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FIRE ENGINEERING June 2009 79www.FireEngineering.com
B Y K R I S T I N A P E T E R S O N , H A R L A N
A M A N D U S , a n d J A M E S T. WA S S E L L
The fi ndings and conclusions in this report are those of the au-
thors and do not necessarily represent the views of the National
Institute for Occupational Safety and Health (NIOSH).
O
VER THE PAST THREE DECADES, VEHICLE-RELATED
crashes have been the second leading cause of fi re-
fi ghter line-of-duty deaths (LODDs). About a quarter
of on-duty fi refi ghter LODDs occur in motor vehicle-related
incidents and crashes, many while responding to or returning
from an incident. More than a third of those deaths involved
fi refi ghters’ personal vehicles, and three-quarters of the
victims
were volunteer fi refi ghters.1 Motor vehicle-related incidents
primarily involve collisions (including those involving aircraft
and boats) and rollovers (see “Fire Truck Rollover”). Other

fatal events include falls from a vehicle or being struck by
a vehicle while working at an emergency scene where the
vehicle plays a key role in the fatality. (1)
Most of the crashes involve personal vehicles or tankers.
Most of the victims are volunteer fi refi ghters. (1) For
example,
personal vehicles were involved in more than a third of fi re-
fi ghter road crash fatalities from 1977 through 2006. (1) Some
deaths are caused by falls from fi refi ghting apparatus while re-
sponding to or returning from alarms (see “Fatal Fall”). Deaths
from falls have reoccurred in recent years after virtually disap-
pearing during the 1990s. (1)
Motor vehicle crashes have increased over the past three
decades relative to other safety issues. While the average num-
ber of annual fi refi ghter deaths dropped by one-third between
1977 and 2006 (1), the average number of fi refi ghter deaths
caused by crashes has not changed much over this period.
The National Fire Protection Association (NFPA) found that

over the past 30 years, many of the fi refi ghter fatalities caused
by motor vehicle-related crashes may have been prevent-
able. The NFPA noted that “of the 406 victims [of road vehicle
crashes], 76 percent were known not to be wearing seat belts
or using restraint systems. Only 13.3 percent were wearing
seat belts or using other restraints.” (1) In 2007, for example,
the NFPA found that 25 fi refi ghters were killed in motor ve-
hicle crashes while riding to or from an incident. Eleven of the
victims were not wearing seat belts, and excessive speed was
a factor in at least six of these crashes.2 The 30-year trend in
on-duty fi refi ghter deaths is shown in Figure 1.
INVESTIGATING ON-DUTY FATALITIES
NIOSH investigates on-duty deaths and injuries. Investi-
gators from NIOSH’s Fire Fighter Fatality Investigation and
Prevention Program (FFFIPP) visit the site, interview the fi re
crew and offi cers, and try to determine the causes of the crash
(see “FFFIPP”).
NIOSH REPORTS
Each investigation results in a report that describes what

happened and why and includes recommendations for pre-
Reducing Firefi ghter
Vehicle Crash Fatalities
Fire Truck Rollover
(1) Fire truck rollover. (Photo courtesy of NIOSH and County
Sheriff’s Offi ce.)
On July 8, 2008, a 25-year-old male volunteer fi refi ghter
(the
victim) was fatally injured after being ejected in a fi re truck
rollover. The crash occurred as the fi re truck was returning to
the station after a call for a propane gas fi re. The driver lost
control of the fi re truck, swerved off the left side of the road,
returned to the pavement, and overturned on the right side
of the road. The fi refi ghter was the only truck occupant. The
victim was transported to a local hospital, where he died from
his injuries. National Institute for Occupational Safety and
Health (NIOSH) investigators determined that lack of seat belt
use and inadequate driver training were among the contribut-
ing factors in the victim’s death.

Reference: NIOSH (2008). “Fire Fighter Dies After Being
Ejected from
a Pumper in a Single Vehicle Rollover Crash - New York,”
Morgantown,
WV: U.S. Department of Health and Human Services (HHS),
Public
Health Service (PHS), Centers for Disease Control and
Prevention (CDC),
NIOSH Fire Fighter Fatality Investigation and Prevention
Program Report
No. F2008-25.
1
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venting future injuries or fatalities. NIOSH has issued hun-

dreds of recommendations since the FFFIPP program began in
1998. They are based on scientifi c fi ndings and on recommen-
dations adopted by experts, such as NFPA and OSHA. NIOSH
recommendations address many topics including training,
motor vehicle safety, and apparatus specifi cations.
As a safety research agency, NIOSH encourages fi re depart-
ments to adopt these recommendations and to follow them.
Individual fi re departments can use the FFFIPP recommenda-
tions as tools to develop an effective safety program.
NIOSH also publishes Alerts, which briefl y present new
information about occupational illnesses, injuries, deaths,
and other documents that summarize patterns and lessons
learned from similar incidents. Periodically, NIOSH mails the
LODD investigation reports, Alerts, and other documents
to the nation’s fi re departments. They are also available at
http://www.cdc.gov/niosh/fi re/. The list of reports can be
found at http://www2a.cdc.gov/NIOSH-fi re-fi ghter-face/state.
asp?state=ALL&Incident_Year=ALL&Submit=Submit.

MOTOR VEHICLE SAFETY RECOMMENDATIONS
The most common FFFIPP motor vehicle safety recommen-
dations for fi re departments involve seat belt use, driver safety,
and driver training3 and are presented below.
Seat Belts
• All fi refi ghters riding in emergency fi re apparatus should
wear seat belts and be belted securely.
• Fire apparatus drivers should not move vehicles until all oc-
cupants in vehicles are secured with seat belts.
Driver Safety
• Drivers of fi re department vehicles should understand that
they are responsible for the safe and prudent operation of
the vehicle under all conditions.
• Drivers of emergency fi re apparatus should come to a com-
plete stop at intersections having a stop sign or a red signal
● CRASH FATALITIES
Fatal Fall
(2) Victim seating area and door. (Photo courtesy of NIOSH and

the Texas State Fire Marshal.)
On April 23, 2005, a 27-year-old male career fi refi ghter
(the victim) sustained a fatal head injury when he fell from
an enclosed-cab quint. The incident occurred shortly after
leaving the station while the truck was en route to a reported
structure fi re. It is believed the victim reached to close a rear
passenger door that had opened during a turn to the right
when he fell out of the quint and landed on the pavement.
The victim was treated at the scene and transported to a local
hospital by ambulance. He died from his injuries two days
later. NIOSH investigators determined that the victim was not
secured in a seat belt at the time of the incident and that this
was a contributing factor in his death.
Reference: NIOSH [2006]. “Career Fire Fighter Fatally Injured
in Fall from
Apparatus—Texas.” Morgantown, WV: U.S. HHS, PHS, CDC,
NIOSH
Fire Fighter Fatality Investigation and Prevention Program
Report No.
F2005-15.
2

FFFIPP
Investigators from the NIOSH FFFIPP visit the LODD incident
scene to take photographs and diagram the area. They obtain
reports from or speak with other entities having jurisdiction
of the incident such as police, fi re marshals, and the Occupa-
tional Safety and Health Administration (OSHA). Investigators
travel to the fi re department to interview emergency person-
nel who were on the scene at the time of the incident and
obtain department standard operating procedures (SOPs) and
training records. They gather weather data, road conditions,
and all other documentation required to determine the cause
of the fatality.
Source: Reprinted with permission from NFPA Journal® 2007
(Vol. 101,
#4) copyright © 2007, National Fire Protection Association,
Quincy, MA.
All rights reserved.
Figure 1. On-Duty Firefi ghter
Deaths in Road Crashes
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__________________________________
http://www.cdc.gov/niosh/fire
http://www2a.cdc.gov/NIOSH-fire-fighter-
face/state.asp?state=ALL&Incident_Year=ALL&Submit=Submit
FIRE ENGINEERING June 2009 81www.FireEngineering.com
CRASH FATALITIES ●
light before proceeding through the intersection.
• Drivers of fi re department vehicles should come to a com-
plete stop at all unguarded railroad grade crossings during
emergency response and nonemergency travel.

