Posts Tagged ‘case study’

Just over a year ago I had the idea to develop a blog focused on compartment fire behavior and firefighting. A bit of work on the technology side and I made my introductory post on 8 August 2008. That month the CFBT-US web site had 2900 page views, this past July the page view count was in excess of 24,000 with 4400 unique readers. While this is not a huge readership in terms of the total number of firefighters in the world who have English as a language, it shows significant growth.

Accomplishments

At the start of this adventure, I set a goal to post twice weekly (Monday and Thursday mornings) and for the most part have managed to keep this schedule. Dominant themes have included:

• Reviews of books, training programs, magazine/journal articles, and conference presentations
• Case studies based on National Institute for Occupational Safety and Health (NIOSH) and agency reports on significant incidents, injuries, and fatalities
• An ongoing series of posts examining the B-SAHF (building, smoke, air track, heat, and flame) organizing scheme for fire behavior indicators and reading the fire
• B-SAHF video and photo based exercises in reading and interpreting B-SAHF indicators to predict likely fire behavior and the impact of tactical operations
• Examination of extreme fire behavior phenomena such as flashover, backdraft, smoke explosion, and flash fire with an emphasis on understanding the underlying causes and influence of tactical operations on fire dynamics
• Discussion of research on positive pressure ventilation and wind driven fires conducted by the National Institute for Standards and Technology
• Identification of the potential learning opportunity presented by systematic investigation of near miss, injury, and fatality incidents
• Discussion of the importance of deliberate practice and the concept of the need for 10,000 hours to master your craft

Hopefully you have found these posts useful in developing your understanding of compartment fire behavior or have motivated you to take action and share your knowledge of our profession with others. I have benefited greatly from the thought process and effort of writing on a regular and systematic basis.

As a reference, I have prepared a printer friendly Compartment Fire Behavior Blog Index in portable document format (PDF) which includes the date, title, URL, and brief synopsis of post content.

I Need Your Help

Your comments and feedback are important to making the Compartment Fire Behavior Blog better. If I write something that you do not agree with or think that a concept could be expressed more clearly, please comment or question!

The Way Forward

I am currently working on a loose editorial calendar to help guide my writing over the next year. Several important themes will continue:

• Case studies and lessons learned
• Reading the fire and B-SAHF exercises
• Practical fire dynamics
• Review of books, magazine/journal articles
• Fire control and tactical ventilation

If there are topics you think should be on the list, please provide your input as a comment on this post.

My next several posts will get back to study of the B-SAHF scheme with a look at Heat Indicators and continuing examination of flashover. As I have been looking back over the last year, I find that I have taken two distinctly different approaches to sequencing posts. Some topics have been addressed in successive posts (e.g., case studies and discussion of wind driven fires) and others have alternated between several different topics (e.g., B-SAHF and flashover). From my perspective, each has its advantages and disadvantages. If you have a preference or opinion, please let me know!

Thanks for your readership and participation,

Ed Hartin, MS, EFO, MIFireE, CFO

My last two posts (Contra Costa County Line of Duty Deaths (LODD) Part 1 & Part 2) examined the conditions and circumstances involved in the incident that took the lives of Captain Matthew Burton and Engineer Scott Desmond while conducting primary search in a small residential structure in San Pablo, California early on the morning of July 21, 2007.

As identified in the Contra Costa County Investigation and NIOSH Death in the Line of Duty Report F2007-28, these line of duty deaths were the result of a complex web of events, circumstances, and actions.

These two reports identify the rapid fire progression that trapped Captain Burton and Engineer Desmond as a fire gas ignition (county and NIOSH reports) or ventilation induced flashover (NIOSH report). Both reports also point to ineffective or inappropriate use of positive pressure ventilation as a contributing factor in the occurrence of extreme fire behavior. However, neither report provides a substantive explanation of how and why this extreme fire behavior occurred.

Investigative Approach

Developing a reasonable explanation of the extreme fire behavior that occurred in this incident involved application of the scientific method as outlined in NFPA 921 Standard on Fire and Explosion Investigations (2008).

The following analysis is based on narrative data and photographic evidence provided in the Contra Costa County Fire Protection District Investigation Report: Michele Drive Line of Duty Deaths and the video taken by the Q76 Firefighter.

In that the district and NIOSH had already collected data, this effort focused on 1) analysis of the data contained in the incident reports, photographs, and video; 2) development of a hypothesis that provided an explanation for what occurred (deductive reasoning), 3) testing this hypothesis (inductive reasoning); 4) revising the hypothesis as necessary; and 5) selecting a final hypothesis.

Figure 1. Fire Development in Bedroom 2

Hypothesis

The fire originated in Bedroom 2, likely on or near the bed. In the growth stage, the fire extended through the hallway into the living room (see Figure 1). The fuel load in the living room and ventilation provided by the open front door permitted the fire to progress through flashover and become fully developed (see Figure 2).

Figure 2. Extension and Fire Development in the Living Room

The extent of fire in the living room consumed the oxygen supplied through the front door, resulting in an extremely ventilation controlled fire in the hallway and bedroom. Unburned flammable products of combustion and pyrolysis products from contents and structural materials accumulated in the upper layer in the bedrooms and hallway.

Figure 3. Fire Control and Development of a Gravity Current

Extinguishment of the fire in the living room allowed development of a gravity current and movement of oxygen through the living room to the hallway and bedrooms allowing flaming combustion in these areas to resume.

Figure 4. Positive Pressure Ventilation

Flaming combustion in the hallway or bedroom resulted in piloted ignition of a substantive accumulation of pyrolysis products and flammable products of incomplete combustion in the upper layer within the hallway and bedrooms. Application of positive pressure at the door on Side A influenced (or speeded up) this phenomena and may have increased the violence of this ignition (due to increased pressure and confinement) but likely aided in limiting the spread of flaming combustion from the hallway into the living room.

Figure 5. Fire Gas Ignition

Supporting Information

Information supporting the preceding hypothesis is divided into three categories: Known, suspected, and assumptions.

Known

The cause and origin  and line of duty death investigation conducted by the Contra Costa Fire Protection District and line of duty death investigation conducted by NIOSH identified and documented a range of data supporting this hypothesis. These data elements include physical evidence, and narrative data obtained from interviews with individuals involved in the incident.

