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Responder Safety: When Attention is “Tunnelled”

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American Airlines 2253

Does what we expect to happen influence our awareness?

Why is constant monitoring essential?

AA 757-200 Over-run
(AP)

Snowy Day

2253 was a Chicago to Jackson Hole, Wyoming (JAC), flight with experienced pilots flying in challenging but typical winter conditions.  (The Captain had extensive experience flying into JAC.) JAC is located at an altitude of 6,400 feet and the active runway was 6,300 feet long.

Weather conditions were better than forecast with light snow and winds though the aircraft would be close to maximum landing weight.  The flight crew conducted a very thorough en-route briefing evaluating runway conditions, weather and aircraft capabilities.

Runway conditions deteriorated during the final third of the length so the plan was to touchdown in the first 1,000 feet and come to a stop quickly.  The aircraft slows and stops using a combination of main gear hydraulic brakes, engine thrust reversers and “speed brakes” or “spoilers.”  These speed brakes cancel wing lift and allow the weight of the aircraft to settle on the main gear so the hydraulic brakes will be fully effective.

Deployed Thrust Reverser

Approach

Engine thrust reversers are manually deployed by the flying pilot after touchdown and the speed brakes can be “armed” for automatic deployment or manually activated at any time.  In addition, the aircraft has a system that automatically confirms that it is on the ground so that deployment is appropriate.

The aircraft was configured for landing, the first officer was the flying pilot and the captain was tasked with monitoring pertinent systems.  He would confirm and call out successful deployment of reversers and speed brakes, a common procedure.

 

Looking Aft

“Two in Reverse”

The aircraft touched down exactly as planned and the Captain called out “deployed” and “two in reverse” suggesting that the speed brakes and thrust reversers were operating.  In the split second after touchdown the “on the ground” sensing system cycled from ground to air to ground again at the exact moment that the flying pilot was manually deploying the thrust reversers.  They froze in mid-deploy position.  In addition, because of an undetected fault in the speed brake system, they also failed to activate.  The aircraft was barreling down the runway, unable to stop and heading for a sketchy runway surface.

Two things were wrong but the pilots noticed and focused only on one–the thrust reversers.  The National transportation Safety Board (NTSB) referred to this as “tunnelled attention” since the pilot responsible for monitoring the “big picture” allowed his focus to be drawn to one area.  The problem with the speed brakes could have been instantly resolved by manually moving the lever to the deployed position.  Activating speed brakes even with late deployment of the thrust reversers would have stopped 2253 on the runway.

“Big Picture”

The NTSB discussed the inability for either pilot to pull back to focus on the “big picture” even though both commented that they were not slowing down.  One of the aspects touched upon is our tendency to expect automated and highly reliable systems to always function correctly.  (The Captain saw the speed brake handle start to move and assumed the rest.)  Our analogous examples could include SCBA, fire pumps or patient monitoring systems.)

Luckily, 2253 rolled to a stop in heavy snow about 500 feet past the end of the runway.  Their ski trip started early.  We can profit by training ourselves to keep the big picture and by not falling into the trap of expecting systems to always function flawlessly.

 

Posted by on February 27, 2013 • Filed under: Administration & Leadership, Command & Leadership, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Firefighter Safety & Health, Firefighting Operations, HazMat, Safety and Health, Technology & Communications, Training, Vehicle Operations & Apparatus

Murders in Webster: The Deafening Silence

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Fire Service Leaders with Nothing to Say

Webster, New York

On Christmas Eve, four Webster, New York, firefighters were shot and two killed when a paroled felon with a prior murder conviction set them up.  It’s more accurate to say they were executed with premeditated precision.  Arson was used as the pretext for drawing them into the killing zone so the connection to our profession is both direct and compelling.

If our national/international fire/rescue organizations exist in part to protect us by formulating solutions, they are all asleep at the wheel on this one.  A scan of web pages (IAFC, IAFF, NFFF, NVFC) reveals either complete silence or the issuing of  platitudinous press releases.  Pretty thin gruel under the circumstances.  So much for decisive leadership.

By the way, I’m not talking about overturning the second amendment but you would think they could momentarily shrug off their collective holiday torpor and (at least) pretend to give a shit.