• Apparatus operators and personal vehicle drivers should
observe all applicable traffi c laws when responding to emer-
gency situations.
Driver Training
Apparatus operators and drivers of fi re department vehicles
should receive initial driver training, including classroom and
practical, on every vehicle and apparatus they will be required
to operate and, at minimum, refresher training at least twice
annually thereafter.
EVALUATING THE EFFECTIVENESS
OF FFFIPP RECOMMENDATIONS
In 2006, NIOSH completed a comprehensive review of the
FFFIPP to assess whether the investigation fi ndings have been
effective in getting information out to the fi re service and if
the recommendations have improved safety practices. Fire-
fi ghters were surveyed to fi nd out if they are aware of specifi
c
recommendations and if they follow them. More than 3,000
fi re departments were contacted in the national survey. We

also held a series of focus groups with frontline fi refi ghters.
Their responses revealed some important fi ndings. The evalu-
ation was conducted by RTI International, a trade name of
Research Triangle Institute, under a contract with CDC/NIOSH.
THE 2006 FIRE DEPARTMENT SURVEY FINDINGS
Seat Belt Use
FFFIPP investigations show that, on average, three-quarters
of the fi refi ghters killed in motor vehicle crashes while re-
sponding to or returning from alarms were not wearing seat
belts. The survey results show that less than two-thirds of
fi refi ghters regularly follow NIOSH’s seat belt recommenda-
tions. Only about 58 percent of fi refi ghters use their seat belts
“most of the time” or “always.” Firefi ghters who are most
likely
to use their seat belts while riding in emergency vehicles are
those in large urban jurisdictions (50,000 or more persons
protected), those in career fi re departments, and those in the
western states (Colorado and westward, including Alaska and
Hawaii).

One reason for the lack of seat belt compliance could be the
lack of suitable equipment. One-quarter of all fi re departments
reported that their fi refi ghters are not able to fi t comfortably
in their seat belts while wearing turnout gear in emergency
vehicles. Large urban departments are more likely than small
rural departments to say that fi refi ghters are not able to fi t
comfortably in their seat belts.
Other fi refi ghters may not be using their seat belts because
they are not required to do so. Although most fi re departments
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(84 percent) require fi refi ghters to wear
seat belts while in emergency vehicles,
about 16 percent of departments do not.
Departments that have had a FFFIPP
investigation of a fi refi ghter fatality are
more likely to require seat belt use. In

addition, fi re departments in the west-
ern region of the country have shown
the greatest compliance in requiring
the use of seat belts among fi refi ghters,
whereas departments in the Midwest are
the least likely to comply with seat belt
recommendations. One out of four of the
midwestern departments fails to require
seat belt use while riding in emergency
vehicles. Fire departments in large urban
jurisdictions appear to be better about
requiring seat belt use, and career fi re de-
partments are more likely than volunteer

departments to require seat belt use.
Driver Training
FFFIPP investigations also show
that most fi refi ghter fatalities in road
crashes could be prevented by wear-
ing seat belts, obeying traffi c laws, and
controlling driving speeds. Most fi re
departments ensure that fi refi ghters
responsible for driving emergency ve-
hicles receive vehicle operations training
before being allowed to operate emer-
gency vehicles. Firefi ghters in most fi re

departments also receive refresher driver
training once or more per year. Overall,
84 percent of the nation’s fi re depart-
ments require driver training. In about
14 percent of departments, training is
offered, but it is optional.
Departments where driver train-
ing is more likely to be optional are
most often in the Midwest. By region,
the proportion of departments where
driver training is optional is as follows:
Midwest, 23.7 percent; Northeast, 19.7
percent; South, 16.1 percent; and West,

10.9 percent. Other departments that
make driver training optional tend to
be in small (fewer than 5,000 persons
protected), volunteer, or rural jurisdic-
tions or in departments that never had
a FFFIPP investigation. Driver safety
training is more likely to be required
most often in career, urban, or large
(more than 50,000 persons protected)
jurisdictions or in jurisdictions that had
a FFFIPP investigation. Driver training is
required least often among departments

in the Midwest. Departments that use
the FFFIPP recommendations in their
training sessions tend to be large career
fi re departments and departments in the
northeastern and western states. Depart-
ments in urban and larger (more than
5,000 persons protected) jurisdictions
are more likely to offer refresher driver
training.
In focus group discussions, frontline
fi refi ghters said that there is room for
improvement in the driver training pro-
vided and that they need to be trained to

the “class of the vehicle.” Home respond-
ers (from the volunteer fi re service) also
need additional training in department
safety requirements for responding to
emergency calls using their personal
vehicles.
Many fi re departments have used
FFFIPP recommendations to train
fi refi ghters on traffi c hazards and to
develop SOPs. Across the country, 29.3
percent of fi re departments train to the
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CRASH FATALITIES ●
FFFIPP recommendations, and 78.8 per-
cent have SOPs consistent with these
recommendations in place. Not surpris-
ingly, departments that have experi-
enced a fatality (regardless of whether
they have had a FFFIPP investigation)
are more likely to make direct use of
the FFFIPP fi ndings for training purpos-
es and SOPs. Also, departments in large
jurisdictions are more likely to use the

FFIPP recommendations for training as
well as for SOPs. Finally, departments
in urban jurisdictions are also more
likely than those in rural jurisdictions to
use FFFIPP recommendations on motor
vehicle safety for SOPs.
REDUCING
FIREFIGHTER DEATHS
In 2007, 23 fi refi ghters were killed
on duty as a result of motor vehicle
crashes and other related events: 11 of
the victims were not wearing their seat
belts. (2) These deaths represent almost

one-quarter of all on-duty fi refi ghter
fatalities that year. We believe that future
incidents of this type are preventable.
As the NFPA recently concluded, “Driver
and passenger safety, particularly the
use of seat belts, can have a direct and
immediate impact on reducing some of
the particularly preventable fi refi ghter
fatalities.” 4
Reducing the number of fatalities
will fi rst require raising awareness
of safety recommendations. The fi re

service appears to have been suc-
cessful at increasing the use of safety
equipment on the fi reground. For
example, the results of the 2006 fi re
department survey show that fi refi ght-
ers in 88 percent of the nation’s fi re
departments use their Personal Alert
Safety System (PASS) devices regularly
and 91 percent use their self-contained
breathing apparatus (SCBA) regularly.
However, inasmuch as only 55 percent
of fi refi ghters are thought to regularly
use their seat belts, work remains to be

done in regard to using safety equip-
ment and implementing safety prac-
tices while traveling to and from the
emergency scene.
One important step is for all fi re
departments to make the use of seat
belts mandatory through SOPs and en-
forcement. If fi refi ghters are required
to don turnout gear prior to boarding
the apparatus, they must be able to
fi t comfortably and safely in their seat
belts. Moreover, emergency vehicle

drivers must be well trained in the op-
eration of each vehicle and apparatus
they will be required to operate. It is
also imperative that volunteer fi refi ght-
ers who routinely respond to incidents
in their personal vehicles know that
they are required to follow safe driv-
ing techniques, including wearing seat
belts and operating within the traffi c
laws of their jurisdiction.
•••
The overall downward trend in on-
duty fi refi ghter fatalities over the past

three decades is partly the result of a
decrease in the number of structure
fi res. However, the number of deaths
caused by motor vehicle crashes and
other related events has not declined
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84 June 2009 FIRE ENGINEERING www.FireEngineering.com
during this period. The evaluation of FFFIPP suggests that
fi refi ghter deaths caused by motor vehicle incidents could
be reduced by enforcing the use of seat belts at all times the

vehicle is in motion and by providing additional driver/op-
erator training, appropriate safety equipment, and effective
compliance monitoring. ●
The authors gratefully acknowledge the contributions of Rita
Fahy, National Fire Protection Association; Chief David
Daniels,
City of Renton (WA) Fire Department; and Virginia Lutz,
NIOSH,
who provided helpful reviews of this manuscript. The authors
alone accept responsibility for the fi nal content.
REFERENCES
1. Fahy, RF, PR LeBlanc, JL Molis. (2007). “Firefi ghter
Fatalities Studies
1977–2006. What’s changed over the past 30 years?” NFPA
Journal, 101:(4),
48–55.

fatalities in the United
States–2007,” NFPA Journal, 102:(4), 74-92.
3. National Institute for Occupational Safety and Health.
(2004). NIOSH Fire
Fighter Fatality. Investigation and Prevention Program, Eight
Years of Rec-
ommendations to Prevent Fire Fighter Fatalities Summarized:
1998–2005.
Centers for Disease Control and Prevention, NIOSH Publication
No. 2009-
100. Retrieved April 21, 2009:
http://www.cdc.gov/niosh/docs/2009-100/
pdfs/2009-100.pdf/.
fatalities in the United
States–2006.” NFPA Journal, 101:(4), 58-71.
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D i fD i f f e rf e r e n c ee n c e
● KRISTINA PETERSON, Ph.D., is a senior research direc-
tor at RTI International, a private not-for-profi t research
organization. She has conducted numerous workplace
safety and health surveys, program evaluations, and policy
studies over her 30-year career. Her studies have focused
on a variety of occupational groups including mineworkers,
fi refi ghters, factory and forestry workers, truck drivers, res-
taurant workers, military veterans, and health care indus-
try staff. She is the author of numerous scientifi c papers,

journal articles, book chapters, and monographs.
● HARLAN AMANDUS, Ph.D., serves as chief, Analysis
and Field Evaluations Branch, Division of Safety Research,
National Institute for Occupational Safety and Health. This
branch is responsible for evaluating injury interventions to
reduce risk of occupational injuries. He has more than 30
years of experience as an epidemiologist and more than
15 years of experience in the epidemiology of occupa-
tional injuries. He has authored papers on occupational
lung disease, cancer, and workplace violence.
● JAMES T. WASSELL, Ph.D., is a research mathematical
statistician who has been with the National Institute for
Occupational Safety and Health for 16 years. His publica-

