Chapter 17

Postincident Responsibilities

Objectives

• Explain the factors that lead to injuries during postincident operations

• Discuss the role of the ISO for informal and formal postincident analysis (PIA)

• List the six specific items on which the ISO should provide input for a PIA

Objectives (con’t.)

• Explain the role of the ISO in accident investigation according to NFPA standards

• List the five parts of the accident chain

• List and explain the three steps of accident investigation

Introduction• Lessons learned from any near miss:

– Should be folded into training– Can be used for ongoing efforts to void similar

situations in the future

• The ISO has duties during:– Postincident activities– Postincident analysis– Accident investigation

Postincident Activities

• Many injuries occur when crews are packing up to leave an incident– Strains, sprains, being struck by objects

• ISOs can take preventive steps to reduce likelihood of injuries

Postincident Activities (con’t.)

• Postincident thought patterns– Reflective or introspective mental wanderings

that firefighters experience just after incident control

– Inattentiveness– Reduced by:

• Simple reminders or jocularity• Brief time-out for incident summary and safety

reminder

Figure 17-1 Postincident introspection is normal but may lead to inattentiveness and injury .

Figure 17-2 Calling a huddle before incident cleanup is the best opportunity to remind firefighters of lingering injury threats

Postincident Activities (con’t.)

• Chemical imbalance– May happen at the end of an incident– Caused by

• Sudden relaxation after working incident• End of adrenaline rush• Return of metabolism to “repair state”

– Remedied by ISO reminders to stay alert

Postincident Analysis (PIA)

• Formal or informal reflective discussions after an incident

• Summarizes successes and improvement areas discovered from incident

• Requires ISO involvement (NFPAs 1500 and 1501)– NFPA 1521 requires ISO to prepare a written

report regarding health/safety issues

Postincident Analysis (PIA) (con’t.)

• PIA philosophy– Positive reinforcement for safe habits– Honest, open desire to prevent future injuries– Discovery from fact-finding point of view– Avoidance of confrontation– Looking forward to the future

Postincident Analysis (PIA) (con’t.)

• ISO PIA issues– ISO should comment on key issues:

• General risk profile of an incident: get crew perceptions

• Effectiveness of crew tracking and accountability: freelancing

• Rehabilitation effectiveness• PPE use: discuss controversial decisions• Close calls: reserve judgment • Injury status: keep medical confidentiality

Postincident Analysis (PIA) (con’t.)

• PIA process– Can be formal or informal: discuss with IC– Formal PIAs should be prepared for significant

incidents• Sometimes takes days or weeks• Use interim PIA to capture responder’s memories

– ISO should take following steps for effective PIA

Postincident Analysis (PIA) (con’t.)

• PIA process (con’t.)– On-scene

• Check-in with responders and ask about injuries

– Documentation• Write quick summary of hazard issues: buildings,

incident timeline

– Trend spotting• Jot down thoughts about recurring issues • Share solutions with IC, supervisor, or HSO

Figure 17-3 The ISO should make a point of checking in with crews to get a sense of their perspective of the incident.

Figure 17-4 Quick incident documentation is essential. The ISO perspective and documentation improve the quality of a postincident analysis.

Accident Investigation

• ISO duties according to NFPA 1521– Initiate accident investigation procedures as

required by fire department– Request assistance from HSO in the event of

serious injury, fatality, or other potentially harmful occurrence

• Investigation is first step to avoiding future injuries and deaths– Look at fatalities and close calls

Figure 17-5 The accident triangle shows that, for every one serious injury, there are thirty minor injuries and more than six hundred close calls. Close calls should also be investigated.

Accident Investigation (con’t.)

• Introduction to accident investigation– Accident chain: series of events or conditions

leading to an unsafe condition that results in injury and/or property damage

– Ideally, the ISO should stop a potential incident by eliminating one of the elements in the chain during the incident

Accident Investigation (con’t.)

• Introduction (con’t.)– Five components of accident chain

• Environment: physical surroundings • Human factors: procedure use (or lack of), fatigue,

fitness, and attitudes• Equipment: use and maintenance, PPE• Event: intersection of first three components• Injury: includes close calls

Figure 17-6 Accident investigation is actually the discovery and linking of the accident chain.

Accident Investigation (con’t.)

• Investigation issues– The ISO must consider liability issues when:

• Performing safety tasks on-scene • Conducting a postincident investigation

– Use due diligence• Act in a reasonable and prudent manner, given the

circumstances, with due respect to laws, standards, and professional conduct

Accident Investigation (con’t.)

• Investigation issues (con’t.)– Recognize discretionary functions

• Certain functions require a value judgment among competing goals and priorities

• Nonliability exists

Accident Investigation (con’t.)

• Investigation issues (con’t.)– Be aware of involvement of outside agencies in

a significant injury or death investigation• Sate and/or federal OSHA and/or NIOSH officials • Labor group investigators• Insurance investigators• Law enforcement officials

Figure 17-7 The occurrence of a serious injury on the incident scene presents the ISO with many issues and concerns.

Accident Investigation (con’t.)

• The investigative process– Step 1: Information collection

• Incident data• Witness statements• Scene sketches/diagrams• Photographs/video• Physical evidence• Existing records

Figure 17-8 The ISO should support an accident investigation with many witness reports.

Figure 17-9 Protective equipment and other physical equipment need to be retained, marked, tagged, and identified.

Figure 17-10 Years of documentation may have to be reviewed to reconstruct an accident cause.

Accident Investigation (con’t.)

• The investigative process (con’t.)– Step 2: Analysis and reconstruction

• Separate facts, perceptions, and unknowns• Determine need for more information• Discard irrelevant data• Construct accident chain

Accident Investigation (con’t.)

• The investigative process (con’t.)– Step 3: Recommendations

• Typical areas of concern: equipment, policy and procedure, or personnel

• ISO presents multiple possible solutions to avoid future reoccurrence

• Avoid blaming or recommending disciplinary measures

• State recommendations in the form of future accident prevention

Summary

• ISO postincident duties– Monitor postincident activities

• Postincident thought patterns• Chemical imbalance

– Provide information for postincident analysis reports

• Report on safety points witnessed during incident

– Begin an accident investigation• Reconstruct accident chain