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We Must Stop The Insanity: Part 1

insanityThe training practices used in many communities are setting up emergency response personnel for failure and flawed situational awareness. The sad part is most don’t even realize they’re doing it. When casualties occur, so do investigations. The investigations result in recommendations for how to prevent future casualty events.

The National Institute of Occupational Safety and Health (NIOSH) published a report titled Preventing Risk and Injuries to Firefighters Using Risk Management Principles at Structure Fires. In the report, they chronicle several case studies. In order to keep my articles short, I am going to parse this into four segments and post them over the coming weeks. We’ll start with an excerpt from a LODD case study,  followed by a listing of four (of many) NIOSH recommendations.  In each article in this series, I will offer an assessment of how the firefighters were Trained for Failure and how this meets the definition of insanity (doing the same thing over and over again while expecting the results to be different).

The NIOSH Case Study

On February 19, 2005, a 39-year-old male career fire captain died after being trapped by the partial collapse of the roof on a vacant, one-story, wood frame dwelling. The 50 year old house was abandoned, in a dilapidated condition, and known by residents in the area to be a “crack house” at the time of the incident.

Crews arriving on the scene could see fire venting through the roof at the rear of the house, with some fire fighters reporting that flames were well above the roofline. The victim was the captain on the first-arriving engine crew, which was assigned to perform a “fast attack”: They were to take a hoseline into the house, locate the seat of the fire, and begin to extinguish it. Thermal imaging cameras were available on scene but not used to locate the seat of the fire. The incident commander walked to the C-D corner of the burning house to size up the situation and determined that roof ventilation was not feasible because of the fire venting through the roof.

The victim and a fire fighter advanced the initial attack line through the front entrance and made their way toward the rear of the house. Conditions deteriorated rapidly as they advanced toward the rear. The fast attack crew had just begun to direct water onto the burning ceiling in the kitchen and den areas when the roof at the rear of the structure collapsed, trapping the captain under burning debris.

Image result for image of a burning houseThe collapse pushed fire toward the front of the house. Soot and combustible dust particles suspended in the air were quickly ignited along with combustible gases, sending a fireball rolling toward the front of the structure. Before the collapse, two other crews had entered through the front. The rapidly deteriorating conditions following the collapse quickly engulfed the other crews with fire, and five fire fighters received burns requiring medical attention. The victim was pronounced dead on the scene by medical examiners [NIOSH 2005a]. The dilapidated condition of the abandoned structure, fire venting through the roof upon arrival, and deteriorating conditions encountered by the advancing interior crews as the fire escalated were all factors suggesting a more defensive strategy was in order.

The NIOSH Recommendations 

NIOSH made many recommendations in their report. There are a few, however, that I would like to focus on to make my point of our insanity:

  1. A thorough size-up and risk analysis should be performed before conducting operations in any burning structure.
  2. Fire-fighting operations should be limited to defensive (exterior) strategy if the structure is judged to be unsafe and in any situation where the risks to fire fighter safety are excessive.
  3. Offensive (interior attack) operations should only be considered when sufficient resources are on scene to conduct offensive operations with a reasonable degree of safety, including the ability to perform essential support functions (i.e., water supply, ventilation, lighting, utility control, accountability, rapid intervention teams).
  4. Additional size-ups and risk analyses should be performed before changing strategies, including any decision to conduct interior overhaul opera- tions following a defensive fire attack.


Using these four NIOSH recommendations above, let’s look at how we train at our burn buildings. In my travels around this country to teach first responders, I have had the good fortune of seeing many training facilities. Most burn buildings I’ve encountered are made of steel, concrete or a combination of the two. The fires are ignited from Class-A combustibles or propane and, for the most part, produce a consistent and predictable amount of smoke and fire. Let’s see how that applies to casualty events.

NIOSH Recommendation #1: A thorough size-up and risk analysis should be performed before conducting operations in any burning structure.

Indeed! However, in order to ensure this will be done at a structure fire, it must be done during training burns. Not once or twice or on occasion. Rather, as the NIOSH report recommends, “in any burning structure.” This means completing a thorough size-up and risk analysis before starting fire attack at every training fire as well. Do we do that? I can’t speak for everyone, but I can tell you that I have observed MANY who do not.

Why not? Because the building is made of concrete and/or steel. There is no risk of the burn building falling down during the evolution. Conducting a thorough size-up of the burn building might be perceived as a waste of time. It might even lead to criticism from firefighters who are anxious to take hose lines into burning buildings and put out fires.

einsteinThis is an important point that cannot get lost here. It’s one that I speak to extensively in my Mental Management of Emergencies classes. Practice does not make perfect. Practice makes permanent. [tweet this] If firefighters are not required to complete a thorough size-up prior to commencing interior operations at EVERY training evolution, their situational awareness will be flawed. Worse, they will not be building the process of completing a size- into the habits formed through repetition. They are being Trained For Failure. To expect firefighters to perform at an emergency scene in a manner inconsistent with their training is INSANE! It won’t happen.

