Archive for the ‘Case Studies’ Category

Public Stakeholder Meeting

On 19 November 2008, National Institute for Occupational Safety and Health (NIOSH) will conduct a public stakeholder meeting to gather input on the Firefighter Fatality Investigation and Prevention Program. This meeting has a similar focus to one held on 22 March 2006 in Washington DC. At the 2006 stakeholder meeting, NIOSH received Input from a diverse range of fire service stakeholders. Feedback was extremely supportive of the program, but provided input on potential improvements to this extremely important program. In 2006, I gave a brief presentation that focused on several key issues:

• The upward trend in the rate of firefighter fatalities due to trauma during offensive, interior firefighting operations.
• Failure of NIOSH to adequately address fire behavior and limited understanding of fire dynamics as a causal or contributing factor in these fatalities.

The issues that I raised at the 2006 stakeholder meeting continue to be a significant concern. In 2007, extreme fire behavior was a causal or contributing factor in 17 firefighter line of duty deaths (LODD) in the United States. Where these incidents were investigated by NIOSH, the investigations, subsequent reports, and recommendations did not substantively address the fire behavior phenomena involved nor did they provide recommendations focused on improving firefighters and fire officers understanding of practical fire dynamics.

Ongoing Challenges

In the 20 months since the 2006 stakeholder meeting, NIOSH has implemented a number of stakeholder recommendations. However, Death in the line of duty reports continue to lack sufficient focus on fire behavior and human factors issues contributing to traumatic fatalities during offensive, interior firefighting operations.

Where these reports could provide substantive recommendations for training and operations that would improve firefighter safety, they continue to provide general statements reflecting good practice. While the recommendations contained in NIOSH Death in the line of duty reports, are correct and critically important to safe and effective fireground operations, they frequently provide inadequate guidance and clarity.

In incidents involving extreme fire behavior, investigators frequently fail to adequately address the fire behavior phenomena involved and the implications of the action or inaction of responders. In addition, while training is addressed in terms of national consensus standards or standard state fire training curriculum, there is no investigation as to how the level of training in practical fire dynamics, fire control, and ventilation strategies and tactics may have impacted on decision making.

Presentation of these issues in general terms does not provide sufficient clarity to guide program improvement. Examination of a recent death in the line of duty report will be used to illustrate the limitations of these important investigations and reports in incidents where extreme fire behavior is involved in LODD.

Death in the line of duty… F2007-29

There are many important lessons to be learned from this incident and the limited information presented in this report. However, this analysis of Report F2007-29 focuses on fire behavior and related tactical decision-making. This analysis is completed with all due respect to the individuals and agencies involved in an effort to identify systems issues related to the identification and implementation of lessons learned from firefighter fatalities.

On August 3, 2007 Captain Kevin Williams and Firefighter Austin Cheek of the Noonday Volunteer Fire Department lost their lives while fighting a residential fire. Neither this information nor any reference to the report on Firefighter Fatality Investigation FY 07-02 released by the Texas State Fire Marshal’s Office was included in NIOSH Death in the line of duty report F2007-29. This is critical to locating additional information regarding the incident. Even more importantly, it is important to remember that firefighter LODD involve our brother and sister firefighters, not simply “Victim #1″� and “Victim #2”.

Reading the Fire

This incident involved a 2700 ft², wood frame, single family dwelling. The fire was reported at 0136 and the first unit arrived on scene at 0150. The crew of the first arriving engine deployed a 1-3/4″� (45 mm) hoseline and positive pressure fan to the door on Side A. NIOSH Report F2007-29 reported that the attack team made entry at 0151 but backed out a few minutes later due to flames overhead just inside the front door and that positive pressure was initiated at 0156 prior to the attack team re-entering the building.