• The fuel load in the bedroom included a bed, dresser, and other contents, exposed wood ceiling, carpet, and carpet pad.
• Fire originated in Bedroom 2 (on or near the bed)
• The female occupant exited the structure prior to making a 911 call to report the fire (via cell phone).
• The female occupant then reentered the building prior to the arrival of the first fire unit in an effort to rescue her husband. [Observations by bystanders included in the report]
• The fire in Bedroom 2 entered the growth stage and extended into the hallway and subsequently the living room. This fire spread was in part due to the combustible wood ceiling. [Information on the cause and origin investigation provided in the report]
• Windows other than the living room window on Side A were substantively intact until the occurrence of the extreme fire behavior event. [Observation by firefighters included in the report]
• E70 knocked down the fire in the living room prior to initiating primary search (without a hoseline). E70 used a left hand search pattern in which they would have moved into the hallway and bedrooms located on Side B of the residence.
• A blower was placed at the front door while E70 and E73 were conducting primary search. Due to the placement of the blower close to the door, it is possible that the air cone did not fully cover the door opening. There is no mention in the report regarding the air track at the door or living room window following placement of the blower. However, E73 reported increased visibility and temperature in the kitchen a short time after the blower was placed, and observed rollover from the hallway leading to the bedrooms.]
• The large window in the living room (if fully cleared of glass) would provide approximately equal area as the door on Side A used as an inlet. Given an equal sized inlet and outlet, efficiency of PPV is likely to be approximately 70%. However, given the location of the exhaust opening next to the inlet, the effectiveness of this ventilation at clearing smoke from compartments beyond the living room and kitchen would have been limited.
• Vertical ventilation was not completed until after the occurrence of the extreme fire behavior phenomena that trapped and killed Captain Burton and Engineer Desmond. The exhaust opening created in the roof had limited impact on interior conditions when it was completed due to the presence of the original roof.
• Fuel load in this compartment was more than sufficient to provide the heat release rate necessary to allow fire development to flashover. [This assessment is based on post-fire photos, room dimensions, and ventilation openings at the time of the ignition].
• Other bedrooms contained a similar fuel load.

Deductions

Several factors supporting the stated hypothesis are not directly supported by physical evidence or narrative data. These elements are deduced based on the design, construction, and configuration of the building and principles of fire dynamics in conjunction with known information.

• The front door remained open after the female occupant reentered. [E70 reported fire and smoke showing from the door and living room window on arrival, but no information provided in the report regarding the position of the door or extent to which the window had failed (fully or partially)]
• Use of the blower is likely to have increased mixing of air and hot, fuel rich fire gases in the hallway, particularly near the opening between the hallway and the living room. Ventilation of smoke from the living room and kitchen through the window on Side A, likely reduced the potential for flaming combustion to have extended from the hallway into the living room.
• Heat conducted through the tongue and groove wood roof/ceiling may have resulted in melting and gasification of asphalt roofing which may have been forced through gaps between the planks to add to the gas phase fuel resulting from pyrolysis and incomplete combustion of contents and structural surfaces within the involved compartments.
• The primary source of air for the fire was through the front door and the living room window. The bottom of the doorway was the lowest opening in the building, likely resulting in a bi-directional air track with smoke exiting out the top of the door and air entering at the bottom. While the sill of the living room window was higher than the door, a bi-directional air track likely developed at this opening as well, with the extreme lower portion of the window opening serving as an inlet while the top of the window functioned as an outlet for flames and smoke [No information about air track at the front door was provided in the report.]
• The fire in the living room reached the fully developed stage after the civilian occupant reentered and prior to the arrival of E70 [This deduction is based on the ability of the female occupant to enter and make her way to the kitchen and the presence of flames exiting the door and living room window on Side A when E70 arrived]

Assumptions

In addition to known and deduced information, the hypothesis is based on the following assumptions.

• The fully developed, ventilation controlled fire in the living room substantively utilized the atmospheric oxygen provided by the air entering through the front door, causing the fire in Bedroom 2 and the hallway to enter ventilation controlled decay. The decay stage fire and heat from the hot gas layer present in the hallway and adjacent rooms continued pyrolysis of fuel packages in this area, resulting in accumulation of a substantial concentration of gas phase fuel in the smoke.
• Control of the fully developed fire in the living room reduced oxygen demand from the fire. The bi-directional air track would have continued and gravity current would have increased air supply to the ventilation controlled decay stage fire in the hallway and bedroom(s).
• Establishment of positive pressure ventilation with the door on Side A serving as the inlet (or inlet and outlet) and the living room window serving as an outlet would have cleared smoke from the living room, but would not have influenced smoke movement from the hallway and bedrooms (as quickly).

Validation

Special thanks to Dr. Stefan Svensson of the Swedish Civil Contingencies Agency and Assistant Professor Greg Gorbett of Eastern Kentucky University for serving as critical friends and providing useful feedback in development of this analysis.

This hypothesis is supported by a range of evidence, deductions and assumptions. However, further validation would require use of other methods such as development of a computational fluid dynamics model and small or full scale fire tests.

More to Follow

My next post will examine the potential influence of positive pressure ventilation (PPV) in this incident as well as a broader look at potential hazards when PPV is used incorrectly or under inappropriate circumstances.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Contra Costa County Fire Protection District.  (2008). Investigation report: Michele drive line of duty deaths. Retrieved February 13, 2009 from http://www.cccfpd.org/press/documents/MICHELE%20LODD%20REPORT%207.17.08.pdf

National Institute for Occupational Safety and Health (2009).  Death in the line of duty report 2007-28. Retrieved May 5, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200728.pdf.

National Fire Protection Association (NFPA) (2008) NFPA 821 Standard on fire and Explosion Investigations. Quincy, MA: Author.

This post continues examination of the incident that took the lives of Captain Matthew Burton and Engineer Scott Desmond early on the morning of July 21, 2007. Captain Burton and Engineer Desmond died while conducting primary search in a small, one-story, wood frame dwelling with an attached garage at 149 Michele Drive in San Pablo (Contra Costa County), California.

This post focuses on firefighting operations, key fire behavior indicators, and firefighter rescue operations implemented after Captain Burton and Engineer Desmond were discovered after rapid fire progression in the area in which they were searching.

Firefighting Operations

Based on the report of trapped occupants, E70 immediately placed a 150′ preconnected 1-3/4″ (45 m 45 mm) line into service using apparatus tank water. The officer of E70, seeing what he believed to be E74 arriving he passed command to the E74 officer. Unfortunately, the second arriving engine was E73 (using apparatus normally assigned to Station 74 and marked E74).

Note: This incomplete passing of command resulted in loss of command, control, and coordination of tactical operations until the arrival of BC7 at 0202 and formally assumed command at 0205. All tactical operations prior to 0205 were the result of independent action by first alarm companies.

