It is an accepted fact that most operational incidents dealt with by UK firefighters manage to avoid the consequences of the inadvertent application of James Reason’s Swiss cheese model of accident causation. Safety on the incident ground depends on the “defence in depth” approach provided by systems of work, sometimes called the “safe person concept” and will include effective selection and training of firefighters, personal protective equipment, well understood rules and procedures and effective command systems.

Failure to comply with these requirements, enshrined in legislation in both The Health And Safety At Work Act (1974) and subsidiary legislation including Management Of Health Safety Work Regulations (MHSWR) 1999, may result in a fine, imprisonment or criminal prosecution but can, more importantly, also result in the death or serious injury of a firefighter or other person.

Most firefighters, serving or retired, will recognise incidents they have attended which, but for the grace of God, could have resulted in serious or fatal consequences had the a final layer of defence (personal protective clothing, observations of a safety officer, good situational awareness) been missing or removed. Sometimes, the element of unpredictability, inherent at all operational incidents, works to firefighters’ advantage and tragically sometimes it does not. In the UK, we are fortunate that at the time of writing, no firefighter has died at an operational incident for over six years. It is, however, recognised that like in most countries, this state of good fortune is unlikely to be permanent and guarding against complacency is essential if this record is to be extended.

 

“Systemic problems still exist with respect to incident command and its application in the UK”

 

Incident Command Systems

Incident command systems manage operational risks and help serve the community by ensuring effort is focussed on keeping firefighters’ safe, enabling them to do their job without undue hinderance. But reducing incident numbers has proved to be a double edged sword. While fewer incidents have led to safer firefighters and safer communities, the lack of “on the job” training and acquisition of real experiences and challenges have perversely made it a potentially more dangerous place. It is an oft quoted fact that even at some of the UK’s formerly busiest stations, there is now a significantly reduced opportunity to gain “career fundamental” operational experience in a short period. There is potentially a whole layer or generation of firefighters and incident commanders that have not had the opportunity for gaining extensive experience of applying the skills of their profession at a wide range of “working jobs” or technically more challenging events.

While this lack of incidents is unarguably a good thing, a lack of familiarity with incidents can have a detrimental effect in a more nebulous way. The Fire and Rescue Service in the UK (or indeed anywhere) has two main societal functions: the first, obviously, is to protect the community from harm and loss. Those who are in direct contact with the FRS at the incidents, however, are a relatively small number. The bigger role, not as critical in the acute sense but more substantial in the wider environment, is that of public reassurance.

Remember the widespread protests in some communities when an “on call” local station, dealing with a small handful of incidents every year, and with an attendance time within the community that was slower than the next nearest whole-time station, was threatened with closure. The palpable fear of not having a supernumerary and unnecessary fire engine in the village did real damage to the perception of risk and the notional reassurance provided to the community, despite the fact that a working smoke alarm is the best form of life safety. The reputation of the service and the consequential reassurance provided to the community is dependent upon making sure that systems work, that resources are effective and sufficient and, importantly, that commanders are well trained and exercised in managing operational incidents wherever they occur and whatever they are.

Unite Kingdom Incident Command

The UK incident command system has evolved over nearly 80 years and now takes an approach that facilitates a systematic approach to incidents that is both scalable and flexible to accommodate an effective response to all incidents – an “all hazards” approach. So, if a super tanker collided with St Paul’s Cathedral (as improbable as a spaceship crashing at St Thomas’ Street in London), following the UK ICS processes should enable an effective response be made, limiting damage and casualties.

These are the same fundamental processes that are used for a domestic incident – gather information, assess incident, implement control measures, render the incident safe and restore to normality – and are adopted and adapted to control the event no matter what the size or complexity. As with all systems, the processes are ultimately controlled by human beings and sometimes failures at the individual, corporate and system design levels can lead to catastrophic personal and societal consequences. Sometimes there are multiple points of failures at all three levels that compound the impact of errors with a resultant outcome that may far exceed that which was expected from single points of failure.

