Archive for the ‘Case Studies’ Category

What is Extreme?

There is some debate about the use of the term extreme fire behavior (some of my colleagues indicate that processes such as flashover is not “extreme” but simply “normal” fire behavior). I contend that flashover would potentially be a normal part of fire development, but is also extreme, at least in the context that we are using the word. As defined in the wildland firefighting community:

“Extreme” implies a level of fire behavior characteristics that ordinarily precludes methods of direct control action. One or more of the following is usually involved: high rate of spread, prolific crowning and/or spotting, presence of fire whirls, strong convection column. Predictability is difficult because such fires often exercise some degree of influence on their environment and behave erratically, sometimes dangerously (National Wildfire Coordinating Group Glossary)

In the structural firefighting environment, occurrence of flashover (particularly while firefighters are operating inside the compartment) fits substantially with the description of extreme used by wildland firefighters.

Classification and Understanding

Ontology may be described as definition of a formal representation of concepts and the relationships between those concepts. An ontology provides a shared vocabulary. Unfortunately we do not have a well developed ontology of fire behavior phenomenon and many types of phenomena have more than one definition. As with the use of the word extreme, there is some debate about the need to classify phenomena as being this or that (e.g., flashover or backdraft). I take the position that it is useful (but difficult as we do not have a common classification scheme or ontology). But, I think that it is still worth the effort.

This is a substantive topic for a later post. This post will examine a type of fire gas ignition phenomena that has been involved in a number of incidents in recent years resulting in near misses, injuries, and fatalities.

Fire Gas Ignitions

In a previous post, I posed the question: Backdraft or Smoke Explosion?. This post used a video clip to open a discussion of the difference between these two phenomena. A smoke (or fire gas) explosion is a type of fire gas ignition, but there are a number of other types of fire gas ignition that present a hazard during firefighting operations.

All fire gas ignitions (FGI) involve combustion of accumulated unburned pyrolysis products and flammable products of incomplete combustion existing in or transported into a flammable state (Grimwood, Hartin, McDonough, & Raffel, 2005). In a smoke explosion, ignition of a confined mass of smoke gases and air that fall within the flammable range results in extremely rapid combustion (deflagration), producing an significant overpressure which can result in structural damage. However, what happens if the mass of gas phase fuel is not pre-mixed within its flammable range and does not burn explosively?

The general term Fire Gas Ignition, encompasses a number of phenomena that are related by the common characteristic that they involve rapid combustion of gas phase fuel consisting of pyrolizate and unburned products of incomplete combustion that are in or are transported into a flammable state. For now, let’s differentiate these phenomena from backdraft on the basis of the concentration of gas phase fuel (backdraft involving a higher concentration than fire gas ignition).

Fire gas ignition can involve explosive combustion (as in a smoke explosion) or rapid combustion that does not produce the same type of overpressure as an explosion. One such phenomenon is a flash fire. In this case, gas phase fuel ignites and burns for short duration, but does not release sufficient energy for the fire to transition to a fully developed stage (as occurs in flashover). While a flash fire may not result in flashover, the energy release is still significant and heat flux (energy transferred) can be sufficient result in damage to personal protective equipment, injury and death. This post uses a case study to examine the flash fire phenomenon.

Residential Fire

This case study is based on a near-miss incident involving extreme fire behavior during a residential fire that occurred on October 9, 2007 at 1119 William Street in Omaha, Nebraska. Special thanks to Captain Shane Hunter (Omaha Fire Department Training Officer) for sharing this post incident analysis and lessons learned.

Unlike many of the incidents used as case studies, no one died or was injured during incident operations. In this near miss incident, the firefighters and officers involved escaped without injury, but the outcome could easily have been quite different.

Weather Conditions

Weather was typical for early fall with a light breeze from the south (blowing towards Side C of the fire building).

Building Information

The fire building was a one and a half story, wood frame dwelling with a basement (see Figure 1). The attic space had been renovated into three separate compartments to provide additional living space.

Figure 1. Exterior View Side A

Figure 2. Floor 2 Layout

Conditions on Arrival

When the first company arrived they observed fire and smoke from the second floor window (see Figure 1) and reported a working fire. The doors and windows on the first floor were closed.

Firefighting Operations

What initial actions were taken? A 200′ hoseline was extended through the door located on Side A and through the living room and kitchen to the stairway to the second floor, which was located at the C/D corner of the structure (Figures 2 and 3).

Figure 5 & 6. Kitchen (view from Floor 1) and Stairwell (view from Floor 2)

What did the fire attack crew observe? The living room and kitchen were clear of smoke and the door to the second floor stairway was closed. When this door was opened and the line was advanced up the stairway to the second floor, the company assigned to fire attack encountered smoke down to floor level on the second floor. Making a left turn at the top of the stairs (see Figure 4) the Captain noted high temperature at the floor level and observed rollover at the ceiling level.

• How did the ventilation profile change when the door to second floor stairway was opened? How might this have changed fire behavior?
• What did the depth of the hot gas layer (from ceiling to floor) indicate about the ventilation profile?
• What did rollover in the center compartment indicate?

The Captain instructed the nozzle operator to apply water to the ceiling. The firefighter on the nozzle applied water in a 30^o fog pattern (continuous application). Simultaneously, a crew working on the exterior vented the second floor window on Side C (see Figures 4 and 6).

How did conditions change? The engine company working on floor 2 heard an audible, whoosh as the hot gas layer ignited producing flames down to floor level. Operation of the hoseline (30^o fog pattern) had no immediate effect. The Captain ordered the crew to retreat into the stairwell and continue water application.

• What extreme fire behavior phenomena occurred?
• What were the initiating events that caused this rapid fire progression?

Figure 4. Floor 2 Side A (Looking Towards Side A)

Figure 5. Floor 2 Side C (Looking Towards Side C)

What action was taken? While the engine company operated from the stairwell, vertical ventilation was completed over the center compartment (see Figures 4 and 5). After the creation of an exhaust opening in the roof, conditions on floor 2 became tenable and the engine crew was able to knock the fire down within several minutes.

• Why did conditions improve quickly after the creation of a vertical exhaust opening?
• What tactical options might have prevented this near miss?

Observations and Analysis

Captain Shane Hunter observed that the initial fire attack crew viewed this incident as an easy job. They thought that an attack from the unburned side would simply push the fire out the window where fire was initially showing on Side A. Why did things turn out so differently than anticipated?

In his analysis of this incident, Captain Hunter points out that there is a considerable difference between a “self-vented” fire and an adequately ventilated fire. As discussed in the April 2008 Officer’s Corner (GFES), horizontally ventilated fires are likely to remain ventilation-controlled. It is important to read the Building, Smoke, Air Track, Heat, and Flame (B-SAHF) indicators to determine the current burning regime (fuel or ventilation-controlled) and anticipate the effect of changes to the ventilation profile.

The fire in the compartment of origin reached flashover resulting in the extension of flames into the center compartment as evidenced by the observation of rollover by the Captain of the engine company performing fire attack. However, the center compartment and the compartment on Side C did not experience flashover (note the condition of contents in the center compartment in Figure 6.). If flashover did not occur in these two compartments, what happened?

In this incident, the fire gases ignited in a flash fire, but combustion did not rapidly transition to a fully developed state in the two compartments adjacent to the compartment of origin.

A flash fire rapidly increases heat release rate, temperature within the compartment and heat flux (as experienced by the fire attack crew in this incident). Like rollover, this phenomenon should not be confused with flashover as fuel in the lower region of the compartment may or may not ignite and sustain combustion. However, fire gas ignition can precede and precipitate flashover (should the fire quickly transition to the fully developed stage).

The concentration of fuel within the hot gas layer varies considerably, with higher concentrations at the ceiling. Concentrations within the flammable range most commonly develop at the interface between the hot gas layer and the cooler air below. Isolated flames (an indicator of a ventilation-controlled fire) are most commonly seen in the lower region of the hot gas layer (as there may be insufficient oxygen concentration in the upper level of the hot gas layer to support flaming combustion). Mixing of the hot gas layer and air due to turbulence increases the likelihood of a significant fire gas ignition.

• What was the ventilation profile and air track when the engine company reached the top of the stairs to begin their attack on the fire?
• How did the tactical ventilation performed from the exterior (removal of the window on floor 2, Side C) influence the ventilation profile and air track?
• What effect do you think that continuous operation of the 30^o fog stream had on conditions on floor 2?
• What combination of factors likely resulting in mixing of air and smoke (fuel) leading to the fire gas ignition that drove the fire attack crew off floor 2 and into the stairwell?

Key Considerations and Lessons Learned

This incident points to a number of key considerations and lessons learned.

• Beware the routine incident! Even what appears to be a simple fire in a small residential structure can present significant challenges and threats to your safety.
• Use the B-SAHF indicators to read the fire and consider both the stage of fire development and burning regime (fuel or ventilation-controlled) in strategic and tactical decision making.
• Flame showing is just that. Do not be lulled into a false sense of security by thinking that the fire is adequately ventilated. Read the air track indicators!
• Continue to read the fire after making entry. Smoke is fuel and hot gases overhead are a threat. Observation of isolated flames indicates a ventilation-controlled fire. Rollover often precedes flashover. Take proactive steps to mitigate the threat of extreme fire behavior.
• Recognize that ventilation-controlled fires will increase in heat release rate if additional air is introduced. Manage the ventilation profile using tactical ventilation and tactical anti-ventilation. Anticipate unplanned ventilation due to fire effects.
• Recognize that both horizontal and vertical ventilation are effective when used appropriately and coordinated with fire control. Consider the influence of inlet and exhaust opening location and size when anticipating the influence of tactical ventilation on fire behavior and conditions within the building.

Again special thanks to Captain Shane Hunter and the Omaha Fire Department for sharing the information about this incident and their work to improve firefighter safety.

