This is the final segment of the Recipe From Hell’s Kitchen series. In this article I want to share my personal perspectives on the catastrophic outcomes that result when the ingredients of the recipe come together. You may recall in the first segment I shared with you that I see this recipe being used over and over again in the creation of first responder casualties. Enough so that it makes me sick, literally.
This segment was the least enjoyable for me to write and I put it off for as long as I could. It may, as well, be the least enjoyable for you to read. Please do not skip it. For if we are going to be compassionate leaders of first responders and committed to improving safety, we must take a dose of distasteful medicine on occasion.
The Recipe from Hell’s Kitchen
STEP 1: Take a large helping of incompetent behavior.
STEP 2: Remove all the consequence.
STEP 3: Cover and allow confidence to rise.
STEP 4: Deny the existence of the deadly mixture until complacency sets in.
STEP 5: Put into PPE and send into an oven. When PASS Alarms ring the catastrophe will be ready.
Moved beyond words
It was the afternoon of December 20, 1991 and I was in my office at the Springfield Township Fire Department near Akron, Ohio wrapping up some work before taking a long overdue break for the Christmas holiday. My phone rang and the conversation I had led to a question being asked of me that would change my life. It was Chief Clarence Bittner on the other end of the phone.
Bittner was the chief of the Lakemore Fire Department, a community we bordered and provided mutual aid to. While I was a relatively new chief, we’d developed an amazing working relationship. “Did you see what happened in Pennsylvania this morning?” he asked. “No, I haven’t seen any news today.” (Remember, this was before Facebook and Twitter could get news out in a flash).
He told me four firefighters had died fighting a structure fire in Brackenridge. I grew up not far outside of Pittsburgh so I knew where Brackenridge was but I’d never been there. It was tragic news, but I was busy. I had a lot to get done before my Christmas break. Then… came the question that changed my life.
“Have you ever been to the funeral for a firefighter whose been killed in the line of duty?” I hadn’t. I closest I had come was attending the funeral of a firefighter/friend from my hometown department who died at home following a fire incident. When I told Chief Bittner I’d not attended a LODD funeral, he said: “You need to. I’ll get the details and get back to you.” Yes, the firefighters’ deaths in Brackenridge were tragic. But it was Christmas. I didn’t want to attend a funeral at Christmas. Let alone a funeral for people I did not know.
But Bittner insisted I go and I held him in high esteem. He’d been a trusted advisor and was one of the wisest people I’d ever met. If he thought I should go, I would go. It was Christmas Eve and I was at a funeral. While being one of the saddest things I’d ever done in my life, it was at the same time one of the best things I ever done. To this day I remember the vivid details. The grief on the faces of the firefighters and family members is seared into my memory.
While we were standing there in formation, Chief Bittner leaned into me and whispered: “Rich, do you see how sad everyone is?” My voice strained and crackled a “Yes” as tears rolled down my cheeks. Then he whispered something I will never forget for so long as I live. “It’s our job to make sure this never happens in Springfield and Lakemore.”
I had attended a funeral for four men I did not know who died fighting a structure fire in a town I’d never been to. I didn’t even know the circumstances of how they died other than what had been reported on the news. But this 2-hour event changed my life forever.
The United States Fire Administration investigates and issues reports on selected major fires. The fire in Brackenridge was among them. Among the observations in the report:
The analysis of this incident provides several valuable lessons for the fire service. Unfortunately these are all revisited lessons, not new discoveries. These firefighters died in the line-of-duty, while conducting operations that appeared to be routine, and were unaware of the situation that was developing below them… This situation bears distinct similarities to other incidents that have claimed the lives of several fire- fighters in the past.
Sadly, the observations in this report are echoed in countless line-of-duty death reports. In fact, I often say in my programs: When it comes to firefighters getting killed in structure fires, we’re not inventing any new ways to do it. We’re simply taking all the ways we already know how to do it and perfecting it by doing them over and over and over again. It truly make my heart ache.
The families of the four firefighters were recently interviewed and the article was published on the PittsburghLive.com website. Here’s a link. Pay close attention to what the family members have to say. Imagine how every aspect of life changed on December 21, 1991.
The wife of one of the firefighters was expecting a child. The following spring her son was born. A son who would never know his dad. A son who would never get tucked in at night by his dad. A son who would never toss a ball around the yard with his best friend. A son who would never share a Christmas with dad.
Imagine how it must feel for a family when a report is issued that identifies organizational or performance deficiencies that could have changed the outcome. That hurts.
Imagine how it must feel for firefighters who now see, after the fact, the tragedy could have been avoided if steps had been taken to improve safety. That hurts.
The tragedy of a firefighter’s death is far reaching and long lasting. I have since attended more firefighter funerals, memorials at the National Fire Academy, and on several occasions been invited in to help fire departments learn and heal from tragic losses. That hurts. In fact, it never stops hurting.
Incompetence. It’s the first ingredient in a recipe that can result in tragedy.
Thank you for the gift of your time to read The Recipe From Hell’s Kitchen series. I am hopeful the information will be valuable to you in your efforts to improve your safety and the safety of others in your organization. Please remember the process of creating organizational change is one that is best accomplished in small increments over a period of time. Trying to change too much, too fast, can result in push-back and resentment from members who may not be as enthusiastic about changing as you may be. Please let me know how I can help. ~ Rich
The mission of Situational Awareness Matters is simple: Help first responders see the bad things coming… in time to change the outcome.
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