tions include work in statistical methodology, occupation-
al injury, back injury, and risk assessment. His publications
have been recognized through the 2001 NIOSH Alice
Hamilton Award and the 2000 CDC and ATSDR Statistical
Science Award.
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Introduction
A question often associated with the discussion of continuity of
operations (COO) and continuity of government (COG) planning
is the relationship of the two as they relate to each other and as
they relate to an emergency operations plan (EOP) as a whole.
As we have seen throughout the course so far, part of the

answer relates directly to the fact that there, again, is no
universally accepted set-up for an EOP. As such, the inclusion
of a COO or a COG plan in an EOP specifically will vary,
depending largely on the jurisdiction or organizational-structure
being planned for.
Successful response to a community-wide disaster requires the
local emergency response system to be able to mobilize its
personnel and resources rapidly. This, in turn, requires a
predetermined concept of operations and its elaboration in the
jurisdiction’s EOP. This concept of operations is a summary
statement of what emergency functions are to be performed and
how they are accomplished. In almost every case, this demands
centralized planning for command and control across a variety
of local public sector, private sector, and NGOs. It also requires
a strategy for coordinating their collective response, as well as
specification of how extra-community resources will be
mobilized and integrated into the response effort. This section
discusses seven specific functions that are the core of the
incident management function. As noted in the previous chapter,
the local emergency response organization is defined by the
EOP in terms of the emergency functions performed, assignment
of responsibility for emergency function performance to local
organizations, and an explicit identification of functions
performed by external organizations upon which local response

is dependent. In addition, the organizational structure must be
defined in terms of the title and duties of each of the positions
within the emergency response system and the reporting
relationships among these positions.
Agency notification and mobilization
This element of incident management initiates the emergency
response. Notification to the jurisdictional authorities comes
from different sources, depending upon the nature of the threat.
Federal agencies usually notify a predetermined warning
point—the local emergency manager or the police or fire
department dispatch center. For “routine” emergencies (or for
apparently routine emergencies that escalate to community-wide
disasters, such as some hazmat incidents or terrorist events),
dispatch centers are the most common warning points. Once the
warning point is notified, it must notify other members of the
emergency response organization and mobilize appropriate
resources. The EOP should specify the channel (e.g., telephone,
radio, fax) and title of all personnel to be contacted.
The principal emergency response agencies (police, fire, and
public works) operate 24 hours a day; relevant departments that
do not operate around the clock should maintain continuous
accessibility by assigning agency personnel to serve shifts as on
call duty officers. Whatever agency notification procedure is
ultimately selected, it should be explicitly defined in the EOP
and elaborated through each agency’s SOPs—including the

mobilization of personnel to activate the jurisdiction’s EOC.
This notification process should end only when all parties
having a duty or capacity to respond have been informed. The
fundamental aims of notification are to identify the
organizations needed in the response, alert them to begin their
own activation processes, and prepare them to initiate the
emergency response. Thus, it is necessary for emergency
managers to establish explicit criteria for determining who is
likely to initiate the notification process, which parties they
should notify, which communications channels are available and
should be used, and what information should be transmitted.
Mobilization of emergency facilities and equipment
A major step in the mobilization of a jurisdiction’s emergency
response organization is the activation of its EOCs. As
facilities, EOCs are extremely variable. In more hazard prone
(and wealthier) cities and at higher levels of government, EOCs
have full time staff in permanent locations with extensive
communications equipment, powerful computers, and
sophisticated display screens. Such arrangements have the
positive effect of creating stable, visible, ready locations for
supporting disaster response operations. At the other extreme,
many communities’ EOCs are temporarily converted from
conference rooms by hanging some status boards on the wall
and installing a few additional telephones. This does not mean
that only an expensively equipped permanent EOC is adequate.

In fact, even a very basic EOC can be effective if it is based on
careful analysis of the functions that will be performed there.
Thus, it is more important to build a modest facility that
matches the EOC’s design to its function than it is to build a
large expensive facility that provides inadequate support to the
emergency response organization.
Federal Implications
At high levels of government, for example, where there could be
a considerable number of important positions to fill and any
number of services to continue, a COO and a COG would both
be extensive. However, there would also be a considerable
separation between the two, despite their obvious relations.
Consider, for example, the number of services provided by the
federal government and the number of government constituents
that could be affected by a single incident. Even if an incident
could occur that would alter the ability of government officials
to perform their duties permanently or temporarily, the services
that are performed across the U.S. would not all necessarily be
affected. The Postal Service, Social Security, and other
government-based services are geographically spread enough
that they would be physically capable of performing at least
some of their basic functions to ensure the continuation of most
services and would have the opportunity to lean on other

facilities to make up for any losses (such as the use of another
post office to help disseminate mail). Similarly, if an incident
were to occur that hampered a government service, such as an
attack on the U.S. Mint, continuity of operations plans would
need to be put in to place but federal government COG plans
would not need to be utilized as most levels, depending, of
course, on who, if anyone, was injured. In these cases, the
ability of the U.S. Postal Service to operate is not hampered by
the death of a president and the loss of the U.S. Mint building
will not prevent a U.S. Senator from acting as a U.S. Senator.
Local Government
In contrast, low levels of government, such as small municipal
governments and small organizations, often have COO and COG
plans that maintain closer relations. The inability of certain
municipal personnel to perform may also hamper the services
that can be performed due to limited geographical spacing and
the limited number of persons capable of filling roles. Consider
small municipalities that utilize a single person to fulfill
multiple roles or use single facilities for multiple departments.
In my current town, for example, the town clerk and deputy
town clerk both work in the same building. Should an incident

occur that took out the facility and both of these wonderful
ladies, there would be a gap in the fulfillment of this elected
position as well as a gap in the services that only these ladies
provide to the town (in this case, water billing, different
licensures, an so forth). In this case, the continuity of the
position within the government and the continuity of the
government services have far closer relations, something that
would, presumably, be reflected in planning.
Summary
The relation of both of these forms of planning to an EOP is
largely up to the planners of each. To be sure, both COO and
COG plans are a part of the planning process but whether or not
they are written as a part of the formal EOP or are written as
their own documents is, again, not universally agreed upon. The
most important aspect to be concerned with is whether or not
the three (EOPs, COOPs, and COG plans) are in existence, well
understood, and capable with working with one another,
something discovered through evaluation, training, and
exercise.
References:
Federal Emergency Management Agency (FEMA). Accessed

March 14, 2016, from
http://training.fema.gov/hiedu/aemrc/booksdownload/fem/
Federal Emergency Management Agency (FEMA). Accessed
March 14, 2016, from
http://www.fema.gov/media-library-data/20130726-1828-25045-
0014/cpg_101_comprehensive_preparedness_guide_developing_
and_maintaining_emergency_operations_plans_2010.pdf
For Further Investigation...
FEMA Interactive web-based course,Introduction to Continuity
of Operations
The Federal Emergency Management Agency offers free access
to a number of interactive courses and simulations that we will
be utilizing throughout the course. Please enhance your
knowledge of the information we will cover each week by
utilizing these resources.
During emergencies, affected citizens rely strongly on the
ability of governments and aid groups to continue their public
services. Despite this dependence, there is limited research

available to determine the number of localities that actually
have COOPs.
For this assignment, consider a location you are familiar with.
Do they possess a COOP? If not, what elements would you
recommend considering in the creation of a COOP for this
locality? Be sure to specify the location you have chosen.
Please start a new thread when creating your initial post and
write any responses to others within their existing discussion
threads. To receive full credit, be sure to respond to at least two
of your classmates’ postings.
Please write a minimum of 250 words
ems news network
It is diffi cult, in cases like this, to ex-
amine the factors surrounding a crash
and reiterate the safety warnings we
routinely give without sounding like

we’re laying blame. Nobody wants to
point fi ngers or tarnish the memory of
the deceased—especially a provider as
dedicated as Antwerp EMS ambulance
driver Sammy Smith, 64, who had de-
voted nearly two decades to emergency
services. We don’t know what went
through Smith’s mind in the seconds
before the July 20 crash, and we can’t
allege specifi c mistakes. From a general
perspective, however, here are some of
the issues raised by crashes like this, and

some thoughts on operating safely.
• Be wary of intersections
Vehicle-safety educators never fail to
emphasize the dangers of intersections.
“Intersections are the riskiest place to
navigate an ambulance, hands down,”
says emergency-driving expert Bob
Krause, EMT-P, of Toledo-based Emer-
gency Services Consultants, Ltd. “Th e
ambulance operator has to give the
motoring public the opportunity to per-
ceive they’re there and respond to them.
People are generally good about giving

