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SAM 007 | Captain Jeff Bowen Line of Duty Death

Published: June 13, 2014, 11 p.m.

Hello and welcome to episode 7 of the Situational Awareness Matters radio show. I\u2019m your host, Rich Gasaway. The purpose of this show is to improve situational awareness and decision making for individuals and teams who work in high stress, high consequence environments. Our mission is simple\u2026 To help you see the bad things coming\u2026 in time to prevent bad outcomes.

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I am broadcasting to you today from my Situational Awareness Matters Get in the Loop Tour Stop in Erwin, Tennessee where I am training 950 employees from Nuclear Fuel Services on situational awareness and the challenges faced by industrial workers. NFS processes the uranium that powers the nuclear navy. I am honored they have engaged me in a multi-year contract to help improve the safety of their employees. Thank you NFS for this opportunity.

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On this episode we\u2019ll talk about:

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1. The Line of Duty Death of Asheville Fire Captain Jeff Bowen.

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2. In the near-miss lesson learned\xa0we\u2019ll\xa0talk about an incident where flawed situational awareness led to firefighters being caught in a ceiling collapse.

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3. And in the Question/Answer segment we\u2019ll take a program attendee question about fatigue.

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FEATURE TOPIC

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Healing and growing from tragedy

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I had an opportunity to present along side Asheville Fire Chief Scott\xa0Burnette\xa0at the North Carolina Society of Fire Rescue Instructors Conference. This opportunity came as a result of another wonderful opportunity that Chief\xa0Burnette\xa0extended to me to conduct facilitated debriefings following the line-of-duty death of Captain Jeff Bowen.

During the debriefing process I was able to learn, first-hand, of the challenges and opportunities the department faced during this horrific event on July 28, 2011. ChiefBurnette\u2019s\xa0presentation (which preceded mine) was titled Fourteen Minutes, Thirteen Seconds. It was so named for the time it took rescue crews to locate and remove Captain Bowen following the Mayday call. Chief\xa0Burnette\xa0told the audience those brief minutes passed like hours.\xa0

The visit and presentation also gave me the opportunity to visit again with Firefighter Jay Bettencourt. Jay is the firefighter who was with Captain Bowen when he went down on the fifth floor of the medical office building. Jay\u2019s acts of heroism to rescue his brother left me awe struck. Jay is a humble man. I am confident he would not see himself as a hero. Rather, he would characterize himself as a firefighter who was just doing his job.

During my portion of the presentation, I focused on how we conducted the facilitated debriefings following the event.\xa0\xa0I brought Jay to the front of the room and, standing beside Firefighter Bettencourt I told the audience. \u201cSome day, my grand kids will ask me if I am a hero. I will tell them no. Grandpa is not a hero. But I have stood among them\u201d and then looked to Jay. He received the most\xa0well-deserved\xa0standing ovation I have ever seen delivered.

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Likewise, when Chief\xa0Burnette\xa0finished speaking he also received a standing ovation from the audience. Chief\xa0Burnette\xa0was very forthcoming with his assessment of the incident and the lessons learned. He\u2019s such a humble leader. One that all of us should emulate. I did not envy the position he was in to give such a tough presentation in front of such a large audience. He remained poised and professional.

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At one point Chief\xa0Burnette\xa0spoke of a dream he had in November where Captain Bowen appeared and walked the chief through the fire incident, step by step, and told him everything that happened. It was, by far, the most riveting story I had every heard. Ever! There can be no doubt for the Chief\u2019s love and compassion for his firefighters. His commitment to learn every lesson possible from this tragedy is very apparent.

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Just two weeks ago I had the opportunity to revisit my friends in Asheville. This was the first visit since my facilitated debriefing last fall. The purpose of this visit was to be briefed by the Post Incident Analysis teams. I was very impressed with the amount of work that had been done based on the recommendations in my report.

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All too often I encounter fire departments\xa0who\u2019ve experienced a line of duty death and, as a result, have changed nothing. Some are in denial. Some say that if they address the issues they will be dishonoring the fallen. This often leaves the firefighters anger and disappointed because they all know things went wrong and there are lessons to learn\u2026 not to dishonor the fallen, but to honor the fallen. We owe it to every fallen firefighter to learn every possible lesson about how the tragedy unfolded and how to prevent it from happening again.

