By Lt. Col. John Garber, 70th ISR Wing
/ Published November 22, 2013
FORT GEORGE G. MEADE, Md. --
When I was a Lieutenant, a wise old fighter pilot told me that complacency is a killer. His comment was likely borne from the many tragedies that he had witnessed over the years, some spawned by inattention. My own recent near miss while performing a relatively mundane task could have met with disaster. The incident reminded me in stark terms that what was true then remains true today. I write with the hope that it will preclude a serious accident for someone else.
This past weekend, my wife planned to go out with some friends and had left me in charge of making dinner for the kids. 'This should be quick and easy,' I thought. 'I'll throw some hot dogs on the grill, make some French fries on the burner and tie it all together with some salad from the 'fridge.' (I'll write a column on healthy diet another time) Afterward, I had planned to relax and admire the view of the back yard from the patio.
I had been working in the yard most of the afternoon. As usual, I underestimated the ratio of work to available time. As the sun sank toward the trees, I was still trying to finish that one last project. My wife bade us farewell and departed. Shortly after that, the younger of my two children asked what I planned to make for dinner. Correctly interpolating that she was telling me that she was now hungry, I tied off the last bag of yard waste and proceeded inside to clean up and assemble dinner. I gathered the ingredients, made the salad, popped it in the 'fridge and then began shuttling needed items to the grill on the back patio. At various points, both kids stopped by to ask 'How long until dinner is ready?'
Sensing their growing hunger, I slid my feet into a pair of nearby flip flops and hurried outside. I chose the flip flops not for the fashion statement they make but because they're just enough to protect the bottoms of my feet from the tiny branches and fragments of mulch that litter the patio no matter how recently I've swept. They could also be donned without having to set down the cooking items that now overloaded my arms. I continued outside, setting my cargo down on the grill next to the house, where it has resided for years. This included an iron frying pan and the cooking oil. I set the pan on the burner attached to the grill, added the correct amount of oil and then lit it to let it heat up. I lit the grill, removed the hotdogs from the package and arranged them to begin cooking over low heat.
I monitored the oil temperature until the thermometer indicated the oil was hot enough to cook the frozen fries, and then added the first half of the batch, as I had done countless times before. Because the fries were frozen, the oil promptly hissed and popped as expected. But something reacted, this time, because the oil frothed and began to rise. As it neared the lip of the pan, I thought "Grease fire," and jumped back to avoid coming in contact with the now scalding oil. As I jumped back, I had the presence of mind to pop the burner knob to the "off" position, probably the only thing I did right in this whole chain of events.
Sure enough, oil overflowed the pan, sloshed through the burner and then to the ground. I had moved far enough away that the oil, other than a few spatters, did not come into contact with my unprotected feet. It did come into contact with the residual flame on the burner and briefly ignited. Medium sized flames erupted around the pan for perhaps 10 seconds, reaching a little above the lip at their zenith before dying out. This was just long enough for me to realize that, while the grill was technically not under the overhang of the house, it was still close enough to quickly spread. I briefly considered dashing to the kitchen to get the fire extinguisher, but by the time that thought crossed my mind, the fire was already sputtering and dying out. Had I not popped off the burner, I probably would have needed the professional services of the local Fire Department. Whew! Close call.
Air Force Instruction 90-802, dated February 2013, identifies that "Risk Management" has replaced "Operational Risk Management." It is now a "Process" instead of a "Program," and these changes emphasize its use in all facets of the Air Force, not just Operations. Airmen are encouraged to use Risk Management principles in all activities, both on and off duty. Having failed that evening to properly implement steps one through four, I'll now present step five, which is to Evaluate and Debrief, in the following paragraphs.
Frozen foods will react unpredictably with hot oil. That's why we see so many warnings about deep frying Thanksgiving Turkeys. Deep frying frozen food occasionally results in a fire. If that fire is not contained, it can spread. Looking at Figure 3 of AFI 90-802, (Severity of a spreading fire = Critical or Catastrophic; Likelihood = Seldom) that equates to medium or even a high risk. I certainly didn't mitigate for even a medium risk that evening. I allowed a false sense of urgency and misidentification of the greatest hazard to override a complete risk consideration (Severity and Likelihood of Occurrence), and failed to apply appropriate mitigation strategies.
I was clearly complacent. I was making dinner on the grill, something I had done many times before without negative consequence. The kids were politely complaining, so I was consciously trying to get food to them as quickly as I could. I misidentified hungry children and small ground debris as greater threats than the hot oil, which drove my choice of footwear. In spite of the warm evening, I might also have considered a suitable apron, both to protect my clothes from spatters and also provide insulation and time in the event of a more serious spill.
Hey, I understand. Now my choice is halting the activity, or adding safety equipment to it. What a buzzkill. I don't want to give up the convenience of cooking frozen French fries in hot oil. Restaurants fry frozen food in hot oil, although they also have redundant safety measures built in to their kitchens that I don't have. Safety equipment is cumbersome, and preparing for every contingency often outweighs the benefits of the activity. But what might have happened had I not turned off the gas? Would the flames have been large enough or spread fast enough to block my entry back into the house? Did you see the video that Wing Safety sent last year of the Christmas tree fire? Did you note how fast it spread? That could have been a critical or even a catastrophic event.
Fortunately, Risk Management is not about zero defects. It's about enhancing awareness and implementing smart mitigation strategies. What if my mitigation strategy made simpler changes such as moving the grill a few feet further from the house? The hazard is not a fire in and of itself. The hazard is a quickly spreading fire. But, by adding distance the likelihood markedly drops. The possible loss of the grill is not critical, and the increased distance allows time to consider my options before I get the fire extinguisher, if needed. Properly attired and distanced, I might have been able to simply cover the fire and let it burn out resulting in a mess but only minor damage.
The Chief of Staff of the Air Force recently shared a paper and slides with his major command and wing commanders depicting statistics which report that FY 13 has, from a safety perspective, been the worst in five years. In his email, he specified that we lost six Airmen in on-duty ground mishaps, equal to the past two years combined. The Air Force finished the summer with 19 total fatalities, compared to 16 and 15 in each of the two past years. In most cases, tragically poor risk mitigation choices are behind these unnecessary losses.
The Air Force Intelligence, Surveillance and Reconnaissance (ISR) Agency commander added that in an ISR wing, most of us work in the relative safety of an office environment. Therefore most of our mishaps or accidents will be ground safety related or in an off-duty context. The Risk Management principles are the same, though, and now is the perfect time for commanders and supervisors at all levels to emphasize Safety, and highlight the new Risk Management Instruction and accompanying Pamphlet.
I was lucky. The French fries were a total loss, but we were able to salvage the hot dogs. My wife didn't have to pick me up at the hospital or return to a damaged house. She did return home in time to smile as I finished cleaning up the mess. I'm thankful that the biggest loss was my quiet time on the patio. I encourage each of you, Airman, civilian, contractor or family member, to learn from my mistakes. Review AFI 90-802 and AFPAM 90-803 with your unit Safety Representative for more information. Enjoy the Thanksgiving holiday weekend, but take a little bit of extra time to apply the principles of Risk Management and return safely. Let's work together to prevent needless tragedies and losses of irreplaceable resources.