the right of way—if they know you’re
there, and if they know where to put
their vehicle.”
“When you’re driving lights-and-siren,
you’re requesting the right of way, which
means it may take several seconds for
the public to yield it to you,” says Dave
Long, RN, EMT-P, who teaches driver
training for North Memorial EMS Edu-
cation in Robbinsdale, MN. “Sometimes
you have to stop and check every lane,
looking for those torpedo vehicles about
to blow by. We teach to look left, right,

left, then right again for every lane you
go through.”
• Know the law
Every state grants certain exemptions
from traffi c laws to emergency vehicles.
You must know what you can and can’t
do in your state. In Ohio, emergency
vehicles are allowed to proceed against
traffi c-control devices as long as the
driver maintains due regard for the
safety of others.
Th e Antwerp ambulance had a stop
sign as it entered the intersection. A

witness said it slowed, but did not stop.
Smith, for whatever reason, apparently
didn’t see the semi.
“In Ohio, the motoring public must
yield the right of way to an emergency
vehicle,” notes Krause. “But fi rst the mo-
toring public has to perceive that the
emergency vehicle is there.”
• Is it an emergency?
Th e passengers being transported
in the Antwerp ambulance, a couple
in their 60s, were apparently not badly
hurt. Robert and Armelda Wells were

experiencing back and neck pain fol-
lowing a previous crash.
Consensus wisdom now leans strongly
against emergent transport of nonemer-
gent patients.
“Our policy is that you can only return
to the hospital lights-and-siren if you
can document that it will reduce the
morbidity and mortality of the patient,”
says Long. “Th e patient has to be in seri-
ous or critical condition.”
• Th e importance of training
Safe-driving skills don’t maintain

themselves, and no one can be expected
to retain everything they learned three,
fi ve or 10 years ago. Regular refreshers
can keep drivers focused on the right
things.
“My experience has been that refresh-
er training in emergency vehicle opera-
tions isn’t always people’s top priority,”
says Krause. “You can’t let complacency
set in. You may have done this 100 times,
but it can still rise up and bite you. We
recommend having discussions about

safety every six months, and training in
the vehicle at least annually.”
—John Erich, Associate Editor
service purchase one, although no for-
mal talks were underway.
Fire Chief Ray Friend described the
support from around the country as un-
real. “Th ey say they are feeling our pain,”
he reported following the crash. “Some
have lost members.”
Smith was a member of the fi re com-
pany as well as the EMS squad. He was
driving the ambulance when it crashed.

“Sammy was always the fi rst guy to
show up,” Friend said, “whether it was a
fi re or a detail or a fund-raiser. It didn’t
make any diff erence what it was. He
didn’t hunt or fi sh. Th e fi re department
was a big part of his life.
“Kelly was in nurses’ training, and she
was going to graduate soon. She also
was studying to be an EMT.”
McDougall was a mother of fi ve. “Hei-
di had just become a paramedic. I think
she was on just her third call as a para-

medic,” Friend said.
—Susan Nicol Kyle, EMSResponder.com
What Should We Take From the
Antwerp Crash?
ASSISTING IN TIMES
OF NEED
A special team trained by the
National Fallen Firefi ghters Foun-
dation sent members to assist with
various tasks, including helping to
plan the memorial service.
The Local Assistance State Team
(LAST) operates through the Ohio
Fire Chiefs Association, says Bill
Wilkins, the coordinator. “We don’t
go in to take over. We offer our as-
sistance, and they invited us to par-
ticipate.”

The team operates under the
incident command system, and as-
signed people various tasks prior
to and during the service. They in-
cluded someone to handle honor
guards, pipers, apparatus and per-
sonnel.
The LAST members also help
the families with the paperwork in-
volved to apply for benefi ts.
So far this year, the Ohio LAST
crew has assisted with seven line-
of-duty funerals, four more than
during 2006.
The NFFF received a Depart-
ment of Justice grant to establish
LAST response units in every state.
—SNK
www.emsresponder.com ■ EMS ■ SEPTEMBER 2007 17

016-017 News Network opener.indd17 17016-017 News
Network opener.indd17 17 8/15/07 1:47:32 PM8/15/07
1:47:32 PM
16 | July 2016 FIRE ENGINEERING
T R A I N I N G N O T E B O O K ❘ B Y G R A Y Y O U N
G
1
2
Making the Hazmat Refresher Fun
O
NE OF THE DRIEST THINGS WE DO IN

the fire service is our annual
hazmat refresher. There are two
groups of firefighters: those who say
IDLH means immediately dangerous to
life or health and those who say IDLH
means I don’t like hazmat. Whatev-
er group you fit into, we need to be
prepared to answer the call safely and
efficiently. One of the most basic tools
we have for responding to a hazmat call
is the Emergency Response Guidebook
(ERG). Ask those who have been on the
job for a while if they know the ERG, and

the answer is usually, “Oh yeah.” But, do
they really know it?
When asked to do a refresher, I usually
get the crew in the day room, give them
an ERG, and get back to basics. I tell the
students that the ERG is orange on the
outside because it’s our job to get to the
orange on the inside.
The first subject we cover is the Table
of Placards in the very front of the ERG.
We all know uphill, upstream, upwind,
so our safest approach is from those

categories. I ask, Where are we com-
ing from and where are we going to?
What did dispatch say we had? What
rig are we taking? Our safest approach
is staging far enough away so that we
are not in the hot zone. If we are that
far away, can we see product names or
numbers? Maybe all we see is the color
of the placard. If that’s the case, we use
the Table of Placards to identify what
guide number we go to. I mention that
I usually choose the lowest number in
the guide just to be on the safe side.

Guides go from 111 to 172, in the order
of decreasing hazard. The guides are
presented in a two-page format; the left
page covers potential hazards. Is it safe
for us to even attempt to do anything, or
do we direct the endangered people to
a safe area and wait on a formal hazmat
team? That page is where we start, and
if we can’t get past it, then we wait.
The Plan Components
The top of the guide tells us the type
of material with which we are dealing.

We can start to formulate a plan. On the
right side is what we do for public
safety and emergency response.
I remind the crew that you are
number one, your partner is
number two, and everyone else is
number three. The first things we
do are identify the material, make
the appropriate notifications, and
then protect ourselves and others.
That is where the initial isolation
and evacuation distances are
mentioned. After we ensure our

safety and that of our citizens,
we research what we are to do for
decontamination for us and the
victims.
Next, we go to the railcar/road
trailer pages. I ask, What shape is
the railcar or road trailer? What’s in
it? Is it corn syrup or methyl ethyl
(1) Photos by Dawn Young.
1607fe_16 16 6/23/16 5:03 PM
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bad stuff? What is the guide number to
the trailer or railcar?
After mastering finding where to go
from there, we move to the color-bor-

dered pages: yellow for identification by
UN/NA number, blue for identification by
name. Easy enough, huh?
I ask the crew to look up crude oil.
Everyone knows that’s hazardous.
Hmmmm ... silence. I ask them to look up
1267. Wow! It’s really called petroleum
crude oil! (photo 1). This is a great oppor-
tunity to stress safety data sheets so they
get the correct name.
After that, we look up random things:
fish meal, fire extinguishers, first-aid
kits, London Purple, and discuss why

those items are hazmat. Use your ERG
to find any known products in your
first-due area, and familiarize your
crew with those products. You may
be surprised at how much discussion
on target hazards your crew comes up
with. Remind your crew about the local
emergency response plan and who the
key players are. Let your crew come up
with other resources on their own; that
gives them ownership and pride in be-
ing part of the solution. You will notice

the thought process coming together
and the interest in coming up with real,
everyday solutions that they own now
and will remember.
After all of that, you will notice that
the crew is actually having fun compet-
ing to find the answers to the questions
you are asking. Their minds are off of
thinking how dull the refresher is, and
they are actually getting experience in
using the ERG. There is much more to
cover, but just by getting the crew “in
the book” and hands on, they are inter-

ested and engaged.
Mitigation, What Ifs
We go to the guide pages and discuss
what we have to do to mitigate a scene
or anything we would need to do our job
safely. Brainstorming about our wants
and needs and what we can substitute
for them in an emergency gets the crew
thinking. What do we have for decon-
tamination? Fancy store-bought stuff or
mop buckets and truck scrub brushes?
How will we get soap or bleach, and is

it compatible with the product? What
about runoff? Do we have kiddie pools,
or can we make a catch-all with a sal-
vage cover? (That leads to another drill.)
We go to the dry erase board or chalk
board and map out protective action
distances and zones (photo 2), and we
talk about “what ifs.” How many people,
schools, churches, businesses could
be affected? What about evacuation or
shelter in place? What are some evacu-
ation routes we will tell the citizens to
take? Are they trapped in an area we

can’t evacuate, or are the routes leading
them into harm’s way? How will we ar-
range for transportation for the victims?
How will we notify the appropriate
shelter-type building owners that we
need their facilities, and will they allow
us to send victims to them? An enor-
mous amount of discussion on just that
will ensue.
The next thing you know is that it
has been a learning experience that we
may not have realized. How much has

the crew learned from the very informal
training? My guess is much more than
from a PowerPoint® presentation. We’ve
all been in that class where all we want
to do is sign the training roster and get
the heck out of there. Getting the crew
engaged, hands on the ERG; discussing
the target hazards in our community;
and fostering the camaraderie that
comes from the friendly competition are
priceless. When I close the drill out, I
usually give them something to think
about: What if it is your family who is

affected by a release? How good will
they think we are in mitigating a hazmat
incident?
I usually end the drill with a little
humor. I ask them to look up UN 3065
and tell me what to do if I accidentally
ingest some of that product. I’ll leave it
at that.
GRAY YOUNG, a 20-year veteran of the
fire service, has worked in volunteer and
career fire departments. He has been chief
of training for South Bossier District Two,

