In an earlier post I mentioned that three UK incident controllers were being prosecuted over the deaths of four firefighters. Fear of prosecution may well have caused an unnecessary death as reported in the UK’s Mail Online: ‘Left to die by the health and safety jobsworths: Mother who fell 45ft down mine shaft wasn’t rescued – because firemen were told life-saving gear would break the rules’.
The gist of the story is that a senior officer arrived on scene where a woman had fallen down an old mine shaft. A firefighter had winched down to her and a paramedic was preparing to do the same. The incident controller ordered the paramedic not to proceed and refused to allow the fire service to winch the victim to the service. This decision was confirmed by two subsequent incident controllers; the fire service chose to wait some four hours for the accredited police rescue squad to arrive and conduct the rescue. The effects of the delay and hypothermia caused the victim to die shortly after being brought to the service.
The Mail Online reports one of the incident controllers ‘refused to allow colleagues to rescue her using ropes because they had not received the correct training. Mr Stewart feared they could be sued if the mission failed.’
Not surprisingly, the paper’s reports may have oversimplified the situation – fire fighters wanted to conduct the rescue but were stopped by rule bound administrators – the reality is not that simple. For further comment see the Response from the Strathyclyde Fire and Rescue. A summary of the Sherriff’s report is available, along with a link to the full report.
The Sherriff (effectively equivalent to our Coroner) found that
It was evident from the first attendance of the Strathclyde Fire and Rescue Service and the Police that any rescue attempt would present a significant challenge to the rescue and emergency services: the terrain was soft and the land was un-illuminated, there was a significant incline to the summit of the hillock, the vegetation surrounding the hole into which Mrs Hume had fallen was dense and high, and conditions were foggy and extremely dark. In addition, there was uncertainty about the stability of the base and sides of the shaft or hole, and doubt as to the integrity of the land surrounding the shaft or hole; there also appeared to be an overhang of earth around the surface of the hole. Further, the cohesion of the site and the depth of the hole could not, initially, be ascertained.
In the circumstances it is unhelpful to say that rescuers should, without regard to their own safety, use equipment that was not designed for such a complex rescue to achieve a good outcome. A risk assessment was undertaken and it was decided that a paramedic, untrained in rope rescue techniques, should be lowered into the hole. The senior fire officer determined that the paramedic’s
… descent into the hole had not been properly risk assessed, that the stability of the environment in general had not been risk assessed, and that, in his view such were the serious deficiencies in the conduct of the operation to this point and that there was great potential for catastrophic consequences in the event of further land displacement.
He refused to allow the procedure to go ahead. The Sherriff concluded
The task facing Strathclyde Fire and Rescue Service should not be under estimated. They were called to a unique incident which required skills which did not immediately fall within their range of training and expertise. Whilst the weather was not inclement, they were impeded by darkness, by dense undergrowth, by soft under-foot conditions, by ignorance of the terrain and its potential for instability and by the magnitude of the hole into which Mrs Hume had fallen.
In essence the Sherriff found there were significant short falls in the response but not that the decision to use specialist services, or to take steps to protect rescuers was wrong. There was a need to protect the rescuers, the fault lay with the procedures of the fire service that required them to call the police rescue service rather than other specialised services, such as mine rescue services, that could have responded sooner or assisted with an assessment of the mine and its stability. The fire service did not have in place sufficient plans on how to deal with these situations, which were foreseeable given there were over 4000 historical mine workings in their area of responsibility. Had they pre-planned for mine rescue they would have identified other relevant rescue services, such as the Mines Rescue Service and the Scottish Cave Rescue Organisation as being services that could be called upon to assist.
The Sherriff was critical of the incident managers who ‘considered that the rescue operation was “a success” [because they] … adhered to the policies and procedures set out by Strathclyde Fire and Rescue Service… There had been no casualties other than the one to whom the Service was called upon to rescue.’
In one sense we can commend the officers for that action. Emergency services have to conduct prior risk assessment and for that purpose put in place policies that they expect their staff will follow. If the service has determined that equipment is not safe for a purpose, they expect that it will not be used for that purpose. If the officer had chosen to use equipment or act contrary to policy, and a firefighter had died, he would have been in front of a different fatal accident inquiry (FAI) having to explain why he took action that the service had expressly determined should not be taken.
