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The beer card story: Have we learned anything from our past?

Jun 18, 2018 | News

 

Pieter Maes, one of our experts and trainer on fire behaviour at Compartment Fire Behaviour Training (CFBT), wrote this interesting perspective from a firefighter’s viewpoint on the need to develop and implement a database that collects fire incidents in Belgium, and the though process behind it.

The article is a call to “beef up” this database so experiences and best practices can be shared among firefighters. Learn from our own accidents helps to avoid a reproduction of a similar accident in the future!

1 A firefighter called.

Last week I was contacted by Johan Broos, a Belgian firefighter. He asked if he could share his story of his accident. About seventeen years ago he was badly injured while battling a fire. A couple days before he made this phone call he was a participant during a Firefighter Mayday Fireground Survival training. For the first time in his career as a firefighter he learned that there was a way to ask for help on the fireground. Calling out a mayday. He discovered that within the Firefighter Mayday Program accidents and incidents are not looked to judge and condemn. They are looked at as learning opportunities through Lessons Learned documents. It was a pretty confronting experience for Johan. Remembering his helplessness during the accident. How he suffered and struggled to get back on his feet after his accident. Not only physically, but also mentally. Not knowing where to go with your story or experience. Desperately wanting to share what he thinks all firefighters can learn from his accident. His colleague and teammate that was involved in the same accident never returned to the fire department…

As the Johan learns that we recently had written a Lessons Learned document, based on an accident not longer than 6 months ago, he decided to ask us to see if we would be willing to write a similar document based on his accident. So I checked in our database, if we already knew anything about his accident. My fear was confirmed, I discovered that we had nothing. A severe accident only 17 years ago and we could not find a thing… It left me perplexed.

I had just spent the day before sifting through the basement of the internet. Once again. Looking over and reading through 250 webpages in research of accidents with firefighters in Belgium and Holland. The motivation for this was that I restarted the research to try to build up an as complete as possible database on accidents with firefighters since the end of the second world war (1945). It has proven to be a very difficult task. So difficult that at one point it prompted me to do an appeal through social media. My hope was that firefighters would ask around, dive in archives, talk to older colleagues and so get info about unknown accidents. The result was not what I hoped for. We discovered 7 new accidents.

Just with one day of research I found a total of 62 firefighters killed, 76 severely or critically injured and 41 mildly injured. The stories you sometimes read give you cold shivers. If you do research on the internet you expect to find more complete information about more recent decades. But since the colleague that called me had an accident only 17 years ago I realized that even in recent history (less than 20 years ago) our database would never be complete. I felt disappointed, but at the same time hopeful. Disappointed since it confirmed my fear that we very likely never ever will discover all accidents with firefighters that happened in the past. Maybe not even all deadly or severe accidents. It makes me sad. The lack of respect for the sacrifice that severely injured or killed colleagues have given is simply incomprehensible. But it also made me hopeful. Hopeful since Johan decided to speak out to us. My hope was that we could help him in sharing his story and that we could share another Lessons Learned document.

2 The story of the beer card.

Once the Johan confirmed his willingness to help us to write a lessons learned document, the next thing to do is to get support from his department. That shouldn’t be too hard since I was seeing his station chief a little later. So I could ask him myself and explain what we were planning to do.

When I met the station chief, Leo Buermans, he was very positive and gave his support. But then the conversation turned. “Hold on he said, let me tell you another story” while putting his hand on my arm to keep me from walking away. I see his hand and I notice how it is covered in old scar tissue. You wouldn’t notice it right away, but if you looked a little longer there was no doubt. These were old burn wounds. I look up (he is an impressive person) and Leo starts telling. Back in 1991, on the 19th of January he was called out for a house on fire. They also got the info that an older women was probably still inside. In a very passionate and lively way Leo shares his experiences. As I was trying to understand what he was telling I asked him about the lay-out of the house. “Wait he said, let me make you a drawing…” and he grabbed a beer card. He started to make a drawing on a beer card.

He draws the house, indicates where he found the old women that he successfully rescued and then explains how he re-entered into the smoke-filling house with a high pressure hose. While drawing he is giving further details and we kept adding info on the beer card to understand the situation as good as possible. We come to a mutual understanding. Based on what we know about modern interior fire behavior we conclude that Leo was probably caught in a flashover.