A personal note

Just once, I’d like to see an investigation report say: Stop training your firefighters to do the things that are killing them. Of course, that would require a knowledge that it’s happening and best practices for how to correct it.

Thank you, in advance, for the gift of your time to read all four articles of the We Must Stop The Insanity series.

I would love to have your feedback. Leave a reply below. Share your thoughts. Join the community and together we’ll improve our safety. Also, thank you so much for sharing links to my articles with your friends and with others in your social media networks. I really appreciate that.

Additional Resources:

TRAINING FOR FAILURE DVD: You will notice that each time I mentioned “Training For Failure” I have it capitalized. Why? Because TRAINING FOR FAILURE is the name of a training program.  In it, I chronicle nine events and the catastrophically important lessons of how responders are being trained to fail and how to fix the problem. The entire DVD is available by clicking HERE.

This program has been delivered as a general session or keynote address at:

Colorado Fire Service Leadership Challenge (Keystone, CO)
British Columbia Fire Training Officer’s Association (Vancouver, BC)
VCOS Symposium in the Sun (Clearwater Beach, FL)
South Carolina Fire Academy (Columbia, SC)
League of Minnesota Cities Safety Symposium (St. Paul, MN)
Southern Alberta Firefighter’s Conference (Lethbridge, AB)

We Must Stop the Insanity: I delivered a keynote address at the Center for Public Safety Excellence Conference in Orlando, Florida entitled: We Must Stop The Insanity. That program provides powerful examples of why the recommendations for improving responder safety are not working and how to fix the problem. Feel free to give me a call to learn how you can get the program!





The mission of Situational Awareness Matters is simple: Help first responders see the bad things coming… in time to change the outcome.

Safety begins with SA! 


Share your comments on this article in the “Leave a Reply” box below. If you want to send me incident pictures, videos or have an idea you’d like me to research and write about, contact me. I really enjoy getting feedback and supportive messages from fellow first responders. It gives me the energy to work harder for you.




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14 thoughts on “We Must Stop The Insanity: Part 1”

  1. Hello mr. Gasaway,

    A very interesting point to your article! As a professional, I train first-aid providers and fire wardens – lay people that are expected to help others during accidents. Most of them are very motivated and of course good hearted, but have a complete lack experience (real life or training). The required amount of training for them is about 8 hours a year! Yet they are still expect to give good aid to victims. Right now I’m studying psychology to understand a bit about the descision making process under stress (human factors). So I do understand that people have an inflated view of themselves. The problem I encounter time after time is that I don’t have enough time to train them with scenarios to help them make a scene survey and good decisions. Even harder is to really make them understand that it is impossible to see the whole situation and be constantly aware of changes in the situation. I love my job! But sometimes I fear for what I let lose on the streets.

    Keep up the good work, regards,
    Jan Draaisma

    1. Jan,

      Thank you for sharing your comment on my blog. I sincerely appreciate your willingness to share. Your anxiety is felt by many who train first responders with limited resources which is quite common here in the U.S. In the end, we can just do the very best with the resources that are provided to us and sleep well at night knowing they are smarter as a result of our efforts. Thank you for what you do to train lay responders. That’s a vitally important task in the overall system to protect our citizens. ~ Rich

  2. Pingback: We Must Stop The Insanity: Part 2 | Situational Awareness (SA) Matters!

  3. Pingback: We Must Stop The Insanity: Part 3 | Situational Awareness (SA) Matters!

  4. Pingback: We Must Stop The Insanity: Part 4 | Situational Awareness (SA) Matters!

  5. Pingback: We Must Stop The Insanity: Part 3 | Situational Awareness Matters!™

  6. I am not sure how to address you sir. Should it be Dr. Chief Gasaway or Chief Dr. Gasaway. That out of the way, here at St. George we have been training on and implementing detailed initial radio reports upon arrival to a scene.

    No matter what the incident; structure fire, first aid, mva, etc. Upon arrival of the first unit, as detailed of a report as possible is to be given. Some of my crews, of course, had questions concerning this when put in place. “How do we give a detailed IRR when we arrive at a first aid call?” “Just how much information do we relay?” Lots of questions to that effect.

    I would relay to them, for a first aid where the patient is inside a house or building; unit x on scene establishing street name command. First aid or mva where the patient is outside, unit x on scene # cars mva (if any vehicles are turned over, on side, on fire, etc.) appears to be # of pt.’s establishing street name command. Reported fire, unit x on scene, working fire flames showing alpha side, beta side, charlie side, etc. or nothing visible or whatever is showing, unit x making offensive or defensive attack, if water supply established, establishing street name command unit x officer be mobile IC exterior or interior.

    Of course the list goes on as to the IRR’s. Crew’s of course then ask, “why on every incident do we have to do this the same way?” My response is always, “If you get in the habit and do it the same way each time on the small calls, when the big ones come about there will be no confusion it will just come about naturally.” Of course it is hard to get some people to grasp this and I still have to have discussions to correct problems when the detailed IRR’s are not being done, but for the most part, it’s coming around and working well.