Ed Hartin, MS, EFO, MIFireE, CFO

25 Years Later

Firefighters Scott Smith and William Duran died as a result of flashover during a search and rescue drill in Boulder, Colorado on January 26, 1982 (Demers Associates, 1982, August). This incident has particular significance in that it was one of the major influences in the development of National Fire Protection Association (NFPA) Standard 1403 Live Fire Training Evolutions in Structures (NFPA, 1986). 25 years after the deaths of the two firefighters in Boulder, rapid fire progress during live fire training claimed the life of Firefighter Paramedic Apprentice Rachael Wilson in Baltimore, Maryland (Shimer, 2007; NIOSH, 2008)

What makes this even more tragic is that unlike the incident in Boulder, for the last 20 years the fire service has had a national consensus standard that defines minimum acceptable practice for live fire training.

Training Exercise on South Calverton Road

Information on the incident that resulted in the death of Firefighter Paramedic Apprentice Rachael Wilson was drawn from the Independent Investigation Report: Baltimore City Fire Department Live Fire Training Exercise 145 South Calverton Road February 9, 2007 (Shimer, 2007) and NIOSH Death in the Line of Duty Report F2007-09 (NIOSH, 2008).

On February 9, 2007 twenty-two members of Baltimore City Fire Department Firefighter Paramedic Apprentice Class 19 were participating in live fire training in an acquired structure. The objectives of this training exercise included practice in fire attack, primary search, forcible entry, and ventilation. The building used for this training exercise was a three story, single family row house of ordinary (masonry and wood joist) construction. The building was of somewhat unusual design with the front (A Side) of the building constructed at an angle (parallel to the street) resulting in a trapezoidal floor plan as illustrated in Figure 1. The third floor was considerably smaller than the first two floors with third floor windows on Side C looking out over the second floor roof. The building had previously been used for training and ceilings and portions of the walls on the second and third floors had been opened up during ventilation and forcible entry practice.

Five instructors assigned to the Training Academy and six adjunct instructors were responsible for managing the live fire training exercise and providing instruction. Lieutenant Crest (Training Academy staff) served as Incident Commander and Division Chief Hyde served as the Safety Officer. Two instructors were assigned as the ignition team and others were assigned to supervise assigned crews of Firefighter Paramedic Apprentices. An engine and truck from the Training Academy were positioned on the A Side of the building. The engine was supplied by a hydrant through a single large diameter hoseline.

The plan for the training exercise called for eight separate fuel packages on Floors 2 (two fuel packages) and 3 (six fuel packages) to be ignited. Each fuel package consisted of one or three pallets and excelsior (soft shredded wood packing material). Crews would be assigned to fire attack on floors two and three while other crews performed forcible entry (in support of fire attack) primary search, ventilation. The trainees were divided into five companies, designated Engine 1 (fire attack on Floor 3), Engine 2 (fire attack on Floor 2), Truck 1 (placement of ladders and then search and rescue), Truck 2 (assist with forcible entry on Side C), and Truck 3 (vertical ventilation). While the Incident Commander outlined the plan for the instructors, the trainees were not provided with a walkthrough of the building or safety briefing prior to the start of the live fire exercise.

The Incident Commander (Lieutenant Crest) accompanied the ignition team into the building and supervised ignition of the fires on Floors 3 and 2. While none of the instructors indicated doing so, a fire was also lit in debris (three mattresses, automobile tire, upholstered chair, and other combustible materials) located just inside the doorway on Floor 1 Side C.

Fire Attack

The crew designated Engine 1 consisted of Emergency Vehicle Driver Wenger (Instructor) and Firefighter Paramedic Apprentice Wilson (nozzle), Paramedic Cisneros (2^nd on the line), and Firefighter Paramedic Apprentices Perez, and Lichtenberg. Engine 1 was tasked with fire attack on Floor 3. None of the crew from Engine 1 was equipped with a portable radio and received their orders face-to-face from Command. When the instructor questioned passing the fire on Floor 2, Command indicated that another line would be coming in right behind them and to go directly to Floor 3. Engine 1 entered from Side A with a 1-3/4″ (45 mm) hoseline and proceeded up the interior stairwell. None of the members of this crew indicated seeing fire on Floor 1 at the time they made entry.

Figure 1. Baltimore Floor Plan.

Note: Adapted from City of Baltimore.� Independent investigation report: The Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007, (Shimmer, 2007, pp. 13)

Upon reaching Floor 2, Engine 1 encountered severe fire conditions and the instructor did not feel comfortable proceeding to Floor 3 without controlling the fire on Floor 2. He instructed Apprentice Wilson to open the nozzle and put water on the fire. In the process of doing so, she fell and the instructor took over the nozzle. He (the instructor) knocked the fire down to the point where he felt that his crew could advance to Floor 3 (bud did not completely control or extinguish the fire on Floor 2). At this point he returned the nozzle to Wilson. Wilson and Cisneros and the instructor proceeded to Floor 3 while Perez, and Lichtenberg remained in the stairwell pulling hose.

Trapped Above the Fire

After reaching Floor 3, Cisneros (2^nd on the line behind Wilson) advised the instructor that Floor 2 was well involved. He instructed her to go into the stairwell and pull up additional hose. She felt intense heat on her legs and advised the instructor that she needed to get out of the building. The instructor climbed through the egress window (see Figure 2) and assisted Cisneros out the window and onto the second floor roof. At this point, Wilson was maintaining a position at the egress window (located at the top of the stairwell) with the nozzle.

Figure 2. Baltimore Cross Section of Floor 3

Note: Adapted from City of Baltimore. Independent investigation report: The Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007, (Shimmer, 2007, pp. 13 & 21-27)

While Engine 1 was making their way to Floor 3, Engine 2 entered from Side C with a 1-3/4″ (45 mm) hoseline, intending to proceeding to Floor 2 as ordered, but encountered a significant fire on Floor 1 with flames beginning to roll across the ceiling. Engine 2 attacked the fire on Floor 1 (which delayed their advancement to Floor 2).

Perez and Lichtenberg (members of Engine 1’s crew pulling hose in the stairwell) felt a rush of air followed by flames rapidly extending up the stairwell from Floor 2 to Floor 3. They moved to the top of the stairs and observed Wilson trying to climb through the egress window. Wilson warned them to get out of the building. Heeding her warning, they proceeded down the stairway with the hoseline and controlled the fire on Floor 2 sufficiently to permit them to exit the building, meeting the crew of Engine 2 who were making their way to Floor 2.

Wilson advised Wenger (instructor with Engine 1) that she needed to get out. She had dropped the nozzle (still operating) and was trying to climb out the window. Wenger tried unsuccessfully to pull her out the window (note the height of the window sill in Figure 2). Wenger asked Wilson if she could help him get her out the window. She replied that she could not and that she was burning up. Wenger lost his grip on Wilson and she fell back into the building. Regaining his grip he pulled her partially out the window again, noticing that her breathing apparatus facepiece was partially displaced. Wenger called for help (shouting as he had no radio). Three members of Truck 3 who were working on the third floor roof dropped down to the second floor roof to assist, but were unable to pull Wilson from the window.

Emergency Vehicle Driver Hiebler (instructor with Engine 2) heard a commotion on Floor 3. He ordered one of his crew to accompany him to Floor 3 with the hoseline and the others to remain in place on Floor 2. Reaching Floor 3, they observed Wilson at the window and Wenger (instructor from Engine 1) working from the second floor roof trying unsuccessfully to pull her out the window. Concerned about the fire on Floor 3, Hiebler instructed the trainee to extinguish the fire while he assisted in getting Wilson out the window.

Wilson was unconscious, pulseless and apnic when she was removed from Floor 3. Her breathing apparatus and protective clothing was removed and cardio pulmonary resuscitation (CPR) was initiated while she was on the second floor roof. At the Incident Commander’s direction she was moved up to the third floor roof so that she could be brought down an aerial ladder that had been placed to the roof from Side A. Prior to being brought down from the third floor roof, Wilson was packaged on a backboard and placed in a stokes basket. On reaching the ground advanced life support medical care was initiated and Wilson was transported to the local trauma center where she was pronounced dead. Firefighter Paramedic Apprentice Rachael Wilson died as a result of thermal injuries and asphyxia.

The Aftermath

The initial investigation of this incident was conducted by the Baltimore City Fire Department, Baltimore City Police Department Arson Unit, and United States Bureau of Alcohol Tobacco and Firearms. Subsequently, Mayor Sheila Dixon commissioned an independent investigation into the circumstances surrounding the death of Rachael Wilson lead by Deputy Chief Chris Shimer of the Howard County Department of Fire and Rescue Services. This investigation concluded that there were in excess of 50 deviations from accepted practice as defined by National Fire Protection Association (NFPA) 1403 Standard on Live Fire Training Evolutions (2002). In addition, the investigators identified significant issues related to the organizational culture of the Baltimore City Fire Department that resulted in a lack of accountability compliance with accepted safety practices (Shimer, 2007)

The Maryland Department of Labor, Licensing, and Regulation cited the Baltimore City Fire Department for 33 safety violations and singled out the fire officers who served as Incident Commander and Safety Officer for the haphazard planning and execution of this live fire training exercise (Linskey, 2007a)

The Baltimore City Fire Department fired Training Division Chief Kenneth Hyde who was the Safety Officer and senior fire officer present at the fatal incident. Citing negligence and incompetence in their roles as Incident Commander (Crest) and supervisor of the rapid intervention team (Broyles) during this incident (Linskey, 2007b) Lieutenants Joseph Crest and Barry Broyles were also terminated.

Following votes of no confidence from the Baltimore City Firefighters and Fire Officers unions and continuing criticism, Fire Chief William Goodwin resigned in November 2007, ten months after the death of Firefighter Paramedic Apprentice Rachael Wilson (Fritze & Reddy, 2007)

Now What?

