In aviation, people are learning lessons from incidents for over a 100 years. Each time there is a serious problem with an airplane, an investigation is started. The airline company and the manufacturer of the plane collaborate in the investigation. Several kinds of experts are taking part in the research. In the past century the aviation sector has learnt a lot: about technology, about manufacturing and maintenance processes, about human behaviour, ... By doing it this way, flying has become safe.
There is no such methodology in the Belgian fire service. We learn very little or nothing at all from incidents. In other countries as the US and the Netherlands lots of resources are invested in research into incidents. The goal of such a research project is not to find the one who is "guilty". It is the intention to obtain "lessons learned". The ambition is that the fire services moves forward as an organization. It shouldn't be the case that colleagues die and that the fire service doesn't draw lessons from what happened. However, this is the way things are done in Belgium. If the aviation would cope with safety as the fire service does in Belgium, a large number of planes that takes off would not safely land on the ground.
Of course, it is not easy to create a change. Nobody likes to tell where it went wrong in his or her organization. Still, this is a challenge for the fire service. The goal is to publish documents on this page from incidents that have been investigated.
A good book about this topic has been edited by the Swedish fire organization. It is called "Learning from accidents". It can be ordered from the following website: https://msb.se/en/Products/Publications/Publications-from-the-SRSA/Learning-from-accidents/
Investigations shouldn't be very big. The safety region Haaglanden in The Netherlands had a fire during which there was an explosion. The safety region made an analysis of the incident. Fire service personal of different stations of the region have been working on the investigation. A brochure was published to share the new knowledge. The fact that this happens and the way how it happens are very good. In the fire service accidents will happen. We can't deny that. But we can make sure that we learn from incidents ant that we create a better fire service. leertafel_haaglanden.pdf
An analysis that was particularly well done is the one about a fire in a factory in 2012 in Harlingen. The report can be found here: harlingen.pdf
Dave Birke, a pilot from the US marine corps, wrote a column about learning from incidents. You can find it here.
In the United States, there have been a number of fires in high-rise buildings. For some of them, there is a report about the fire and the way it was dealt with:
- Interstate Bank Building Fire, Los Angeles
- One Meridian Plaza Fire, Philadelphia, Pennsylvania
Deadly incident with Baltimore County FD:
January 19th 2011, firefighter Mark Falkenhan was killed in the line of duty whilst fighting a fire. The accident was investigated and this investigation resulted in a movie in which the events of that day are discussed. One can find the movie here.
Interesting things that can be seen during the movie are the following:
- upon arrival, a situation report is given. One mentions a.o. the number of floors.
- The focus is on rescue in stead of on extinguishing. Though this is a human reaction, because of this choice the fire is allowed to grow. An important difference is that occupants are relatively safe in our country because of the concrete floors that are standard here. In the US concrete floors are the exception.
- De mogelijkheden van door control komen in dit onderzoek duidelijk naar boven. Op het moment dat brandweerlui een appartement boven de brand doorzoeken, dient de inkom deur gesloten te worden. Op die manier wordt het appartement geïsoleerd van de stroming van de brand. Zelf het sluiten van een schilderdeur in het appartement kan de stroming stoppen.
- Een brand van de buitengevel kan naar binnenslaan op een hogere verdieping. Dergelijke problemen zijn ook bij ons te verwachten. Het valt immers steeds meer voor dat men brandbare isolatie afdekt met crepi. Dan is zo'n scenario niet ondenkbaar.
Research into Line of duty deaths in the US:
The United States are a very big country. There live millions of people and there is a lot of activity. This means that there are also a lot of fires. As in Belgium, something goes wrong from time to time. Sometimes things go awfully wrong. On average, every year about 100 firefighters die during their work in the US. In contrast to Belgium, every accident is evaluated thoroughly. NIOSH, the national institute for occupational safety and health, performs an in-depth evaluation of each line-of-duty-death and writes recommendations. Studying these cases is very interesting. The recommendations can often be copy-pasted into the Belgian context. The website of the "Firefighter fatality program" contains a search engine to search LODD's within several categories. You can find the website here.
NIOSH composed a document with recommendations for fighting fires in abandonned structures. In the document several cases are discussed: fighting fires in unoccupied buildings
NIST is another American governmental organisation. It has studied lots of fires in the past. An infamous fire is the one in Keokuk, Iowa which claimed the lives of 3 firefighters. NIST has made a short movie about this fire.
