56 lines
4.0 KiB
Markdown
56 lines
4.0 KiB
Markdown
# Misstep led to death of two firefighters
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- **期号**: SRE Weekly Issue #24（2016-05-22）
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- **作者**: —
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- **链接**: http://www.iol.co.za/news/south-africa/gauteng/misstep-led-to-death-of-two-firefighters-2022089
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## 简介
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Having a standard incident response process is crucial. When we fail to follow it, incidents can escalate rapidly. In the case of this story from South Africa, the article alleges that the Incident Commander led a team into the fire, rather than staying outside to coordinate safety.
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I believe that mistakes during incident response in my job don’t lead directly to deaths now, but how soon before they do? And are my errors perhaps causing deaths indirectly even now? (Hat-tip to Courtney E. for that line of thinking.)
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## 正文
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# Misstep led to death of two firefighters
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**How The Star reported on the incident.** How The Star reported on the incident.
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Johannesburg - One vital step in the standard operating procedures of City of Joburg Emergency Management Services (EMS) firemen was missed a year ago today.
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And it was that missed step that caused a ripple-effect in the mismanagement of a fire in the seven-storey Nedbank Mall in Albertina Sisulu Street in the inner city that claimed the lives of two firemen, Michael Letsosa and Dan Zwane.
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But nobody has been held to account for this yet.
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On Sunday, neither the city nor the EMS management could name the person responsible for the misstep, or say what action would be taken against them and when, despite having concluded three investigative reports detailing where things went wrong.
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Authorities could say only that the EMS would need to conduct another investigation to determine culpability in the incident.
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The head of public safety for Joburg's EMS Hlula Msimang explained what should have, but didn’t, happen on the night of May 16 last year.
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“Once an incident is reported, and an incident commander arrives on the scene, their job is to appoint a safety officer. The safety officer’s job is to ensure that the firefighters arriving are properly dressed, properly equipped and that the building is safe to enter.
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“If the incident commander doesn’t do that, challenges like these happen... if one element is breached, it has a ripple effect on how an incident is managed.”
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However, on the night in question, according to the city’s overall report, the first arriving crew found dark smoke billowing out of the mall's parking basement.
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During the deployment of crews, a breathing apparatus team led by the incident commander became “fragmented”, with individual members becoming disoriented and lost.
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The incident commander got out of the building but his two colleagues died in it.
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At the time, The Star reported on allegations within the department of equipment shortages and unavailability of the required resources to conduct active fire-fighting. Three days later, The Star also reported that a firefighter at the scene said the incident manager was supposed to have stayed outside the building, ensuring the men had a guideline from which to work, also ensuring they had enough oxygen, and checking that they emerged safely.
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On Sunday, member of the mayoral committee for public safety Sello Lemao revealed more damning findings in what he called an “unprecedented occurrence”.
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A chilling finding was that the personal-alert safety system devices which each firefighter carried were not activated. The device tracks a firefighter’s movement through a building and beeps when they don‘t move.
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“The devices weren’t on so when the two collapsed, they couldn’t be located by the rescue team,” Lemao said.
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Among others, the EMS had failed to implement an incident command system.
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**The Star**
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