If “balls”, (or rather the lack of them) is the problem, they can look to NYPD’s Chief Ray Kelly for leadership inspiration.  Kelly said,”I think it’s important to let the federal government know that something has got to change.”  Kelly backs his tough words up with action, something fire service leadership, both labor and management, seem unable or unwilling to do.  Come to think of it, we don’t even have the tough words so we are a long  way from action.

NYPD’s Ray Kelly

 

And Chief Kelly is no simpering-pinko-liberal-lefty.  He is a combat veteran and Marine who served (and led troops) in Vietnam as a Second Lieutenant.

The guy’s got balls enough to loan out.  Perhaps he’ll give us some.

 

We are certainly in need of them.

 

(Credits:  USA Today and NYDN)

Posted by on December 27, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, Firefighter Safety & Health, Fires, In the Line of Duty, Line of Duty, Major Incidents, Mass Casualty Incident, Values and Ethics

PG’s Kentland Scores PR Gusher

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Post Assigns Witless Reporter

33′s PR coup

 

 

 

 

 

 

 

 

 

 

Prince George’s County, Maryland, is infamous for any number of things including what passes for a fire department in a metropolitan county of just under 900,000 people.

The PGFD is mostly known by regular folks from what they read in the press: endless stories of tit-for-tat spats in the firehouse between volunteers and career firefighters interspersed with fire scene brawls when they take the show on the road.

Firefighters are slightly more likely to pay attention to the constant stories of apparatus accidents and burn injuries.

In a gift straight from Santa, the Washington Post parachuted a clueless reporter into the special world of 33′s to spend a Christmas day with Santa’s fire elves.

Packed into one article is every sappy cliche ever written about firefighters, complete with “A Christmas Story” playing in the background.

But don’t be fooled:  the Kentland “brotherhood” are very media savvy. According to the Post, 33′s  ”Web site gets 60,000 hits a day, and buffs follow its two Twitter accounts and Facebook page, which include routine updates…”  They are on a mission and they are also on their public relations game.

In the rather bizarre world of Prince Georges County where the FBI works overtime wiretapping and prosecuting elected officials, 33 fits in nicely.  They are “100% volunteer 100% of the time!”  Whether that’s a good thing is debatable.

Washington, DC, with which Prince George’s shares a border, is substantially smaller.  Its population is right around 600,000 yet it employs well over 1,000 firefighters in all of its 33 stations.  Ironically, not a few of these firefighters then travel to PG county where they “protect” the community by volunteering in a fire environment that is more urban than many parts of DC.  In fact, the Post story references off-duty firefighters from DC and Baltimore County making up the crew.

Let’s be professionally honest:  few things are more bizarre than a career firefighter leaving his urban job to go serve at his “all volunteer” urban fire house.  Would the two firefighters mentioned in the article be OK with DC or Baltimore County citizens coming in while they were at work and telling them they were no longer needed?   (I think we know the answer to that question.)  Imagine the crew at DCFD Rescue Squad 1 or Truck 13 being bumped by off-work congressional pages.  Weird, but that is exactly what is happening in PG.

The Post’s irresponsibility here is inexplicable.  We can only hope that the starry-eyed reporter walked away with a belly full of that “pork roll, scrapple and bacon” because she sure came away empty where critical reporting is concerned.

 

 

 

 

 

Posted by on December 26, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, Firefighting Operations

Kathmandu FD

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Nepal’s Bravest

Kathmandu Valley

 

 

 

 

 

 

 

 

 

Nepal’s Capital, Kathmandu, is nestled in a broad valley at about 4,000 ft above sea level.  As it is about the same latitude as Key West, Florida, and despite it’s proximity to the world’s tallest mountains, it is surprisingly warm.

The Valley is roughly 220 square miles with about 1,000,000 residents.  Most live in apartments that are sometimes crowded onto very narrow  streets where access of any kind is quite difficult.

Traffic in the city is horrible and is compounded by the fact that many side streets are unpaved mud paths.  Getting around is very difficult.

Center City Street

 

 

 

 

 

 

 

 

 

The sprawling valley is comprised of three main centers: Kathmandu, Lalitpur and Bhaktapur.  Each has but a single fire station, meaning three for about 1,000,000 people.