Moments before the flashover Leo had taken off his fire-gloves to manipulate his radio. Sitting on his knees, he made a radio call asking for a low pressure hose and lights to improve visibility. But he will not have the time to put his fire-gloves back on. The flash over comes through in full force and immediately Leo feels how his hands are getting burned. The heat pushes him to the ground and he puts his hands in between his chest and the ground. Desperately trying to keep them from burning. He loses all visibility. His visor of his facial mask was brown baked in seconds. Crawling around he hits his head against a wall. Even while he was less than 5m deep in to the house, he was unable to orient himself towards the exit.

He had entered the house, went right and in a straight line following the wall on his right he passed an interior door 4m to 5m deep into the house. It is just behind this door that Leo was trying to find his bearings while lying on the ground. “Where was the exit? How do I get out of here?” questions racing through his mind. The heat keeps getting worse, up to the point were his facial mask partially melts away. Just above his right eye a small opening is formed due to the melting of the mask. Lying down, trying to look around, he suddenly realises he sees a source of light through the hole in is facial mask. Immediately he starts crawling as fast as possible towards the light. Then, suddenly, he feels how he is grabbed and dragged outside. Colleagues were looking inside fearing for his life. When he was close enough to the door they could see him, they grabbed him and pulled him out. He was out. It were the same colleagues that, after Leo’s radio message, had placed a light on the ground near the exit door. It is this light that Leo saw and used to find his way out. It saved his life.

Outside Leo sees his hand, which weren’t hurting no more. But he sees and understand that they are burned. As he was learned, he went to cool them for 10 minutes with water, not realising the seriousness of his injuries… He had no pain because he had third degree burns.

Little later Leo will be taken to the hospital and quickly ends up in the burn unit of the Stuyvenberg hospital in Antwerp. There he goes into an artificial coma for two weeks since pain would be unbearable otherwise. For the next two years Leo will go through further care and revalidation to finally come back to the fire department.

I am stunned. For a moment speechless. I could only think of one thing and that was to reach out to Leo and, as a sign of respect, shake his hand. Firmly. I feel the scar tissue when we shake hands. It is an awakening moment. I was still coping with the uncovering of the other accident and within 24hrs I get a first hand witness account of another severe accident, not that long ago. It makes me realise that we can not continue this way. Yes, it is good to look back and to try to make the most comprehensive database on accidents with firefighters in Belgium. But action is needed to make sure that these important moments aren’t lost. We will be able to capture Leo’s experience and we will write it down into a Lessons Learned document. But we have to come up with a system to avoid that we keep running behind these facts.

3 It wasn’t over yet…

A short time later I am teaching the concept of Case Studies to future Firefighter Mayday Fire ground Survival instructors. We learn them how we can learn from experiences from the past through Lessons Learned documents. And as always within the Firefighter Mayday program, we don’t look to judge and condemn. We look for learning opportunities. It is during this workshop that one of the participants, Kris Oostvogels, suddenly shares his experience from the day before: “I was stuck inside a house fire…”. I really needed to ask him to repeat what he just said. “I got stuck inside a house fire…”, he replied. Since he was sitting in front of me and obviously ok the adventure had turned out fine for him. But of course he immediately had 100% of my attention and asked him to explain what had happened. And for the third time in 24hrs I was sitting down with a firefighter who was sharing his learning experience. The major difference was that this one had a good outcome. It was an incident and not an accident.

The day before Kris arrived with his team on a working house fire. They gained access through the front door. With the door open they observed the air track: smoke coming out top half and air going in bottom half. They had a low pressure hose with them and decided to push for an interior attack. Putting his gas cooling techniques into practice Kris entered the house. Conditions were acceptable. Some heat but bearable and good visibility below the smoke-layer.

