OSHKOSH, WIS. (September 23, 2008) – The following is a summary of information pertinent to the single vehicle accident that occurred on September 23, 2008, involving an aircraft rescue firefighting (ARFF) apparatus operated by the Airport Division of the Atlanta Fire Rescue Department (AFRD) at Hartsfield-Jackson Atlanta International Airport (H-JAIA) which resulted in a vehicle roll-over and minor injuries to the AFRD personnel on board.

Background
The AFRD is the responsible agency for emergencies at H-JAIA involving structural fire, medical, hazardous materials, and aircraft rescue firefighting (ARFF). The Airport Division of AFRD operates five fire stations situated strategically around the airfield. Fire Station 24 is located in the northeast corner, fire station 32 in the northwest, fire station 33 in the south, fire station 35 in the east and fire station 40 in the mid-south.
 
The H-JAIA airfield has five parallel runways in an east/west configuration divided by a central terminal/concourse complex. There are two runways to the north of the terminal/concourse line, 8L/26R and 8R/26L, and two runways to the south of the terminal/concourse line, 9L/27R and 9R/27L. Separated by cargo, and other facilities, is the southernmost runway, 10/28. For ARFF protection the Division maintains a fleet of ten Oshkosh Striker 3000’s with two units assigned to each fire station. Each apparatus is capable of carrying 3000 gallons of water, 420 gallons of foam and 1,000 pounds of extinguishing agent.

Incident Data Time: Approximately 11:30 hours.

Conditions: Clear and sunny.

Activity: ARFF 4 responded from their base location at fire station 32 on a regularly held response drill to a dispatched location on taxiway November simulating an aircraft emergency on the airfield.

Route: ARFF 4 exited fire station 32 and proceeded south on the west Ramp 1 road which runs parallel to the main terminal and T gates. As ARFF 4 approached the intersection of Ramp 1 road and taxiway Lima the crew observed a significant number of aircraft in line for departure at the west end of runways 9L and 9R. The primary route to taxiway November from this point would require ARFF 4 to cross these runways by traveling a series of taxiways. The Officer-in-Charge of ARFF 4 elected to instead take a secondary route by accessing the non-licensed vehicle road (NLVR) which circles the airfield.

Incident: Once ARFF 4 accessed the NLVR the unit encountered a security checkpoint located just off the end of runway 9L. The gate at the checkpoint was in the up position as ARFF 4 approached and there was no other vehicle traffic on this section of the NLVR at the time. After the security checkpoint the NLVR begins a left-hand curve with a moderate downhill grade in the same direction of travel. Physical evidence from the scene and video recovered from the apparatus reveal that almost immediately after proceeding through the security checkpoint, and as ARFF 4 began to enter the left-hand curve, the rear wheels of the apparatus suddenly lose traction with the roadway resulting in the rear of the vehicle skidding to the right and the rightrear tires of the apparatus leaving the roadway. Statements from personnel on board ARFF 4, and the abovementioned evidence show that at this point an attempt was made by the driver to correct the skid and recover control of the vehicle. This resulted in the vehicle making a pronounced skid in the opposite direction causing the rear of the vehicle to move precipitously back to the left. As the vehicle continued in this skid, video shows that part of the front of the apparatus left the roadway and became momentarily suspended in the air. At this juncture the apparatus was perpendicular to the centerline of the roadway skidding out of control on a downhill grade. The speed and momentum of the apparatus then led to the vehicle rolling over and coming to res with the apparatus upside down.
 
Incident Review
After the incident a comprehensive review was conducted which involved representatives from the AFRD, the City of Atlanta Fleet Maintenance, the Department of Aviation Maintenance, and the vehicle manufacturer. The incident was also bound over to the internal AFRD accident review process. A thorough post-incident examination of the ARFF 4 apparatus revealed that, while the apparatus suffered significant damage from the accident, the major components of the vehicle such as brakes, drive-train, suspension, and engine remained essentially intact. The team involved in the examination concluded that there was no obvious mechanical malfunction that might have contributed to the accident. In addition, the review also revealed that the AFRD member operating the apparatus was a veteran employee with several years overall experience as an apparatus operator. Training records, as well, indicate achievement of requisite skills for operating the Oshkosh Striker 3000.

The video recovered from the onboard recorder was scientifically analyzed frame by frame to determine the distance the apparatus traveled measured against fixed objects found in the video.
This analysis indicates that the apparatus was traveling approximately 47 mph when the vehicle initially lost traction with the roadway. The posted speed limit in that area of the NLVR is 25 mph. This, along with the configuration of the roadway and the fact that the video clearly shows the point at which the apparatus loses traction with the roadway, as well as other physical evidence from the scene (i.e. skid marks), led to a determination regarding the speed of the vehicle to be the primary factor involved in the accident and that, therefore, the driver of the apparatus was at fault in the accident for driving too fast for conditions and failing to maintain control of the vehicle while in operation.