Fire protection is obviously on the back Burner, (no pun intended) since the response times and lack of staffing are so great as to render a quick attack impossible.

Firefighter on Duty

 

 

 

 

 

 

 

 

 

Kathmandu’s fire station is in the “New Road” area not far from the historic Durbar Square.  The equipment bays face the street and an enclosed and gated courtyard.  The rigs exit through the courtyard for security.  In fact, guards with automatic weapons are on patrol on the grounds.  Some will know that Nepal has struggled with a Maoist insurgency and political instability.  Terrorist attacks targeting the police and the military, especially in the countryside, were once common.

SCBA Bottles and Compressor

 

 

 

 

 

 

 

 

 

Much of the apparatus and equipment comes from Europe, often as a donation.  Kathmandu is like much of the rest of the world, including many parts of the US where fire protection is either an after-thought or entirely ignored.  Police protection takes pride-of-place over fire safety and protection.  Perhaps because of the extreme shortage of resources,  nuisance fires are allowed to burn in streets and vacant lots where they add to the pollution and can easily spread to structures.

Fire protection plays “Second Fiddle” the world over.

Posted by on December 19, 2012 • Filed under: Fire Rescue Topics, Firefighting Operations, Fires, Travel

Coming to Terms With the Past: Emory, Garaufis and FDNY

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“Caucasian, Jew, or Other”

Bishop John Emory

Atlanta’s Emory University, one of the top schools in America, dates from the 1800′s and is named after John Emory (1789-1835), an early bishop in the Methodist Episcopal Church.

Emory, both the man and the school, have strong New York connections.  John Emory played an important role in the founding of New York University (NYU)  and Emory University was saved after the American Civil War by a $100,000 grant from Brooklyn businessman George Senney.

Emory’s religious association also contains an element of virulent anti-semitism.  From about 1948 through 1961, under Dean John Buhler, the school engaged in a campaign of widespread sustained discrimination against Jewish students.  Well over half of these students were failed outright or forced to repeat classes simply because of their heritage and religion.

Though Emory now has a student population that is about 20% Jewish, they have taken the step of confronting their largely unacknowledged past.  Gary Hauk, Emory’s vice-president, is quoted in the New York Times:

“We need to be fearless in confronting our past as individuals and an institution.  There are often things we regret about our past, but there is the possibility of making amends and of building on the acknowledgment of those things. Part of our vision of Emory is being ethically engaged, and that means wrestling about what it means to have these warts.”

Judge Garaufis

The concept of acknowledgment and amends also came to light this week as the federal judge overseeing the FDNY case, Nicholas G. Garaufis, was profiled in the Times. Termed a “liberal crusader” and an “Emperor”,  it turns out that the judge has been on a journey of his own.  Though he is currently vilified as the man effectively forcing the integration of FDNY, he was once a staunch advocate of the status quo where New York schools were concerned.  As a Queen’s politician he fought federal integration efforts in his majority white district.

Somewhere along the way, Garaufis moved from being a partisan politician representing his (mostly) white constituents to a man who saw the city, and its citizens as a whole, all of whom are worthy of a measure of justice.  We all know that the converted can be especially zealous and Judge Garaufis has been relentless.  The NYT reports that Garaufis at one point queried a senior black judge, Sterling Johnson, Jr., effectively asking him what it had been like to be a minority officer in NYPD in the early days.

Judge Johnson

Sterling Johnson, Jr., Marine, NYPD officer and senior judge had become a mentor for Garaufis, according to the Times.  Anyone who has had the good fortune to have a mentor knows the powerful role they can play in making sense of life.  Of course, Johnson could not be a mentor unless he was there in the first place.  Judge Johnson was appointed to the bench by President George H. W. Bush in 1991.

The Johnson-Garaufis relationship illustrates the obvious fact that we cannot know others or share their wisdom and insight when they are not around.  Sometimes in life it takes an open mind and courage to create change that can have a profound result.  President Bush’s nomination of  Johnson placed him in a position where his story has become a catalyst for change.

FDNY cannot really begin their journey of change until they acknowledge their history and accept help from a man whose past they can surely profit from.

 

(Sources:  NYT, Wiki, Emory)

Posted by on October 8, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, History, Religion and Spirituality, Values and Ethics, What We Call "Race"

Here Come Da Judge: FDNY’s Garaufis Does Some (White) Handholding

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Tell Me What You Really Think.