However, the Texas State Fire Marshal’s Report FY 07-02 indicated the following:

Flint-Gresham Engine 1 arrived on scene at 01:50:21 positioning short of Side A� and reported, “On location, flames visible.”�

Firefighters Joshua Rawlings and Ben Barnard of the Flint-Gresham VFD pulled rack line 2, a 200� long 1.3/4” (45 mm) � line, to the front door on Side A.� Flint-Gresham VFD Firefighter Robles conducted a quick survey of the north side and then positioned the vent fan at the front door to initiate Positive Pressure Ventilation (PPV). Robles stated that the PPV was set and operating prior to entry by the first attack team. Robles stated that he started to survey the south side and noted heavy black smoke from the top half of a broken window. He stated that he reported this to the IC.

Flint-Gresham Firefighters Barnard (nozzle) and Rawlings (backup) entered through the open front door and advanced 8-10 feet on a left hand search. This attack team noted flames rolling across the ceiling moving from their left to their right as if from the attic. Rawlings stated that flames were coming out of the hallway at the ceiling area and around the corner at a lower level. Barnard reported the hottest area at the hallway. The interior attack team then backed out to the front doorway and discussed their tactics. After a brief conversation, Rawlings took the nozzle with Barnard backing him and they re-entered. They entered approximately 10 feet and encountered flames rolling from their left to their right. They used a “penciling technique”� aimed at the ceiling to cool the thermal layer. Rawlings reported in interview that there was an increase in heat and decrease in visibility as the thermal layer was disrupted and heat began to drop down on top of them.

There is an inconsistency between the NIOSH and Texas State Fire Marshal’s reports regarding the timing of the positive pressure ventilation. The NIOSH report indicates that positive pressure was applied between the first and second entries by the attack team. However, in the Fire Marshal’s report, Firefighter Robles is quoted as stating that positive pressure was applied before entry. This seems to be a minor point, but if effective, positive pressure ventilation would have significantly changed the fire behavior indicators observed from the exterior and inside the building. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

The NIOSH report did not identify the fire behavior indicators initially observed by Firefighter Robles or the attack team, nor did they draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation.

NIOSH Report F2007-29 did not speak to the fact that none of the first arriving personnel verified the size and adequacy of the existing ventilation opening, the potential implications of inadequate exhaust opening size, and the need to verify that the positive pressure ventilation was effective prior to entry. In addition, the initial attack crew observed flames moving toward the point of entry, which would not be likely if the positive pressure ventilation was effective. However, no mention was made in the NIOSH report regarding conditions inside building and the observations of the attack team.

Window size is not specified, but it is likely that the opening was significantly less than the area of the inlet being pressurized by the fan. Inadequate exhaust opening area leads to excessive turbulence, mixing of hot smoke (fuel) and air, and can lead to extreme fire behavior such as vent induced flashover or backdraft. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

In reading this case study, it would be useful for the reader to be able to make a connection between key fire behavior indicators, the decisions made by on-scene personnel, and subsequent fire behavior. The NIOSH report did not identify the indicators initially observed by interior or exterior crews, nor did it draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation, all of which were likely factors influencing the outcome of this incident.

NIOSH Report F2007-29 indicated that the attack team exited the building at 0213 due to low air and reported that the fire was knocked down, identified the location of a few hot spots, and that smoke conditions were light. The report follows to indicate that one of the chief officers did a walk around two minutes later and observed smoke in all the windows and smoke coming from the B/C and C/D corners of the structure. However the Texas State Fire Marshal’s Report 07-02 stated:

Firefighters Rawlings and Barnard penciled the rolling flames in the thermal layer until Rawlings’s low air alarm sounded. The Incident Commander, Captain Williams and Firefighter Cheek met Firefighters Rawlings and Barnard at the front door and a briefing occurred. Firefighters Rawlings and Barnard reported to Asst. Chief Baldauf they had the hot spots out. Rawlings stated in a later interview that they told Williams and Cheek they knocked down the fire and only overhaul was needed.

At 02:13, Captain Williams and Firefighter Cheek entered the structure as attack team 2, using the same line previously utilized by Firefighters Rawlings and Barnard.

