Fire Cause Determination

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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.

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Skills Objectives

• Demonstrate how to secure the scene using rope or barrier tape to prevent unauthorized persons from entering the incident scene.

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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

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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.

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Introduction to Fire Cause Determination (3 of 4)

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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.

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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.

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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.

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Wildland Fire Cause Determination

• Quite different characteristics from structural fires

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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.

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Indicators of Incendiary Fires (2 of 2)

• Tampered or altered equipment:– Document unusual conditions.

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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.

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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.

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Legal Considerations (3 of 11)

• Three types of evidence:– Demonstrative evidence: tangible items– Documentary evidence: written items– Testimonial evidence: witnesses speaking

under oath

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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.

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Legal Considerations (5 of 11)

© Frances Roberts/Alamy Images

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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.

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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.

Crew Resource

Management

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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.

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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.

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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

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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.

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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.

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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.

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Human Error (2 of 12)

• The “dirty dozen”:– Lack of communication– Complacency– Lack of knowledge– Distraction– Lack of teamwork– Fatigue

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Human Error (3 of 12)

• The “dirty dozen” (continued):– Lack of resources– Pressure– Lack of assertiveness– Stress– Lack of awareness– Norms

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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.

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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.

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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.

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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

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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

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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.

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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.

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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.

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Human Error (12 of 12)

Courtesy of Dr. Robert Helmreich

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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

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Debriefing (2 of 3)

Photographed by Mike Legeros

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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?

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Summary

• Human errors play a significant role in fire fighter deaths.