Rachael Wilson’s death was the result of a complex web of contributing factors. It is easy to say that failure to comply with the provisions of standards and regulations regarding live fire training was the problem. But it is more complex than that.� It is essential that we examine our organizational culture and training practices on an ongoing basis and ask hard questions regarding the safety and effectiveness of what we do.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Demers Associates. (1982, August) Two die in smoke training drill. Fire Service Today, 17-63.

Fritze, J. & Reddy, S. (2007) City’s fire chief resigns. Retrived June 5, 2008 from http://baltimoresun.com/recruit

Linsky, A. (2007c) Baltimore fire department cited in cadet’s death. Retrieved June 4, 2008 from http://baltimoresun.com/recruit

Linsky, A. (2007d) City dismisses two more fire officials. Retrieved June 4, 2008 from http://baltimoresun.com/recruit

National Fire Protection Association. (1986). Standard on live fire training evolutions in structures. Quincy, MA: Author.

National Fire Protection Association. (2002). Standard on live fire training. Quincy, MA: Author.

National Institute for Occupational Safety and Health (NIOSH). (2002). Death in the line of duty, F2007-09. Retrieved February 19, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200709.pdf

Shimer, R. (2007) Independent investigation report: Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007. Retrieved February 19, 2009 from http://www.firefighterclosecalls.com/pdf/BaltimoreTrainingLODDFinalReport82307.pdf.

This is the first of a series of posts that will examine the events and circumstances surrounding the death of a Firefighter Paramedic Apprentice in Baltimore Maryland in 2007. Unfortunately many of the factors involved in this incident are not unique, but are common to many live fire training fatalities that have occurred over more than 25 years.

Last Monday marked the second anniversary of the death of Firefighter Paramedic Apprentice Rachael Wilson. The death of this young mother in Baltimore, Maryland during live fire training on February 9, 2007 raised many questions.

The investigations conducted by the Baltimore City Fire Department, an independent commission appointed by the Mayor of Baltimore (Shimer, 2007), and National Institute for Occupational Safety and Health (2008) determined that this training exercise was not conducted in compliance with National Fire Protection Association (NFPA) 1403 Standard on Live Fire Training in Structures (2002). �But does this answer the question of how this happened or why Rachael Wilson died? I contend that lack of compliance with existing standards provides only a partial answer.

Historical Perspective

It is unknown exactly when fire service agencies began the practice of live fire training to develop and maintain skill in interior firefighting operations. However, it is likely that firefighter fatalities have occurred during this type of training activity since its inception

Two Firefighters Die in Fire Training Flashover – On January 26, two firefighters died from burns and smoke inhalation during a search and rescue drill held in a vacant single story building (Demers Associates, 1982, August).

Two Firefighters Die in Fire Training Flashover – On July 30, two firefighters died from burns and smoke inhalation during a search and rescue drill held in a vacant single story building (National Institute for Occupational Safety and Health, 2003)

At first glance, the only difference between these two incidents is the month and day of occurrence. However, a major difference between these two tragic events is that the first occurred in Boulder, Colorado in 1982 while the second occurred 20 years later in Kissimmee, Florida in 2002. Five years later a similar story is repeated with the death of Firefighter Paramedic Apprentice Rachael Wilson.

This comparison provides a dramatic example of the limited impact that existing live fire training policy has had on the safety of individuals participating in this essential training activity. This observation is not to minimize the important guidance provided by NFPA 1403 (2007), but to point to several limitations in the scope of this standard and examining this critical type of training activity simply from a reactive, rules based approach.

A fire in a structure presents complex and dynamic challenges. Firefighters are faced with the need to protect the lives of the building occupants as well as their own while controlling the fire and protecting the uninvolved areas of the structure and its contents. Structure fires develop quickly requiring decision-making and action under extreme time pressure. These conditions require a high level of situational awareness and decision-making skill that is dependent on recognition of complex patterns of information presented by the fire environment (Klein, 1999; Klein, Orasanu, Calderwood, & Zsambok, 1995).

Firefighters learn their craft through a mix of classroom and hands-on training. A majority of skills training is performed out of context (i.e. no smoke or fire) or in a simulated fire environment (i.e. using non-toxic smoke). However, this alone does not prepare firefighters to operate in the heat and smoke encountered in an actual structure fire nor to develop critical decision-making skills. Developing this type of expertise requires live fire training!

Live fire training presents the same types of hazards encountered during emergency response operations. However, as a planned activity, training requires a higher standard of care to ensure the safety of participants. This is consistent with standard risk management practices in firefighting operations outlined by Chief Alan Brunacini (2002).

• We will risk our lives a lot, in a calculated manner to save savable lives.
• We will risk our lives a little, in a calculated manner to save savable property.
• We will not risk our lives at all for lives or property that are already lost.

This perspective on risk management is commonly accepted throughout the fire service in the United States. Live fire training parallels the second element of the risk management profile: We will risk our lives a little in a calculated manner to develop competence in structural firefighting operations.

NFPA 1403

In 1986, the National Fire Protection Association first published NFPA 1403 Standard on Live Fire Training. This important standard has been updated and revised five times since its inception. Often, revisions reflect the conditions and actions surrounding the deaths of firefighters during live fire training since the last revision.

Detailed review of the latest revision of NFPA 1403 (National Fire Protection Association, 2007) shows little substantive change in areas that potentially have the most impact on firefighter safety. The 2007 edition of this standard prohibits location of fires in designated exit paths (a reasonable idea) and increases emphasis on the responsibility of the instructor-in-charge, stating: “It shall be the responsibility of the instructor-in-charge to coordinate overall acquired structure (or training structure) fireground activities to ensure correct levels of safety.” While this too is a reasonable idea, what exactly is the “correct level of safety” and how is the instructor-in-charge to coordinate this effort?

NFPA 1403 (National Fire Protection Association, 2007) places specific emphasis on addressing unsafe acts and conditions directly connected to accidents that have occurred during live fire training (e.g., removal of low density fiberboard, prohibiting the use of flammable liquids except under specific conditions, prohibiting fires in exit paths and use of live victims). However, it does not explicitly address the primary causal factor influencing traumatic fatalities during live fire training. Most firefighters who die from traumatic injuries during live fire training die as a result of human error, often on the part of the individuals charged with ensuring their safety, the instructors. Reducing the risk of error requires both technical proficiency and competence in leadership, communication, and teamwork (i.e., crew resource management).

Learning from the Past

Unfortunately many firefighters and fire officers have not heard of Firefighters Scott Smith and William Duran (Boulder Fire Department), Lieutenant� John Mickel and Firefighter Dallas Begg (Osceola County Fire-Rescue), and Rachael Wilson (Baltimore City Fire Department).

In each of the incidents that resulted in firefighter fatalities during live fire training, those involved did not intend for it to happen. The purpose of live fire training is to develop the knowledge and skills necessary to safely and effectively engage in firefighting operations. Firefighters Scott Smith and William Duran died before the development of national consensus standards on safe practices for live fire training. In other cases the instructors and other participants were unaware of the standard or lacked detailed knowledge of how it should be applied. But in each case where firefighters were caught by rapid fire progress, they did not understand fire behavior and practical fire dynamics.

Subsequent posts will examine the incident in which Rachael Wilson lost her life, the lessons that can be learned from live fire training fatalities, and action steps we can take to reduce the risk to participants while conducting realistic and effective live fire training.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Brunacini, A. (2002). Fire command (2nd ed.). Quincy, MA: National Fire Protection Association.

Demers Associates. (1982, August) Two die in smoke training drill. Fire Service Today, 17-63.

Klein, G. A. (1999). Sources of power. Cambridge, MA: MIT Press.

Klein, G. A., Orasanu, J., Calderwood, R., & Zsambok, C., E. (Eds.). (1995). Decision making in action: Models and methods. Norwood, NJ: Ablex.

National Fire Protection Association. (2002). Standard on live fire training. Quincy, MA: Author.

National Fire Protection Association. (2007). Standard on live fire training. Quincy, MA: Author.

National Institute for Occupational Safety and Health. (2003). Death in the line of duty (Report Number F2002-34). Retrieved February 16, 2009, from http://www.cdc.gov/niosh/pdfs/face200234.pdf

National Institute for Occupational Safety and Health. (2008). Death in the line of duty (Report Number F2007-09). Retrieved February 16, 2009, from http://www.cdc.gov/niosh/fire/pdfs/face200709.pdf

Shimer, R. (2007) Independent investigation report: Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007. Baltimore, MD: City of Baltimore.

Applying NIOSH Recommendations

NIOSH Death in the Line of Duty reports generally contain two types of recommendations, those that focus on specific contributory factors and others that address general good practice. As when examining contributory factors, it is important to read the NIOSH recommendations critically. Do you agree or disagree and why? What would you change and what additional recommendations would you make based on the information presented in the report?

Brief Review of the Incident

NIOSH Report F2008-06 examines a fire in a wood frame duplex that resulted in injury to Lieutenant Scott King and the death of Firefighter Brad Holmes of the Pine Township Engine Company. The fire occurred on February 29, 2008 in Grove City, Pennsylvania.

When the fire department arrived, the unit on Side D was substantially involved and a female occupant was reported trapped in the building. Initial operations focused on fire control and primary search of Exposure B. Rapid fire development trapped Lieutenant King and Firefighter Holmes while they were searching Floor 2 of Exposure B.

The following photographs are part of a series of 37 pictures taken during this incident and provided to NIOSH investigators during their investigation.

Additional detail on this incident is provided in Developing & Using Case Studies: Pennsylvania Duplex Fire Line of Duty Death (LODD) and Pennsylvania Duplex Fire: Firefighting & Firefighter Rescue Operations . In addition, readers should review NIOSH Report F2008-06.

Recommendations

NIOSH Report F2008-06 contains 11 recommendations. Several of these recommendations are well grounded in the contributory factors identified in the report. Others have a more indirect relationship to the factors influencing the injury to Lieutenant King and death of Firefighter Holmes.

Recommendation #1: Fire departments should be prepared to use alternative water supplies during cold temperatures in areas where hydrants are prone to freezing.