Exterior crews from Noonday and Bullard started horizontal ventilation by breaking a window out on Side C (north side). Noonday Chief Gary Aarant performed a walk around, then reported heavy smoke from the B/C,and C/D� corners and at 02:15:51 asked if vertical ventilation had been started. Command then gave the order to begin vertical ventilation.

Understanding what occurred in this incident requires more than the cursory information provided in the NIOSH report. Developing the understanding of critical fire behavior indicators is essential to situational awareness. Discussion of fire behavior indicators and their significance in NIOSH reports would provide an excellent learning opportunity. For example, in this incident, the difference between “smoke” as described in the NIOSH report and “heavy smoke” as reported in the Texas State Fire Marshal’s report is likely a significant difference in assessment of conditions from the exterior of the building (particularly if this is a change in conditions).

NIOSH Report F2007-29 made brief mention of smoke discharge from the point of entry which was being used as the inlet for application of positive pressure. “At 0236 hours, heavier and darker smoke began pushing out of the entire front door opening and overriding the PPV fan”. However, the report does not speak to the significance of this indicator of impending extreme fire behavior.

The Texas State Fire Marshal’s Report 07-02 included a series of photographs provided by the Bullard Fire Department which provided a dramatic illustration of these key smoke and air track indicators. Inclusion of these photographs in the NIOSH report would have aided the reader in recognizing this key indicator of ineffective tactical ventilation and imminent potential for extreme fire behavior.

Photo of Conditions on Side A at 0210

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0217

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0223

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

NIOSH Report F2007-29 addresses the need for the incident commander to conduct a risk versus gain analysis prior to and during interior operations. However, the report does not address the foundational skill of being able to read fire and predict likely fire behavior as a part of that process. In addition, reading the fire and dynamic risk assessment are not solely the responsibility of the incident commander. Everyone on the fireground must be involved in this process within the scope of their role and work assignment. For example, the initial and subsequent attack teams were in a position to observe critical indicators that were not visible from the exterior.

While there is no way to tell, it is likely that if Captain Williams and Firefighter Cheek recognized the imminent probability of extreme fire behavior or the significance of changing conditions they would have withdrawn the short distance from their operating position to the exterior of the building. Likewise, if the incident commander or others operating on the exterior recognized deteriorating conditions earlier in the incident it is likely that they would have taken action sooner to withdraw the crew working on the interior.

Understanding practical fire dynamics, recognition of key indicators and predicting likely fire behavior is a critical element in situational awareness and dynamic risk assessment. Fire behavior and fire dynamics receive limited focus in most standard fire training curricula. It is important that NIOSH examine this issue when extreme fire behavior is a causal or contributing factor in LODD.

My next post will continue with the analysis of NIOSH Report F2007-29 and will make specific recommendations for program improvement.

Ed Hartin, MS, EFO, MIFireE, CFO

Firefighter survival skills, MAYDAY, and rapid intervention training have received a great deal of emphasis over the last several years. These skills are critical. Firefighters must react correctly when faced with a breathing apparatus malfunction, structural collapse, or extreme fire behavior event. However, the most effective approach to survival is to prevent or reduce the probability of firefighters from facing these conditions.

My last several posts have examined the events surrounding a multiple firefighter injury incident that occurred at a residential fire in Loudoun County, Virginia on May 25, 2008. The report prepared by Loudoun County Fire, Rescue, & Emergency Management took a systems approach to examining this incident and the investigative team made 123 recommendations for improving department operations, firefighter safety, communications, behavioral health, training, apparatus and equipment, uniforms and personal protective equipment, and other considerations. This post will examine four of those recommendations that deal with firefighter safety and training. Read the report for additional detail and to examine the other recommendations.

Recommendation: Reiterate the importance of visualizing the entire structure prior to making entry [whenever possible].

Recommendation: Develop a system-wide training program that focuses on situational awareness, particularly how to “read” interior and exterior smoke conditions to identify the location and predicted spread of the fire.

Recommendation: Implement ongoing, mandatory, system-wide training on Northern Virginia MAYDAY procedures and self-survival techniques. In post incident interviews, all four interior personnel credited their escape from the structure with ongoing self-survival training.

