Posts Tagged ‘firefighter fatality’

This post continues study of an incident that resulted in two line-of-duty deaths as a result of extreme fire behavior in a townhouse style apartment building in Washington, DC.

A Quick Review

The previous post in this series, Fire Behavior Case Study of a Townhouse Fire: Washington, DC examined building construction and configuration that had a significant impact on the outcome of this incident. The fire occurred in the basement of a two-story, middle of building, townhouse style apartment with a daylight basement. This configuration provided an at grade entrance to the Floor 1 on Side A and an at grade entrance to the Basement on Side C.

The fire originated in an electrical junction box attached to a fluorescent light fixture in the basement ceiling (see Figures 1 and 2). The occupants of the unit were awakened by a smoke detector. The female occupant noticed smoke coming from the floor vents on Floor 2. She proceeded downstairs and opened the front door and then proceeded down the first floor hallway towards Side C, but encountered thick smoke and high temperature. The female and male occupants exited the structure, leaving the front door open, and made contact with the occupant of an adjacent unit who notified the DC Fire & EMS Department at 0017 hours.

Dispatch Information

At 00:17, DC Fire & EMS Communications Division dispatched a first alarm assignment consisting of Engines 26, 17, 10, 12, Trucks 15, 4, Rescue Squad 1, and Battalion 1 to 3150 Cherry Road NE. At 0019 Communications received a second call, reporting a fire in the basement of 3146 Cherry Road NE. Communications transmitted the update with the change of address and report of smoke coming from the basement. However, only one of the responding companies (Engine 26) acknowledged the updated information.

Weather Conditions

Temperature was approximately 66^o F (19^o C) with south to southwest winds at 5-10 mi/hr (8-16 km/h), mostly clear with no precipitation.

Conditions on Arrival

Approaching the incident, Engine 26 observed smoke blowing across Bladensburg Road. Engine 26 arrived at a hydrant at the corner of Banneker Drive and Cherry Road at 00:22 hours and reported smoke showing. A short time later, Engine 26 provided an updated size-up with heavy smoke showing from Side A of a two story row house. Based on this report, Battalion 1 ordered a working fire dispatch and a special call for the Hazmat Unit at 00:23. This added Engine 14, Battalion 2, Medic 17 and EMS Supervisor, Air Unit, Duty Safety Officer, and Hazmat Unit.

Firefighting Operations

DC Fire and EMS Department standard operating procedures (SOP) specify apparatus placement and company assignments based on dispatch (anticipated arrival) order. Note that dispatch order (i.e., first due, second due) may de different than order of arrival if companies are delayed by traffic or are out of quarters.

Standard Operating Procedures

Operations from Side A

The first due engine lays a supply line to Side A, and in the case of basement fires, the first line is positioned to protect companies performing primary search on upper floors by placing a line to cover the interior stairway to the basement. The first due engine is backed up by the third due engine. The apparatus operator of the third due engine takes over the hydrant and pumps supply line(s) laid by the first due engine, while the crew advances a backup line to support protection of interior exposures and fire attack from Side A.

The first due truck takes a position on Side A and is responsible for utility control and placement of ladders for access, egress, and rescue on Side A. If not needed for rescue, the aerial is raised to the roof to provide access for ventilation.

The rescue squad positions on Side A (unless otherwise ordered by Command) and is assigned to primary search using two teams of two. One team searches the fire floor, the other searches above the fire floor. The apparatus operator assists by performing forcible entry, exterior ventilation, monitoring search progress, and providing emergency medical care as necessary.

Operations from Side C

The second due engine lays a supply line to the rear of the building (Side C), and in the case of basement fires, is assigned to fire attack if exterior access to the basement is available and if it is determined that the first and third due engines are in a tenable position on Floor 1. The second due engine is responsible for checking conditions in the basement, control of utilities (on Side C), and notifying Command of conditions on Side C. Command must verify that the first and third due engines can maintain tenable positions before directing the second due engine to attack basement fires from the exterior access on Side C.

The second due truck takes a position on Side C and is responsible for placement of ladders for access, egress, and rescue on Side C. The aerial is raised to the roof to provide secondary access for ventilation (unless other tasks take priority).

Command and Control

The battalion chief positions to have an unobstructed view of the incident (if possible) and uses his vehicle as the command post. On greater alarms, the command post is moved to the field command unit.