In preparation for potential issues, fire departments should develop standard operating procedures (SOPs) for temporary water sources to be dispatched like tankers, water shuttles, or portable drop tanks.

While this recommendation is valid and good practice, it has little to do with loss of water as a contributory and likely causal factor in the injury to Lieutenant King and death of Firefighter Holmes. Had Command been notified immediately of the frozen hydrant and implemented alternate water supply strategies, the outcome would have likely been the same if tank water had been used as it was in this incident to sustain initial operations.

However, it is critical for fire departments to have a plan to respond to respond to water supply problems. In this case, apparatus had substantial tank water which was used to support initial firefighting operations. In addition, there was sufficient hose available on first alarm companies to stretch to other hydrants (such as the one eventually used east of Garden Avenue on Craig Street). Use of a reverse lay to establish water supply allows the apparatus operator to continue the lay to the next hydrant (hose capacity permitting) or another apparatus to continue the lay and establish a relay. Depending on the distance to the next operational water source, this could be considerably more efficient and rapid than waiting for greater alarm resources to establish a tender shuttle.

Recommendation #2: Fire departments should ensure that search and rescue crews advance or are protected with a charged hoseline.

This recommendation is critical. However, the discussion fails to speak to the need for backup lines to protect the means of egress when crews are working above the fire. Recent incidents in Loudoun County, Virginia and Sacramento California, resulted in crews with a hoseline working above the fire without a backup line having their hose burn through, and means of egress cut off, necessitating emergency egress via second floor windows.

Recommendation #3: Fire departments should ensure fire fighters are trained in the tactics of a defensive search.

While training in search under marginal circumstances is important, this recommendation fails to speak to the need to understand fire behavior and applied fire dynamics as a foundation for maintaining situational awareness on the fireground. This applies to command personnel, company officers, and individual firefighters. While there are a number of points in the sequence of events that lead to Lieutenant King’s injury and Firefighter Holmes’s death, all are dependent on this. Failure to recognize the potential for extension and rapid fire progress, the influence of creating ventilation openings on Floor 2, and recognition of developing fire conditions were likely the most significant causal factor in this incident. Had this not been the case, the firefighters and officers involved would have had the opportunity to adjust their tactical operations or exit the building prior to the occurrence of the extreme fire behavior that trapped the search team.

NIOSH Report F2008-06 quotes Deputy Chief Vincent Dunn regarding flashover indicators:

There are two warning signs that may precede flashover: heat mixed with smoke and rollover. When heat mixes with smoke, it forces a fire fighter to crouch down on his hands and knees… As mentioned above, rollover presages flashover.

This statement is scientifically incorrect. Heat is simply energy in transit due to temperature difference. It is not a substance and cannot mix with anything else. Increasing temperature is an indicator of potential for flashover, but perception of a rapid increase in temperature is not certain to give adequate warning to take corrective action or escape from the hazardous situation. In addition, rollover does not always precede flashover (it is an important indicator, but only one of many).

The report also quotes Chief Dunn regarding defensive search tactics.

Three defensive search tactics are as follows:

1. At a door to a burning room that may flashover, fire fighters should check behind the door to the room and sweep the floor near the doorway. Fire fighters should not enter the room until a hose line is in position.
2. When there is a danger of flashover, fire fighters should not go beyond the “point of no return.” The point of no return is the maximum distance that a fully equipped fire fighter can crawl inside a superheated, smoke-filled room and still escape alive if a flashover occurs. The point of no return is approximately five feet inside a doorway or window.
3. When searching from a ladder tip placed at a window, look for signs of rollover if one of the panes has been broken. If rollover is present, do not go through the window. Instead, crouch below the heat and sweep the interior area below the windowsill with a tool. If a victim has collapsed there, you may be able to crouch below the heat enough to pull him to safety.

While these tactics have validity, making for search without without protection of a hoseline even to Chief Dunn’s “point of no return”� presents a significant risk. Further, I am uncertain that there is any scientific evidence supporting the concept of the point of no return as described by Chief Dunn. There are numerous examples of situations where firefighters thought they had time to complete a search, but were trapped by extremely rapid fire development. The risk of searching under marginal conditions requires firefighters to effectively read the fire and mitigate hazards in the fire environment through effective use of gas cooling and control of the ventilation profile (either tactical ventilation or anti-ventilation as appropriate) and establishing fire control in addition to primary search.

Recommendation #4: Fire departments should ensure that fire fighters conducting an interior search have a thermal imaging camera.

The thermal imaging camera is a tremendous technological innovation which can significantly speed search operations and provide visual indication of differences in thermal conditions. However, implementation of this recommendation would not necessarily have impacted on the outcome of this incident.

Recommendation #5: Fire departments should ensure ventilation is coordinated with interior fireground operations.

In the discussion of this recommendation, the NIOSH Report F2008-6 states “By eliminating smoke, heat, and gases from the fire it will help minimize flashover conditions”�

This statement is not always true. The influence of ventilation on fire development is dependent on burning regime (fuel or ventilation controlled) and the location of the inlet and exhaust openings. Heat release rate from a ventilation controlled fire will increase as ventilation is increased, potentially taking the fire to flashover (rather than the reverse as indicated by the statement in this NIOSH report). In addition, creation of an air track that channels the spread of hot gases and flames to additional fuel packages can result in fire extension and subsequent flashover. Both of these factors were likely to have been significant in this incident. Coordination of ventilation and search or ventilation and fire attack (as frequently stated in NIOSH reports related to incidents involving extreme fire behavior) requires knowledge of fire dynamics and the influence of ventilation in fire behavior.

Recommendation #6: Fire departments should ensure that Mayday protocols are developed and followed.

This recommendation is important, but fails to address other individual level survival skills that must be integrated with these procedures. For example, in this incident, the Lieutenant and Firefighter might have been able to take refuge in one of the bedrooms, closing the door to provide a barrier to hot gases and flames. A ladder was initially placed to a window in the bedroom on Side B (in close proximity to the location where Firefighter Holmes was found). Ladders were subsequently placed to the bedroom windows on Side A. While it may have been difficult to accomplish this under conditions of extreme thermal insult, if developing conditions had been recognized soon enough (see my earlier observation on situational awareness), this may have bought critical seconds and allowed the trapped search team to escape or be rescued.

Recommendation #7: Fire departments should ensure that the Incident Commander receives pertinent information during the size-up (i.e., type of structure, number of occupants in the structure, etc.) from occupants on scene and that information is relayed to crews upon arrival.

Had the Incident Commander received more specific information from the occupants or law enforcement, this may have shifted focus in search operations as survivability in the original fire unit was doubtful. Despite this, the civilian casualty was later located outside the fire unit, behind the door in the front foyer that served both dwelling units.

Recommendation #8: Fire departments should ensure that fire fighters communicate interior conditions and progress reports to the Incident Commander.

This is a key element in maintaining situational awareness (on the part of the Incident Commander). However, it is equally important for Command to communicate with interior crews regarding conditions observed from the exterior or situations (such as water supply limitations) that will impact interior operations.

Recommendation #9: Fire departments should develop, implement, and enforce written standard operating procedures (SOPs) for fireground operations.

This recommendation focuses on general good practice, but is not tied to specific contributing factors related to the injuries and fatality that resulted in this incident. This type of recommendation should likely be included, but placed in a separate section so as not to dilute the focus on lessons learned.

Recommendation #10: Fire departments and municipalities should ensure that local citizens are provided with information on fire prevention and the need to report emergency situations as soon as possible to the proper authorities.

Recommendation #11: Building owners and occupants should install smoke detectors and ensure that they are operating properly.

If implemented prior to this incident, Recommendations #10 and #11 would likely have had a positive impact on its outcome, particularly with regards to the civilian casualty and the severity of conditions encountered by the firefighters.

However, these two recommendations do not go far enough. Citizens must also recognize the need for rapid egress and the value of closing doors to confine the fire and limit inlet of air required for continued fire development and increasing heat release rate.

Detailed Case Study

CFBT-US has developed a detailed case study based on this incident and the data contained in NIOSH Report F2008-06. Download the Grove City, Pennsylvania Residential (Duplex) Fire Case Study in PDF format.

Now What?

Over the last two weeks we have spent considerable time with a NIOSH Report F2008-06. NIOSH has completed 335 investigations during the first 8 years that this program has been in existence. 49 more investigations are pending. The information contained in these reports provides a vast reservoir of data that can be used to deepen understanding of your craft and improve decision-making and risk management skills.

Make a commitment to developing your expertise as a firefighter or fire officer in the new year and for the rest of your life. Look for the this logo (more information to follow)!

Have a safe and happy new year!

Ed Hartin, MS, EFO, MIFIreE, CFO

I would like to extend my thanks to Steve Berardinelli and Tim Merinar of the NIOSH Firefighter Fatality Investigation and Prevention Program for their assistance in developing the Case Study based on NIOSH Report F2008-06. Just prior to my first post regarding this incident, I forwarded a request for additional information to the NIOSH staff and received a quick response from Tim that he would forward my request to the investigators. This morning I had an excellent conversation with Steve and obtained additional information that was extremely helpful in refining the case.

I will be revising Developing & Using Case Studies: Pennsylvania Duplex Fire Line of Duty Death (LODD) and Pennsylvania Duplex Fire: Firefighting & Firefighter Rescue Operations based on additional information provided by NIOSH. Changes include addition of information related to the ventilation profile, initial fire conditions, and occupant actions.

Analysis and Critique

It is important to note that the observations in this post regarding the contributory factors identified in NIOSH Report F2008-06 are made as a critical friend. Most firefighters and fire officers who read this (or any) NIOSH report will agree with some of the recommendations, may disagree with others, and undoubtedly would make additional recommendations based on their individual assessment of the incident. Analysis of contributing factors and recommendations (rather than simply accepting them) is an important element in the learning process. Dig a bit deeper and build an understanding of why events may have unfolded the way that they did. Identify the critical points at which the outcome could have been changed (there are likely more than one). Think about how these recommendations might apply to you and your department.