 

“The response to the Manchester Arena bombing shows that there is a need for increasing the amount of training and exercising for large-scale and/or complex events at all levels and in all blue light agencies”

 

Decision Control Process

At an individual level, a full understanding of rule-based operational procedures and ICS is essential, but the ability to flex and upscale these procedures is an important skill on the part of commanders. It is also essential that incident commanders have acuity to recognise incidents that are beyond the “norm” (norm in footballing terms being conference league equivalent when compared with the rarer “premiership” scale type incidents), which are of a magnitude that require the adoption of a wider, more circumspect perspective that recognises that the incident is not “business as usual”.

This can be a real challenge for some as it can be difficult to change an ingrained process of command that has evolved over the years and fails to recognise significant changes between “bread and butter” incidents and major events and adopt different procedures while thinking “big” and more imaginatively.

There have been numerous examples of where the first attending crews at a major fire have deployed two breathing apparatus wearers with a hose reel jet to a fire already well established and eventually requiring many jets to control. An understanding by individuals of how these ingrained, frequently used methods of working need to be very carefully considered before use at these low frequency, high consequence incidents can help commanders recognise when they need to change their approach for these rarer incidents. The UK Decision Control Process (DCP), much criticised in some quarters, provides, if used correctly, a system of checks and balances that ensures commanders at all levels consider all aspects of an incident and ensure that risks and tactics in undertaking an intervention are proportionate and balanced against the potential outcome. Resistance to change can be a fundamental human failing and the introduction of the DCP has been no exception. Irrespective of claims by many of those responsible for introducing and embedding process within services, there still appears to be patchy understanding by many across the Service, including those who frequently have to make critical operational decisions.

It is also true that the more senior the commander, the more probable it is that she or he have not attended large numbers of incidents for many years and with even greater infrequency as they are elevated in role. It has been argued by some very senior managers in the UKFRS that tactical command on the incident ground should be left in the hands of those who regularly practice incident command. Citing that in an ideal world, the highest command role at an operational incident should be at a Group Manager level where experience and maintenance of competence is likely to be at its most current. More senior roles should be left to manage strategic and political issues at Strategic Coordination Group (SCG) or service specific “Gold” levels. This is true for senior commanders and managers at the head of many large organisations where high consequence events happen only on rare occasions.

It can be a glib statement to say that more senior commanders need to rehearse and exercise for events on a regular basis, but in the real world, post austerity, where individuals now carry out roles and tasks which where completed by a team a decade ago, finding time to take part in exercises is a real challenge, despite the fact that the failure to understand and apply principles of incident command correctly can have fatal consequences.

It is also the case that while “desktop” exercises are useful in developing knowledge, skills and understanding of incident command procedures, “vertically integrated” exercises, where all levels of command are involved in real-time, real environments are vital in helping to ensure that senior commanders maintain appreciation of the capabilities, skills and limitations of those who are expected to carry out their instructions. It is also provides a good “reality check” and is helpful in reducing the potential for unrealistic expectations of crews at incidents.

JESIP Principles

More complex incidents, even those requiring attendance only one or two pumps, may require a multi-agency response to resolve successfully. The Joint Emergency Services Implementation Program (JESIP) was successfully implemented across the whole of the UK blue light responding agencies nearly five years ago. While, at the time, uptake and retention of information was fairly good, proportionate to the amount of training time allocated by each station, organisational churn has meant that a great deal of organisational knowledge and experience has been lost at all levels and, again, knowledge of the protocols across all three services is becoming patchy.

Structured coordination in response, particularly for larger incidents, is essential for delivering effective outcomes for the community. The failure of the fire and rescue service response to the Manchester Arena explosion cannot be laid solely at the door of the FRS or individuals: why was it that any of the other blue light responders did not notice that there were no big, red fire engines at the scene of operations for nearly two hours? If nothing else, events at the arena show how the failure to adopt JESIP principles when it counts can have real consequences. The community reassurance unfairly lost as a result of this incident may take years to rebuild. If nothing else, the response to the Manchester Arena bombing shows that there is a need for increasing the amount of training and exercising for large-scale and/or complex events at all levels and in all blue light agencies.