Ladder 16
157 East 67th St.

Federal Judge Nicholas Garaufis, showing his kinder and gentler side, has cleared his judicial calendar for much of the week in order to hear from those who may be affected by his efforts to open up FDNY to minority applicants.

Curiously, the NYT reports that of the 180 who signed up for Monday, only 36 testified.  Perhaps rage, like beauty and color, is only skin deep.

Garaufis has cut a wide swath, throwing out exams, creating new ones and mandating back pay and retroactive seniority.  The seniority provision, which is tantamount to the awarding of punitive damages, is a stinker since you can’t create experience retroactively.

One applicant reported that he had scored 94% on the 2002 exam yet never heard back from FDNY, surely a missed opportunity if broadening the department is a serious leadership goal.

Most firefighters can keep two ideas in their heads simultaneously: advance on the fire while being alert for victims.  Two similar ones would be to create a diverse and professional FDNY.  Why is FDNY so good at the first set of  ideas and so bad at the second?

The answer, of course, is failed leadership at all levels.  In New York, the “leaders” don’t.

Thus, the way was paved for a Federal Judge, one Nicholas Garaufis, to lead from the bench.

Time for FDNY members to be REALLY pissed, at themselves, for their communal lack of leadership.

Sources:  NYT, NYDN, Gothamist

 

 

Posted by on October 2, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, Firefighter Politics, Values and Ethics, Words

The Chief and the ‘Stache

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Tagging the Chief

Chief Ellerbe

DC’s all atwitter after a mustache was drawn on a photo of FEMS Chief Kenneth Ellerbe which was then turned upside down at 10 Engine and 13 Truck in the Trinidad neighborhood of Northeast.

Our own Dave Statter and Tom Sherwood, one of DC’s most respected local reporters, covered the story.

Seems like a Deputy gave the troops an ass-chewing and then the Metropolitan Police were called to dust for prints and take a report.

Ellerbe’s response to the hoopla was to call off the dogs and express his disinterest in an investigation.

As is often the case here, it comes down to a neck-and-neck race on who looks more foolish: labor or management.  Labor wins the round, hands down.

Calling the police was as poor a decision as the incident itself.  More importantly, the incident casts firefighters (once again) as adolescent pranksters who are unprofessional.

Did the petty vandalism show a lack of respect for the chief?  What does it mean to respect someone, anyway?

Curiously, they drew a mustache on the chief, a time honored firefighter symbol of courage, tradition and virility.  In their contempt they subconsciously embraced him by tagging him with the tribal totem.

Obviously, some troops are itching to express contempt for a chief, some of whose ideas have folks scratching their heads.  The better way to take him on is to be politically active in the City, including voting.  But, we all know the problem with that idea.  It’s hard to cast your vote from Maryland or beyond.

Whether you respect Ellerbe or not, the real danger is creating or fostering a culture of general disrespect for the City and the people that live and work here.  FEMS or DC Fire, whichever you prefer to call it, has a sordid history of lawsuits emanating from cases where public service took second place to contempt at the worst and laziness at the best.

 

Posted by on September 30, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, Values and Ethics

The Deutsche Bank Fire and J’accuse? Not So Fast.

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Yesterday’s blog post at IAFF online by Rich Duffy trumpets a “must read” article in a “prestigious, professional online magazine” by author John Steadman concerning the fatal fire at the former Deutsche Bank building which was under demolition at the time of the incident.

First, employing “J’accuse”, a reference to the 19th century Dreyfuss affair in France is at least odd.  Captain Alfred Dreyfus, a low-level artillery officer, was wrongly convicted of treason on trumped up charges.  He was not a commander or senior officer in the French military establishment and using him as a surrogate in the Deutsche Bank affair is singularly inapt.  Dreyfus was not only completely innocent, he was framed.

Mr. Steadman’s breathless prose has much chaff but it also has its share of wheat.  He correctly points out the infuriating bureaucratic bumbling in various city agencies (including FDNY) which set the stage for the fire.  He also documents that FDNY staff had much of the information they needed to protect fire companies but it never made its way to the troops.