The crew of E70 (officer and firefighter) initiated fire attack through the door on Side A and advanced 3′-5′ (0.9-1.5 m) through the door and quickly knocked down flaming combustion in the living room and through dispatch, requested the first arriving truck to establish vertical ventilation. Retrieving a thermal imaging camera (TIC) from the apparatus, the crew of E70 began a left hand search (towards the bedrooms), but left the hoseline just inside the door on Side A (see Figure 1)

Figure 1. Floor Plan-149 Michelle Drive

E73 hand stretched 200′ of 5″ (127 mm) supply line to a nearby hydrant. As he returned from the hydrant the firefighter from E73 observed a large volume of smoke from Side B. E73 officer tasked E70 engineer with placing a blower at the door on Side A. E73 (officer and firefighter) entered through the door on Side A and began a right hand search (taking the opposite direction from E70). E73 encountered poor visibility, but moderate temperature. While E73 conducted the search, E73 engineer shut off the natural gas service to the house.

E69 arrived at 0157 and prepared to perform vertical ventilation. The officer performed a size-up while the engineer obtained a chain saw and the firefighter placed a 14 ladder to provide access to the roof at the A/D corner. E70 engineer, asked the E69 officer about placing a blower to the front door (as previously ordered by the officer of E73) and he answered in the affirmative. The engineers from E70 and E73 placed a blower into operation 3′ (0.9 m) from the front door due to a half wall that partially enclosed the porch.

Note: No information is provided in the report regarding air track prior to or following pressurization of the building. The only substantive exhaust opening at the time the blower was placed into operation was the window in the living room immediately adjacent to the door on Side A.

E73 located the first civilian casualty, a female occupant in the kitchen (see Figures 2 and 5). As they removed the victim, both visibility and temperature increased dramatically. As they move the victim through the living room, they observed rollover coming from the hallway leading to the bedrooms (see Figures 2 and 5). The E73 officer briefly operated the hoseline left in the living room by E70 to control flaming combustion in the upper layer. The blower was turned 90^o to permit removal of the victim, but was then returned to its original operating position. E69 officer assigned the E69 firefighter to assist E73 with patient care on Side A.

The E69 officer and engineer proceeded to the roof and began making a vertical ventilation opening on Side A roof, over the hallway. At 0159 Q76 arrived and while the officer was donning his breathing apparatus (BA), the window in Bedroom 1 failed suddenly followed by a significant increase in flaming combustion from the windows in Bedroom 1 and 2 on Sides A and B.

The firefighter from E73 who was providing emergency medical care to the civilian fire victim observed that the window in Bedroom 1 which had been cracked with some discharge of smoke, failed violently with glass blowing out onto the lawn and a large volume of flames venting from the window for a period of 10 to 15 seconds (see Figure 2).

Figure 2. Extreme Fire Behavior

Note: Adapted from eight seconds of video was shot by Q76 firefighter from in front of Exposure D, looking towards the A/D corner of the fire building.

Figure 3. Post Fire Photo from in Front of Exposure D

Note: This screenshot from Google Maps Street View is from a similar angle as the video taken by Q76 firefighter and is provided to provide a point of reference and perspective for the video.

The E73 officer reentered the building and initiated fire attack using the hoseline left in the living room. E70 engineer stretched a second 150′ 1-3/4″ (45 m 45 mm) line to the front door. The second line was stretched into the building by Q76. Immediately after entering through the door on Side A, the Q76 met E73 officer who was exiting with low air alarm activation. Q76 took over the initial hoseline and worked their way down the hallway leading to the bedrooms, leaving the second line in the living room (see Figure 2) Q76 encountered poor visibility and high temperature with flames extending out of Bedrooms 1 and 2 and rollover in the hallway.

Shortly after exiting the building E73 officer advised E73 engineer that he was “out of air” [he was likely in a low air condition with low air alarm sounding rather than completely out of air] and expressed concern regarding E70’s air status.

Battalion 7 (BC7) arrived at 0202 and attempted to make face-to-face contact with Command (E70) as he had not heard E70 attempt to pass command to E74. At 0203, BC7 confirmed that a medic unit was responding and requested that the medic upgrade from Code 2 to Code 3. (Code 2 is a non-life threatening medical emergency requiring immediate response without the use of red lights or siren. Code 3 is a a medical emergency requiring immediate response with red lights and siren.) BC7 then attempted to contact E70 on the tactical channel and asked other crews operating at the incident about the status of E70. At 0205, BC7 ordered a second alarm and attempted to contact E70 on non-assigned tactical channels (in the event that their radios were inadvertently on the wrong channel). The second alarm added three engines (E74, E75, and E73) and a battalion chief (BC71) to the incident.

While BC7 was attempting to locate E70, Q76 was operating in the hallway and bedrooms in an effort to control the fire. They knocked the fire down in Bedroom 2 and controlled the rollover extending from Bedroom 1 down the hall. Q76 officer scanned Bedroom 2 with a TIC, but did not observe any victims. Q76 then advanced to Bedroom 1.

E69 completed a 6′ x 6′ (1.8 m x 1.8 m) ventilation opening in the roof on Side A, two thirds of the way from their access point at the A/D corner to Side B. Immediately after making the opening, they observed minimal smoke discharge (and were able to see items stored in the attic and the attic floor (original roof). They attempted to breach the attic floor, but were unable to do so (as it was constructed of 2″ x 6″ (51 mm x 152 mm) tongue and groove planks).

At 0206, after repeated unsuccessful attempts to contact E70, BC7 transmitted a report of a missing firefighter and assumed Command. Command requested an additional engine (E68) be added to the second alarm assignment. Battalion 64 (BC64) added himself to the incident and advised dispatch.

As E69 exited the roof they heard a loud pop and observed flames exiting the roof ventilation opening a distance of 8′-10′ (2.4-3.0 m). After knocking down the fire in Bedroom 1 Q76 moved back to Bedroom 2. Failure of the gypsum board on the wall between Bedrooms 1 and 2 allowed operation of the stream from their hoseline into both bedrooms.

While at the doorway of Bedroom 2, Q76 observed a substantial volume of fire in the attic through a small hole in the hallway ceiling (see Figure 4) and attempted to apply water into the attic. However, their stream was ineffective.

Figure 4. Hallway Ceiling.

Note: Adapted from Contra Costa Fire Protection District Photos, Investigation Report: Michele Drive Line of Duty Deaths. Brightness and contrast adjusted to increase clarity.

