ATP)
ASRS Report Number.Accession Number : 984026
Human Factors : Fatigue
Human Factors : Situational Awareness
Human Factors : Workload
Events
Anomaly.Aircraft Equipment Problem : Less Severe
Anomaly.ATC Issue : All Types
Anomaly.Deviation - Procedural : Published Material / Policy
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Anomaly.Deviation - Procedural : FAR
Detector.Person : Flight Crew
When Detected : In-flight
Result.General : Maintenance Action
Result.Flight Crew : Overcame Equipment Problem
Result.Air Traffic Control : Issued New Clearance
Assessments
Contributing Factors / Situations : Aircraft
Contributing Factors / Situations : Human Factors
Contributing Factors / Situations : Procedure
Primary Problem : Ambiguous
Narrative: 1
On hand off to ABQ Center from LAX Center on the GEELA 4 we began to receive numerous airspeed
assignments and revised altitude clearances. We ended up at 260 KIAS and were cleared in multiple
step downs to 17,000. During this the FMC seemed to be responding more slowly after every speed
change was entered, in particular the auto throttles were slow to respond to the new path. Just after
crossing LZIRD we were told to descend via the GEELA 4 Runway 25L. Because of the step downs we
were above the profile and I advised the Controller that we would be high over HYDRR. The Controller
gave us relief on that altitude and said we were fine “as long as we made the 12,000/250 KIAS
restriction at GEELA. There is no published restriction like that for GEELA. There has been a NOTAM for
several months now to cross GEELA at or below 16,000 at 250 KIAS. (I do not understand why this has
not shown up on the plates.) The Controller was extremely busy so there really wasn’t a good
opportunity to query him about the clearance. We saw that we could make the restriction with use of
spoilers and so complied with the clearance. (Left to its own devices the VNAV path normally crosses
GEELA at around 12,500 FT.) Also at this point the auto throttles failed to respond appropriately to for
the VNAV path and we had to disconnect auto throttles, come out of VNAV and use Level Three
automation, requiring a reset of the MCP altitude to protect the next fix. At that point we were
handed off to PHX Approach, who continued to issue further speed reductions. The task loading did
not let up until about an eight mile final with hand off to PHX Tower. At that point I noticed that the
landing lights were not on and that my altimeter was set at 29.92. The First Officer’s (pilot flying) was
set correctly at 30.18. It was apparent that we had not done the Descent/Approach checklist. I
followed by ensuring lights, autobrake, and other items were set correctly. Landing was uneventful.
The First Officer and I spoke about the event afterward and we concluded that the multiple speed
changes, step down altitudes and a clearance to descend via right at FL180 task-loaded us to the point
where we missed the checklist. 1. The optimum descent profiles work very well as long as the
automation is allowed to fly it without interruption. The more often ATC adjusts speed and/or altitude
the more likely the opportunity for error. Task loading under these circumstances triples. Some arrivals
are more tolerant of this than others. The GEELA 4 for some reason seems to be the most difficult
when receiving multiple speed adjustments. A vector off the arrival and then back on seems to work
better than constantly adjusting the speeds. 2. This was leg five of a long day. Neither of us was as
sharp as were on leg one. 3. For reasons I do not understand, the FMC interface with auto throttles
seems to be less robust with update 10.7 than it was with update 10.5. A revision of the GEELA 4 might
be in order. Based on the number of times I personally have flown it without speed adjustments I
don’t think it works well at all for ATC. Also, if there is an altitude and speed restriction regularly used
on an approach, that information belongs ON THE PLATE, not as local knowledge or as a NOTAM. We
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probably should watch 10.7 equipped airplanes for a while to see if there is some underlying issue. I
have seen all our airplanes “act up” to a certain extent, but today this aircraft warranted a write-up. .
Synopsis
A B737-300 Captain reported difficulty complying with the GEELA 4 RNAV arrival to PHX due primarily
to numerous airspeed assignments and revised altitude clearances. On final approach it was
discovered that the Captain’s altimeter was not set to local and the descent and approach checklists
had not been accomplished.
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Example of a Report from the National Firefighter Near-Miss Reporting
System
Report Number: 08-0000460
Report Date: 09//22/2008 0958
Synopsis
Lack of water supply, command presence, creates hazard for crew.
Demographics
Department type: Paid Municipal
Job or rank: Captain
Department shift: 24 hours on - 72 hours off
Age: 43 - 51
Years of fire service experience: 27 - 30
Region: FEMA Region I
Service Area: Rural
Event Information
Event type: Fire emergency event: structure fire, vehicle fire, wildland fire, etc.
