Posted By Near Miss Team/ Monday, January 7, 2019 / Print
The engine was dispatched to a medical aid incident. After realizing they were busy with station duties, two other companies both said they would take the call for them. This miscommunication led some firefighters to think they would not be responding to the call. One member was the tiller operator on a truck. The remainder of the truck company made their way down to the truck and proceeded to get ready to leave. The truck has a failsafe built in, an engine start switch in his/her cab. The starter button is there to prevent the driver from starting the engine or leaving without the tiller member. There had been paper wedged into the start switch inside the tiller cab, and this allowed the engineer to start the engine with or without anyone seated in the tiller operators seat. Before the engineer began to leave, he asked: "you guys ready?". At the same instance, a warning light started to flash indicating a door was left open somewhere, and the crew began to close the doors to fix the issue. This distraction was enough to allow the engineer to miss the fact that not everyone had replied "ready." Once the flashing stopped, the engineer failed to confirm again that everyone was ready. The truck left the apparatus bay and started to drive down the street. The trailer portion began to get out of alignment for no reason, which was enough to clue the engineer and the captain into the fact that the tiller operator was not in the back steering. The engineer immediately stopped the apparatus, and the captain jumped into the tiller seat to safely operate the truck. No damage was done, and there were no injuries.
Describe the lessons learned at this event. What recommendations do you have to prevent a similar occurrence?
The engineer and tiller operator should always confirm by voice they are both ready; The sensors and warnings in the apparatus should be utilized to confirm members are seated; Safety mechanisms and fail safes should never be tampered with.
What changes are being implemented due to this event?
An email was sent to all members about the near miss and how it can be avoided in the future.
Describe the leading practices you noticed at this incident:
Date the event occurred:
Approximate time the event occurred:
Location of the emergency/ event:
Was a 360-degree size-up performed?
List any other info that was important for situational awareness. What were key indicators and factors to consider?
Always have voice confirmation with the tiller member before moving; Always check all seat sensors to confirm all members are seated; Never tamper with safety devices or fail safes.
Were unsafe act(s) performed?
Categorize the unsafe act:
Human Error (actions unintentionally committed
Explain the unsafe act:
The tiller operator fail safe engine start switch was tampered with allowing the engineer to start the engine by himself
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