Louisiana, since 2002. He is the assistant
manager of the Louisiana State University
Fire and Emergency Training Institute.
He is president of Brothers of the Boot, a
F.O.O.L.S. chapter.
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gtronics.com
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Risk Analysis, Vol. 26, No. 1, 2006 DOI: 10.1111/j.1539-
6924.2006.00731.x
Commentary
Scientific Peer Review to Inform Regulatory Decision
Making: A European Perspective
Ragnar Lofstedt1∗ and Robyn Fairman1
1. INTRODUCTION
The authors, Patton and Olin, should be congrat-
ulated for producing a concise “wish list” on the use
of scientific peer review for regulatory decision mak-
ing (Patton & Olin, 2005). As a wish list, we agree

with the authors particularly with regard to defining
and distinguishing review processes (which is a much
talked about topic in Europe), and the need to take
into account external scientific peer review seriously.
We do have two specific comments on the substantive
content. First, we feel that the exclusion of a discus-
sion of how social scientific or economic data could be
“peer reviewed” leaves this otherwise comprehensive
review lacking. Such analyses are a crucial factor in en-
suring the “credibility of science-based rule-making
decisions” and validating these data is as important
in many instances to the final regulatory decision as it
is for the “harder” scientific data. Second, we would
challenge the statement that “[p]eer review is one of
several complementary venues for public participa-
tion.” We understand the drivers for increasing pub-
lic participation in regulatory decision making, but
would question whether peer review should ever be a
“venue” for public participation.
This brief comment attempts to shed further
light on the changing scientific peer-review process in
Europe. We will explore how the nature of the scien-
tific advice used by U.K. food regulators has changed
over the last 10 years. The bovine spongiform en-

cephalopathy (BSE) crisis in the United Kingdom
1 King’s Centre for Risk Management, King’s College, London,
UK.
∗ Address correspondence to Ragnar Lofstedt, King’s College,
King’s Center for Risk Management Strand, London WC2R
2LS,
England, UK; tel: +44(0) 20-7836-5454; fax: +44-207-848-
2748;
[email protected]
has led to radical changes in both regulatory struc-
tures and changed the “rules of the game” by which
they operate. We then expand this discussion from a
U.K. base to look at scientific review in the European
Commission.
Our discussion is therefore based on evidence
from scientific advisory groups in regulatory decision
making. This is not a classical peer review of new data
as would occur in the publication of journal articles. It
is the examination and analysis by a group of experts
of the application of peer-reviewed science to a policy-

relevant problem. These two functions are conceptu-
ally distinct. This analysis and critique of the chang-
ing institutional arrangements and culture of review
in the United Kingdom and Europe support many of
the items in Patton and Olin’s wish list, although it also
raises implementation issues. Through this discussion,
we hope to enlighten the readers of Risk Analysis re-
garding the differences between how peer review is
conducted in Europe vis-à-vis the United States.
2. SETTING PEER REVIEW OF SCIENCE IN
REGULATION IN CONTEXT: PUBLIC
TRUST AS A DRIVER
During the period between World War II and the
mid 1960s, the U.S. landscape of regulation was not
significantly different from that in Europe (Brickman
et al., 1985; Vogel, 1986). The American public was
generally supportive of business, believing that a
strong industrial sector was essential in meeting the
Soviet threat and for the United States to continue to
assert its authority in the world. Washington trusted
industry to manage its own affairs, a decision rein-
forced by a legacy of remarkable growth and expan-
sion during the war. Similarly, until the late 1960s,

25 0272-4332/06/0100-0025$22.00/1 C© 2006 Society for Risk
Analysis
26 Lofstedt and Fairman
regulators in Western Europe were largely seen as
credible. The public and stakeholders viewed them
as working on behalf of society as a whole, although
the regulatory styles primarily used, corporatist and
consensual, were significantly different from the ad-
versarial style in the United States (O’Riordan, 1985).
The future of environmental and health regula-
tion in Europe as well as in the United States were fun-
damentally shaped by the environmental events of the
1960s and 1970s. Both trade blocks had their fair share
of environmental disasters (Aberfan, Torry Cannon;
Minimata; Love Canal) (Andrews, 1999; McCormick,
2001). These and other environmental events had
profound effects in the United States and Europe.
Between 1965 and 1975, according to Vogel “more
legislation was enacted and more regulatory agen-

cies were established (in the United States) to ad-
minister them than in the entire history of the federal
government” (Vogel, 1986, pp. 250–251). Similarly in
Europe, these events led to establishment of environ-
mental protection agencies (e.g., Sweden established
its Environmental Protection Board in 1967) as well
as tougher regulations (e.g., the 1974 Clean Air Act
in Germany and the 1969 Swedish Environmental
Protection Act). However, the levels of public and
stakeholder distrust witnessed in the United States
(caused by these environmental disasters as well as
the prevailing climate of the Vietnam War, and the
appointment of Anne Gorsuch as EPA Administrator
in the first Reagan Administration) were not present
in Europe. As a result, at the time American regula-
tors, arguably, went further than their European coun-
terparts in many cases, arguing for a separation of
risk assessment from risk management (NRC, 1983),
greater use of science in the policy-making process,
and greater use of cost–benefit analysis (Andrews,
1999; Landy et al., 1994; Viscusi et al., 1995).
Over the past 10 years the West European reg-
ulatory scene, however, has changed dramatically.
Rocked by a number of regulatory scandals, rang-

ing from BSE, to dioxin in Belgian chicken feed,
to tainted blood in France, the public and stake-
holders no longer trust their respective regulators
(Lofstedt, 2005). Majone and Everson (2001) argue
that the consensual style of regulation is now dead.
Because of this mounting public distrust, there is ev-
idence that European regulators and advisory bod-
ies are in effect “Americanizing” European regula-
tions (Lofstedt, 2003). In the next section, this will
be illustrated by examining the impact of BSE on
scientific advice for food safety regulation, first in
the United Kingdom and then in Europe. Do we see
what has been part of the U.S. regulatory landscape
since at least 1983 (Andrews, 1999) being exported to
Europe?
3. U.K. SCIENTIFIC ADVICE FOR
FOOD REGULATION
Scientific or expert advisory committees are a
long-established part of British regulatory decision
making. The traditional consensual approach of U.K.
regulation led to expert committees playing a piv-
otal role in advice and guidance. Formalized expert

committees have been involved in food regulation
since the early 1980s and include technical commit-
tees (such as the Committee on Toxicity) or wider
advisory committees that examine risk management
issues (such as the Food Advisory Committee). A dis-
tinction has always been made between expert advi-
sory committees and scientific or technical advisory
committees, with their remit being determined by his-
torical precedent (Fairman, 1999).
Fundamental questions have been posed about
the scientific advisory process in the United Kingdom
as a result of successive food safety crises. The main is-
sues have been the composition and remit of advisory
boards, and how their information was used by gov-
ernment. The shortcomings of the system were voiced
by a former minister of the Ministry of Agriculture,
Fisheries and Food (MAFF) in a House of Lords de-
bate in 1997.
We set up those committees and used them in a way that
lead to many of the problems . . . , and which lead to a
breakdown in trust between the people of this country

and MAFF. (Lord Lucas, 1997)
Lord Lucas then went on to explore the expecta-
tions of MAFF:
that the people on the committee should display a great
deal of level-headedness and that they should not rep-
resent extremes of opinion; that they should be able
to agree together and not produce dissenting opinions.
(Lord Lucas, 1997)
The net result was a system “strongly biased to-
wards consensus.” Scientists wish to see their research
funded. The two principal sources of income for re-
search are the government, which tends toward con-
sensus in its research funding, and industry, which
tends toward research that does not undermine its
own business. Lord Lucas commented that “that pro-
cess has also led to committees that excludes people
from participation” and that “leads to a whole process