Event date and time: 11/03/2007 1730
Hours into the shift:
Event participation: Involved in the event
Weather at time of event: Cloudy and Rain
Do you think this will happen again?
What were the contributing factors?
Weather
Command
Decision Making
Communication
What do you believe is the loss potential?
Property damage
Event Description
On [date deleted] our department responded to a reported structure fire during the remnants of
Hurricane [deleted]. Heavy rain with winds gusting to hurricane strength was causing multiple
responses to a variety of incidents. At the time of this incident the department was responding to 3
separate structure fires. Because of this the response was piecemealed to make up a structure fire
response.
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One firefighter, who was standing by at an arcing wires call not far from the incident, responded to the
scene. The firefighter never told dispatch he was responding. When he went to give a report he was
told to “stand by” as dispatch still thought he was at the arcing wires call and they were in the process
of dispatching structure fire responses. The firefighter on the scene did not state “urgent message” or
“priority traffic” or any communication that would have clued the dispatcher to answer. The firefighter
did not take command as required by ICS, as well as in local county and department protocols.
The first engine on scene reported a heavy smoke condition in the area and then found a two-story
wood frame dwelling with 50% involvement. The apparatus driver stopped at the hydrant and the
lieutenant ordered him to “go right in”. In speaking to the lieutenant after the incident, he admitted he
had “moth to the flame” syndrome. His engine carries 700 gallons of water. The first due firefighter did
confirm that all occupants were out of the house.
On arrival the lieutenant failed to take command, as he thought the shift commander was close to
being on location. The crew then pulled a 1-3/4” line to fight a dwelling involving 50%.
The second engine arrived on location and was sent to the hydrant per department SOGs if the first
unit had not already down so. Despite computers on the apparatus that show hydrant locations, the
hydrant could not be located due to visibility. Later it was reported the computer system had gone
down.
I arrived as the shift commander and took command, but did not seek out the first arriving lieutenant
as I should have. With 2 engines on location I “assumed” a water supply had been established. Had a
water supply been established I would have initiated a “blitz attack” with a deck gun, due to the
amount of fire and storm conditions.
A 2-1/2” line was ordered to the front door and up the stairway to the second floor. Shortly afterward
I was informed there was a hole in the floor just inside the doorway of Side A. Due to the extent of fire,
the storm, and the report of a hole in the floor, all crews were ordered out. It should be noted here
that they had made little interior progress anyway.
A neighboring fire chief arrived on location and was assigned to Side C. We conferred about going to a
second alarm assignment but were in agreement that due to the storm all neighboring resources were
also taxed and that since it was now a defensive operation additional resources would not be of any
use. The department’s fire chief had arrived on location and was assigned to Safety and Accountability.
With all units ordered out of the building a PAR was conducted.
About this time I asked if a water supply had been established and was told yes. However, the captain
on the third due engine reported that I did not have a water supply. The second engine in, with a crew
of four, not being able to find the first hydrant, left one firefighter to establish a water supply. This
consisted of him hand jacking 4” LDH for about 500’.
As the fire became under control, I ordered a crew to Side C to get into the interior and start to
extinguish the rest of the fire and then begin overhaul to ensure the fire was out. Doing this I, as the
IC, failed to notify Safety of my change in strategy. So while I was ordering one crew in, he was
ordering them out per the last report.
The incident started because when the power went out, the homeowners had lit candles in the living
room. They heard their small children, the youngest being 3, yell “Fire”. The father evacuated all of
them and his wife out of the house and went back in to find the couch on fire. As he attempted to
smother the fire on the couch with a blanket the curtains became involved and he left to call 9-1-1.
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A review of the radio tapes later found that it took approximately 22 minutes to establish a water
supply.
Lessons Learned
Lessons learned: The importance of first in units taking command. With command established it forces
senior officers arriving on scene to physically talk to you before command is transferred.
Often when you review close calls, near misses, or fatalities, there are a number of small events that
occur and together they lead to injury or death. Considering the possibilities at this incident, our
department had a lucky day that there were no injuries.
The need for establishing a water supply can never be over emphasized.
Communications: When there are difficulties, such as failing to find a hydrant, or a change in tactics,
those must be communicated to the IC, and/or the IC to all on the fireground. We need to use
terminology such as “priority traffic” or “urgent” to break into communications to allow dispatch to
acknowledge the call.
To correct this we critiqued the incident from all angles. On the on-duty shift involved we did a number
of practical evolutions set up from the NFPA.
We reviewed Incident Command and communications including the department’s mayday parameters.
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Example of a Reporting Form from the C3RS Site
Click on the page below to view all four pages
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