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Clearly, The Asheville Fire Department is an organization that is taking the lesson from the tragedy of July 28, 2011 and making real changes to improve their safety and operations. Their actions will become a blueprint for other departments to follow. To say I\u2019m impressed is an understatement. This is a first-rate organization that is well on its way to healing and growing out of tragedy. Congratulations Asheville Fire Department.

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SITUATIONAL AWARENESS NEAR MISS LESSON LEARNED

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This lesson comes to us from the Firefighter Near Miss Reporting System, where lessons learned become lessons applied.

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We responded to assist another fire department at a structure fire that was caused by a lightning strike. The fire was in the attic of a two-story home of approximately 3000 square feet. The first due engine had pulled two 1 3/4" lines and a 2 1/2" line with a cellar nozzle. My crew went upstairs to assist with the fire attack. There was a very light haze of smoke on the second floor. After opening a hole in the ceiling, we put the 2 1/2" line with the cellar nozzle into the attic.

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We then noticed the room next to us had a glow coming from under the door. As the attack team went to make entry into that room, the entire ceiling collapsed on top of us and visibility went to zero. One firefighter had their face-piece knocked off and we all were disoriented. Everyone made it out without injury.

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LESSONS LEARNED

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Be aware of what the conditions are around you. When you use a cellar nozzle in the attic, anticipating a collapse.

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This near-miss serves as an example of flawed Level 3 situational awareness \u2013 where the crew had a flawed ability to predict, project, or forecast future outcomes based on current information. This often happens when personnel are operating in the moment with a fixation on the task and little thought is given to cause and effect.

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When you are applying water, you are adding 8.35 pounds of weight into the structure for every gallon of water you apply. If you flow a 100 GPM nozzle for two minutes, that\u2019s 1,670 pounds of water being loaded into the ceiling.

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As you apply water, think\u2026 how much weight and I loading into the structure? Where is it going? Can the structure support the weight? What are the potential outcomes if it cannot? Can we anticipate those outcomes before they happen? Can we take action to prevent the bad outcome?

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Level 3 situational awareness is developed by using past experience, past training and your imagination to envision future events. It\u2019s the foundation of the mission ofSAMatters\u2026 to help you see the bad things coming\u2026 in time to avoid bad outcomes.

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You can visit them at\xa0www.FirefighterNearMiss.com

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If you have experienced or witnessed a near miss and would like to be interviewed on this show, visit my companion site:\xa0

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www.CloseCallSurvivor.com\xa0

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Click on the \u201ccontact us\u201d link. Thank you, in\xa0advance,\xa0for sharing your lessons learned so others may live.

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Peeling Back the Layers

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Situational awareness is consistently identified as one of the leading contributing factors in firefighter near-miss events. Yet many firefighters who know, with confidence, they lost\xa0their\xa0situational awareness don\u2019t understand how\u2026 or why\u2026 their situational awareness was impacted.

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There are two essential reasons for this. First, many responders don\u2019t understand what situational awareness is nor do they understand how to develop and maintain it. Second \u2013 and this can be a shocker for some \u2013 flawed situational awareness is not the root cause of a\xa0near-miss\xa0(or a casualty event for that matter). Flawed situational awareness is a\xa0SYMPTOM.\xa0\u2028\u2028

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Let\u2019s address the first issue \u2013 understanding what situational awareness is.

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Situational awareness is your ability to capture and understand information about what is happening around you, in the context of place and time. Then being able to take the understanding of the information and make accurate predictions about future events before they occur. The acronym I created that may help you remember this is G-A-S.\u2028

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G\xa0\u2013 Gather information

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A\xa0\u2013 Assess the information

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S\xa0\u2013 Speculate on future events\u2028\u2028

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When you read a report (near-miss or casualty) that identifies flawed situational awareness as a contributing factor the first question you should ask is: \u201cWhat flawed the situational awareness.\u201d This is where the understanding of situational awareness becomes more complex. I have identified and researched over one hundred barriers to situational awareness. A barrier is anything that causes the loss of situational awareness or anything that keeps situational awareness from being restored once it is lost.

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Asking probing questions can help you peel back the layers and get to the root cause. For example, asking: \u201cWhat mission were the responders trying to accomplish at the time of the near-miss (or casualty)?\u201d This starts the process of peeling back the layers to allow you to understand how a deep focus on a critical mission can cause a narrowing of attention to a limited number of clues and cues. I term this situational awareness barrier \u201cMission Myopia.\u201d As you understand how mission myopia occurs and the consequences, you begin peeling back the layers and see how the same thing might happen to you. That is when the real learning occurs.\u2028\u2028

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Peeling back the layers takes the understanding of near miss and casualty events to a whole new level. In the book, Situational Awareness for Emergency Response (PennWell\xa02013, p.8) I offer the following questions to help you peel back the layers:\u2028

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.\xa0\xa0\xa0\xa0What were the responders trying to accomplish at the time things went wrong?