Notes: This summary of DC Fire & EMS standard operating procedures for structure fires is based on information provided in the reconstruction report and reflects procedures in place at the time of the incident. DC Fire & EMS did not use alpha designations for the sides of a building at the time of this incident. However, this approach is used here (and throughout the case) to provide consistency in terminology.

First due, Engine 26 laid a 3″ (76 mm) supply line from a hydrant at the intersection of Banneker Drive and Cherry Road NE, positioned in the parking lot on Side A, and advanced a 200′ 1-1/2″ ( 61 m 38 mm) pre-connected hoseline to the first floor doorway of the fire unit on Side A (see Figures 1 and 2). A bi-directional air track was evident at the door on Floor 1, Side A , with thick (optically dense) black smoke from the upper area of the open doorway. Engine 26’s entry was delayed due to a breathing apparatus facepiece malfunction. The crew of Engine 26 (Firefighters Mathews and Morgan and the Engine 26 Officer) made at approximately 00:24.

Figure 1. Plot and Floor Plan-3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 18 & 20. District of Columbia Fire & EMS, 2000; Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 12-13, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology, and NIOSH Death in the Line of Duty Report 99 F-21, 1999, p. 19.

Engine 10, the third due engine arrived shortly after Engine 26, took the hydrant at the intersection of Banneker Drive and Cherry Road, NE, and pumped Engine 26’s supply line. After Engine 10 arrived at the hydrant, the firefighter from Engine 26 who had remained at the hydrant proceeded to the fire unit and rejoined his crew. Engine 10, advanced a 400′ 1-1/2″ (122 m 38 mm) line from their own apparatus as a backup line. Firefighter Phillips and the Engine 10 officer entered through the door on Floor 1, Side A (see Figure 2) while the other member of their crew remained at the door to assist in advancing the line.

Truck 15, the first due truck arrived at 00:23 and positioned on Side A in the parking lot behind Engine 26. The crew of Truck 15 began laddering Floor 2, Side A, and removed kitchen window on Floor 1, Side A (see Figure 2). Due to security bars on the window, one member of Truck 15 entered the building and removed glass from the window from the interior. After establishing horizontal ventilation, Truck 15 accessed the roof via a portable ladder and began vertical ventilation operations.

Engine 17, the second due engine, arrived at 00:24, laid a 3″ (76 mm) supply line from the intersection of Banneker Drive and Cherry Road NE, to a position on Cherry Road NE just past the parking lot, and in accordance with department procedure, stretched a 350′ 1-1/2″ (107 m 38 mm) line to Side C (see Figure 2).

Approaching Cherry Road from Banneker Drive, Battalion 1 observed a small amount of fire showing in the basement and assigned Truck 4 to Side C. Battalion 1 parked on Cherry Road at the entrance to the parking lot, but was unable to see the building, and proceeded to Side A and assumed a mobile command position.

Second due, Truck 4 proceeded to Side C and observed what appeared to be a number of small fires in the basement at floor level (this was actually flaming pieces of ceiling tile which had dropped to the floor). The officer of Truck 4 did not provide a size-up report to Command regarding conditions on Side C. Truck 4, removed the security bars from the basement sliding glass door using a gasoline powered rotary saw and sledgehammer. After clearing the security grate Truck 4, broke the right side of the sliding glass door to ventilate and access the basement (at approximately 00:27) and then removed the left side of the sliding glass door. The basement door on Side C was opened prior to Engine 17 getting a hoseline in place and charged. After opening the sliding glass door in the basement, Truck 4 attempted to ventilate windows on Floor 2 Side C using the tip of a ladder. They did not hear the glass break and believing that they had been unsuccessful; they left the ladder in place at one of the second floor windows and continued with other tasks.

Figure 2. Location of First Alarm Companies and Hoselines

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 27. District of Columbia Fire & EMS, 2000.

Unknown to Truck 4, these windows had been left open by the exiting occupants. Truck 4B (two person team from Truck 4) returned to their apparatus for a ladder to access the roof from Side C. Rescue 1 arrived at 00:26 and reported to Side C after being advised by the male occupant that everyone was out of the involved unit (this information was not reported to Command). Rescue 1 and Truck 4 observed inward air track (smoke and air) at the exterior basement doorway on Side C and an increase in the size of the flames from burning material on the floor.

