Organizational Learning from Post Incident Analyses

Technical BulletinLast updated Monday, August 8, 2011
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The problem studied for this applied research project was that the Montgomery County Fire and Rescue Service (MCFRS) had endured seven fireground Mayday incidents, resulting in ten significant firefighter injuries since the implementation of the Standard Operating Procedures for Safe Structural Firefighting Operations in 2005. The purpose of this applied research project was to determine if MCFRS is learning the lessons needed to prevent critical fireground injuries and death. The descriptive research method was used, which included a literature review and a meta-analysis of MCFRS post-incident analyses published over the past six years.

The research questions were: how did MCFRS's post-incident analysis process compare to national standards and best practices; what were the causes of the Maydays and resulting firefighter injuries; what warnings were indicated in previous post-incident analyses, and what recommendations were made in the previous post-incident analyses that may have averted the Mayday incidents and resulting firefighter injuries? The literature review developed into a comparison matrix to compare the MCFRS process with other processes. The meta-analysis produced quantifiable data for analysis on the causes of Maydays and fireground injuries, and the warning signs and recommendations from previous post-incident analyses. The results showed that MCFRS meets NFPA standards for post-incident analysis and is comparable to FEMA guidelines, but needs to integrate other best practices.Failure to maintain crew integrity and failure to recognize the fire conditions and effects on structural components are the causes of the Maydays and resulting injuries. There were adequate warning signs and recommendations in previous post-incident analysis that could have averted the aforementioned Maydays. It is recommended that MCFRS update its post-incident analysis process based on best practices. Additionally, MCFRS needs to integrate a culture of risk assessment into its initial fireground operations.

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