Scientific Peer Review to Inform Regulatory Decision Making
27
of dissatisfaction, a feeling of cover-up and a lack of
trust” (ENDS, 1998).
In his analysis, Lord Lucas identified the require-
ment by politicians and government for a “single clear
recommendation” from expert committees as a factor
that ensures that only those from within the accepted
middle-ground of science were invited onto commit-
tees. The decisions can then be based upon consensus
but they exclude extremes or innovative views. If the
government’s desire for openness and the inclusion of
lay people within this framework is considered in this
context, then lay people on the committee would ei-
ther have to represent the middle-ground of opinion
or they will severely threaten consensus. An example
of this has been on the Advisory Committee on Re-
leases to the Environment (ACRE), which deals with
the issue of genetically modified (GM) biotechnology
applications. The one lay member of the committee

repeatedly dissented from the consensus arrived at by
the committee (ENDS, 1999). She contended that it
was not up to ACRE to judge whether the spread of
genes from GM crops into the environment matters
or not, and that the issue needed wider debate.
The biggest shake-up to food safety regulation
and scientific advice came with the BSE crisis. MAFF
was replaced by the Food Standards Agency (FSA),
an independent body established to explicitly “protect
the public” (MAFF, 1998). The Phillips inquiry into
BSE (Phillips, 2000) and the May review (May, 1997)
into the handing of risk in scientific advisory com-
mittees both made recommendations in line with that
in Patton and Olin’s article. They focused in particu-
lar on the separation of risk assessment and manage-
ment; being clear about the evidence reviewed and us-
ing peer-review comments in reports; the importance
of lay voices; selection of reviewers; and the disclo-
sure of interests. As a result of the Phillips inquiry
and in line with some of the criticisms voiced by Lord
Lucas, all the advisory committees (including techni-
cal committees) included lay members and this has
been strengthened to two lay people on all commit-
tees since 1999. Partly as a result of the Phillips and

May reviews, the U.K. Parliamentary Office of Sci-
ence and Technology issued a Code of Practice for
Scientific Advisory Committees (POST, 2000).
In their review of how expert committees oper-
ated (UK FSA, 2002a), the FSA recommended “that
committees should not be asked to manage risks al-
though they will be asked to provide scientific ad-
vice on risk management options.” This pragmatic
approach to the separation of risk assessment and
management in scientific committees arose as a re-
sult of some members of committees expressing their
disquiet at the practical issues in attempting to sep-
arate assessment from management issues, and the
stilting of discussion that this may cause. In the min-
utes of an FSA meeting discussing scientific review it
was recorded that:
It is recognised that during discussion on risk assess-
ment it was inevitable that questions on risk manage-
ment will occur. Furthermore discussions by commit-

tees on risk management should not be suppressed as
it was useful to bring to light future research require-
ments. (UK FSA, 2002b)
To assist in the separation of risk assessment and
management the minutes record that “public com-
ment should be invited on the form of the questions
to be put to advisory committees” (UK FSA, 2002b).
Further recommendations of the review relate
to the appointment of experts. Positions have to be
openly advertized (as a result of government rules
on all appointments) but “efforts should be made to
ensure that suitably qualified individuals from all sec-
tions of the population have the opportunity to apply.”
They recognize that open competition discourages
some experts from applying and recommend that “the
Agency should actively search for suitable candidates
and encourage them to apply” (UK FSA, 2002a). Ex-
perts from around the world are encouraged and some
committees are served by experts from outside the
United Kingdom.

The impact of BSE on the scientific advisory sys-
tem in the United Kingdom has been fundamental and
resulted in two driving forces, sometimes operating
against each other. On the one hand, distrust by the
public and the consensus nature of the views present
in committee has led to the inclusion of lay people
on expert groups and the public and open approach
to recruiting experts. The second driver has been the
attempt to reduce the consideration of the impacts of
the risk assessment in the conduct of the risk assess-
ment itself. The NRC (1983) called for the concep-
tual separation of risk assessment and management.
The response of the FSA to this driver can be seen in
the operation of committees such as the Spongiform
Encephalophy Advisory Committee, which is wholly
and exclusively focused on the scientific assessment
of risk. The example of ACRE shows that in practice
some of the lay people or consumer representatives
on these committees can open the debate wider than
“pure” assessment issues.
This raises the question as to the function of the
inclusion of the lay people on committees. Does in-
clusion of two lay people on a scientific committee
make it participatory? Could this be an example of

the “venue of public participation” identified by Pat-
ton and Olin? These lay people can only ever repre-
sent one of the many “publics” with a particular view
on any issue. The United Kingdom has an example of
a more participatory scientific review process. Theses
are the scientific advisory bodies established to as-
sist the Health and Safety Commission/Executive in
their decision making. These expert groups, like the
Commission they serve, are tripartite, consisting of
experts nominated by trade unions, employers, and
the Commission. For instance, the Working Group
on the Assessment of Toxic Chemicals is a tripartite
scientific committee serving a tripartite expert com-
mittee (Advisory Committee on Toxic Substances).
Here, judgments about the application of science to
policy-relevant questions are made by scientists with
different values representing different constituents.
The next part of the commentary will examine
these issues from a European context.

4. EUROPEAN SCIENTIFIC PEER REVIEW
TO INFORM REGULATORY
DECISION MAKING
Since the mid 1990s, the EU institutions have
taken steps to improve the quality and credibility
of scientific evidence and peer review used in their
decision making. Major reforms include the creation
of independent scientific committees, the creation of
independent risk assessment agencies for both food
and medicine, and the introduction of a Commission-
wide policy for the collection and use of expertise.
This is not to say that scientific advice or scientific
committees did not exist prior to the mid 1990s (they
did—the Scientific Committee for Food was estab-
lished in 1974, for example), but reforms were seen
as necessary in the wake of the BSE crisis. The is-
sue of the Commission’s credibility was at stake, as
policymakers, regulators, and, increasingly, scientists
were no longer believed. Indeed, it is interesting to
note, for example, that the then President of the Eu-
ropean Commission, Jacques Santer, announced in a
1997 speech to the European Parliament a new set of
scientific principles for the management of food safety

and consumer health at the height of the BSE scare
(Koning & Jasanoff, 2001). The 1997 Communication
resulting out of this restructuring noted that:
Consumer confidence in the legislative activities of the
EU is conditioned by the quality and transparency of
the scientific advice and its use on the legislative and
control process. (European Commission, 1997)
One of the primary outcomes of both the BSE
(and related regulatory crisis) and the resignation of
the Santer Commission on charges of corruption was
the 2001 Commission’s White Paper on Governance
(European Commission, 2001). This, too, discussed
the role of scientific committees and scientific exper-
tise. It notes, for example:
It is often unclear who is actually deciding—experts or
those with political authority. At the same time, a better-
informed public increasingly questions the content and

independence of the expert advice that is given. These
issues become more acute whenever the Union is re-
quired to apply the precautionary principle and play its
role in risk assessment and risk management.
To get around this conundrum, in the same Gov-
ernance White Paper, the Commission proposed two
separate solutions. First, guidelines were needed on
the collection and use of expert advice, and second
that a Science in Society program (situated in DG
Research) should be established. The research guide-
lines were put forward in a Communication in 2002
(European Commission, 2002b), and the Science and
Society program was established the same year. The
Commission’s research guidelines put forward three
core principles, namely, that the Commission should
seek advice of an appropriate high quality; it should
be open in seeking and acting on advice from experts;
and that it should ensure that its methods for collect-
ing and using expert advice are effective. The guide-
lines, which became operational on January 1, 2003,

were seen as a positive step forward with regard to the
use of scientific expertise and these are now being im-
plemented through the various DGs in the European
Commission.
With regard to the use of scientific expertise to
inform regulatory decision making was the launch of
the Science in Society program in 2002. The program,
based on 38 Actions, aims to “pool efforts at European
level to develop stronger and more harmonious rela-
tions between science and society” (European Com-
mission, 2002a).
Among the issues raised by the Science in Society
Action Plan Document is the use of scientific expertise
(European Commission, 2002a, pp. 24–26). It notes
that although the community-level scientific commit-
tees for food and consumer health have now been well
established and that frameworks have been set up to
ensure distinctions between collective more formal
advice and that of solicited and unsolicited opinions
and findings, that more work is needed. The report
notes the following:

29
�
Science is often perceived as dealing with cer-
tainty and hard facts, whereas this is rarely
the case, . . . leading to a sense of frustration
and despair when experts fail to provide sim-
ple answers to apparently simple questions. A
more coherent interface is needed between the
providers and receivers of advice, with mu-
tual understanding and clear communication
between the two;�
Policy makers do not find it easy to tap into the
resource of knowledge provided by the diver-

sity of scientific cultures and range of special-
ized centers of excellence in Europe . . . . There
is a need to be a more systematic and open
approach, at national and European level, to
identify the best expertise at the right time;�
Advice can appear remote if the public and
stakeholders are excluded, and are unable to
or ill equipped to contribute to the debate and
to challenge the experts and the advice they
give. There is a need to open the process by
providing opportunities for the voicing of al-
ternatives views, for scrutiny, and for construc-
tive debate.