After exiting the roof, E69 proceeded counter clockwise around the building to Side C where they removed window screens and broke out several panes of glass, but did not observe an appreciable discharge of smoke. Continuing around the B/C corner, E69 observed flames from the window of Bedroom 2 and the attic.

At 0208 Command (BC7) repeatedly attempted to contact E70 by radio on the tactical channel. Unsuccessful, he requested an additional Code 3 ambulance and advised that the status of the missing firefighters was unknown.

E69 met with Command (BC7) and was assigned to continue primary search for the second reported occupant. E69 firefighter and engineer began the search while the officer replaced his SCBA cylinder. As they entered, they picked up a hoseline (second 1-3/4″ (45 mm) hoseline) and used it to extinguish small areas of fire as they moved towards the kitchen. Q76 handed off their TIC to E69 as they exited the building with low air alarms sounding.

Q76 replaced SCBA cylinders and was tasked with search for E70 on the exterior. While conducting this search, they observed flames 10′-15′ (3.0-4.6 m) in length issuing from the gable vent on Side B.

After E69 officer rejoined his crew in the kitchen, they located the second civilian casualty who was determined to be diseased (see Figure 2). Command (BC7) ordered E69 to defer removing the victim and continue searching for E70.

Firefighter Rescue Operations

E69 walked through the interior of the dwelling looking for E70 and used a hoseline to knock down fire still burning in the closet of Bedroom 2. E69 advised command that E70 was not inside, but was instructed to conduct a second search of the interior.

At 0127, Command (BC7) asked dispatch to conduct a “head count” [personnel accountability report (PAR)]. Second alarm resources arrived between 0218 and 0221.

E69 reentered the building and conducted a thorough search for E70. At 0221, Command (BC7) ordered companies to “evacuate” [withdraw from] the building. Based on the urgency of his assignment to locate E70, E69 officer decided to continue the search into Bedroom 2. At approximately 0222, E69 located Captain Burton (fire service casualty 1) under debris on the right side of the bed (see Figure 2). His facepiece was still in place and his low air alarm was ringing slowly. E69 attempted to remove the Captain, but were only able to move him to the doorway to Bedroom 2 before smoke conditions worsened and visibility decreased. Near exhaustion, one member of the crew experience low air alarm activation and became disoriented requiring assistance to exit to the door on Side A.

Command (BC7) assigned Q76 to assist with the search. As E69 exited, they advised Q76 that they had located one member of E70 in the bedroom. After exiting, E69 advised Command (BC7) that they had located one member of E70 and that he appeared to be diseased and that they were having difficulty in removing him. Q76 quickly located Captain Burton inside the doorway of Bedroom 2 and removed him to Side A at 0228. E73 attempted resuscitation, but quickly determined that the Captain’s injuries were fatal.

BC64 and E76 officer continued the search in Bedroom 2 and located Engineer Desmond (fire service casualty 2) on the left side of the bed (see Figure 2). E72 assisted in controlling the fire in Bedroom 2 and the removal of the second member of E70 on a backboard. Engineer Desmond was removed from the building at approximately 0224. After both members of E70 were removed, crews removed the deceased civilian occupant.

Timeline

Review the Michelle Drive Timeline (PDF format) to gain perspective of sequence and the relationship between tactical operations and fire behavior.

Questions

The following questions focus on fire behavior, influence of tactical operations, and related factors involved in this incident.

1. The E73 officer tasked E70 engineer with placement of a blower at the door on Side A (use of this tactic was reaffirmed by the E69 officer). What air track did this use of positive pressure create and what effect did this have on 1) conditions in the living room and kitchen and 2) in the hallway and bedrooms? Why do you think that this was the case?
2. What type of extreme fire behavior phenomena occurred in this incident? Do you agree with the Contra Costa County Fire Protection District report conclusion that this was a fire gas ignition or do you suspect that some other phenomenon was involved?
3. How did the conditions necessary for this extreme fire behavior event develop (address both the fuel and ventilation sides of the equation)?
4. What was the initiating event(s) that lead to the occurrence of the extreme fire behavior that trapped Captain Burton and Engineer Desmond? How did the use of positive pressure ventilation influence the occurrence of the extreme fire behavior (if in fact it did)?
5. What action could have been taken to reduce the potential for extreme fire behavior and maintain tenable conditions during primary search operations?
6. How did building design and construction impact on fire behavior and tactical operations during this incident?

Ed Hartin, MS, EFO, MIFireE, CFO

References

Contra Costa County Fire Protection District.  (2008). Investigation Report: Michele Drive Line of Duty Deaths. Retrieved February 13, 2009 from http://www.cccfpd.org/press/documents/MICHELE%20LODD%20REPORT%207.17.08.pdf

National Institute for Occupational Safety and Health (2009).  Death in the Line of Duty Report 2007-28. Retrieved May 5, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200728.pdf.

As discussed in previous posts, developing mastery of the craft of firefighting requires experience. However, it is unlikely that we will develop the base of knowledge required simply by responding to incidents. Case studies provide an effective means to build our knowledge base using incidents experienced by others.

Introduction

The deaths of Captain Matthew Burton and Engineer Scott Desmond in a residential fire were the result of a complex web of circumstances, actions, and events. This case study was developed using the Contra Costa County Fire Protection District Investigative Report and NIOSH Death in the Line of Duty Report 2007-28 and video taken by a Firefighter assigned to Quint 76 (Q76), the first alarm truck company. This case study focuses on the fire behavior and related tactical operations involved in this incident. However, there are a number of other lessons that may be learned from this incident and readers are encouraged to review both the fire district’s investigation and NIOSH report for additional information.

The Case

Early on the morning of July 21, 2007, Captain Matthew Burton and Engineer Scott Desmond were performing primary search of a single family dwelling in San Pablo, California. During their search, they were trapped by rapidly deteriorating conditions and died as a result of thermal injuries and smoke inhalation. Two civilian occupants also perished in the fire.

Figure 1. 149 Michele Drive-Alpha/Delta Corner

Note: Contra Costa Fire Protection District (Firefighter Q76) Photo, Investigation Report: Michele Drive Line of Duty Deaths. This photo illustrates conditions shortly after 0159 (Q76 time of arrival).

Building Information

The fire occurred in a 1,224 ft² (113.7 M2), one-story, wood frame dwelling with an attached garage at 149 Michele Drive in San Pablo (Contra Costa County), California. The house was originally built in 1953 and remodeled in 1991 with the addition of a pitched rain roof over the original (flat) roof.

