by Marc Castellnou and Marta Miralles
Documentary ‘El Gran Silenci’ (in Catalan: http://blogs.ccma.cat/senseficcio.php?itemid=54002)
Scenes from this documentary, examining the entrapment and its aftermath, will be presented at the Human Dimensions/Fire Safety Conference in Boise, with a discussion led by the authors of this preview. We asked them the questions we’ve asked so many presenters. Here are their answers.
After Horta de Sant Joan entrapment in 2009, where 5 firefighters died and one was severely injured, we’ve asked ourselves why accidents are increasingly happening to units who have planned and are reviewing their LACES (Lookouts, Anchor Points, Communications, Escape Routes, Safety Zone). Reports after the accident done with hindsight concentrate on causes, and they tend to focus on the accumulation of small factors causing unforeseen risk resulting in failures. But as the possible combination of small factors that can cause accidents tends to be infinite, lessons to be learnt keep piling up. The awareness part is getting bigger and bigger. What LACES was supposed to simplify, is becoming complex once again.
In Horta de Sant Joan accident, we concentrated on the decision-making process to reduce hindsight, and then uncertainties clouding the awareness and the decision-making emerge. The question we asked was: Was this a set of mistakes facing a known risk and failing? Or was this a disaster, where people involved applied the known precaution (controls), but it was the uncertainty of the risk assessment and controls that culminated in the fatalities? The answer to this question would tell us if we should concentrate on the crews, on improving the awareness, protecting from individual risk and becoming more defensive, or on the decision-making process of the organization, decreasing the fragility of the system and being more pro-active.
If we only concentrate on risk when uncertainty is a big problem, our success will depend on luck, because our crews will be facing both risk and uncertainty. With every new accident and every new accumulation of factors, more noise will be delaying decisions on the ground. The more decisions are delayed, the bigger the mismatch with reality, the bigger the uncertainties faced by crews. A change in strategy is needed.
A new set of tools is needed in our fire organizations, in order to provide more certainty to scenarios/briefings to crews, where safety protocols such as LACES can be applied.
(4) APPLY? How would you suggest we might apply what you’ve discovered?
Awareness should be tackled by the whole command structure. In the low levels of ICS, LACES should be applied to reduce exposure and vulnerability in front of known risks and in given scenarios. Meanwhile, in high levels of ICS, ambiguous risks and uncertain scenarios should be identified, and be embedded in the scenarios/briefings provided to the crews, and in the strategy on managing the fire. Concepts such as black boxes, couplings, trigger points, and others will be discussed. Lessons on uncertainty and risk in entrapments in Catalonia will be shared.
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About the Authors: Marc Castellnou and Marta Miralles are with the Forest Division of Catalan Fire Service. For more information, email Marc at firstname.lastname@example.org.