    We are having better IRR’s which gives me and the other incoming units a better picture of what is going on; and by the time I arrive on scene, I really don’t have to get much of an update from the initial IC. I just go to him, confirm everything is the same as what I last heard on the radio, and command is transferred. We have also started to do a computer based virtual training, mainly for the company officers and chief officers, where you can give a more true to life picture of what a situation may look like once arriving on scene. I know it is not hands on and just virtual, but you can change the building (residential, commercial, high rise, etc.), change the arrival conditions (nothing visible, smoke showing, working fire, etc.), do a virtual 360, make entry, change interior conditions, if the officer makes a “wrong” decision, conditions can be quickly changed for the worse without having to worry about anyone being injured.

    Everyone is at different terminals, one person “playing” dispatch and controlling the incident. It has been a great training tool to modify and correct inadequate IRR’s. Also it does not wear the crew out by going in and out all day and you can run how ever many scenarios time allows resetting the scene with the touch of a button. It really helps to form the habits needed to do the same thing, the right way, each time. Once a scenario is completed, it is discussed and evaluated, deficiencies corrected, no finger pointing, no blame thrown, just “how can we do this better next time?”, “what needs to be done differently?”. It is a wonderful training tool and one I feel will be a big help in correcting training for failure. Thank you for your work in helping to bring about the needed awareness and sharing your experience, thoughts and research to bring about that awareness and correct deficiencies.

    James Newman
    District Chief 604-A
    St. George Fire Protection District
    Baton Rouge, LA

    1. Chief Newman,

      First… what to call me… I prefer “Rich.” (Thanks for the chuckle) Ok, that out of the way… Thank you for sharing what you are doing in St. George. You are SO on target with best practices. I hope everyone reads your reply and benefits from what you have shared. I really appreciate your participation on the site. ~ Rich

  7. I did receive this newsletter and found the literature exceptional. I would like to continue receiving the newsLetter. I believe this information is of vital importance to all firefighters. Thank you for doing this. I wish everyone would request a copy and make sure they read it and pass it onto members of their departments.

    1. Gail,

      Thank you VERY much for your kind words about my newsletter. You can help spread the word by sharing the website link with others in your circle of influence (email, Facebook, etc.). Encourage them to sign up for the newsletter. I appreciate your feedback SO much. ~ Rich

  8. WOW! After several years of MY telling firefighters that we are HURTING OURSELVES AND THE PUBLIC with today’s burn buildings and techniques, I have your site forwarded to me.

    I don’t want to get long winded here, but one of the examples I site is a townhouse fire in Fairfax, VA. You know – FAIRFAX – some of the BEST trained, BEST equiped and BEST paid FF’s in the nation if not the world! Call comes in for a house fire. The caller is ON THE LINE with 9.1.1 telling them EXACTLY what the conditions are and EXACTLY where she is located. This goes on and on – she is on the 2nd floor in a bathroom at the top of the stairs. She has wet towels on the floor in front of the door.

    OVER FORTY MINUTES LATER, they find her dead body! The houses were all the same floor plan there – the connected house to the left and the right (“B” and “D”) were searched. This fire was “essentially” (MY WORDS HERE, and I stress that I was NOT on scene) a room and contents fire. It was found to have started with a microwave (I think, it’s been several years ago now) and spread into cabinets and the kitchen wall.

    Smoke condition was ‘thick’ and I think the crew MIS-READ conditions / scared / unprepared / TRAINED FOR FAILURE!!!! Long story short – todays burn buildings are set that when it reaches some absurdly low temp (700? 900?) the lights come on , the doors and windows fly open, cool misting water is sprayed, fans immeadiately cool the place to 78′ and a ice cold Coke is put into the hands of the trainees!

    Todays “house fire” is more like a CLASS B fire than ever before – burning THICK, HOT, BLACK, OILY, GREASY – and new firefighters don’t even get wet straw to experience “smoke”. OK, I’ll get off my soap box and go continue to check your stuff out. NO DOUBT I’ll be signed up for your newsletters very shortly. (I *HATE* to say it, but can it be? Is it possible that we have become “too safe” and its coming around to bite us)?! KLW

    1. KLW,

      Thank you for sharing your views. It is important that we get some conversations going on these important topics and learn when things do not turn out well. I appreciate your acknowledgment that you were not on the scene of the emergency that you referenced. The emergency scenes are often different than what is portrayed in dispatch tapes, media, or articles. I do recall learning about the incident you were discussing.

      I have had the opportunity to conduct training for Fairfax County and from that exposure I found everyone I dealt with to be professional and committed to their mission. Just the mere fact that they hosted a program speaks volumes to their commitment for self-improvement. Many places won’t do that and they can find every excuse in the world why they can’t or don’t. ~ Rich

  9. I can see the argument for why firefighters should only deal with exterior defensive strategies. But the problem is that sometimes, they need to go in a save someone. It is a touchy topic that takes a lot of thinking and training to even have a good opinion on it.

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