This single story structure was of Type V, platform frame construction. The building was originally constructed with 4″ x 8″ (102 mm x 203 mm) beams supporting a flat roof with 2″ x 6″ (51 mm x 152 mm) tongue and groove planking with a built-up overlay consisting of several layers of tar and gravel. The pitched roof was constructed of 2″ x 8″ (51 mm x 203 mm) rafters covered with plywood and asphalt composite shingles. The ridge of the pitched roof was parallel to Side A. The gable ends on Sides B and D were constructed of plywood and fitted with a small gable vent.

Figure 2. Floor Plan-149 Michelle Drive

Note: This floor plan is based on data provided in the Contra Costa Fire Protection District Investigation Report and is not drawn to scale. The position of exterior doors and condition of windows as illustrated is based on the narrative or photographic evidence. Interior doors are shown as open as illustrated in the report. Fire service casualties are designated as follows: 1) Captain Burton, 2) Engineer Desmond.

All windows with the exception of the Living Room and Bedroom 1 (see Figure 2) were fitted with security bars (see Figure 3). The front door was the primary exit. In addition, an additional exit was provided from the kitchen through the garage to the exterior on Side D. The exterior door on Side D was fitted with a security grate.

Figure 3. View of Side C from the B/C Corner

Figure 4. Hallway and Bedroom 2

Note: Figures 3 & 4 adapted from Contra Costa Fire Protection District Photos (brightness and contrast adjusted to provide increased clarity).

Interior walls were gypsum board with wood veneer paneling on some of the walls (e.g., living room). All ceilings with the exception of the kitchen were exposed 2″ x 6″ (51 mm x 152 mm) tongue and groove planking (see Figure 4). The kitchen ceiling was covered with gypsum board. Ceiling height was 8′ (2.4 M).

Figure 5. Living Room

Note: Adapted from Contra Costa Fire Protection District Photos, Investigation Report: Michele Drive Line of Duty Deaths.

The Fire

Investigators determined that the fire likely originated on or near the east end of the bed in Bedroom 2 (see Figures 2 & 3). The likely source of ignition was improper discard of smoking materials. Developing into growth stage, the fire progressed from Bedroom 2 into the hallway (see Figures 2 & 4) leading to the living room, dining area, and kitchen (see Figures 2 & 5). It is likely that the door on Side A was closed at the time of ignition, but was opened by an occupant exiting some time after discovery of the fire.

Dispatch Information

Occupants discovered the fire and notified a private alarm company via two-way intercom at 0134. The alarm company notified the Contra Costa Regional Fire Communications Center of receipt of a fire alarm from 149 Michelle Drive at 0136 using the non-emergency telephone number. The alarm company did not indicate that they had talked to the resident who had reported a fire, but simply that they had received a fire alarm. The caller was placed on hold due to a higher priority 911 call. The dispatcher returned to the call from the alarm company at 0142 to obtain the address and callback information. Two attempts were made to call the incident location prior to dispatch of Engine 70 at 0144 to investigate the alarm. Contra Costa County Fire Protection District (CCCFPD) Engine 70 responded at 0145.

Shortly after Engine 70 responded, the communications center received a cell phone call from the female occupant at 149 Michelle Drive. This call was originally received by the California Highway Patrol and transferred to Contra Costa County Regional Fire Communications Center. The caller reported a residential fire and indicated that she had not been able to get her husband out of the building. Between the time that she spoke to the dispatcher and arrival of Engine 70, the female occupant reentered the building to attempt to rescue her husband (leaving the door on Side A open).

At 0146, the dispatcher upgraded the response to a residential fire and added two additional engines, a quint (as the truck company), and a battalion chief. Subsequent to the upgrade to a residential fire, additional 911 calls were received reporting a residential fire at 149 Michelle Drive.

Resources dispatched on the first alarm were as follows: Engine 70 (already responding on the initial dispatch for a residential alarm), Engine 69 (CCCFPD) as well as Rodeo-Hercules Fire Protection District Quint 76, and Battalion 7.  Richmond Fire Department Engine 68 was requested for automatic aid response through the Richmond Communications Center to fill out the first alarm assignment. Pinole Fire Department Engine 73 cleared a medical call a short distance away from the incident location and added themselves to the first alarm assignment. With the addition of Engine 73, the dispatcher canceled response of Engine 68 through Richmond Dispatch.

Note: Engine 73 was using an apparatus normally assigned at Station 74 which was marked with the designation Engine 74. This created some confusion during initial incident operations.

Weather Conditions

Conditions were clear, temperature was approximately 61^o F (16^o C), with a south to southeast (Side D to Side B) wind at between 2 and 6 mph (3.2 and 9.7 kph).

Conditions on Arrival

Shortly prior to arrival, Engine 70 reported “smoke showing a block out” and was advised by the dispatcher that the female occupant had been trying to get her husband out of the house and that it was uncertain if she had been successful. Engine 70 arrived at 0150, reported heavy smoke and fire from a single-story residential structure (flames and smoke were exiting from the open front door and large living room window on Side A), and established Command. Due to delays in the dispatch process, the time from the initial auomatic alarm until the arrival of E70 was approximately 16 minutes.(Refer to Contra Costa Fire Protection District, Investigation Report: Michele Drive Line of Duty Deaths for additional information regarding factors influencing the dispatch delay.

Questions

The following questions provide a basis for examining the first segment of this case study. You have an advantage that Captain Burton did not in that you are provided with a floor plan, photographs of Side C and the interior, and have knowledge of the eventual outcome. However, it is important that you place yourself in the situation encountered on arrival.

1. What stage(s) of fire and burning regime(s) were present in the building when E70 arrived? Consider potential differences in conditions in the living room, hallway, and bedrooms?
2. If you suspect that fire conditions in the living room were different than the hallway and bedrooms, why might this be the case? What evidence supports your position? What are your assumptions?
3. While limited information is available about the fire behavior indicators present during this incident, what Building, Smoke, Air Track, Heat, and Flame (B-SAHF) indictors did E70 observe when they arrived?
4. What B-SAHF indicators would you anticipate could have been observed on Sides B and C had this reconnaissance been conducted prior to making entry?
5. If you were faced with this situation, fire showing from the front door and window of a single family dwelling with persons reported, what actions would you take?
6. How do you think your selection of tactics would have influenced fire behavior and interior conditions?