Engines 26 and 10 encountered thick smoke and moderate temperature as they advanced their charged 1-1/2″ (38 mm) hoselines from the door on Side A towards Side C in an attempt to locate the fire. As they extended their hoselines into the living room, the temperature was high, but tolerable and the floor felt solid. It is important to note that engineered, lightweight floor support systems such as parallel chord wood trusses do not provide reliable warning of impending failure (e.g., sponginess, sagging), failure is often sudden and catastrophic (NIOSH, 2005; UL, 2009).

Prior to reaching Side C of the involved unit, Engine 17 found that their 350′ 1-1/2″ (107 m 38 mm) hoseline was of insufficient length and needed to extend the line with additional hose.

Engine 12, the fourth arriving engine, picked up Engine 17’s line, completed the hoselay to a hydrant on Banneker Drive (see Figure 2). The crew of Engine 12 then advanced a 200′ 1-1/2″ (61 m 38 mm) hoseline from Engine 26 through the front door of the involved unit on Side A and held in position approximately 3′ (1 m) inside the doorway. This tactical action was contrary to department procedure, as the fourth due engine has a standing assignment to stretch a backup line to Side C.

Rescue 1’s B Team (Rescue 1B) and a firefighter from Truck 4 entered the basement without a hoseline in an effort to conduct primary search and access the upper floors via the interior stairway. Engine 17 reported that the fire was small and requested that Engine 17 apparatus charge their line.

Questions

Consider the following questions related to the interrelationship between strategies, tactics, and fire behavior:

1. Based on the information provided to this point, what was the stage of fire development and burning regime in the basement when Engine 26 entered through the door on Floor 1, Side A? What leads you to this conclusion?
2. What impact do you believe Truck 4’s actions to open the Basement door on Side C will have on the fire burning in the basement? Why?
3. What is indicated by the strong inward flow of air after the Basement door on Side C is opened? How will this change in ventilation profile impact on air track within the structure?
4. Did the companies at this incident operate consistently with DC Fire & EMS SOP? If not, how might this have influenced the effectiveness of operations?
5. Committing companies with hoselines to the first floor when a fire is located in the basement may be able to protect crews conducting search (as outlined in the DC Fire & EMS SOP). However, what building factors increased the level of risk of this practice in this incident?

More to Follow

My next post will examine the extreme fire behavior phenomena that trapped Firefighters Phillips, Mathews, and Morgan and efforts to rescue them.

Remember the Past

This week marked the anniversary of the largest loss of life in a line-of-duty death incident in the history of the American fire service. Each September, we stop and remember the sacrifice made by those 343 firefighters. However, it is also important to remember and learn from events that take the lives of individual firefighters. In an effort to encourage us to remember the lessons of the past and continue our study of fire behavior, each month I include brief narratives and links to NIOSH Death in the Line of Duty reports and other documentation in my posts.

September 9, 2006
Acting CAPT Vincent R. Neglia
North Hudson Regional Fire & Rescue Department, NJ

Captain Neglia and other firefighters were dispatched to a report of fire in a three-story apartment building in Union City. Upon their arrival at the scene, firefighters found light smoke and no visible fire. Based on reports that the structure had not been evacuated, Captain Neglia and other firefighters entered the building to perform a search. Due to the light smoke conditions, Captain Neglia was not wearing his facepiece.

Captain Neglia was the first firefighter to enter an apartment. Conditions deteriorated rapidly as fire in the cockloft broke through a ceiling . Captain Neglia was trapped by rapid fire progress and subsequent collapse. Other firefighters came to his aid and removed him from the building. Captain Neglia was transported to the hospital but later died of a combination of smoke inhalation and burns.

NIOSH did not investigate and prepare a report on the incident that took the life of Captain Neglia.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

National Institute for Occupational Safety and Health (NIOSH). (2005). NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters Due to Truss System Failures. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

This series of posts focused on Understanding Flashover has provided a definition of flashover; examined flashover in the context of fire development in both fuel and ventilation controlled fires; and looked at the importance of air track on rapid fire progression through multiple compartments. To review prior posts see:

• Myths and Misconceptions
• Myths and Misconceptions: Part 2
• The Ventilation Paradox
• The Importance of Air Track

This post begins study of an incident that resulted in two line-of-duty deaths as a result of extreme fire behavior in a townhouse style apartment building in Washington, DC. This case study provides an excellent learning opportunity as it was one of the first times that the National Institute of Standards and Technology (NIST) Fire Dynamics Simulator (FDS) and Smokeview were used in forensic fire scene reconstruction to investigate fire dynamics involved in a line-of-duty death. Data development of this case study was obtained from Death in the line of duty, Report 99-21 (NIOSH, 1999), Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999 (District of Columbia (DC Fire & EMS, 2000), and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999 (Madrzykowski & Vettori, 2000).