The Commission addresses these three issues by
stressing the need for guidelines (as discussed above)
and by calls for improving the delivery of scientific
support to policymakers, such as via creating open
Internet-based networks of scientists and organisa-
tions concerned with scientific issues (European Com-
mission, 2002b).
Since these initiatives there have been some fur-
ther changes. For example, DG SANCO now has a
unit that just deals with the science and communica-
tion issues that are generated by the European Food
Safety Authority. In addition, the Science and Society
program (88 million Euros between 2003 and 2006)
has sponsored a number of workshops and research
projects, including “Science Education and Careers”
(3 million Euros), “Deepening the Understanding of
Ethical Problems” (5 million Euros), and in August
2004, it helped coorganize the first EuroScience Open
Forum meeting in Stockholm (this latter initiative is
mirrored by the American Association for the Ad-
vancement of Science meetings in the United States).
The question remains, however, whether the

Commission has put its primary attention on what can
be called “soft” areas of the scientific peer-review pro-
cess. For example, to ensure that the process is trans-
parent, that the process is efficient, and that it is of
high quality is always useful in terms of gaining public
credibility (Lofstedt, 2004, 2005). It is also clearly im-
portant to ensure public “buy in” to the scientific pro-
cess and rekindle public interest of science (Funtowicz
et al., 2000). These issues, however, do not address the
core aspects of scientific peer review to inform regu-
latory decision making. For example, in research that
we have been doing on Commission scientific commit-
tees over the past year one can note that quotas op-
erate in the recruitment of experts. The Commission
implements country quotas in many instances with re-
gard to setting up scientific advisory boards. Hence,
scientists may be picked because of where they come
from rather than based on the scientific expertise that
they can bring to the table. In addition to this, gen-
der quotas operate with the expectation that no less
than 40% of experts will be either male or female. In
many cases only European citizens can serve on these
boards even if the actual competence in certain in-
stances can actually be found in Japan or the United

States. The selection process of those scientists who
participate is not via peer nominations (as is the case
for US EPA SAB) but, rather, scientists are asked
to apply via advertisements in select publications to
possibly take part in the scientific committees. As a re-
sult, the committees are not necessarily staffed with
the most competent scientists. To complicate matters,
there is, first, no real scientific oversight committee,
playing the role of the National Academy of Sciences
in the United States, and, second, the broad scientific
community is, relative to the United States, poorly
paid and funded (Lofstedt, 2005), although this lat-
ter point is something that the Commission is now
addressing (European Commission, 2004).
Over the past year, the first author served as
the academic advisor on a European Policy Centre
project examining what the European Commission
should do with regard to ensuring rigorous scientific
peer review of the policy-making process, thereby ad-
dressing the problems noted above. Among the find-
ings coming out of this document (for a full discussion,
please see Ballantine, 2005) were the following.
� The Commission should publish a Decision

containing a new formal and binding policy
statement covering risk analysis in policy mak-
ing;� The EU institutions should issue a joint Com-
munication affirming that high-quality science
will have a principal role in policy-making and
decision-making processes;� The Commission should establish
a new coher-
ent policy for the collection and use of scientific
advice; the policy should be applied to all in-
stitutions to all stages of the regulatory cycle
and to all sources of scientific advice;
� The Commission should establish Chief Sci-
entific Advisors or Scientific Advisory Groups
in all relevant services or agencies with
responsibility for ensuring the integrity, qual-
ity, and effective operation of the scientific ad-
visory system in the service/agency concerned;� The
Commission should also establish an inde-
pendent Chief Scientific Advisor or Scientific
Advisory Group, reporting directly to the Pres-

ident of the European Commission, with re-
sponsibility for ensuring the integrity, quality,
and effective operation of its overall scientific
advisory system;� The Commission should establish a central
unit in the Secretary General’s Office in sup-
port of the Chief Scientific Advisor or Scien-
tific Advisory Group;� The Parliament should review the
provision
of independent scientific advice available to
Members of the European Parliament (MEPs)
and ensure that it is able to support the devel-
opment and updating of technical legislation;� The creation of
a “European Academy of Sci-
ences” should be encouraged.
At present, European Commission officials are
considering whether some of these points should be
implemented in the EU.
5. CONCLUSIONS
One of the main drivers of the reforms of the sci-
entific peer-review process that has been ongoing in
Europe is the loss of public trust in science. This can
be viewed as a part of the ongoing Americanization of

European regulation. Among reforms that have been
put in place to date are the development of guidelines
for how scientific committees can best be used, the
importance of getting society to buy into science, and
the role of greater transparency. Little attention, how-
ever, has been paid at a European level to improving
the selection process of scientists, to develop scien-
tific oversight committees with the Commission, or to
establishing an equivalent to the National Academy
of Sciences. Both the European Commission and the
United Kingdom are going in the right direction of
reforming the scientific peer-review system, but they
have a long way to go to reach the standards set out
in the Patton and Olin article. Maybe a useful next
step would be for the two authors to travel to Europe
and with the assistance of ILSI Europe hold a num-
ber of seminars based on their conclusions with the
Brussels-based regulators?
ACKNOWLEDGMENTS
The research leading to this article was par-
tially supported by grants from the Swedish Research
Council via the Centre for Public Sector Studies

(CEFOS), University of Gothenburg, where the lead
author is a visiting professor, and the European Policy
Centre-Risk forum program. We would like to thank
the following individuals for commenting on previous
drafts of this article and for bringing relevant mate-
rial to our attention: Lorenzo Allio, Stanley Crossick,
Baruch Fischhoff, Anna Jung, and Ortwin Renn. This
commentary is dedicated to the memory of the late
Bruce Ballantine.
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• © C A S E REVIEW | By J a m e s J.Augustine, MD, FACEP
E X P O *
JIMAUGUSTINEI
is a featured t
speaker ot I

EMS World I
Expo 2013, I
Sept. 8-12, g
Los Vegos |
Convention S
Center, Las |
Vegas. NV. i
AnACK ONE RECEIVES a midafternoon
call for a child injured in a bicycle acci-
dent. "Oh, no, not another one," a crew
member groans. "We just had a bike
accident on our last shift."
The crew recalls the shift before.
Middle of the afternoon, they arrived
on a residential street to find a child
lying motionless in the road. The car
had heen moving quickly, hased on the
skid marks. As they walked up, they
saw heavy damage to the bike but
noticed a bike helmet still in place
on the child. As they arrived at the
boy's head, he opened his eyes, then
moved his arms and legs and spoke

some magical words:
"What happened? Can I get up?"
The child moved around, popped up
to a sitting position before the EMTs
could even reach for him, and looked
around for his house. Concern melted
away as the child asked questions
and told the crew only his abrasions
hurt, and he hated to see his bicycle
so beaten up. The crew removed his
helmet as they immobilized him, noting
cracks in the side of the headgear. An
equally relieved mother arrived at the
scene and reported the child always
wore his helmet as he cruised the quiet
neighhorhood. The child had several
abrasions and a possible fracture of his
wrist, but smiled as he was loaded into
the ambulance. The police sergeant
had the helmet photographed to use
in future teaching.

But this is the next shift, and the
Attack One crew pulls up on a quieter
residential street. There are not so
many bystanders, and no car sits at
the far end of a set of skid marks. This
child lies motionless against a curb, his
bike behind him. The police officer at
his head appears very concerned, and
as they move toward the boy, they find
no helmet.
"Someone in the apartments here
called when they saw this child lose
control of his bike and strike his head
on the curb," the officer reports. "I was
right down the street, and he hasn't
moved since I got here."
The child is on his right side, and
the officer holds his neck in a stable
position. There's blood on the ground
underneath the right side of the hoy's
head, and during assessment the
A male of approximately 8 years

who was seen having a bike accident
and Í5 unresponsive w i t h a head
injury.
> Airway: Originally found to be
compromised, then opened by EMS
crew.
> Breathing: No distress.
> Circulation: Normal capillary refill,
pink skin.
> Disability: Small, reactive pupils;
no movement of extremities; no
verbal response. Has a generalized

tonic-clonic seizure during transport.
> Exposure of Other Major
Problems: None noted; no signs of
injury to any area except head.
VITAL SIGNS
Time
1520
1529
1547
HR
144
12a
112