Tactical Operations & Fire Behavior

My next post will examine tactical operations conducted by the first arriving companies and fire behavior encountered inside the building.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Contra Costa County Fire Protection District.  (2008). Investigation Report: Michele Drive Line of Duty Deaths. Retrieved February 13, 2009 from http://www.cccfpd.org/press/documents/MICHELE%20LODD%20REPORT%207.17.08.pdf

National Institute for Occupational Safety and Health (2009).  Death in the Line of Duty Report 2007-28. Retrieved May 5, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200728.pdf.

The deaths of Captain Matthew Burton and Engineer Scott Desmond in a residential fire on July 27, 2001 were the result of a complex web of circumstances, actions, and events. The Contra Costa County Fire Protection District and National Institute for Occupational Safety and Health (NIOSH) both investigated this incident and have published reports that outline the sequence of events, contributing factors, lessons learned, and recommendations. Readers are encouraged to read the Contra Costa County Fire Protection District Report and National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty Report F2007-28. Also have a look at Tim Sendelbach’s post In Their Honor at Firefighter Nation.

Incident Overview

Early on the morning of July 21, 2007, Captain Matthew Burton and Engineer Scott Desmond were performing primary search of a small, one-story, single family dwelling in San Pablo, California. During their search, they were trapped by rapidly deteriorating conditions and died as a result of thermal injuries and smoke inhalation. Two civilian occupants also perished in the fire.

The crews of the first arriving companies (two engines arrived almost simultaneously) faced significant challenges with a report of civilian occupants trapped in the building, flames from the door and a large window on Side Alpha and smoke throughout the structure. The two engines rapidly initiated fire attack, primary search, and placed a blower for positive pressure ventilation. During interior firefighting operations, Captain Burton and Engineer Desmond were trapped extremely rapid fire development in the hallway and bedrooms while conducting search without a hoseline.

Contributing Factors

NIOSH Report F2007-28 identifies eight factors that contributed to the tragic outcome of this incident.

• Failure by the alarm company to report a confirmed fire
• Inadequate staffing to effectively and safely respond to a structure fire
• The failure to conduct a size-up and transfer incident command
• Conducting a search without protection from a hoseline
• Failure to deploy a back-up hoseline
• Improper/inadequate ventilation
• Lack of comprehensive training on fire behavior
• Failure to initiate/deploy a Rapid Intervention Crew

NIOSH identified these factors as contributing, not causal factors. This reflects the complex and interrelated relationship between the factors that resulted in the occurrence of extreme fire behavior during primary search operations and inability of the search crew to escape from the building.

As you read the reports on this incident consider the contributing factors identified by NIOSH. Do you agree that these factors were contributory; if so, in what way; if not, why not?

NIOSH Recommendations

Based on analysis of this incident and the contributing factors, NIOSH made nine recommendations [emphasis added]:

• Ensure that fire and emergency alarm notification is enhanced to prevent delays in the alarm and response of emergency units
• Ensure that adequate numbers of staff are available to immediately respond to emergency incidents
• Ensure that interior search crews are protected by a staffed hose line
• Ensure that firefighters understand the influence of positive pressure ventilation on fire behavior and can effectively apply ventilation tactics
• Develop and implement standard operating procedures (S.O.P.’s) regarding the use of backup hose lines to protect the primary attack crew from the hazards of deteriorating fire conditions
• Develop and implement (S.O.P.’s) to ensure that incident command is properly established, transferred and maintained
• Ensure that a Rapid Intervention Crew is established to respond to fire fighters in emergency situations
• Implement joint training on response protocols with mutual aid departments

Additionally standard setting agencies, states, municipalities, and authorities having jurisdiction should:

• Consider developing more comprehensive training requirements for fire behavior to be required in NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA102 1 Standard for Fire Officer Professional Qualifications and states, municipalities, and authorities having jurisdiction should ensure that fire fighters within their district are trained to these requirements

This final recommendation is extremely significant in that this is the first time that NIOSH has indicated that lack of effective fire behavior training in the US fire service is a systems problem. Fire training is often driven by the need to meet (rather than exceed) minimum standards. This is understandable, given the wide range of competencies required of today’s firefighters and fire officers. However, the need to develop a sound understanding of fire behavior and practical fire dynamics is critical. While this issue needs to be addressed in the professional qualification standards, we should not wait until this is accomplished. Firefighters and fire officers must become (or continue to be) students of fire behavior and develop proficiency in reading the fire and mitigation of the hazards presented by extreme fire behavior phenomena such as flashover, backdraft, smoke explosion, and flash fire.

Ed Hartin, MS, EFO, MIFireE, CFO

On March 24, 1994 Captain Drennan and Firefighters Young and Seidenburg of the FDNY were trapped in the stairwell of a three-story apartment building  by rapid fire progression that occurred as other companies forced entry into the fire apartment on the floor below. The FDNY requested assistance from National Institute for Standards and Technology (NIST) in modeling this incident to develop an understanding of the extreme fire behavior phenomena that occurred in this incident.

Brief Review

A short case study of the 62 Watts Street incident was presented in my last post. As a brief review, FDNY companies responded to 62 Watts Street for a report of smoke and sparks coming from the chimney (see Figure 1). On arrival, there was no indication of a serious fire in the building. Companies opened the scuttle over the stairwell and stretched a line to the first floor apartment while Captain Drennan and the other members of the Ladder 5’s inside team proceeded to the second floor to search for occupants. When the door to the first floor apartment was opened, air rushed in and then warm smoke pushed out. This pulsation in the air track at the door was followed by a flaming combustion filling the upper portion of the door and almost immediately filling the stairwell. Firefighters on the first floor were able to escape, while Captain Drennan and Firefighters Young and Seidenburg were trapped on floor 2.

Figure 1. 3D Cutaway View of 62 Watts Street

Analysis and Computer Modeling

FDNY asked NIST to assist in developing a computerized model to aid developing an understanding of the fire behavior phenomena that occurred during this incident.

Hypothesis: The fire burned for over an hour under severely ventilation controlled conditions resulting in production of a large quantity of unburned pyrolyzate and products of incomplete combustion. Opening the apartment door allowed exhaust of warm fire gases and inflow of cooler ambient air, resulting in a combustible fuel/air mixture. Bukowski (1995) does not identify a source of ignition. However, it is likely that the combustible fuel/air mixture underwent piloted ignition as flaming combustion resumed in the apartment. Once the gas phase fuel was ignited, flaming combustion extended from the door through the stairwell to the ventilation opening at the roof.