Recommendation: Develop and implement system-wide, entry-level and ongoing firefighter self-survival training that at a minimum addresses RIT, flashover, MAYDAY procedures, crew integrity, ladder bails, emergency SCBA procedures, firefighter drags and carries and practical scenario-based evolutions.

These recommendations are excellent, but do not go far enough!

Visualizing the entire structure whenever possible and “reading” smoke conditions on the exterior and interior are a critical component in developing awareness of incident conditions and predicting anticipated fire development and spread. However, smoke is only one fire behavior indicator; a more comprehensive approach integrates assessment of Building, Smoke, Air Track, Heat, and Flame (B-SAHF) indicators along with a sound understanding of practical fire dynamics.

Flashover training often focuses on recognition of late (interior) indicators of this extreme fire behavior phenomena and last minute control efforts to increase the chance of escape and survival. In discussing the flashover training attended by the Loudon County firefighters and officers involved in this incident, the report states:

If flashover is imminent, firefighters are taught to practice aggressive cooling with a 30^o fog pattern to the right, to the center, and to the left.

If this tactic fails, firefighters are directed to get as close to the floor as possible, open the nozzle fully, on a wide fog pattern, and rotate the nozzle about their head in a circular pattern.

Unfortunately, many flashover training programs teach these methods, but do not substantively address use of gas cooling and ventilation tactics to control the fire environment and prevent the occurrence of flashover or other extreme fire behavior phenomenon.

Several years ago, Phoenix Fire Department implemented an initiative that placed 75% of the effort into training to stay out of trouble and 25% into getting out of trouble if it happened. The same principle applies in addressing the hazards presented by potential for extreme fire behavior such as flashover. In addition to survival skills, firefighters must receive training and education to develop the ability to:

• Understand and apply practical fire dynamics on the fireground
• Read critical fire behavior indicators, understand the impact of tactical operations, and predict likely fire behavior
• Understand and skillfully apply fire control and ventilation strategies on a proactive basis to mitigate hazards and control the fire environment

Ed Hartin, MS, EFO, MIFireE, CFO

Previous posts examined key factors and initial company operations at a residential fire involving flashover that resulted in multiple firefighter injuries at a residential fire in Loudoun County, Virginia. This post will examine the action taken by the trapped firefighters and crews on the exterior.

Reserve Engine 6 was performing fire attack on Floor 2 and Tower 6 had just completed searching the second floor when they experienced a rapid increase in temperature and thickening smoke conditions. Flames were extending from the first floor, up the open foyer and staircase, trapping the two crews on Floor 2.

When the firefighter from Reserve Engine 6 opened the nozzle, the line immediately lost pressure. The engine company officer attempted to diagnose the problem without success. Unknown to the engine crew, the hoseline had partially failed approximately 10′ from the nozzle, drastically reducing the available flow. Lacking an effective stream, the engine crew moved down the hallway towards Bedroom 2 in an attempt to find an alternate means of egress.

Partial collapse of the ceiling separated the Tower 6 firefighter and officer. The firefighter joined up with the crew from Reserve Engine 6 in Bedroom 2. The Tower 6 firefighter partially closed the bedroom door, providing some relief from the increasing temperature. The two firefighters and officer trapped in Bedroom 2 were able to escape over a ladder placed on Side Charlie by the apparatus operator of Reserve Engine 6. It is likely that this quick action by the tower firefighter in closing the door had a significant impact on the tenability of Bedroom 2 for the time required for these three individuals to escape.

Trapped in the Master Bedroom, the officer from Tower 6 attempted to break a window to escape the increasing temperature and thick smoke, but was unable to do so. He exited the master bedroom and eventually escaped through an unspecified window on Floor 2, Side Charlie.