The Case

In 1999, two firefighters in Washington, DC died and two others were severely injured as a result of being trapped and injured by rapid fire progress. The fire occurred in the basement of a two-story, middle of building, townhouse apartment with a daylight basement (two stories on Side A, three stories on Side C).

Figure 1. Cross Section of 3146 Cherry Road NE

The first arriving crews entered Floor 1 from Side A to search for the location of the fire. Another crew approached from the rear and made entry to the basement through a patio door on Side C. Due to some confusion about the configuration of the building and Command’s belief that the crews were operating on the same level, the crew at the rear was directed not to attack the fire. During fireground operations, the fire in the basement intensified and rapidly extended to the first floor via the open, interior stairway.

Building Information

The unit involved in this incident was a middle of row 18′ x 33′ (5.6 m x 10.1 m) two-story townhouse with a daylight basement (see Figures 1 and 3). The building was of wood frame construction with brick veneer exterior and non-combustible masonry firewalls separating six individual dwelling units. Floors were supported by lightweight, parallel chord wood trusses. This type of engineered floor support system provides substantial strength, but has been demonstrated to fail quickly under fire conditions (NIOSH, 2005). In addition, the design of this type of engineered system results in a substantial interstitial void space between the ceiling and floor as illustrated in Figure 2.

Figure 2. Parallel Chord Truss Construction

Note: This is not an illustration of the floor assembly in the Cherry Road Townhouse. It is provided to illustrate the characteristics of wood, parallel chord truss construction.

The trusses ran from the walls on Sides A and C and were supported by steel beams and columns at the center of the unit (See Figure 3). The basement ceiling consisted of wood fiber ceiling tiles on wood furring strips which were attached to the bottom chord of the floor trusses. Basement walls were covered with gypsum board (sheetrock) and the floor was carpeted. A double glazed sliding glass door protected by metal security bars was located on Side C of the basement, providing access from the exterior. Side C of the structure (see Figure 3) was enclosed by a six-foot wood and masonry fence. The finished basement was used as a family room and was furnished with a mix of upholstered and wood furniture.

The first floor of the townhouse was divided into the living room, dining room, and kitchen. The basement was accessed from the interior via a stairway leading from the living room to the basement. The door to this stairway was open at the time of the fire (see Figures 1 and 3). The walls and ceilings on the first floor were covered with gypsum board (sheetrock) and the floor was carpeted. Contents of the first floor were typical of a residential living room and kitchen. A double glazed sliding glass door protected by metal security bars similar to that in the basement was located on Side C of the first floor. An entry door and double glazed kitchen window were located on Side A (see Figure 3). A stairway led to the second floor from the front entry. The second floor contained bedrooms (but was not substantively involved in this incident). There were double glazed windows on Sides A and C of Floor 2.

Figure 3. Plot and Floor Plan-3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 18 & 20. District of Columbia Fire & EMS, 2000; Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 12-13, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology, and NIOSH Death in the Line of Duty Report 99 F-21, 1999, p. 19.

Figure 4. Side A 3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 17. District of Columbia Fire & EMS, 2000 and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 5, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology.

Figure5. Side C 3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 19. District of Columbia Fire & EMS, 2000 and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 5, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology.

The Fire

The fire originated in an electrical junction box attached to a fluorescent light fixture in the basement ceiling (see Figures 1 and 3). The occupants of the unit were awakened by a smoke detector. The female occupant noticed smoke coming from the floor vents on Floor 2. She proceeded downstairs and opened the front door and then proceeded down the first floor hallway towards Side C, but encountered thick smoke and high temperature. The female and male occupants exited the structure, leaving the front door open, and made contact with the occupant of an adjacent unit who notified the DC Fire & EMS Department at 0017 hours.

Questions

It is important to remember that consideration of how a fire may develop and the relationship between fire behavior and your strategies and tactical operations must begin prior to the time of alarm. Assessment of building factors and fire behavior prediction should be integrated with pre-planning.

1. Based on the information provided about the fire and building conditions, how would you anticipate that this fire would develop?
2. What concerns would you have if you were the first arriving company at this incident?