Richard Bukowski of the NIST Building and Fire Research Laboratory modeled the fire using CFAST to determine if a sufficient mass of gas phase fuel could have accumulated in the apartment to account for the severity and duration of flaming combustion that occurred. CFAST is a two-zone fire model used to predict the distribution of smoke and fire gases and temperature over time in a multi-compartment structure subjected to a fire. A two-zone model is based on calculations that describe conditions in the upper and lower layers (see Figure 2). While there are obvious differences in conditions within each of these zones, these differences are relatively small in comparison to the differences between the two zones (Jones, Peacock, Forney, & Reneke, 2005).

Figure 2. Upper and Lower Layers in Two Zone Models

Bukowski’s (1995) model of the Watts Street fire divided the involved area of the structure into three compartments. The apartment was defined as a single 6.1 m (20′) x 14 m (46′) x 2.5 m (8’3″) compartment. The stairwell was defined as a second 1.2 m (4′) x 3 m (10′) x 9.1 m (30′) compartment connected to the apartment by a closed door and having a roof vent with a cross sectional area of 0.84 m² (9 ft²). The fireplace flue was defined as a vertical duct with a cross section of 0.14 m (1.5 ft2) x 10 m (33′).

The heat release rate in the initial growth phase of a compartment fire is nearly always accelerating with energy release as the square of time (t²). Multiplying t² by a factor ?, various growth rates (e.g., ultra-fast, fast, medium, slow) can be simulated (Karlsson & Quintiere, 2000).

Based on experimental data from burning trash bags, Bukowski (1995) estimated the initial heat release rate at 25 kW with the fire transitioning to a medium t² fire (typical of residential structure contents) which would have had a peak HRR of 1 MW, but did not reach this HRR due to limited ventilation.

Figure 3. Heat Release Rate of Growth Phase t² Fires.

Note: Adapted from CFAST – Consolidated model of fire growth and smoke transport (Version 6).

Results of the computer model indicated that the HRR of the fire in the apartment grew to a heat release rate of 0.5 MW (see Figure 4) and then HRR decreased rapidly as oxygen concentration dropped below 10% (see Figure 5).

As the fire continued to burn under extremely ventilation controlled conditions, the concentration of unburned pyrolizate and flammable products of incomplete combustion in the apartment continued to increase.

Figure 4. Heat Release Rate

Note: Adapted from Modeling a Backdraft: The 62 Watts Street Incident.

Research indicates that the concentration of gas phase fuel (e.g., total hydrocarbons, carbon monoxide) is a critical determinant in the likelihood of backdraft occurrence. In small scale, methane fueled compartment fire experiments, Fleischmann, Pagni, & Williamson (1994) found that a total hydrocarbon concentration >10% was necessary for occurrence of a backdraft.  At lower concentrations, flame travel is slow and compartment overpressure is lower. As total hydrocarbon concentration increased, the overpressure resulting from backdraft increased. Similarly, Weng & Fan (2003) found mass fraction (concentration by mass) of unburned fuel to be the critical determinant in the occurrence and severity of backdraft. In their small scale, methane fueled experiments, increases in mass fraction of unburned fuel resulted in increased overpressure and more severe backdraft explosions.

Both of these research projects involved use of a methane burner in a compartment and the researchers identified the need for ongoing research using realistic, full scale compartment configurations and fuel loads.

Figure 5. Oxygen Concentration

Note: Adapted from Modeling a Backdraft: The 62 Watts Street Incident.

Figure 6. Temperature

Note: Adapted from Modeling a Backdraft: The 62 Watts Street Incident.

Estimating the time that fire companies forced the door to the apartment, the front door in the simulation was opened at 2250 seconds. As in the actual incident, there was an outflow of warm air from the upper part of the doorway, followed by inward movement of ambient air in the lower part of the doorway. Almost immediately after this air track pulsation, the heat release rate in the stairwell increased to nearly 5.0 MW (see Figure 5), and raising temperature in the stairwell to in excess of 1200^o C (2200^o F).

Theory and Practice

Output from the CFAST model was consistent with the observation and conditions encountered by the companies operating at 62 Watts Street on March 28, 1994.  The model showed that sufficient fuel could have accumulated under the ventilation controlled conditions that existed in the tightly sealed apartment to result in the extended duration and severity of flaming combustion that occurred in the stairwell.

Following this investigation, FDNY identified a number of similar incidents that had occurred previously, but which had gone unreported because no one had been injured. Remember that it is important to examine near miss incidents as well as those which result in injuries and fatalities.

Questions

The following questions focus on fire behavior, influence of tactical operations, and related factors involved in this incident.

1. Examine the oxygen concentration and temperature curves (Figures 5 & 6) up to the time that the door of the apartment was opened (2250 seconds). How does this data fit with the observations of the company making entry into the first floor apartment and your conception of conditions required for a backdraft?
2. How might the temperature in the apartment have influence B-SAHF indicators visible from the exterior an when performing door entry during this incident?
3. In Modeling a Backdraft Incident: The 62 Watts St (NY) Fire, Bukowski (1995) states “as buildings become better insulated and sealed for energy efficiency such hazards [e.g., ventilation controlled fires, increased concentration of gas phase fuel, backdraft] may become increasingly common. Thus, new operational procedures need to be developed to reduce the likelihood of exposure to flames of this duration” (p. 5) What operational procedures and practices would be effective in reducing risk and mitigating the hazards presented by ventilation controlled fires in energy efficient buildings? Consider size-up and dynamic risk assessment as well as strategies and tactics.
4. The often oversimplified tactical approach to dealing with potential backdraft conditions is to ventilate vertically. In this case, existing roof openings were used to ventilate the stairwell, but this had no impact on conditions in the apartment. How can tactical ventilation be used effectively (or can it) when faced with potential backdraft conditions on a lower floor or in a basement?
5. Another, less common approach to dealing with potential backdraft conditions is to cool the atmosphere and  inert the space with steam to reduce the potential for ignition. Examine the temperature curve prior to opening of the door (2250 seconds) and determine if this was a viable option?
6. Bukowski’s (1995) paper did not speak to the door entry procedures used by the companies at the apartment door. How might good door entry procedures have reduced risk in this incident?

Ed Hartin, MS, EFO, MIFIreE, CFO

References

Bukowski, R. (1996). Modeling a backdraft: The 62 Watts Street incident. Retrieved March 14, 2009 from http://fire.nist.gov/bfrlpubs/fire96/PDF/f96024.pdf

Fleischmann, C., Pagni, P., & Williamson, R. (1994) Quantitative backdraft experiments. Retrieved March 15, 2009 from http://www.fire.nist.gov/bfrlpubs/fire94/art135.html

Jones, W., Peacock, R., Forney, G., & Reneke, P. (2005). CFAST – Consolidated model of fire growth and smoke transport (Version 6) Retrieved March 15, 2009 from http://cfast.nist.gov/Documents/SP1026.pdf.