As discussed in my earlier post; Criticism Versus Critical Thinking, the intent of this analysis and critique is to share what I have learned from this case, with all due respect to those involved. The firefighters and fire officers involved in this incident were faced with a difficult situation to begin with, having an occupant reported trapped in the building. This was compounded by challenging water supply problems due to multiple frozen hydrants. It is far easier to examine incident information in a comfortable environment with no time pressure than to deal with these issues in the cold, early morning hours.

My original intent was to examine both the contributory factors and recommendations in NIOSH Report F2008-06. However, due to length, this critique will be divided into two separate posts.

A Brief Review of the Incident

On February 29, 2008 The Grove City Fire Department, Pine Township Engine Company, and East End Fire Department responded to a fire in a two-story, wood frame duplex in Grove City, Pennsylvania. Initial dispatch information and the initial size-up indicated that a female occupant was trapped in the building. When the Chief and first engine company arrived, the unit on Side D was substantially involved with smoke in the unit on Side B. Several hoselines were placed into operation for fire control, but fire conditions precluded an offensive attack in the involved unit. Pine Township Engine 85 was assigned to search and rescue of the trapped occupant. Firefighter Brad Holmes and Lieutenant Scott King were tasked with primary search of Exposure Delta. Firefighting operations were hampered by two frozen hydrants, necessitating support of initial operations using only apparatus tank water while an operable hydrant was located. During their search, water supply was interrupted and rapidly deteriorating conditions trapped the search crew. After being rescued by the Rapid Intervention Team, both members were transported to Pittsburgh’s Mercy Hospital Burn Unit. Firefighter Brad Holmes had burns over 75% of his body, and died from his injuries on March 5, 2008. Lieutenant King suffered less serious injuries and was treated and released. A 44 year old female occupant of the dwelling also died.

Figure 1. 132 Garden Avenue-Side Alpha

Note: Fire Department Photo – NIOSH Death in the Line of Duty Report F2008-06. This photo likely illustrates conditions after 0635 (approximately 19 minutes after arrival of the first fire unit, Chief 95).

Additional detail is provided in Developing & Using Case Studies: Pennsylvania Duplex Fire Line of Duty Death (LODD) and Pennsylvania Duplex Fire: Firefighting & Firefighter Rescue Operations. In addition, readers should review NIOSH Report F2008-06.

Contributory Factors

NIOSH Report F2008-06 identifies seven contributory factors in the injury of Lieutenant King and death of Firefighter Holmes. While each of these factors may have had some influence on the outcome of this incident, this analysis provides insufficient clarity and misses several key factors.

• Inadequate water supply. Two hydrants in the vicinity of the burning structure were frozen from the cold weather.
• The victim and injured Lieutenant did not have the protection of a charged hoseline during their search for the trapped occupant.
• Inadequate training in defensive search tactics.
• Non-use of a thermal imaging camera which may have allowed the search and rescue crew to advance more quickly through the structure.
• Ventilation was not coordinated with the interior search.
• Size-up information about the structure was not relayed to the interior search crew. The interior crew was searching in the wrong duplex for the trapped occupant and did not realize they were in a duplex.
• The incident commander was unaware of the search crew’s location in the building. He did not receive any interior reports and was concentrating on resolving water supply issues.

Water Supply: The lack of a continuous water supply likely influenced the loss of the structure and loss of water supply to handlines was in all probability a causal factor in the injury of Lieutenant King and death of Firefighter Holmes. However, the volume of tank water available on apparatus that arrived prior to the search team becoming trapped on Floor 2 (5000 gallons) was likely adequate to support search of the uninvolved areas of the building and confine the fire to the unit of origin for the time required to search uninvolved areas of the building. Anticipation that a continuous water supply would be established may have influenced the tactics and water application used by initial arriving companies.

Protection of the Search Team: Failure to protect the search team with a hoseline was a significant factor in this incident. However, the outcome would likely have been the same if the search team had a hoseline as fire extended from below to cut off their means of egress. A backup line should also have been in place to protect the search team’s egress while they were working above the fire. There was an additional hoseline initially deployed to the doorway on Side A, however, the position and operation of this line while the search team was on Floor 2 was not specified in the report. Without additional tactical changes, the loss of water supply would have precluded effective hoseline support of search operations.

Training in Defensive Search Tactics: Identifying a lack of training in “defensive search tactics” is too narrowly focused. The issue here is significantly broader than stated in the report and should be restated as lack of situational awareness. This causal factor fails to identify the lack of situational awareness on the part of the search crew, the incident commander, and others on the fireground to developing and potential fire conditions and water supply limitations. This lack of situational awareness is likely due to inadequate training in fire behavior and applied fire dynamics (rather than simply inadequate training in defensive search tactics).

Use of a TIC: Undoubtedly effective use of a TIC can speed search operations. However the NIOSH report indicated that visibility was not excessively compromised during the initial stages of search on both floors 1 and 2. Reducing the time required to complete the search could have been influenced by use of a TIC, by assigning a separate crew to perform fire control on Floor 1 of Exposure B and allowing Firefighter Holmes and Lieutenant King to focus on primary search or by both of these actions. While technology may useful in improving firefighter safety, it is important to not simply look for a technological solution to a problem which can be substantively related to human factors such as situational awareness, communications, and decision-making.

Tactical Ventilation: The location, sequence, and lack of coordination in ventilation was likely a causal factor (along with failure to protect the means of egress with a hoseline and loss of water supply) in the injury to Lieutenant King and death of Firefighter Holmes. Creation of exhaust openings above the fire created a clear path of travel for hot gases and flames from Floor 1 to Floor 2 via the interior stairs and increased air supply to a fire which was likely ventilation controlled (resulting in an increase in heat release rate (HRR) sufficient to result in flashover. This contributory factor also points to the need for training on the influence of tactical operations (particularly ventilation) on fire behavior.

Communication of Size-Up Information: Size-up information related to the building and possible victim location could have been a significant factor in focusing the location of the search. However, the civilian occupant was not in either unit, but was located (after fire control) behind the door in the foyer. If it was known that the trapped occupant was from the fire unit, it may have appeared that there was no savable life (due to the extent of fire involvement). But this does not preclude the assumption that she may have been confused and gone into the other unit.

Note: There is some difference of opinion between the fire investigator and operational personnel as to the likely location of the victim prior to structural collapse. It is possible that the victim died on Floor 2 of the fire unit and fell to the position where she was found due to structural collapse.

Accountability and Situation Status: Accountability and communication of situation status is critical to the safety of everyone operating on the fireground. Clear communication in advance of the loss of water supply could have influenced the outcome of this incident. When operating off tank water, it is essential to follow a similar philosophy as the Rule of Air Management and retain sufficient water to exit from the hazardous environment. However, it does not appear that the lack of accountability regarding the search team significantly delayed the rescue effort.

My next post will examine the recommendations made in NIOSH Report F-2008-06 and will provide a link to a detailed, written case study based on this incident in PDF format.

Happy Holidays,
Ed Hartin, MS, EFO, MIFireE, CFO

This post continues examination of NIOSH Death in the Line of Duty Report F2008-06. My previous post, Developing & Using Case Studies: Pennsylvania Duplex Fire Line of Duty Death (LODD) emphasized the importance of case studies to individual and organizational learning and presented initial information about the incident which resulted in injury to Lieutenant Scott King and the death of Firefighter Brad Holmes of Pine Township Engine Company.

Figure 1. 132 Garden Avenue-Side Alpha

Note: Fire Department Photo – NIOSH Death in the Line of Duty Report F2008-06. This photo likely illustrates conditions after 0635 (approximately 19 minutes after arrival of the first fire unit, Chief 95).

Firefighting Operations

Command assigned Engine 95 (officer and five firefighters) to fire suppression. They deployed a 1-3/4″� (45 mm) line to the door on Side A, but were unable to make entry due to the volume of fire in the involved unit. Engine 95 also deployed a 2-1/2″� (64 mm) handline to the A/D corner. Both lines were immediately placed into operation. NIOSH Report F2008-06 indicated that the 1-3/4″� line stretched to the door on Side A was “unable to make entry due to heavy fire conditions”�. However, exact placement and operation of the 2-1/2” handline was not specified. This line may have been used to protect Exposure D (a wood frame dwelling approximately 20′ from the fire unit), for defensive fire attack through first floor windows, or both.

Figure 2. Fire Unit and Exposure Bravo Floor 1

Note: This floor plan is based on data provided in NIOSH Report F2008-06 and is not drawn to scale. Windows shown as open are based on the narrative or photographic evidence. Door position is as shown based on information provided by NIOSH Investigator Steve Berardinelli (this differs from the NIOSH report which includes the fire investigators rough sketch showing all doors open). Windows shown as intact are not visible in the available photographs, but may be open due to fire effects or firefighting operations (particularly those in the fire unit).

Second due, Engine 95-2 performed a forward lay from a nearby hydrant and supplied Engine 95 with tank water while waiting for the supply line to be charged.

Engine 85 (chief, lieutenant, and three firefighters) was assigned to primary search and rescue of the trapped occupant. Tasked to conduct primary search in Exposure B, Firefighter Holmes and Lieutenant King were performed a 360^o reconnaissance prior to making entry. While this was being done other members of the company placed a ladder to a window on Floor 2 Side B (see Figure 3). The NIOSH Report does not specify if the search team was aware of ladder placement.

The Officer of Engine 95 vented the window on Floor 1 Side A of Exposure Bravo and observed that the ceiling light was on (indicating that there was limited optical density of the smoke on Floor 1 of the exposure). Firefighter Holmes and Lieutenant King entered through this window (see Figure 2) to conduct primary search of the exposure and observed that the temperature was low and there was limited smoke on Floor 1. Engine 95 passed the search team a 1-3/4″� (45 mm) handline through the window and the search team knocked down visible fire extension and completed their search of the first floor. At this point, Firefighter Holmes and Lieutenant King left the hoseline on Floor 1, went up the stairs to Floor 2 and began a left hand search.