 

“Most firefighters, serving or retired, will recognise incidents they have attended which, but for the grace of God, could have resulted in serious or fatal consequences had the a final layer of defence… been missing or removed”

 

Impact of Variable Crewing Levels

At an organisational level, changes in operational response levels can have an impact upon the management of an incident. The increasing trend to reduce standard crewing on pumping appliances to four firefighters means that command of the incident in the early stages when critical activities need to be carried out maybe less than optimum. Crews of five enable interventions to be taken (pitching a ladder, initiating an offensive attack all fire with BA), while enabling the initial incident commander to do their essential function of commanding the incident: gathering information, developing tactics, assessing and requesting additional resources, coordinating the response and making risk critical decisions. With a crew of four at a critical incident, the incident commander is faced with a dilemma between carrying out the command role or undertaking tasks as part of the team – a “wicked problem” if ever there was one.

Similarly, the introduction of rapid response vehicles (RRVs) from the command and control point of view can be a double-edged sword: specific role designation of these vehicles when arriving at the incident first can mean that an effective command and control structure will be set up from the outset. This enables the initial incident commander to structure the incident, forced by lack of resources to focus on this key activity rather than undertake rescue or firefighting tasks. The downside is that if, as happened at a relatively recent incident, an initial incident commander (riding a RRV, crew of three) may deploy himself into a building to investigate the source of a fire, leaving no command structure, nor information for oncoming resources or idea of his whereabouts. Whereas a larger crew may have had sufficient crew members to implement a formative command structure.

Plethora of Documentation

Systemic problems still exist with respect to incident command and its application in the UK. The plethora of documentation now under the banner of the National Operational Guidance (NOG) means that gaining an overall understanding of concepts and techniques for operational procedures and incident command have become more difficult.

Under the National Fire Service era during the Second World War, basic guidance on tactics and firefighting strategy could be found in the Manuals of Firemanship. As this evolved over the half-century or so, it culminated in the introduction of concepts such as sectorisation and tactical mode from the USA, where studies of and practical guidance on incident command had been produced several decades earlier by Alan Brunacini and John Norman amongst others.

The current vogue for all things web-based can undermine a comprehensive understanding of incident command procedures and indeed all matters operational and has created a couple of practical problems. Firstly, the sheer mass of documentation on the NOG website means that firefighters can easily be overwhelmed by a tsunami of paper, currently running at over 8,000 documents. This is particularly exacerbated where services are not well supported in terms of IT and computer provision. Access to the website by individuals (and indeed staff who are required to translate guidance into service specific policy) is essential to keep up to date with current documentation and some services are unable to facilitate what has become a platform for individualised learning. Secondly, navigation around the current version of the site is difficult and can seem more like playing a multilevel game of Dungeons and Dragons rather than a linear “how to” guide to incident command and operational procedures. Accumulation of these difficulties can ultimately lead to information being missed and at a practical level, incident command reverting to what could be remembered from previous, now redundant or wrong iterations of ICS systems.

So while the UK has been notably successful in reducing firefighter deaths and injuries over recent decades, it is entirely possible that as yet unrealised gaps in personal knowledge and skill levels, organisational policies and training and a systemic failure to produce an easily accessible and usable guide to ICS may be leading the UKFRS down a dangerous road where safety may be systematically compromised.

Until recently, it had been a requirement for airport firefighters to requalify in basic skills and industry developments every four years. This recertification/revalidation approach (used by many fire departments in the USA), combined with an effective audit of skills and knowledge by external bodies, such as the HMCIFS, would go some way to providing reassurance for the public, government and the Service itself.