OBJECTIVES OF MY PRESENTATION ARE
- share some OBSERVATIONS based on 10 years experience evaluating hazardous materials emergency responses in transportation accidents,
- give a short EXPLANATION describing how I reached the conclusions I'll be sharing,
- describe my findings, arid
- ask your support with efforts to improve management of future hazardous materials emergency responses.
I PLAN TO DISCUSS
- THE 1971 DISCOVERY THAT FIREFIGHTERS WERE BEING PROGRAMMED TO GET INTO TROUBLE DURING EMERGENCIES;
- THE GRADUAL DISCOVERY OF REASONS FOR THIS SITUATION
- THE PERSONAL CHALLENGES INVOLVED, AND
- WHAT HAS BEEN ACCOMPLISHED SINCE THEN
REDEFINING THE PROBLEM
First step was to RECOGNIZE there was a problem.
- Houston TX 1971: the first 5 mm of BLEVE movie are now history; I'll never forget the first time I saw it, or when Mr. Crowder of the Houston Post agreed to let me use the footage to the Safety Board's hearing because he too recognized its potential safety value.
- But, the Houston accident really troubled me; how could a training officer get killed and 39 well trained fire officers and firefighters in the 8th largest metropolitan area in the nation, with a reputation for hazardous materials emergency response leadership, get hurt in a typical railroad hazmat accident,
MANAGING THE DISASTER SCENE
- Concern intensified as I realized their injuries were being accepted as a hazard of their jobs, and that nothing would really change unless an outsider tried to do something!
- Felt somebody had to do something that this kind of injury was really was not inevitable! So I went to work.
- when I understood what was going on, I suddenly realized that the safety problem was not the firefighters, or even their trainers, but rather the programs trainers were using, and the technology behind that training:
- Even more dismaying to me was the discovery that nobody was trying to tie the experience back to the advice on which the training was built: we had, in effect, an open loop, that is a situation where pronouncements were being made, but no effort was being made to determine if they were right or wrong!
REASONS FOR THE PROBLEMS
As I worked on the questions, I discovered a lot of reasons that helped explain why Houston happened.
The reasons included:
Other findings included
- shaky assumptions. These assumptions were that:
- hazardous materials emergency responses objectives were understood: they weren't
- roles of involved persons were understood: they weren't
- decision making process was understood: it wasn't
- data needed for emergency response decision making was understood: it wasn't
- testing of cook book instructions against the way they were interpreted or
results they produced in actual emergencies was not needed: it was
- criteria to evaluating what training was effective and what was ineffective before trainees are confronted by an emergency were known and used: they weren't.
- Shippers knew from "predictive*' analyses of hazmat behavior in emergencies what the best response actions should be: they didn't.
- technical basis for developing training was understood: it wasn't.
- suitable training approaches were available: they weren't
- accident data deficiencies inhibited getting help from accidents; so NTSB started doing HAZARDOUS MATERIALS SPILL MAPS
- BLEVE covers only one commodity group: more groups need to be covered
- Incomplete, inconsistent and inadequate guidelines and technical advice are being offered firefighters
- The vital role of adequate safeguards which protected against harm before hazardous materials first responders arrived at the scene
- many of the problems stemmed from unsystematic analyses
- criteria to help distinguish what response ideas and training produce better outcomes from what does not produce better outcomes are desperately needed!
THE PERSONAL CHALLENGE
Once I understood the reasons, life didn't get any simpler. I felt a professional and personal challenge. My challenge:
- to figure out a better way to analyze, handle, explain and teach hazardous materials emergency responses andŽ
- to figure out how to tell if the new was better;
- In other words, give something to firefighter trainers that would really make a difference in outcomes.
WORK AT MONTGOMERY COLLEGE UNDER BRANNIGAN
Frank Brannigan offered opportunity to develop the ideas
- with the help of some very patient students/firefighters, a new approach to thinking your way through emergencies was developed
- models representing several aspects of hazardous materials emergency responses were developed, which led to principles for better responses
- applied them in accident investigations; helped define problems and test principles more precisely
- models and new principles were tried out on students to see how they could be taught
- adjusted ideas, based on their feedback
- settled on new objectives that provided criteria to use to test response effectiveness
Developed special new technical tools to do the job, including:
- EVENTS CHARTING methods to guide data collection and organize analytical data;
- TIME/LOSS ANALYSIS method to evaluate effectiveness of response actions, and understand roles of safeguards and hazardous materials emergency responses specialists
- decision making model of hazardous materials emergency responses process, so data needed and resultant decisions could be understood and taught
- Model of hazardous materials emergencies to help explain what an emergency was, so roles could be understood and taught
- Use of pattern recognition methods to predict how hazardous materials behave in an emergency, to help explain and teach prediction efforts
- Laws and principles that had general application in hazardous materials emergency responses and could be taught to help think way through any emergency
- Data format for conveying historical accident data so it could be applied to teaching the analytical, planning and operation tasks to the individuals involved in emergency responses.
WHERE ARE WE TODAY
Progress has been made, BUT
- Though usually less frequent and severe, these hazmat accidents still happen.
(Report NTSB conclusions and Mississauga recommendation)
- its 1981 and we still have serious problem
For fire service managers and trainers,
- APPLYING the improved METHODS for ANALYSIS, and CRITERIA for EVALUATION:
PROBABLY THE MOST CRITICAL HEEDS FACING the fire service today!!!
- For command officers, PRACTICING THE TRAINING PERIODICALLY to see if it
produces better outcomes is essential.
And I believe that simulations of past emergencies under the direction of the command officers who will be involved, using principles with general application to any emergency, offer a better way to prepare for Hazmat emergencies than teaching chemistry and cookbook methods that have to be remembered and interpreted under duress
The Standardized hazardous materials spill maps put out by NTSB provide a basis for doing this.
Let's take a look at these maps now.
(SHOW NTSB MAP SLIDES)
Now, let's take a look at some of the more important principles that have been developed.
(MOD 2 SLIDES)