Several factors contributed to the survival of the crews working on floor 2:

• Proper use of personal protective equipment
• Recognition of rapidly deteriorating conditions
• Immediate action to locate an alternate means of egress
• Availability of a secondary egress route provided by the ladders placed by the apparatus operators of the tower and engine
• Closing of the door to Bedroom 2 to increase tenability during emergency egress

Read the report for additional detail on this incident.

The crews of Reserve Engine 6 and Tower 6 who were on Floor 2 had completed survival skills and flashover training. Training and quick reactions contributed to their survival, but increased situational awareness, earlier recognition of developing fire conditions, and control of the fire environment would likely have prevented this accident.

The next post will examine key issues in training focused on “reading smoke” as well as flashover and survival skills training.

Ed Hartin, MS, EFO, MIFireE, CFO

My last post provided an overview of the factors influencing the occurrence of flashover and multiple firefighter injuries at a residential fire in Loudoun County Virginia identified in the report released by Loudoun County Fire, Rescue, and Emergency Management. Let’s look at the events that occurred from the time of dispatch until flashover occurred.

Loudoun County Emergency Communications Center (ECC) dispatched four engines, a truck, rescue, ambulance and two chief officers were dispatched to a reported house fire at 43238 Meadowood Court. The caller reported a fire in the area of the sunroom on the first floor of the home at this address with smoke coming from the roof. Subsequent callers reported heavy smoke in the area. While the call taker received information about the location of the fire in the building, the dispatcher did not pass this information to responding companies.

The first arriving company, Reserve Engine 6 reported that the building was a two-story, single-family dwelling with a fire in the attic or running Side Charlie. Uncertain of the status of building occupants, the engine company officer assigned the truck to perform primary search.

As part of his size-up, the engine company officer walked from Side Alpha around Side Delta to the Charlie/Delta corner to assess conditions. Unfortunately, from this position, he was unable to observe the fire in the area of the sunroom on Floor 1; this factor would become extremely significant over the next seven minutes.

Reserve Engine 6 was staffed with a crew of three, and the firefighter and officer extended a 200′ 1-3/4″ (60.96 M 45 mm) preconnected hoseline to the door on Side Alpha. As the hoseline was being deployed Tower 6, also with a crew of three, arrived on scene and the tower officer and firefighter joined the engine crew at the front door.

When they entered the building, the crews of Reserve Engine 6 and Tower 6 encountered moderately thick smoke and no significant increase in temperature in the two-story (open) foyer. The smoke was thick enough that they had some difficulty in locating the interior staircase. There is no indication that either crew picked up on the presence of significant smoke on Floor 1 as a violation of their expectation of a fire on Floor 2 or in the attic or a potential indicator that there may be a fire on Floor 1.

As they proceeded up the stairs, the crews of Reserve Engine 6 and Tower 6 did not encounter an appreciable change in conditions. Smoke remained moderate, with no significant increase in temperature. Reaching the top of the stairs, the engine crew turned right towards the Master Bedroom. The crew from Tower 6 went left into Bedroom 1 and conducted primary search, venting a window on Side Alpha. The report does not mention if the crew of Tower 6 closed the door to the bedroom while conducting their search or the position of the door when they completed their search of this room and continued to Bedroom 2.

Computer modeling of fire development in this incident has not yet been completed and the report does not indicate that this change in ventilation profile was a significant factor in the occurrence of flashover or extension of flames to Floor 2. However, presence or creation of an air track with crews working between the fire and exhaust opening has been a factor in other incidents. For example, see NIOSH Report 99-F21 and F2000-04 as well as NIST Reports 6854 and 6510.

Entering the master bedroom, the crew of Reserve Engine 6 encountered thick smoke, an increase in temperature, and observed flames on the opposite side of the room (Side Charlie). The officer directed the firefighter to attack the fire while he opened a window on Side Charlie. Tower 6 completed the primary search of Bedroom 2 (no mention of the tower crew making any ventilation openings in Bedroom 2) and then completed a search of Bedroom 3. After finishing the search of Floor 2, the Tower determined the need to pull ceilings for Reserve Engine 6, but doe to the height of the ceiling, did not have tools long enough to accomplish this task.