But both Mr. Duffy and Mr. Steadman can be excused for missing a central point  because neither are firefighters:  serious fires typically occur in buildings with serious problems.  How many times have firefighters ridden past a structure only to comment to each other, “That’s going to be a bear when it goes up.”  Such a statement, uttered daily by firefighters belies the truth that we usually know which buildings in our districts are likely to pose the biggest danger.  Was Deutsche Bank a magic exception for company officers, battalion and district commanders?  Maybe, but probably not.  In fact, falling debris from the Deutsche Bank had previously damaged Engine/Ladder 10 in a not so subtle reminder of the danger lurking close by.

It’s not simplistic to say that on a fundamental level firefighting is a deadly “game”.  Watch those training films, drill non-stop, and practice key plays, but on game day, surprises may await you.  Senior firefighters, company officers and their commanders witness but often fail to internalize that it seldom goes the way we think it should.

The Deutsche Bank fire ground was mayhem:

-  Firefighters were committed to extremely exposed and dangerous positions in an abandoned building under active demolition.

-  It took over 80 minutes to obtain a reliable water supply.

-  Desperate calls for help went unheard and unanswered.

-  Fire crews split up losing accountability and control.

Company officers and commanders allowed these events to unfold and any writing about the fire that fails to state these facts is neither a “must read” nor “professional.”

The Steadman article references “stop work” orders issued in at least one case by inspectors after a torch incident.  Another stop-work order should have been issued by the incident commander the day of the fire as the losing proposition became glaringly apparent.

Finally, revisionist writing touted as safety literature is both confusing and potentially deadly.

 

Posted by on May 2, 2012 • Filed under: Administration & Leadership, Command & Leadership, Fire Rescue Topics, Firefighter Safety & Health, Firefighting Operations, Fires, In the Line of Duty, Major Incidents, Rescues, Safety and Health

Willy-Nilly? Two FDNY Members Burned.

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Willy-Nilly: in a haphazard or spontaneous manner.

A Monday morning fire at 1100 Prospect Place in Crown Heights,  Brooklyn, resulted in serious injuries to members of Rescue Company-2 as they apparently conducted a search on the top floor of the dwelling.

According to the New York Times, a family with four children lives in the brownstone and R-2 was on the four-bedroom, top floor when the fire rapidly spread.  Video from the scene captures fire exploding from the top floor bay window as a firefighter emerges onto an aerial ladder positioned below.

Steve Cassidy, President of the Uniformed Firefighters Association, was quoted in the Times  as saying that, “When you take one firefighter away from the team, it takes longer, … there was at least a one-minute delay today in getting water to the fire, and if they had been there with a fully staffed engine, the fire never would have gotten out of the back room.”

First-in Engine 234 is apparently one of the companies to lose a firefighter as part of FDNY cutbacks.  Chief of Department Edward Kilduff denied Cassidy’s assertions stating, “It was a very short stretch across the street, and the line was in position in a sufficient, adequate amount of time.”

City residents must shake their heads at two fire professionals taking such diametrically opposing views about such an obvious point.   Does having one less person available result in increased time required to suppress a fire?

The answer is, yes, up to a point, if the firefighters are trained, which in FDNY, they certainly are.  This is especially true if the company is the first arriving engine and therefore responsible for putting the first water on the fire.

There can be little professional doubt that E-234 was less effective in the one scenario where it counts the most: first arriving engine, uncontrolled fire, people in exposed positions.

It would turn out that those exposed persons were FDNY members who are presumably well aware of the lost efficiencies when an engine crew is down a member.  They also knew of the thin ice on which they were about to skate as they were apparently operating ahead of the first line.

While Cassidy is obviously right, FDNY members continue to place themselves in extremely exposed positions where any environmental hiccup (unexpected ventilation, flash-over) or operational glitch (understaffed or late arriving company) can spell disaster.  The question is, when will Cassidy’s own members hear the message he so clearly espouses?

FDNY’s brave victories are at once heroic and pyrrhic, performed amidst an adoring public, largely ignorant to the irony of it all.

 

Sources:  NYT, FFN, Statter911, NYP, Daily News

Posted by on December 21, 2011 • Filed under: Command & Leadership, Fire Rescue Topics, Firefighter Safety & Health, Firefighting Operations, Fires, Rescues