Figure 3. Fire Unit and Exposure Bravo Floor 2

Note: See the prior comments regarding windows and door position.

The Officer of Engine 95 noticed that the search crew had finished their search on the first floor and were advancing to the second floor. He placed a ladder and broke the window on Floor 2, Side A (See Figure 3). He stated that there was not much heat on the second floor because the plastic insulation on the window was not melted, but he did notice heavy black smoke beginning to bank down. The NIOSH Report did not specify the depth of the hot gas layer (down from the ceiling) or the air track at the window that was vented or Floor 1 openings (windows and door).

The hydrant that Engine 95-2 laid in from was frozen as was the hydrant several houses beyond the fire buildingFirst alarm companies used tank water to support initial firefighting operations. The crew from Engine 95-2 began to hand stretch a 3″� line to a working hydrant on a nearby cross street.

After Firefighter Holmes and Lieutenant King partially completed their search of Floor 2, Lieutenant King’s air supply was at one half and Firefighter Holmes was unsure of his air status, so the Lieutenant decided to exit. At approximately the same time, Engine 95 ran out of water and the Command ordered companies to abandon the building with Engine 85 sounding its air horn as an audible signal to do so. The Accountability Officer called for a Personnel Accountability Report (PAR), but received no response from Lieutenant King or Firefighter Holmes.

Almost immediately after Engine 95 ran out of water, conditions changed rapidly decreasing visibility and increasing temperature on Floor 2 of Exposure B and fire involvement of Floors 1 and 2 of both units. With deteriorating conditions on the second floor, Lieutenant King became disoriented and separated from Firefighter Holmes. He radioed for help at 0638 hours. “Help! Help! Help! I’m trapped on the second floor!” In a second radio transmission, Lieutenant King indicated he was at a window on Side D.

Firefighter Rescue Operations

After hearing radio traffic that the search crew could not find their way out and they were by a window the Engine 95 officer accessed a window on Side B Floor 2 (using a ladder previously placed by Engine 85-2). He broke out the window to increase ventilation and attempt contact with the search team.

A crew from Engine 77 was tasked as a second search team and preparing for entry when the IC ordered companies to withdraw. However, when they heard the Lieutenant’s call for help, they immediately went to Side D, not seeing the Lieutenant at the window, they continued to Side B. The officer from Engine 77 climbed the ladder they had placed earlier to attempt contact with the initial search team. There was heavy black smoke coming from this window, but no fire. He straddled the window sill attempting to hear any movement, a PASS device, or voices. He banged on the window sill as an audible signal to the search team, but received no response. He also attempted to locate the search team using a TIC, however, it malfunctioned.

Flames now pushing out the first floor windows of both the unit originally involved in fire as well as Exposure B. Lieutenant King managed to find his way to the staircase, stumbled down the stairs and out the door on Side A. His protective clothing was severely damaged and smoldering. He collapsed in the front yard and told the other firefighters that the victim was trapped on the second floor. The RIT (R87) made entry supported by a hoseline operated from the entry point by Engine 85-2. Firefighter Holmes was located approximately 10′ (3 m) from the top of the stairs (as illustrated in Figure 3). He was semi-conscious and on his hands and knees. The RIT removed Firefighter Holmes via the stairway to Side A. Lieutenant King and Firefighter Holmes were transported to a local hospital where they were stabilized prior to transport to the Mercy Hospital’s Burn Unit in Pittsburgh.

Questions

The following questions provide a basis for examining the second segment of this case study. While limited information is provided in the case, this is similar to an actual incident in that you seldom have all of the information you want.

1. What was the stage of fire development and burning regime in the fire unit when the search team entered the exposure?
2. What Building, Smoke, Air Track, Heat, and Flame (B-SAHF) indictors can be observed in Figure 1?
3. What was the stage of fire development and burning regime in Exposure B when the search team entered?
4. What type of extreme fire behavior event occurred in the exposure, trapping Firefighter Holmes and Lieutenant King? What leads you to this conclusion?
5. What were the likely causal and contributing factors that resulted in occurrence of the extreme fire behavior that entrapped the Firefighter Holmes and Lieutenant King?
6. What self-protection actions might the search team have taken once conditions on Floor 2 of Exposure B began to become untenable?
7. What action could have been taken to reduce the potential for extreme fire behavior and maintain tenable conditions in Exposure B during primary search operations?
8. What was the tactical rate of flow for full involvement of a single unit in this building? (The tactical rate of flow is the flow required for fire control and does not include the flow rate for backup lines.)
9. What factors may have influenced the limited effectiveness of the 1-3/4” and 2-1/2” attack lines deployed by Engine 95?
10. What tactical options might have improved the effectiveness of fire control operations given the available water supply?

My next post will examine the contributing factors and recommendations made in NIOSH Death in the Line of Duty Report F2008-06 and will include a link to a more detailed written case study of this incident in PDF format.

Ed Hartin, MS, EFO, MIFireE, CFO

Developing & Case Studies

The National Institute for Occupational Safety and Health (NIOSH) recently released Death in the Line of Duty Report F2008-06 on an incident that occurred in February 2008 in Grove City, Pennsylvania. As I read through the narrative and recommendations I began to ask myself how other firefighters and fire officers might use these reports and how much time they would spend engaged with a particular case. Talking with a number of colleagues, we came to the conclusion that many people would read the summary and recommendations and quickly skim through the detailed information to get a sense of what happened. A smaller number of firefighters and fire officers would really dig into the report to identify lessons learned that go beyond or differ from the NIOSH recommendations.

Developing, teaching, and learning using case studies can be an effective element in deliberate practice (see Outstanding Performance). However, as published NIOSH Death in the Line of Duty reports are not necessarily effective case studies. In most cases, reports involving traumatic fatalities need additional clarification or detail and recommendations may need to be removed or at least separated from the description of the incident. When using a case study, it is essential to have the learners make sense of what happened and develop their own conclusions. However, it is often useful to follow this process with a detailed examination of the NIOSH recommendations to determine points of agreement and disagreement and engage in discussion of why.

I have started developing a case study using NIOSH Report F2008-06. Over the last two weeks, I have invested roughly 35 hours in this process (not completely finished). Development has included producing a comprehensive timeline based on data provided in the report as well as from other sources, a narrative designed to assist learners in drawing key lessons from the case, and developing supporting graphics.

This case study will serve as a foundation for a series of posts over the next few weeks. The case will be presented in the following segments: Initial response and size-up, tactical operations, extreme fire behavior and firefighter rescue, water supply, and analysis of NIOSH recommendations.

The Case

On February 29, 2008 Firefighter Brad Holmes and Lieutenant Scott King were assigned to perform primary search of Exposure Delta at a fire in a wood frame duplex in Grove City, PA. During their search, rapidly deteriorating conditions trapped the search crew. After being rescued by the Rapid Intervention Team, both members were transported to Pittsburgh’s Mercy Hospital Burn Unit. Firefighter Brad Holmes had burns over 75% of his body, and died from his injuries on March 5, 2008. Lieutenant King suffered less serious injuries and was treated and released. A 41 year old female occupant of the dwelling also died attempting to rescue a pet.
Figure 1. 132 Garden Avenue-Side Alpha

Note: Fire Department Photo – NIOSH Death in the Line of Duty Report F2008-6. This photo likely illustrates conditions after 0635 (approximately 19 minutes after arrival of the first fire unit, Chief 95).

Building Information

The fire originated in the D Side unit of a two-story, wood frame duplex at 132 Garden Avenue in Grove City, Pennsylvania. The building was originally built in the 1930s and remodeled into two separate dwelling units in the 1960s.

Figure 2. Fire Unit and Exposure Bravo Floor 1

Note: This floor plan is based on data provided in NIOSH Report F2008-06 and is not drawn to scale. Windows shown as open are based on the narrative or photographic evidence. Door position is as shown based on information provided by NIOSH Investigator Steve Berardinelli (this differs from the NIOSH report which includes the fire investigators rough sketch showing all doors open). Windows shown as intact are not visible in the available photographs, but may be open due to fire effects or firefighting operations (particularly those in the fire unit).

Figure 3. Fire Unit and Exposure Bravo Floor 2

Note: See the prior comments regarding windows and door position.

As illustrated in Figures 2 and 3, the floor plan of each unit was a mirror image of the other. The first floor had a living room, dining room and kitchen and a deck on Side C. The units shared a common entry on Side A. The second floors had two bedrooms and a bathroom.

The 36′ x 30′ structure was of balloon-frame construction and had a basement. Interior construction was plaster over wood lath with carpeting over hardwood floors. The unit on Side D (fire unit) had wood paneling throughout the first floor. Exterior construction was wood clapboards over wooden framing. The building was not insulated and did not contain a rated fire wall between the units. The roof covering was asphalt shingles over an undetermined type of wood sheathing.

Dispatch Information

The initial call reporting this incident was 0606 hours, but was disconnected prior to communication of the nature of the emergency. A law enforcement unit was initially dispatched to the address to investigate the interrupted call. A second call was received from an occupant of the fire unit (Side D) at 0609 reporting the fire and that his wife was trapped.

Station 95 (Chief 95, Accountability Officer (POV), Engine 95, Engine 85-2, Squad 95) and Ambulance 100 were dispatched at 0609 followed by Stations 85 (Engine 85, Engine 85-2, Squad 85) and 87 (Rescue 87) at 0611.

The law enforcement officer initially dispatched to the disconnected call arrived at 0612 and reported a working fire with entrapment. Based on this report, the Station 95 Assistant Chief (unit not specified) requested an additional engine prior to arrival. Station 77 (Engine 77, Brush 77, and Water Tender 77) was dispatched at 0614.

Weather Conditions

The temperature was 6^o F (-14^o C) with no wind.