While crews were working on the interior, the apparatus operator of Tower 6 placed a ladder on Side Alpha to a window in Bedroom 3, removing approximately 2/3 of the glass from the opening. The apparatus operator of Reserve Engine 6 placed a ladder on Side Charlie to a window in Bedroom 2, which broke, but did not remove the glass.

A chief officer arrived and assumed Command on Side Alpha. Command assigned the second chief, who arrived a short time later to perform reconnaissance on Side Charlie. In his transfer of command radio report, the officer of Reserve Engine 6 indicated that the fire was in the attic. Command confirmed that there were flames visible from the attic ridge vents and flames were visible from both sides.

On the interior, the crews of Reserve Engine 6 and Tower 6 experienced a rapid increase in temperature and thickening smoke conditions. The crew of Tower 6, who were exiting to obtain longer tools, encountered flames coming up the open foyer and staircase from the first floor.

MAYDAY, MAYDAY, MAYDAY! Due to a problem with his radio, the tower officer, directed his firefighter to transmit a Mayday message. Concurrently, second arriving chief reported a collapse on Side Charlie.

As with many other incidents resulting in serious injuries or fatalities, this “appeared to be a routine incident”. Companies initiated standard firefighting tactics based on their assessment of incident conditions and the problems presented. The following three events contributed significantly to limited situational awareness:

1. Limited information provided by dispatch
2. Completing a 180^oreconnaissance rather than viewing all sides of the structure
3. Not recognizing key smoke indicators (location, thickness) on Floor 1

While not identified in the report, changing the ventilation profile by opening windows on Floor 2 (possibly based on the assumption that the fire was on Floor 2 or in the attic and the placement of a hoseline by Reserve Engine 6) may have had a negative influence on fire behavior. On the other hand, the placement of ladders to second floor windows by the apparatus operators of the engine and tower provided alternate means of egress for the crews trapped on Floor 2.

Read the report for additional detail on this incident.

The next post will examine the actions taken by Reserve Engine 6 and Tower 6 that aided in their escape from the extreme conditions encountered on Floor 2.

Ed Hartin, MS, EFO, MIFireE, CFO

Earlier this month the Loudoun County Department of Fire, Rescue, and Emergency Management releases a report flashover in a single family dwelling which resulted in injury to six firefighters and one EMS provider. Four firefighters received serous burn injuries, two sustained other traumatic injuries, and the EMS provider experienced minor respiratory distress. This extremely detailed report examines the multiple factors adversely influencing the sequence of events resulting in these injuries.

• Lack of supplemental information to responding companies regarding the location of the fire within the building
• Limited situational awareness based on lack of a 360^o size-up and failure to recognize key fire behavior indicators pointing to potential of a first floor fire
• Working above the fire by initiating fire attack on Floor 2, based on the assumption that this incident involved an attic fire based on fire behavior indicators visible from Side A
• Limited staffing on the first arriving units and delay in arrival of additional resources taxed the capability of the initial companies operating at the incident, negatively influencing situational awareness
• Building construction, lack of compartmentalization in the open floor plan dwelling, and significant fire load contributed to fire development and occurrence of flashover and a partial collapse on Floor 2

However, the investigation also pointed to a number of factors that positively influenced the outcome of the incident.

• Quick and appropriate response to escape from the building once conditions deteriorated and water supply was lost to the attack line
• Rapid placement of ladders to provide secondary egress from Floor 2
• Immediate acknowledgment of the Mayday and recognition of the need to abandon the building
• Completion of Mayday: Firefighter Down curriculum and Flashover training
• Stability of dimensional lumber supporting Floor 2 allowing members on the interior time to escape
• Performance of personal protective equipment, limiting the extent of injuries

The investigators took a broad based, systems approach in examining this incident. Read this report and evaluate the applicability of the lessons learned to your own organization. The next several posts will examine fire behavior, situational awareness, and tactical factors in this incident and recommendations made by the investigative panel

Ed Hartin, MS, EFO, MIFireE, CFO