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.\xa0\xa0\xa0\xa0What was the overall mission of the incident, and what role were the responders playing in advancing the mission when things went wrong?

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.\xa0\xa0\xa0\xa0Why did it make sense for the responder to be doing what they were doing at the moment things went wrong?

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.\xa0\xa0\xa0\xa0What task or objective were the responders focused on that kept them from seeing the bad outcome on the horizon?

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.\xa0\xa0\xa0\xa0Were there any distractions or interruptions that drew the responders\u2019\xa0attention away from their task?

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.\xa0\xa0\xa0\xa0Did the responders understand the overall incident goals and objectives, their roles in the mission, and how other individuals or teams were going to influence the outcome?

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INFORMATION

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If you\u2019re interested in attending a live event, you can check out the Situational Awareness Matters Tour Stop schedule at:\xa0SAMatters.com. Click on the Program and Keynotes tab just below the header. Then click on the \u201cEvents Schedule\u201d tab. If I\u2019m in your area, I hope you\u2019ll consider attending a live event.

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If you\u2019re not able to attend a live event, consider signing up for the\xa0SAMatters\xa0On-Line Academy. The Academy contains videos and articles that cover the same content as a three-day live tour\xa0event,\xa0delivered in 14 modules you can go through at your own pace, from your own computer. The Academy Plus version includes four books that are referenced throughout the Academy.

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The Plus version is a great bargain because the tuition simply covers the cost of the books\u2026 making the Academy free!

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Just click on the link below the header on the\xa0SAMatters\xa0home page titled \u201cOn-Line Academy.\u201d

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SAMatters\xa0COMMUNITY QUESTION

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This question comes from an attendee of the Fifty Ways to Kill a First Responder class in Indiana.

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QUESTION: What is the impact of fatigue on first responder situational awareness?

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ANSWER: Fatigue diminishes situational awareness significantly. The\xa0impact of fatigue on all aspects of mental performance are\xa0well-documented in research. I know this answer may not be popular with responders who work 24 or\xa048 hour\xa0shifts, but the science backs my assertion that the fatigued brain does not function as well as the rested brain.

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Severe fatigue can have the same impact as alcohol, impairing coherent thought, gross motor skills and fine motor skills. Fatigue can impact reasoning, memory, recall and impact sight and hearing.

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This is a great question and we\u2019ll dedicate an upcoming episode to the topic of worker fatigue so look for that on the horizon.

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CLOSING

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Well, that\u2019s it. Episode 7 is complete. Thank you for sharing some of your valuable time with me today. I sincerely appreciate your support of my mission.

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If you like the show, please go to iTunes, and search for\xa0SAMatters\xa0Radio and subscribe to the podcast and leaving your feedback and a 5-star review. This will help others find the show.

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You can also sign up for the free\xa0SAMatters\xa0monthly newsletter by visiting\xa0www.SAMatters.com\xa0and clicking the red box on the right side of the home page.

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Be safe out there. May the peace of the Lord, and strong situational awareness, be with you always.

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You\u2019ve been listening to the Situational Awareness Matters Radio show with Dr. Richard B. Gasaway.\xa0\xa0If you\u2019re interested in learning more about situational awareness, human factors and decision making under stress, visit\xa0SAMatters.com. If you\u2019re interested in booking Dr. Gasaway for an upcoming event, visit his personal website atRichGasaway.com

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If you are interested in purchasing a copy of Situational Awareness for Emergency Response, visit SAMatters.com, click on the \u201cStore\u201d link and then the \u201cPrint Books\u201d link. I personally sign every book purchased through my store as a show of appreciation for supporting my mission. The proceeds of all book and video sales are invested back into our mission and help ensure you can continue to receive valuable articles and radio show content for free.

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NIOSH Line of Duty Death Report

http://www.cdc.gov/niosh/fire/pdfs/face201118.pdf

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Asheville Fire Department website

http://www.ashevillenc.gov/Departments/Fire.aspx

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Situational Awareness Matters!\xa0website

www.SAMatters.com

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On-Line Academy

http://www.samatters.com/situational-awareness-matters-academy/