BP
1ia/palp.
lao/palp.
i2a/6a
RR
24
28
24
Pulse Ox.
88%
99% on
mask
99%

A M P L E A S S E S S M E N T
> Allergies: Not known.
> Medications: Not known.
> Past Medical History: Not known.
> Last Intake: Not known.
> Event: Bicycle accident with
isolated head trauma and no helmet
in use.
28 SEPTEMBER 2013 I EMSWORLD.com
• C A S E REVIEW
paramedic finds a large lump and
laceration just ahove the right ear. No

one knows who the child is, but he
appears around 8 years of age. His
extremities and face are not injured;
it appears his head took the direct
impact against the tall curb on the
side of the road.
The EMTs take control of the head
and neck while the paramedic does
the assessment. The child is on a very
warm asphalt surface, so they roll a
blanket underneath him as he's lifted
onto a long backboard, maintaining
spinal motion restriction. As the
crew hegins to apply straps and
head pads, the child starts to retch.
The paramedic asks everyone to
take hold of the child and roll the
hoard and child to the right side. As
they do the child forcefully vomits a
large amount. The Attack One crew
and police officer stahilize the child
throughout, and when he finishes the
paramedic sweeps his mouth, then
directs the rescuers to quickly strap

the child to the board in a way that
they can roll him again if needed.
"With that type of vomiting, this
child has a severe head injury and
likely has pressure huilding in his
brain," the medic says. "We'll need to
"With that type of
vomiting, this
child has a severe
head injury and
likely has pressure
building in his
brain."
move him quickly to the trauma center.
We can't wait for parents." He turns
to the police officer. "Will you please
advise any parents when they arrive
that we're taking the child immediately

to the children's hospital? We'll let the
hospital know we had to leave before
we had a name."
The immobilized child is rapidly
placed on the stretcher, with a crew
memher maintaining a constant vigil
for more vomiting. The stretcher is
loaded into the ambulance, and the
crew attempts to obtain the first set
of vital signs. The hoy starts to retch
and vomits again. Once more the crew
rolls him to the right. As he finishes
vomiting he hegins to tremble and then
slips into a generalized seizure.
The paramedic delivers crisp
orders: "Keep him rolled to the right
so he doesn't aspirate. Place an oxygen
maskvidth 10 liters above his face hut
not strapped on. Get the pédiatrie
hag-valve mask and airway kit ready for
me. I'm going to give him some seizure
medicine in his nose, and then we'll

intuhate him. Get the intraosseous kit
out and an IV setup ready, and we'll do
that last if we have time."
All hands are working as they keep
the backboard rolled, obtain the
vital signs, deliver oxygen to improve
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»CASE REVIEW
saturation and assist giving a dose of
IN midazolam through a device that
produces a fine mist of it. Before
administering it, the paramedic
examines the nose and makes sure
there's no blood or other material in
it, and no drainage from either ear.
Within about two minutes the child
stops seizing. A secondary evalua-
tion follows, and the boy's clothing is
removed while he is kept warm. No
injuries are noted except the one to
his head.
"How far are we from the hospital?"
the paramedic asks. "About 5-7 more
minutes," the driver reports.
The medic then addresses the crew:
"He's breathing on his own, and with

his oxygen level at an acceptable point
on the pulse oximeter, we're not going
to intubate right now. He's not going
to be a quick IV start, so I'm not going
to try. We need to apply the end-tidal
carbon dioxide monitor to make sure
he's breathing at a correct rate. Keep
the board elevated a little and off to the
right side. I'm calling the hospital and
"The occurrence
of seizures is also
a common
complication of
severe head
injury.
asking them to be prepared to manage
his airway We'll support his breathing
for the few minutes until we get there."
The crew applies a nasal cannula

to the child, which measures carbon
dioxide levels through a port on the
side that's connected to their monitor
device. The first readings show an
EtCO, level of 37 mmHg.
"That's where we want him for the
head injury, so we don't need to assist
ventilations," the medic says. "Keep
the oxygen flowing around his face
to maintain oxygénation. We'll try to
keep his oxygen level over 95% and his
carbon dioxide between 3 5 ^ 0 mmHg.
If he vomits or seizes again, we'll have
to modify what we're doing."
But the remaining miles to the
children's hospital pass quickly, and
the patient has no further events.
Hospital Management
The trauma team is in the ED
resuscitation area, and there's a

quick transfer onto the ED cart.
They keep the child's head slightly
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CASE REVIEW
elevated, with a 30-degree tilt to the
right. The paramedic gives the report
to the hospital team leaders. The
staff switches the boy to the hospital
monitors, and the trauma leader sets
the same target values for oxygen and

carbon dioxide. The nursing staff
surveys for an intravenous site but
can't find one quickly, so they place an
intraosseous line in the boy's Iefr leg.
The team finds no other wounds
on the child, but assessment of the
skull indicates a likely fracture in the
very dangerous area just above the
right ear. The emergency physician
tells the team the child will need an
airway in place before he can have a
CT scan and will need to be started
on seizure-prevention medications.
The team performs a rapid-sequence
intubation, using medicines to reduce
the impact of the procedure on the
child and the risk of further seizures.
The medicines are given into the IO
line, and within a minute the child
has an endotracheal tube inserted. A
tube is then placed from his mouth
into his stomach to completely empty
his stomach. Then they take him to

the CT scanner.
The boy's parents have not arrived
at the hospital yet, so the Attack One
crew contacts the dispatcher to see if
they've been identified at the scene.
The dispatcher reports there's still
no parental presence and neighbors
aren't sure of the child's name. The
crew advises the hospital, and the child
will be treated with an alias until he
can be identified.
The crew has a big cleanup to do, so
they're still present when the results of
the CT scan come back. The child has
a very bad brain injury and bleeding in
the right side of his head, where his
skull is fractured. He will go directly
to the operating room.
The boy has a very difficult hospital
course and is not able to communicate
or care for himself when he leaves the

hospital for a longer-term rehabilita-
tion facility.
Case Discussion
The prehospital emergency care of a
child with a head injury will focus on
proper immobilization, maintenance
of the airway, adequate oxygénation,
prevention of shock and poor perfusion
of the brain, and reducing the risk of
complications. The injury to the brain
cannot be reversed by prehospital care,
but secondary injury can be prevented,
and the possibility of a great outcome
is enhanced by good perfusion, oxygén-
ation and attention to the details of
patient packaging.
The child in this case had two
common complications of head
Photo is
depleting a
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EMSWORLD.com I SEPTEMBER 2013 3 3
• CASE REVIEW
Customer Service Opportunity
The EMS system has an important role in pubiic education
programs that reduce
the risi< of injuries and ilinesses, and mitigate the bad

outcomes of injury events.
There are a number of programs intended to reduce the impact
of coiiisions on
chiidren. Some encourage the safe use of restraint devices in
motor vehicies, iii<e
appropriateiy fitted car seats, and protective headwear when
children are engaged
in activities that put the head at risi<. Some programs provide
the headwear for
free or at a reduced cost. But simpiy providing head protection
isn't enough; there
must be constant messaging to encourage chiidren to wear the
devices in organized
athietic events and day-to-day recreational activities.
In this case baci<-to-baci< events iiiustrated a difference in
outcomes based
on the use of protective headwear. The EMS crew recognized
the terribie grief of
the second set of parents. Hoping to prevent the same thing
from happening to
others, they contacted their agency's public
education officer and the office of public

information at the hospitai where both
children were treated. The hospitai's pubiic
information staff was weii aware of the
serious injury suffered by the second chiid,
but not of the injury and circumstances of
the first child.
The second child's parents were asked to
a meeting with physicians caring for their
son, chapiaincy staff supporting the famiiy
Copyright granted
for ttiis article for
department use
only up to 20
copies.
There are many
programs
intended to
reduce the
impact of
collisions on

children.
and pubiic education leaders at the hospitai. Emphasizing that
they would protect
the chiid's privacy, they asked if the parents would like to
participate in community
education activities regarding head-injury prevention. Though
stili unsure of their
chiid's uitimate outcome, the parents offered their support for
any activities that
might benefit other children and help parents faced with
decisions about using
heimets. They were especially interested in the concept of
publicly contrasting
outcomes based on the presence of bike helmets, The parents
and chiid invoived in
the prior accident were then approached to explore their interest
in participating.
Uitimateiy a pubiic safety message was developed using input
from both sets of
parents. The primary message was deiivered by chiidren, not
adults. The elements
of the campaign were expressed in a positive way, with
messaging that encouraged

children to support other chiidren in wearing their heimets.
LEARNING POINT
Two contrasting cases of significant
head trauma to children, with
outcomes based on the presence of
protective headgear. Head trauma
remains a common cause of poor
outcomes in chiidren who are injured;
EMS care must focus on preventing
secondary insults to the brain. II
injuries, vomiting and seizing. Many
children will vomit, and that risk
increases when there is rising pressure
inside the skull. EMTs must be on
constant alert for vomiting and quickly
clear the airway and prevent aspira-

tion of vomited gastric content into
the airway and lungs. A rapid and easy
method for protecting the airway from
aspiration is correct immobilization of
the child, then using that immobili-
zation method to roll the child to the
side. Suction alone cannot capture
all the content coming up from the
stomach, so a vomiting child is better
protected by techniques that allow
gravity to help.
The occurrence of seizures is also a
common comphcation of severe head

FIRE ENGINEERING June 2009 79www.FireEngineering.comB Y K .docx

FIRE ENGINEERING June 2009 79www.FireEngineering.comB Y K .docx

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