When Kris is about one meter inside he hears a rattling noise behind him. It gets dark really quick and temperature starts to rise. For Kris it is not clear what just happened. But with zero visibility and rising temperatures he knows he has to react. He back tracks on the hose line to localise the door again. To his surprise there is no more door. He seems to be enclosed in the smoke filled house with a working fire ongoing. Not understanding the situation he uses his hands to scan the area in front of him. He wants to find the latch thinking that the door had closed. He discovers that the hoseline is going underneath something. Upwards of that ‘something’ he can’t find anything that resembles like a door. When he places his hands in what seems like the middle and pushes forward (outward of the house) he feels that he can bend whatever is blocking his exit. Kris quickly made his mind up. He had two options: self rescue by exiting through whatever was blocking him or calling a mayday. He decided to first try the self rescue option. He moves a little backwards to take a little run-up throws himself against the enclosure. Immediately he is outside landing on the ground. It is only then, when Kris is looking back to the house, that he understands what probably had happened.

4 Learn from the incident, avoid the accident.

The door through which Kris had entered was equipped with an exterior roller shutter. The strap to open or close the shutter was a plastic one. This strap and the whole roller system was located in the outgoing air track. Meaning it was exposed to the heat of the smoke. The plastic strap melted and caused the roller shutter to close by itself. Kris ended up being trapped inside for about 20 seconds.

This incident has a good outcome. Kris made good decisions. Thanks to his Fire ground Survival training he actually even knew that if plan A (self-rescue) didn’t work he would have to call a mayday. That was his plan B. He was ready to do so.

Fairly soon after the incident the local fire station (Fire Station Wuustwezel) reacted in a very good way. They made up a brief report with a factual reproduction of the event. They understood that an incident had happened this time, but that it could become an accident the next time. The way to avoid to avoid the future accident is by learning valuable lessons from this incident. The simple fact that firefighters the next time will look if there is a roller shutter system on a door makes a huge difference. Measures can be taken to assure that the entry-exit door stays usable for the interior crew. Tools can be put in place that if the roles shutter does close by itself the outside teams can quickly (re-)create an opening.

4.1 A cultural change to avoid accidents.

Currently in Belgium we do not use an incident to avoid a future accident. Even more painful, we do not learn from our own accidents to avoid a reproduction of a similar accident in the future. The reality is that there is a culture to try and keep incidents and accidents discretely hidden. We simply have never learned how to look at these in a non-judging way. This is a consequence of how our legal system concerning accidents at work is set up.

The legal frame surrounding work-related accidents is internally focused on prevention. And thus on this level people involved will try to prevent accidents often based on lessons learned from previous incidents / accidents. But, this is an internal procedure. Most organizations will strive for a discrete handling of the incident / accident. If possible. Because if it is a serious accident very quickly the justice department gets involved. There is an important shift when this happens. The focus of the investigation is no longer prevention, but finding the answer to the question “Who is responsible?” Everybody can imagine that this difference in approach will not motivate people to share their experience and formulate possible points for improvement. Most certainly if it is an accident with serious consequences like permanent physical injury, important damage to properties or the worst lives lost. The perverse effect of our way to evaluate accidents is that the greater the consequences the less likely it is that we will ever fully understand what happened. As a consequence, we are not learning all potential lessons. Which in turn means that the same accident can be reproduced.

4.2 The lost legacy of our fallen colleagues.

The culture of blaming rather than learning has some serious consequences. First of all it is very questionable of really valuable lessons are learned. Is the intent of trying to prevent a repetition of an accident really achieved? Since it is not sure that all involved will fully disclose there part in the event(s) it is indeed very doubtfully that every stone is turned around. In the current legal framework disclosing your part in an accident is basically exposing yourself for prosecution.

Secondly, you can’t blame persons involved in the accident for not always telling the full story. They are justly afraid for consequences that can severely influence their life and their family. And on the other hand, don’t expect anybody to fully understand what has happened. Both situations (not being able to tell / not being able to understand) are mechanisms know to reinforce the danger for Post Traumatic Stress Syndrome. If you expect people to mentally deal with a tough situation you are not helping them with a culture of hiding and blaming. You must allow them to safely share their concerns and experiences so that they know they have done what they could to avoid a recurrence of the same accident in the future.