On the other hand, this appears to be a tragic misunderstanding of OHS regulation ( though in these comments I shall limit my discussion to Australian law, including the uniform OHS law that is due to be implemented across Australia in 2012). Modern OHS law does not focus on strict rules – ‘you must do…’ or ‘you must not do …’ rather the focus is on risk assessment. Considering the potential consequences, the likelihood of the poor outcomes and what steps can be reasonably undertaken to deal with the risks (Model Work Health and Safety Bill (23 June 2011) s 17). What is reasonable must take into account the nature of the task including the inherent risks to workers (which will include volunteers) (Model Work Health and Safety Bill (23 June 2011) s 18).
For most events that the emergency services attend, the risk assessment is done well in advance. The emergency services have determined that there are risks to their staff so they issue PPE, have Standard Operating Procedures and provide equipment to do the sorts of things they do everyday, with safety. Staff and volunteers are trained and expected to comply with their training. Untrained people should not use equipment or attempt tasks that they are not trained to do as that is exposing them to an unnecessary risk; so special units (whether its HAZMAT, Breathing Apparatus, confined space rescue, helicopter rescue, ambulance Special Casualty Access Teams, Police SWOS teams etc) exist and are called upon to perform their specialist tasks. It would be usual practice to wait for those teams to come and perform their specialist tasks. So far that sounds like what happened here. The controller attended, determined that the task was outside the training and skills of the team on scene, and waited for the appropriate rescue squad. What does not appear to have happened is a true risk assessment. That is asking ‘given the delay in the police response, what might happen to the victim, what can we do about it, and how can we manage the risk to our staff?’
As the Sherriff said
For a rescue to be achieved, some imagination, flexibility, and adaptability were necessary. There was clearly a balance to be struck between the interests and safety of the rescuers, and those of the casualty they were there to rescue … [I]n my view, there was a preoccupation with adherence to Strathclyde Fire and Rescue Service policy which was entirely detached from the event with which Strathclyde Fire and Rescue Service were confronted… The core consideration of a risk assessment is a question of whether or not the risks to be taken are proportionate to the benefits gained.
It is difficult not to form the view that [the]… approach to risk assessment was to effectively eliminate risk. I did not think that a process of risk assessment was adopted whereby risks were identified and those risks accommodated to achieve the central purpose of the attendance of Strathclyde Fire and Rescue Service. In other words, by identifying the risks evident in a given situation or to be reasonably apprehended from a set of given circumstances there should have been a positive and more constructive way to overcome those perceived difficulties and attempt a rescue. That was not the approach which was taken in Mrs Hume’s rescue.
This sort of approach is, in my view, consistent with Australian OHS legislation (see also my article ‘Changes to occupational health and safety laws and the impact on volunteers in the emergency services’ in the November 2011 issue of the Australian Journal of Emergency Management).
The reality is that incident controllers are in a very difficult position. Many people are in positions where they have to try to balance competing objectives and considerations to decide what to do. Unlike emergency service incident controllers, they don’t have to do it in a dynamic environment where, whatever they decide, lives are in the balance. Whatever they decide, if someone dies, they are going to be at least required to answer questions to justify their decision.
As a community it appears we simply don’t accept ‘unplanned outcomes’ by our emergency services. They have to affect the rescue with no other injuries; anything less is unacceptable. Unfortunately crews at the scene can’t know how the event will play out, so they have to make a judgement call.
Disregarding policy and safety, a cowboy approach, is unacceptable as is a rigid adherence to policy that simply is not applicable in the circumstances of the actual event. Risk management policy has to equip, empower and help managers make decisions about how to respond to an actual event – to identify factors that should be considered and competing considerations but leave it to incident controllers to make the final judgement call. Even then we will end up with consequences we don’t like, lives lost, homes burned, people allowed to die because the assessed risk to rescuers exceeded the likely benefit. We like to portray rescuers as ‘heroes’ (consider the movies ‘Backburn’ and ‘Ladder 52’, and reading US firefighting web sites suggests that US firefighters like to see themselves as soldiers, willing to die for their cause)but the partners and children of firefighters want their loved ones to come home.
The answer is not, however, to remove obligations upon firefighters and emergency services to take steps to protect health and safety. What is required is better understanding of what that means. It does not mean that safety must be guaranteed. In this incident the ‘approach to risk assessment was to effectively eliminate risk’ but that was not required by UK law and is not required by Australian law. What is required is a process to measure the risk against the benefit.
8 December 2011.