NFPA is also an American organisation that does a lot of work with regards to fire and fire fighting. They wrote a report about the fatal fire in Keokuk.
Lessons from Belgium:
August 30th 2008, two Brussels firefighters made the ultimate sacrifice at a fire in Ukkel. An article about this fire was published but there is also a movie available that discusses this unfortunate incident.
January 28th, 2014 the Saint-Hubert Fire Department was confronted with a house fire in Moircy. Emmanuel Belaire of the Liège Fire Department wrote a report (in French) about this fire.
December 6h, 2014 a fire started in the FN factory at Herstal, which produces weapons. Lots of resources were necessary to handle this fire. The report about this fire is only available in French.
June 17th, 2015 a fire broke out in an abandonned building in Liege. Because of the size of the incident, a report was written.
August 12th, 2015 the Liege fire department had to fight a fire in the Bank street (rue de la banque) in Seraing. Both an article and a report were published. However they are only available in French.
November 23rd 2015, a firefighter got hurt while battling a fire in Fléron. The Liège fire department published a report about this incident.
August 28th 2016, a firefighter got hurt while battling a fire in Charleroi. The Liège fire department made an analysis of this incident.
November 27th 2016, the Liege fire department had to fight a fire in an underground parking in Liege. A report was published. However it is only available in French.
April 15th, 2017, a fire started in the Brussels North-South Junction. This is the most important train tunnel in Belgium. The chronology of this fire is described in the report about this fire (which is only available in Dutch or French for the moment). There is also a section about the lessons learned.
October 21st 2017, Antwerp fire department fights a residential fire on the 3rd floor of an apartment block. The company officer made an excellent analysis of the incident using helm camera footage and thermal images.
April 14th 2018, Firefighters from Liege had to deal with an industrial fire. They wrote an interesting report (in French) about this fire.
April 26th 2018, The Liege fire service had a fire in a shop on their hands. Again, a report (in French) about the fire is available.
Three firefighters that were taking part in a course to become a station officer (lieutenant) wrote a document (in dutch) about a fire they had in Taxandria. It has become a very nice example of how you can make a complete analysis with lots of effort whilst using little resources. It shows all fire departments that everybody make case studies to learn from fires. You can find the document (in dutch) here.
December 24th 2018, the Fluvia fire department is dispatched to a fire in Waregem. Geert Phyfferoen wrote an analysis of this fire and applied the BE-SAHF model to it. You can download his report (in dutch) here.
Lessons from Sweden:
Lithium-Ion batteries are getting more common. During a fire, they pose a serieus threat for firefighters. PerOla Malmquist from Sweden wrote a safety message with his concerns regarding these batteries.
The Forward Avenue fire in Ottawa, Canada:
The fire in Forward avenue in Ottawa resulted in severely injured firefighters. The fire marked the beginning of a series of changes within the fire service of the Canadian capital. They started a CFBT-progam. Eventually, instructors from all Canadian provinces were trained to become a CFBT-instructor in the project From Knowledge to Practise. An important element was the report that was written by the Ottawa Professional Fire Fighter Association.
Lessons from The Netherlands:
In The Netherlands, a firefighter lost conscience during a live fire drill. His fire service had a short movie clip about this incident. However, the movie is in Dutch.
Lessons from The United Kingdom (UK):
The Institution of Fire Engineers (IFE) is an organisation that shares knowledge about fire & firefighting at a high level since 1918. For a while, they have been working on a database with accidents where firefighters die or get seriously injured as well as incidents from which lessons can be drawn. You can consult the database here.
The most important fire in the past decades in the UK is without a doubt the Grenfell fire. Many people died that night. In the UK, an inquiry was started to look into what went wrong and what can be learned. The inquiry has a website where one can follow the actions of the team that evaluates the fire. In the meantime, a Phase 1 report was released. It has become a very large document in different volumes:
GTI - Phase 1 Full report - Volume 1
GTI - Phase 1 Full report - Volume 2
GTI - Phase 1 Full report - Volume 3
GTI - Phase 1 Full report - Volume 4
There is an executive summary available. It contains only 32 pages. It is a good idea to start with this document.