After all, if we would suffer from an accident, isn’t our most human natural reflex to do all the possible to prevent this from happening to our colleagues and friends afterwards? Isn’t it the purest and most important way to show our respect, for the sacrifice of somebody, the fact that we should be able to say “We fully understand how this accident has happened and we can now do all the possible to avoid it from happening in the future. This accident, how sadly it is, will help us to keep firefighters safer in the future.” Isn’t that what parents and family members from somebody who died in an accident most often say: “Please, don’t let this happen again, don’t have other people going through the same suffering…” We have to ask ourselves, with the nobleness that our profession carries, do we really respect the legacy of our injured and fallen colleagues?

4.3 In the end, we are only human.

Society sees first responders and firefighters as heroes that never fail. We all know, deep down in our hearts, that that is not the reality. We do make mistakes. But mistakes are not intentional. There can be tens of reasons why a situations goes South, becoming an accident. And nobody involved actually realises at the moment of the event that he or she might have done something wrong. Or, to phrase it better: realise that maybe there was a better way to tackle that particular fire. We should never forget that part of the nature of our job is the fact that our job is unpredictable. And on top of that, the world in which we do our job is changing more rapidly than ever. We are actually struggling to keep up with all the evolutions going on. But, neither of those can be an excuse not to learn from things that didn’t go as expected. Accidents are always going to happen. We can excuse ourselves from that. But we can not find any valuable excuse not to learn in the most efficient way from an incident or accident.

Isn’t it time that our policy makers accept that accidents will happen and that the first concerns should be how can we avoid them from happening again? Instead of finding out who can be blamed for it. Shouldn’t we seriously think about a learning-culture to replace the blaming culture? Haven’t too many colleagues and families suffered immensely and what have we learned?

5 You are the culture!

We don’t have to re-invent how to do this. There are plenty of examples around the world that show us how a learning culture based on incidents and accidents can be achieved.

5.1 NIOSH1, Fire fighter fatality investigation and prevention.

Since the 1984 NIOSH has been investigating and reporting on every deadly accident with a firefighter in the USA. The database at the moment consists of 642 records that are all searchable and downloadable. It is an enormous amount of information with countless valuable lessons to learn. The Firefighter Mayday Program has used two of these reports to produce case-study documents. These are ready to use documents to go through the events of the accident and work with a group on how one can avoid it in the future.

Website: https://www.cdc.gov/niosh/fire

5.2 The Dutch Safety Board.

The Netherlands have a long history with investigating accident and incidents. (The Dutch Safety Board, 2018) Beginning as early as 1930 they had independent committees investigating different accidents in the transport business. But they were different committees for different ways of transport (maritime transport, water transport,…). From the 1990’s on there was a growing demand for a permanent independent organism able to investigate all accidents or incidents. After all, why had the transport sector its permanent board with experts and did other sectors need to put in place ad hoc committees? This demand kept coming back until the firework disaster in Enschede and the deadly new years eve fire in Volendam. These two events triggered the government to take the necessary steps the put in place the Dutch Safety Board. This happened in February 2005. From that day on the Dutch Safety Board has followed up on his mission (The Dutch Safety Board, 2018): to improve the safety in the Netherlands. To achieve this they will investigate incidents and accidents to draw lessons from the results of the investigation. Their independence is a critical core value in their working. Nowhere on their webpage that states their mission and vision the words ‘responsible’, ‘mistake’ or any other blaming term can be found.

The Dutch Safety Board has become a very highly respected institute that can count on the trust of the people that they will do all the possible to learn from incidents or accidents. And this without taking the risk that you will get the full brunt of responsibility thrown on you because you acknowledge something went not as expected. It results in some impressive learning documents and video’s. People involved in incidents / accidents are often willing to participate in the learning document. This result in very strong testimonies that transfer experiences in a unique way. It is learning from accidents / incidents in the most effective way. Told by those who were there and supported by a strong organisation as the Dutch Safety Board.

5.3 And in Belgium?

Within Belgium there has been a call for an independent safety board in the aftermath of the Wetteren train disaster. But there was and is no political willingness to support this initiative. It will probably take several years before a Belgian Safety Board will ever see the light. So maybe we should start as it has begun in the Netherlands back in the 1930’s. By doing the investigations and reporting from within our own sector, our own organisations the Fire Departments. We can change a culture, we are the culture.

