1. Fire Cause Determination 17

2. Objectives Describe the role of the fire officer in determining the cause of a fire. List the common causes of fire. Explain when to request a fire investigator.

3. 17 Skills Objectives Demonstrate how to secure the scene using rope or barrier tape to prevent unauthorized persons from entering the incident scene.

4. 17 Introduction to Fire Cause Determination (1 of 4) A preliminary investigation is conducted to determine how a fire started. This is done: –Once the fire is extinguished –Before property is turned back to the owner Understanding the cause: –Helps prevent future fires –Helps determine if criminal acts involved

5. 17 Introduction to Fire Cause Determination (2 of 4) Incident commander is responsible for conducting a preliminary investigation. –Completes the National Fire Incident Reporting System (NFIRS) documents or local equivalent –First goal is to determine whether a formal fire investigation is needed. Common causes of fire are next.

6. 17 Introduction to Fire Cause Determination (3 of 4)

7. 17 Introduction to Fire Cause Determination (4 of 4) Fire officer should be able to determine point of origin and probable cause of most fires. –On small or routine incidents, this is the only investigation conducted. An investigator is requested if there is a death or serious burn injury, deliberate fire, large loss, or possible crime.

8. 17 Finding the Point of Origin Fire growth and development: –Fire Fighter I and II courses teach basic concepts. –Fire officer should also understand conduction, convection, and radiation. –Apply these concepts to understand fire growth and interpret fire spread.

9. 17 Vehicle Fire Cause Determination Fire departments respond to more vehicle fires than structure fires. NFPA 921, Guide for Fire and Explosion Investigations, provides a standardized procedure. 47 percent of vehicle fires are caused by mechanical factors.

10. 17 Wildland Fire Cause Determination Quite different characteristics from structural fires

11. 17 Indicators of Incendiary Fires (1 of 2) Disabled built-in fire protection: –May be encountered in fires involving large industrial or commercial occupancies Delayed notification or difficulty getting to fire: –Prompt notification when smoke detector, water-flow, or manual pull station activated –Points of origin in attic, basement, or closet require special consideration.

12. 17 Indicators of Incendiary Fires (2 of 2) Tampered or altered equipment: –Document unusual conditions.

13. 17 Legal Considerations (1 of 11) Fire department has the right to search to determine cause and origin. –Michigan v. Tyler (1978) –If re-entry is needed after leaving the scene, however, a warrant is needed.

14. 17 Legal Considerations (2 of 11) If fire officer suspects a crime has occurred: –Immediately request a fire investigator. –Secure scene: Prevent unauthorized access. Limit the number of fire personnel. Fire line tape or police crime scene tape can be used.

15. 17 Legal Considerations (3 of 11) Three types of evidence: –Demonstrative evidence: tangible items –Documentary evidence: written items –Testimonial evidence: witnesses speaking under oath

16. 17 Legal Considerations (4 of 11) Artifacts include: –Remains of material first ignited –Remains of ignition source Evidence must be protected. –Identify the point of origin and the cause of the fire.

17. 17 Legal Considerations (5 of 11) © Frances Roberts/Alamy Images

18. 17 Summary (1 of 2) Determining the initial origin and causes of fires is a responsibility of the company officer. The origin is the point where the fire began. After it is determined, the fire officer must determine what material was first ignited, how, and why.

19. 17 Summary (2 of 2) Classifications of causes are accidental, natural, incendiary, and undetermined. If the fire is intentional, the fire officer gathers information used by a prosecutor to determine whether it rises to the level of arson.

20. Crew Resource Management 18

21. 17 Objectives Discuss the origins of crew resource management (CRM). List Dupont’s “dirty dozen” human factors that contribute to tragedy. Describe the five steps in a successful debriefing.

22. 17 Origins of Crew Resource Management (1 of 2) In 1978, a mechanically sound airplane crashed, killing 10, because the people flying the machine became over- engrossed in a burned-out light bulb. NASA developed a training system known as crew resource management (CRM) in 1979.

23. 17 Origins of Crew Resource Management (2 of 2) CRM became mandatory training. It was resisted by senior pilots until a spectacular crash landing in 1989. –The crew attributed their success to their CRM training. –Validated CRM’s worth

24. 17 Researching and Validating CRM Concepts (1 of 2) The aviation industry’s 80 percent reduction in accidents rate is partly attributed to CRM. CRM trains team members how to achieve maximum mission effectiveness in a time-constrained environment under stress.

25. 17 Researching and Validating CRM Concepts (2 of 2) The University of Texas Human Factors Research Project (HFRP) studied CRM. –Applications in aerospace, aviation, the military, maritime, and medical profession Many CRM publications and industry practices have come from Professor Robert Helmreich and his staff at the HFRP.

26. 17 Human Error (1 of 12) Gordon Dupont noted similarities between errors in the cockpit and in the maintenance hanger. Dupont’s “dirty dozen” are considered a comprehensive list of reasons and ways humans make mistakes.

27. 17 Human Error (2 of 12) The “dirty dozen”: –Lack of communication –Complacency –Lack of knowledge –Distraction –Lack of teamwork –Fatigue

28. 17 Human Error (3 of 12) The “dirty dozen” (continued): –Lack of resources –Pressure –Lack of assertiveness –Stress –Lack of awareness –Norms

29. 17 Human Error (4 of 12) James Reason took a systems approach to human error management. High-tech systems have many defensive layers: –Some are engineered. –Others rely on people. –Some depend on procedures and administrative controls.

30. 17 Human Error (5 of 12) Reason points out that each layer of defense is more like a slice of Swiss cheese than a solid barrier. –The presence of a hole in one layer does not create a bad outcome event. –But when the holes in all levels of defense align, there is a bad or catastrophic outcome.

31. 17 Human Error (6 of 12) Reproduced from Br Med J, J. Reason, vol. 320, pp. 768–770, © 2000 with permission from BMJ Publishing Group Ltd.

32. 17 Human Error (7 of 12) Reason provides two causes for holes appearing in the layers of defense. –Active failures: Unsafe acts committed by people They have direct, short-lived effects on the integrity of defenses. Example: not wearing a seat belt

33. 17 Human Error (8 of 12) –Latent conditions: The inevitable “resident pathogens” within the system They can translate into error-provoking conditions within the local workplace. Examples: time pressure, inexperience They can also create long-lasting holes or weaknesses in defenses. Examples: untrustworthy alarms, unworkable procedures

34. 17 Human Error (9 of 12) Latent conditions may lie dormant within the system for years. They combine with active failures and local triggers to create an accident opportunity.

35. 17 Human Error (10 of 12) CRM is an error management model with three activities: –Avoidance –Entrapment –Mitigating consequences Errors not avoided are trapped at the second level.

36. 17 Human Error (11 of 12) Errors that slip through the first two levels require mitigation. –Mitigation is the action taken by emergency responders to minimize the effect of an emergency on the community.

37. 17 Human Error (12 of 12) Courtesy of Dr. Robert Helmreich

38. 17 Debriefing (1 of 3) Valuable for the fire service, although not found in all CRM models Offers personnel the opportunity to “replay” the event: –Extracting lessons learned –Evaluating performance

39. 17 Debriefing (2 of 3) Photographed by Mike Legeros

40. 17 Debriefing (3 of 3) Lubnau and Okray recommend a five- step model: –Just the facts –What did you do? –What went wrong? –What went right? –What are you going to do about it?

41. 17 Summary Human errors play a significant role in fire fighter deaths.