Karlsson, B. & Quintiere, J. (2000). Enclosure fire dynamics. New York: CRC Press.

Weng, W. & Fan, W. (2003). Critical condition of backdraft in compartment fires: A reduced scale experimental study. Journal of Loss Prevention in the Process Industries, 16, 19-26.

Fifteen years ago tomorrow, three members of the Fire Department of the City of New York (FDNY) lost their lives while conducting search in a three story apartment building located at 62 Watts Street in Manhattan. Captain Drennan and Firefighters Young and Seidenburg were trapped in a stairwell by rapid fire progression that occurred as other companies forced entry into the fire apartment on the floor below.

The Case

This case study was developed using a paper written by Richard Bukowski (1996) of the National Institute for Standards and Technology (NIST) Building and Fire Research Laboratory (BFRL). The FDNY requested the NIST assistance in modeling this incident to develop an understanding of the extreme fire behavior phenomena that took the lives of Captain Drennan and Firefighters Young and Seidenburg.

At 1936 hours on March 28, 1994, FDNY responded to a report of heavy smoke and sparks from a chimney of a three-story apartment building at 62 Watts Street (see Figure 1) in Manhattan. On arrival companies observesd smoke from the chimney, but no other evidence of fire. The first due engine and truck companies stretched a hoseline to the first floor unit and vertically ventilated over the stairwell.

Figure 1. 62 Watts Street-Side A

Working as the inside team of the second due truck company, Captain John Drennan (Ladder 5), Firefighter James Young, and Firefighter Christopher Seidenburg (both detailed from Engine 24 to Ladder 5) went to the second floor to begin primary search of the upper floors. At the doorway to the second floor apartment unit they were trapped by an explosion and rapid fire progression from the first floor apartment up the common stairwell. Both firefighters died within 24 hours as a result of thermal injuries. Captain Drennan survived for 40 days in the burn unit before succumbing to his injuries.

Building Information

The fire occurred in a 6.1 m (20′) x 14 m (46′), 3 ½ story apartment building of ordinary (Type III) construction, containing four dwelling units (the basement apartment was half below grade). Each unit had a floor area of slightly less than  81.7 m² (880 ft²). The basement unit had its own entrance and the units on Floors 1-3 were served by a common stairwell on Side D of the building (see Figure 1). Exposure B was an attached building identical to the fire structure. Exposure D was a similar structure. Neither exposure was involved.

Figure 2. Floor Plan-First Floor Apartment

Note: Adapted from Modeling a Backdraft Incident: The 62 Watts St. (NY) Fire.

The building was originally built in the late 1800s and had undergone numerous renovations. Recent renovations involved replacement of plaster and lath compartment linings with drywall over wood studs and lowering of the ceiling height from 2.8 m (9’3″) to 2.5 m (8’4″). All apartments had heavy wood plank flooring. During the latest renovation, windows and doors were replaced and extensive thermal insulation added to increase energy efficiency. The building was originally heated with the use of multiple fireplaces in each apartment. However, most of these had been sealed shut. However, the fireplace in the living room of the first floor apartment (unit of origin) was operable and had a 0.209 m² (2.25 ft²) flue.

All apartments had similar floor plans (differences resulting from location of the stairwell). The floor plan of the first floor apartment (unit of origin) is illustrated in Figure 2. Each apartment consisted of a living room, kitchen, bathroom, and bedroom. The first floor unit had an office constructed within the bedroom.

The structure had a flat roof with a scuttle and skylight over the stairwell.

The Fire

The occupant left the first floor apartment at 1825 hours, leaving a plastic trash bag on top of the gas fired kitchen range (see Figure 2). Investigators deduced that the bag was ignited by heat from the pilot light. Fire extended from the bag of trash to several bottles of high alcohol content liquor located on the counter adjacent to the stove. The fire progressed into the growth stage, involving other fuel packages within the apartment. The apartment was tightly sealed with the only sources of ventilation being the open fireplace flue and minimal normal building ventilation.

Weather Conditions

The weather was 10^o C (50 ^o F) with no appreciable wind.

Conditions on Arrival

On arrival companies observed smoke from the chimney of the apartment building, but no other signs of fire from the exterior.

Firefighting Operations

The outside team from the first due truck went to the roof and opened the scuttle over the stairwell while the first arriving engine company stretched a hoseline to the interior and prepared to make entry into the first floor apartment along with the inside team from the ladder company. Ladder 5 was the second due truck. The inside team from Ladder 5, Captain Drennan, Firefighter Young, and Firefighter Seidenburg, went to the second floor to begin primary search.

When the first due engine and truck forced the door to the first floor apartment they observed a pulsing air track consisting of an inward rush of air followed by an outward flow of warm (not hot) smoke. This single pulsation was followed by a large volume of flame from the upper part of the door and extending up the stairwell.

Figure 3. 3D Cutaway View of 62 Watts Street

Note: Adapted from Modeling a Backdraft: The 62 Watts Street Incident.

The crews working on Floor 1 were able to escape the rapid fire progression, but Ladder 5’s inside team was engulfed in flames which filled the stairwell. Flames extended from the doorway of the first floor apartment through the stairwell and vented out the scuttle opening and skylight. This flaming combustion continued in excess of 6 minutes 30 seconds. The intense fire in the stairwell severely damaged the stairs and melted the wired glass in the skylight.

Questions

The following questions focus on fire behavior, influence of tactical operations, and related factors involved in this incident.

1. Other than smoke and sparks from the chimney, what B-SAHF indicators might have been present and visible from the exterior or at the doorway that may have provided an indication of conditions inside the apartment?
2. What do you make of the observations of the company making entry to the first floor apartment for fire attack? Is this consistent with your understanding of backdraft indicators? Why or why not?
3. What steps can you take when making entry if you suspect that the fire is ventilation controlled? How would this change if you suspected or saw indicators of potential backdraft conditions?
4. Firefighters often identify vertical ventilation when given a scenario where backdraft indicators are present. If there is value (savable people or property) and the fire is on a lower floor (as it was in the Watts Street incident), what tactical options are available to mitigate the hazards of potential backdraft conditions?

Analysis and Computer Modeling

My next post will examine the results of this investigation and how the computer modeling performed by NIST contributes to our understanding of the events that took the lives of Captain Drennan and Firefighters Young and Seidenburg.

Ed Hartin, MS, EFO, MIFIreE, CFO

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.