It is extremely hopeful to notice that as recent as December 2017 we have been able to publish a lessons learned document based on an accident happened in August 2017. This was possible only because the Antwerp Fire Department and the persons involved agreed that we all could learn something from their accident. So there is something changing! Let’s make that change the culture we need to respect the legacy of all our injured and fallen colleagues. We should not be afraid to share information that has the sole intention of learning and preventing a recurrence of an accident. Although we have to acknowledge that this needs to be done with care. It is a sensitive process where all steps and formulations need to be well considered.

6 Learning lessons, where do we start?

We have an enormous historical deficit if we look at how we have ‘treated’ our accidents. It is a simple but painful fact that we have no centralised database that can tell us what accidents have happened and how. It becomes even more worrisome if you discover that we not only have not done this in the past, we are still not doing it!!! With the Firefighter Mayday Program we find this unacceptable. The first step is to create and maintain a database with all accidents. We also should not forget to offer a neutral platform for Lessons Learned documents following incidents. An incident is an accident that did not happen. Those are the cases, as Kris’ story (see 3), were we learn the most for the lowest price.

6.1 Belgian Accident database.

To achieve this the Firefighter Mayday Program started to build up an online database in which all accidents that we know of are listed. The accidents are listed in chronological order and if there is extra information (photo’s, articles, video) available it is included in the webpage concerning the accident. We aim to make this database searchable in the near future.

At the moment the database contains about 140 accidents since 1945. We are working on making it as complete as possible. But since there has never been, and still not is, a centralised recording of accidents with firefighters it is a very difficult task to complete.

With this article we want to appeal to all reading this article to help us to get this database as complete as possible. If you know about an accident please check our database to see if it is in there. If not take the time to contact us and report the accident. If you notice that the accident is already in the database, then please take the time to check the information and if needed complete it or correct it. You can find the database through the following link or with the QR code.

http://www.brandweermaninnood.be/accidents

6.2 Belgian Lessons Learned documents.

At the moment we can say there are two document concerning an accident with Belgian firefighters. Karel Lambert has written an article covering the deadly accident with Patrick Batselier and Alain Taqenière. It was the first time this dramatic accident received the closer look that it deserved. It was also the first time that we could really start to think about what had happened. This was eight years after the accident had happened… The other document was realised thanks to the initiative of the Antwerp Fire Department. Quite soon after the accident they got in touch with the Firefighter Mayday Program and with a mutual effort we produced the first Lessons Learned document based on a recent accident with a Belgian firefighter.

On the website from the Firefighter Mayday Program we have a webpage dedicated to accident reports and lessons learned documents. We are expecting to add two more documents quite soon. You can find them with the QR code or the link below:

http://www.brandweermaninnood.be/page/ongevalsrapporten

6.3 Let’s make a beer card story obsolete!

Wouldn’t it be great that sometime in the future a firefighter wouldn’t have to rely on a beer card to share the story from his accident. That he can trust in an independent investigation that will clarify what has happened and how it can be prevented in the future. True and valuable lessons learned documents!

Sadly we can say that in the current political atmosphere this in nog going to happen very soon. So let’s do what we can ourselves. Let’s continue the exemplary work from the Antwerp Fire Department in sharing the information of the accident in the Arendbergstraat (28/8/2017). Let’s take an example from Johan Broos, Leo Buermans and Kris Oostvogel who, with support from their department, have chosen to share their experience. So that others can learn from it.

If you have suffered from an accident and think that colleagues could learn valuable lessons from it, then we are always willing to look into it and consider the creation of a Lessons Learned document. But, the truth is also that we can not promise that it will always be possible to create a public document right away. Only with the support of all parties involved a lot is possible. At the moment there still is the dark legal shade in Belgium. That being said, it should not keep you from documenting the accident. So that if the day comes that the experience can be shared, the learning document is ready.

To achieve the best results we try to follow the following principles:

  • We aim to improve the safety of every firefighter.
  • We will gather information and write a comprehensible document to learn lessons and offer learning experiences to others.
  • We hold a neutral position and have no interest in searching for responsibility. We look for the mechanisms of the accident and don’t see profit in blaming We seek to learn.
  • We work as transparent as possible and don’t hesitate to rely on expertise of experts from the field.We hope that this initiative can be the game changer for the Belgian culture of blaming and turn it into a culture of learning.