Conditions on Arrival

Chief 95 arrived at 0616 and established Command. Fire was showing from the first floor unit on Side D extension and there was significant involvement of Floor 2 of the same unit. The IC did a quick 360^o size-up and determined the structure was a duplex by the two separate decks at the rear of the structure. However, this information was not communicated to the responding companies. The IC spoke to law enforcement and confirmed that there was an occupant trapped, but received no information about the occupant’s last known location.

Questions

The following questions provide a basis for examining the first segment of this case study. While limited information is provided in the case, this is similar to an actual incident in that you seldom have all of the information you want.

1. What stage(s) of fire and burning regime do you believe existed in the involved unit when Chief 95 arrived? (Remember that Figure 1 illustrates conditions considerably later in the incident than Chief 95’s arrival.)
2. What building factors are likely to influence fire development and extension?
3. What information should Command communicate to responding companies based on his size-up and assessment of the situation?

What impact might weather conditions have on firefighting operations?

4. Chief 95 was on-scene for four minutes prior to the arrival of the first arriving engine company. If you were Chief 95, what actions would you take during this time (and why)?

Ed Hartin, MS, EFO, MIFireE, CFO

Photo by Mark E. Brady, Prince Georges County Fire/EMS Department

Experienced Judgment

Firefighters frequently base their expectations of how a fire will behave on their experience. Wildland fire scientist Harry Gisborne’s1948 observations about wildland firefighters experienced judgment can be paraphrased to apply to structural firefighters as well:

For what is experienced judgment except opinion based on knowledge acquired by experience? If you have fought fires in every type of building with every different configuration and fuel load, under all types of conditions, and if you have remembered exactly what happened in each of these combinations your experienced judgment is probably very good

Unfortunately this is rarely the case. Firefighters and fire officers often have limited experience and do not have sufficient understanding of fire dynamics to recognize potential for extreme fire behavior.

Riverdale Flashover

Two firefighters from the Riverdale Volunteer Fire Department in Prince Georges County Maryland recently were surprised by a flashover in a small, single family dwelling. Probationary Firefighter Tony George captured initial operations in a series of four photos taken over a period of two minutes.

In the first photo, firefighters from Engine 813 and Truck 807 prepare to make entry. Note that the front door is closed, the glass of the slider and windows are darkened, and smoke can be observed in the lower area of the front porch.

• What can be inferred from these observations?
• What is the stage of fire development and burning regime?

Six seconds later it appears that the front door has been opened, flames are visible through the sliding glass door, and the volume of smoke in the area of the porch has increased. However, the smoke is not thick (optically dense).

• Has your perception of fire conditions changed?
• Why did fire conditions change after the door was opened?

Forty eight seconds later, as the crew from Truck 807 makes entry to perform horizontal ventilation the volume of smoke from the front door increases and thickens (becomes more optically dense). The crew from Engine 813 experiences a burst hoseline, delaying fire attack.

• If the fire was ventilation controlled prior to opening the door, how are fire conditions likely to change?
• If the truck crew increases ventilation by opening windows, how will this influence fire development?
• What is the potential impact of the delay in deployment of a hoseline to attack the fire?

Two minutes after the first photo, and shortly after the crew from Truck 807 made entry, flashover occurred.

According to a press release from Prince Georges County Fire/EMS Department Chief Spokesperson Mark Brady:

The engine from Riverdale Heights arrived first and advanced a hoseline to the front door and paused to don their personal protective equipment (PPE) and self contained breathing apparatus (SCBA). The house was vacant and a small fire could be seen in the front living room. The ladder truck from Riverdale Fire/EMS Station #807 was the second to arrive, almost at the same time as Riverdale Heights. The crew from Truck 807 donned their PPE and SCBA and entered the structure to begin ventilation by removing windows. As the engine crew from Riverdale Heights prepared to enter the structure and extinguish the fire their hoseline sustained damage from glass or debris and was cut; rendering it useless. As additional arriving firefighters stretched another hoseline into position, a flashover occurred.

Two firefighters involved in this incident were seriously injured, FF Johnston was treated and released. FF Blazek was admitted to the MedStar Burn unit. Visit the Riverdale Volunteer Fire Department Web Site for updates on FF Blazek’s condition.

Things to Think About

Near misses and injuries such as occurred during this incident happen all too frequently. All too often, firefighters and officers consider this to be part of the job. Fire behavior is extremely predictable. It will do the same thing every single time under the same conditions. The problem is that the conditions are seldom exactly the same and our experienced judgment is not perfect.

What can you do to reduce the risk of being surprised by extreme fire behavior? Become (or continue to be) a student of your craft and develop an improved understanding of fire dynamics and the influence of tactical operations on fire behavior. Practice reading the fire (see my earlier post Reading the Fire: B-SAHF) using photos, video, and every fire you respond to.

Ed Hartin, MS, EFO, MIFireE, CFO

A few days ago I watched a video clip of a fire officer performing a vent enter search (VES) operation on firevideo.net. Shortly after the officer made entry into the second floor, the room flashed over and he was forced to make emergency egress over a ladder.

Yesterday, I came across the same video clip on vententersearch.com and saw that the Captain involved in the incident had posted his perspective on the event. There were quite a few posts related to this video and it took me a few minutes to find the Captain’s comments. Reading through the posts, I began to think about the nature and purpose of criticism.

Some firefighters can be quite judgemental, particularly when commenting on decisions or actions taken by someone else. This is often painfully evident when reading comments on fire service blogs or forums. I frequently use video clips and written case studies as learning and instructional tools. Often, these involve mistakes or errors in judgment on the part of the participants. However, it is important to remember that it is quite different to sit around the coffee table or in a classroom and discuss an incident than it is to be faced with a parent screaming that their child is trapped on the second floor of a burning building.

Firefighters and fire officers are faced with the need to rapidly assess the situation and make decisions under dynamic conditions and with limited information. Sometimes the outcome is good and in other cases, the outcome is injury or death in the line of duty. These injuries and deaths are unacceptable, but as long as humans are involved in fighting fires, we will occasionally make errors in judgement. The key is to work together to reduce the probability and frequency of these events.

Criticism

A critic is a person who offers reasoned judgment or analysis, value judgment, interpretation, or observation. While is it possible for a critic to agree with what is being criticized, the term is more frequently applied with someone who disagrees.

Criticism can be constructive or destructive. Constructive criticism is compassionate and respectful. This is often the case when we receive useful feedback from a trusted colleague, friend, coach, or teacher. Constructive feedback is essential to participatory learning. Destructive criticism on the other hand serves to derogate and destroy someone’s work, reputation and self-esteem on whatever level it might be. Destructive criticism might be intentional or done out of ignorance and foolishness.

When criticism is raised, some firefighters say if you weren’t there you have no room to comment (negatively) or take offense when questions are raised about the appropriateness of the actions taken by firefighters who have been injuured or died in the line-of-duty. I strongly disagree with this position. It is essential that we examine these events from a constructively critical perspective to identify the lessons learned.

Decisions made under stress are influenced by many factors, including individual values, organizational culture, experience, training, and education. Photographs and video clips of fireground operations do not lay this foundation nor do they provide situational context such as reported information (e.g., persons trapped) or conditions outside the view of the camera.

VES and Emergency Egress

When using Vent, Enter, and Search (VES); firefighters make entry directly into threatened compartments from the exterior and isolate that compartment by closing the door and then conduct a primary search of that single compartment and exit throught the entry point/ventilation opening. This is a potentially high risk tactic that requires an ability to read the fire and experienced judgment related to both fire conditions and potential for rapid fire progression into the compartment to be searched. The following incident involved VES at a residential structure where rapid fire progress required the Captain conductin the search to perform emergency window egress from a second floor window onto a ladder.

Companies were dispatched to a residential fire at 0400 hours with persons reported. On arrival, cars were observed in the driveway and neighbors reported the likely location of a trapped occupant on the second floor.

Given fire conditions on Floor 1, the Captain of the first in truck, a 23 year vetran, determined that Vent, Enter, and Search (VES) was the best option to quickly search and effect a rescue. In his post on vententersearch.com, Captain Van Sant provided the following information about his observations and actions:

When we vent[ed] the window with the ladder, it looks like the room is burning, but the flames you see are coming from the hallway, and entering through the top of the bedroom doorway. Watch it again and you’ll see the fire keeps rolling in and across the ceiling.

When I get to the window sill, the queen-sized bed is directly against the window wall, so there is no way to check the floor. Notice that you continue to see my feet going in, because I’m on the bed.

Believe me, in the beginning, this was a tenable room both for me and for any victim that would have been in there…

My goal was to get to the door and close it, just like VES is supposed to be done. We do it successfully all the time.

When I reached the other side of the bed, I dropped to the floor and began trying to close the door. Unfortunately, due to debris on the floor, the door would not close.

Conditions were still quite tenable at this point, but I knew with the amount of fire entering at the upper level, and smoke conditions changing, things were going to go south fast.

I kept my eyes on my exit point, and finished my search, including the closet, which had no doors on it. Just as I was a few feet from the window, the room lit off…

The following video clip illustrates conditions encountered at this residential fire:

Find more videos like this on firevideo.net

Things to Think About

Incidents in which persons are reported present considerable moral pressure to take action. The International Association of Fire Chiefs (IAFC) Rules of Engagement for Structural Firefighting and Acceptability of Risk states:

All firefighting and rescue operations involve an inherent level of risk to firefighters.

A basic level of risk is recognized and accepted, in a mesured and controlled manner, in efforts that are routinely employed to save lives and property. These risks are not acceptable in situations where there is no potential to save lives or property.

A higher level of risk is acceptable only in situatios where there is a realistic potential to save known endangered lives. This elevated risk must be limited to operations that are specifically directed toward rescue and where there is a realistic potential to save the person(s) known to be in danger.