Lessons Learned

1. Personnel Safety: The primary lesson learned from this incident is that of personnel safety.Normally there would be no more than two personnel on any particular ARFF apparatus in the AFRD fleet, but on this particular day there was an additional firefighter receiving airport familiarization training for a total of three personnel on board. The AFRD has a written policy requiring the wearing of seat belts anytime the apparatus is in motion. All three personnel were secured in their seat belts at the time of the incident. From observations of the incident scene it is evident that the force of this accident was sufficient to have caused major bodily injury. Although all three personnel sustained minor injuries (a fractured wrist, a sprained back and a bruised shoulder) it is clear that the proper wearing of seatbelt harnesses prevented serious or fatal injuries from befalling our personnel.
    
2. Safe Driving Practices for ARFF type Apparatus: All of our organization’s apparatus operators are required to complete rigorous training courses for each specific type of apparatus that the individual will be operating, or that the department maintains in its overall fleet. A training course was developed specific to the Oshkosh Striker 3000 and its particular functions and capabilities. While this course has many appropriately developed modules, a review indicated that information related to the physics of carrying large amounts of water on board an apparatus and the proper and safe driving techniques for such apparatus were not given sufficient priority and focus. Additionally, standing AFRD SOP specifies that apparatus responding during emergencies should not exceed 10 MPH above the posted speed limit. For ARFF apparatus that is equipped with a G-Force detection and warning system the speed of the vehicle should be reduced any time the detection warning device is activated.
    
3. Operation and Maintenance of Specialized Vehicle Safety Systems: Post-incident analysis revealed that there were several anomalies regarding the operation and maintenance of on-board vehicle safety systems. All of the Oshkosh Striker 3000s in the AFRD fleet are equipped with three primary vehicle safety systems: The data logging system which is similar in function to an aircraft black-box. When certain environmental factors are encountered the data logging recording feature is activated and all data collected immediately before and after the event is saved and the device is locked until such time as the data is downloaded and the unit reset. The vehicle also has a tri-axial G-Force detection and alerting system (lateral, axial and vertical), and an on-board video recording system. A review of the entire fleet revealed that the systems on several apparatus were not being properly maintained and were not in prime working condition.
   
   The systems on ARFF 4 were operational; however, the MADAS had been tripped (and locked) by an event that occurred prior to the September 23, 2008 incident. Thus, we were unable to use any data that the MADAS system may have provided to analyze the cause of the accident.
    
4. Technician Training: Modern fire apparatus, as the rest of the automotive industry, is becoming more technical in nature. When an organization purchases new apparatus from a manufacturer that they have not worked with before, or have not worked with in a significant amount of time, it is imperative that the organization take advantage of all training opportunities offered by the manufacturer in order to thoroughly familiarize themselves with the apparatus, the components comprised therein, and especially the highly technical systems that are peculiar to that type of apparatus. Review of this incident revealed that training offered by the apparatus manufacturer specifically related to the operation and maintenance of specialized safety systems was not acted upon by representatives of our municipality.

Corrective Actions

1. Safe Operation and Maintenance of Apparatus: Members of all agencies involved in the operation or maintenance of fire apparatus were reminded that at no time should an apparatus be operated where systems that monitor the safe operation of that vehicle are not fully functional.  Fire personnel were instructed to immediately take any apparatus out of service where a maintenance issue exists that compromises the safe operation of the vehicle.
    
2. Apparatus Training: Supplemental training was administered to all airport personnel on the specifications of the Airport Division’s ARFF fleet. The training focused on the limitations of ARFF apparatus, the benefits of safety systems- in particular the G-Force force detection and alerting system, and the danger of a rollover incident in apparatus that carries significant amounts of water on board. Members were directed to be expedient in their response to alarms, but to do so in a manner that does not compromise standing policy of the organization, safety, or the limitations of the apparatus they are operating. Modules related to these issues are being developed and will be included in future training for ARFF apparatus.
    
3. Periodic Maintenance of Apparatus and Systems: Training was given to apparatus technicians on all of the safety systems on how to test and diagnose equipment and the procedures for getting any needed repairs done in an efficient and timely manner. These systems were also added to the items that are routinely checked during periodic maintenance cycles for all ARFF apparatus.
    
4. Daily Apparatus Checklists: Visual checks and diagnostics for the apparatus safety systems that can be performed by fire personnel were added to the department’s daily apparatus checklist.
   Personnel identifying any such issue with these systems during apparatus inspections are directed to immediately report the matter to the company officer. A work order will then be promptly executed to report the issue and start the process for corrective action.

In conclusion, this was a traumatic incident, especially for the members directly involved, but also for the organization as a whole. On a positive note, the incident highlighted the benefits of following the safety protocol regarding seat belts. The incident also brought to light some troubling practices related to safety equipment training and procedures, as well as operator training, that contributed to the circumstances in which an incident such as this could occur. We are reminded that policies and procedures related to the safe operation and driving of fire apparatus must be adhered to at all times. In order for our dedicated members to make a difference during the mitigation of emergencies they must first arrive on the scene safely. Safety is paramount and cannot be compromised.

I encourage each of us then to carefully review the circumstances of this incident. Let it be an educational tool to closely scrutinize the lessons learned and corrective actions put in place to prevent another such occurrence. And let us together be vigilant in the safe execution of all our duties and responsibilities as professional firefighters.