If you were faced with the circumstances described by Captain Van Sant and observed in the video clip:

• In general, do you feel that VES an acceptable tactic when there are potentially savable lives? Why or why not?
• Would you have initiated VES operations in this situation? Why or why not?
• Based on conditions observed prior to entry, would you have committed to entering the room as Captain Van Sant did? Why or why not?
• If you were the firefighter on the ladder outside the window, what action would you take while your crew member conducted the search?

The safety of firefighters or officers engaged in VES is dependent in part on the ability to close the door to the room being searched. This use of anti-ventilation changes the ventilation profile, permitting smoke to clear from the room, but reducing potential for fire exension into that compartment. In many cases this can be accomplished quickly, but in other situations the door cannot be closed (as occurred in this incident) or there may be no door present.

• If you encountered this situation, what action would you take?
• Under what circumstances would you discontinue the search to immediately exit the compartment?
• What other strategies might be appropriate under these circumstances

Each of these questions focuses on what you would do if faced with this situation. It is important not to criticize simply for the purpose of pointing out others errors. The value in thinking critically is to help ourselves and others become more skilled at our craft. As Theodore Roosevelt observed:

Criticism is necessary and useful; it is often indispensable; but it can never take the place of action, or be even a poor substitute for it. The function of the mere critic is of very subordinate usefulness. It is the doer of deeds who actually counts in the battle for life, and not the man who looks on and says how the fight ought to be fought, without himself sharing the stress and the danger.

Entering a burning building to attempt a rescue takes courage. Not doing so, in the face of tremendous moral pressure when conditions and circumstances preclude savable lives also takes courage. Act on the basis of your knowledge, skill, and experience.

Ed Hartin, MS, EFO, MIFireE, CFO

This post is a continuation of my feedback to the National Institute for Occupational Safety and Health that will be presented at the public stakeholder meeting conducted in Chicago, IL on 19 November 2008. My recommendations are presented in the form of an analysis of NIOSH Report F2007-29. This incident resulted in the death of Captain Kevin Williams and Firefighter Austin Cheek of the Noonday Volunteer Fire Department.

This post continues with discussion the NIOSH reports examination of the influence of ventilation in this incident and provides specific recommendations for improvement of the NIOSH Firefighter Fatality Investigation and Prevention Program.

Tactical Ventilation

The NIOSH report makes a general recommendation that “fire departments should ensure that properventilation is done to improve interior conditions and is coordinated with interior attack”� [emphasis added]. However, the report is misleading and fails to address key issues related to tactical ventilation, its effective application, and its tremendous influence fire behavior.

NIOSH Report F2007-29 indicated that positive pressure ventilation was initiated prior to the second entry by the initial attack crew (a significant difference from the information provided in the Texas State Fire Marshal’s report). However, no mention is made of any action (or lack thereof) to create an adequate exhaust opening for effective horizontal positive pressure ventilation. While advising that ventilation needs to be proper, it would be helpful to provide more specific guidance. Lack of an adequate exhaust opening prior to pressurizing the building has been a major factor in a number of incidents in which application of positive pressure resulted in extreme fire behavior such as ventilation induced flashover or backdraft. Positive Pressure Attack for Ventilation and Firefighting (Garcia, Kauffmann, & Schelble, 2006), Fire Ventilation (Svensson, 2000), and Essentials of Firefighting (IFSTA, 2008) all emphasize the importance of creating an adequate exhaust opening prior to application of positive pressure.

The NIOSH report pointed out that smoke pushed out the inlet and overrode the effects of the blower, but attributed this to the presence of an attic floor that interfered with vertical ventilation rather than the lack of an adequate exhaust opening for the initial horizontal ventilation.

The PPV fan and vertical ventilation had little effect due to an attic floor being installed. At 0231 Chief #2 had horizontally vented the window on the D side near the A/D corner.

In this incident, ventilation was being performed while the interior attack crew was already inside working. When the ventilation was completed, minimal smoke was pushed out of the vented hole but dark smoke pushed out of the front door, in spite of the fact that a PPV fan was set up at the front door. Note: The dark smoke pushing out the door indicated that the conditions were worsening and the vertical ventilation was not impacting the fire.

In addition, the report fails to note that the opening made on Side D near the AD Corner placed the attack team between the fire and an exhaust opening. As with lack of an adequate exhaust opening, this has been demonstrated to have the potential for disastrous consequences (see NIOSH Death in the Line of Duty F2004-02).

Floor Plan Illustrating the Position of Captain Williams and Firefighter Cheek

Texas State Fire Marshal’s Office Firefighter Fatality Investigation Report FY 07-02

Extreme Fire Behavior

Command ordered companies to abandon the building at 0234 hours using three air horn blasts as an audible signal. The NIOSH report indicated that heavy fire “continued to roll out the front door”� but it is unclear how soon this occurred after smoke conditions at the doorway changed.

NIOSH Report F2007-29 does not clearly identify that extreme fire behavior was a causal or even contributory factor in the deaths of Captain Williams and Firefighter Cheek. It simply states that they died as a result of smoke inhalation and thermal burns.

NIOSH Recommendations

NIOSH made six recommendations based on analysis of the incident in which Captain Williams and Firefighter Cheek lost their lives. Several of these recommendations focused on factors that may have contributed to these two LODD. These included radio communications equipment and procedures, accountability, rapid intervention, and the importance of mutual aid training. Two recommendations were more directly related to causal factors: The importance of ongoing risk assessment and use of proper and coordinated ventilation. However, these broad recommendations miss the mark in providing useful guidance in minimizing the risk of similar occurrences.

Ensure that the IC conducts a risk-versus-gain analysis prior to committing to interior operations and continue the assessment throughout the operation.

This statement is necessary but not sufficient. Size-up and risk assessment is not only the responsibility of the incident commander. All personnel on the fireground must engage in this process within the scope of their role and assignment. Understanding practical fire dynamics is critical to firefighters’ and fire officers’ ability to recognize what is happening and predict likely fire behavior and the influence of tactical operations. To effectively address this issue, NIOSH death in the line of duty reports must be explicit and detailed with regards to key fire behavior indicators observed, subsequent fire behavior phenomena, and the influence of the action or inaction of responders on fire development.

Fire departments should ensure that proper ventilation is coordinated with interior attack.

NIOSH Report 2007-29 focused on the ineffectiveness of the vertical ventilation, but failed to recognize the impact of the sequence of action (i.e. pressurization of the building and creation of exhaust openings), inadequacy of initial exhaust openings, and eventual location of exhaust openings in relation to the operating position of Captain Williams and Firefighter Cheek.

As with situational awareness, effective tactical operations are grounded in training, education, and experience. The incident commander and crews tasked with carrying out tactical ventilation must understand how these tactics influence the fire environment and fire behavior. As with size-up and risk assessment, this is dependent on an understanding of practical fire dynamics.

Other than indicating that ventilation must be coordinated with interior attack, the NIOSH report did not speak to fire control operations conducted during this incident. From the building floor plan and information presented in both the reports by NIOSH and the Texas State Fire Marshal, it appears that the fire was shielded and direct attack was not possible from the position of the first attack team nor the position reached by Captain Williams and Firefighter Cheek. The Fire Marshal’s report indicated that the initial attack team “penciled”� the ceiling to control flames overhead and experienced disruption of the hot gas layer and an increase in temperature at floor level.

Just as ventilation must be appropriate and coordinated with interior fire attack, fire control must also be appropriate and coordinated with tactical ventilation. Cooling the hot gas layer is an appropriate tactic to create a buffer zone and increase the safety of the attack team as they access a shielded fire. However, penciling (use of an intermittent application of a straight stream) the ceiling is an ineffective method of cooling the hot gas layer and results in excessive steam production. In addition, cooling the hot gas layer is not an extinguishment technique; it must be integrated with other fire control methods such as a direct attack on the seat of the fire.

NIOSH death in the line of duty reports must explicitly address the effect of tactical operations, particularly where effectiveness or ineffectiveness was a contributing or causal factor in the LODD.

The Way Forward

While this assessment has been quite critical of NIOSH’s investigation of traumatic fatalities involving extreme fire behavior, it is important to emphasize that with all its faults, the Firefighter Fatality Investigation and Prevention program is a tremendous asset to the fire service.

The following recommendations are made to further strengthen and improve the quality of this program and the utility of recommendations made to reduce the risk of firefighter line of duty deaths as a result of extreme fire behavior during structural firefighting operations:

• Emphasize the criticality of understanding fire behavior, causal factors in extreme fire behavior, and the influence of tactical operations such as fire control and ventilation.
• Increase attention to building, smoke, air track, heat, and flame indicators when investigating incidents which may have involved extreme fire behavior as a causal or contributing factor in LODD.
• Examine training in greater detail, with specific emphasis on fire behavior, situational assessment, realistic live fire training, and crew resource management.
• Provide fire behavior training to all NIOSH investigators to improve their understanding of fire development, extreme fire behavior phenomena, and the impact of tactical operations.
• Include a fire behavior specialist on the investigation team when investigating incidents that may have involved extreme fire behavior as a causal or contributing factor.
• Initiate investigations quickly to avoid degradation of the quality of information obtained from the individuals involved in the incident and other witnesses.

Ed Hartin, MS, EFO, MIFireE, CFO

References

National Institute for Occupational Safety and Health (NIOSH). (2008). Death in the line-of-duty… Report 2007-29. Retrieved November 14, 2008 from NIOSH http://www.cdc.gov/NIOSH/FIRE/reports/face200729.html.

Texas State Fire Marshal’s Office (2008). Firefighter fatality investigation FY 07-02. Retrieved November 14, 2008 from http://www.tdi.state.tx.us/reports/fire/documents/fmloddnoonday.pdf

Svensson, S. (2000). Fire ventilation. Karlstad, Sweden: Swedish Rescue Services Agency

Garcia, K., Kauffmann, R., & Schelble, R. (2006). Positive pressure attack for ventilation & firefighting. Tulsa, OK: Pen Well

International Fire Service Training Association. (2008) Essentials of Firefighting (5th ed). Stillwater, OK: Fire Protection Publications.