More to Follow

My next post will examine dispatch information and initial tactical operations by first alarm companies.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

National Institute for Occupational Safety and Health (NIOSH). (2005). NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters Due to Truss System Failures. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

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

Application of the B-SAHF (Building, Smoke, Air Track, Heat, & Flame) organizing scheme for critical fire behavior indicators to photographs or video of structure fires provides an excellent opportunity to develop your knowledge of fire behavior and skill in reading the fire.

This video clip was recommended by Captain Virgil Hall, Tualatin Valley Fire & Rescue. Virgil is stationed at Station 64 and is one of TVF&R’s CFBT Instructors.

Residential Fire

Download and print the B-SAHF Worksheet. Consider the information provided in the short video clip. First, describe what you observe in terms of the Building, Smoke, Air Track, Heat, and Flame Indicators and then answer the following five standard questions?

1. What additional information would you like to have? How could you obtain it?
2. What stage(s) of development is the fire likely to be in (incipient, growth, fully developed, or decay)?
3. What burning regime is the fire in (fuel controlled or ventilation controlled)?
4. What conditions would you expect to find inside this building?
5. How would you expect the fire to develop over the next two to three minutes?

Review the video again, watch the indicators on Side A closely, and give some thought to the following questions posed by Captain Hall:

1. How did the smoke and flame indicators change?
2. What did this indicate?
3. Why did these changes occur (what were the influencing factors)?

Special thanks to Captain Hall for recommending this video clip. Please feel free to contribute to this process and share or recommend video clips or photographs that will help us develop our skill in reading the fire.

Remember the Past

While some firefighters have heard about the incidents involving multiple fatalities, others have not and most do not know the stories of firefighters who died alone. In an effort to encourage us to remember the lessons of the past and continue our study of fire behavior, I will occasionally be including brief narratives and links to NIOSH Death in the Line of Duty reports and other documentation in my posts. The first narrative in this post is incomplete as this incident, resulting in the death of two members of the Houston Fire Department occured last Sunday. It is important for us to continue our efforts to understand and mitigate the complex and interrelated factors that result in firefighter fatalities occuring during structural firefighting operations.

April 12, 2009
Captain James Harlow
Firefighter Damion Hobbs
Houston Fire Department, Texas

Captain James Harlow and Firefighter Damion Hobbs of the Houston, Texas Fire Department lost their lives in the line of duty while conducting primary search in a single family dwelling on the morning of April 12, 2009. Preliminary information indicates that Captain Harlow and Firefighter Hobbs were trapped by rapid fire progress, possibly influenced by wind. The Houston Fire Department, Texas State Fire Marshal, and National Institute for Occupational Safety and Health (NIOSH) are all investigating this incident. More information will be posted as it becomes available.

April 11, 1994
Lieutenant Michael Mathis
Private William Bridges
Memphis Fire Department, Tennessee

On April 11, Lt. Michael Mathis and Private William Bridges of the Memphis (TN) Fire Department were killed when they became trapped and overcome by smoke during a fire on the ninth floor of a high rise building. Two civilians also died in the arson fire. Lt. Mathis became disoriented when he was caught in rapidly spreading fire conditions on the fire floor, burning him and causing his SCBA to malfunction. He found his way into a room on the ninth floor were he was later discovered by other fire crews with his SCBA air depleted. Private Bridges, aware that Lt. Mathis was unaccounted for after several unsuccessful attempts to contact him by radio, left a safe stairwell where he had been attempting to fix a problem with his own SCBA. Investigators believe Bridges was trying to locate Lt. Mathis. Bridges became entangled in fallen cable TV wiring within a few feet of the stairwell, and died of smoke inhalation after depleting his SCBA supply. A Memphis Fire Department investigation found many violations of standard operating procedures by companies on the scene, including crews taking the elevator to the fire floor, problems with the incident command system and coordination of companies, operating a ladder pipe with crews still on the fire floor, and a failure of personnel, including Lt. Mathis and Private Bridges, to activate their PASS devices.

April 16, 2007
Firefighter-Technician I Kyle Robert Wilson
Prince William County Department of Fire and Rescue, Virginia

Technician Wilson was assigned to Tower 512, a ladder company. Tower 512 was dispatched to a reported house fire at 0603 hours. The Prince William County area was under a high wind advisory as a nor’easter moved through the area. Sustained winds of 25 miles per hour with gusts up to 48 miles per hour were prevalent in the area at the time of the fire dispatch.

Initial arriving units reported heavy fire on the exterior of two sides of the single-family house, and crews suspected that the occupants were still inside the house sleeping because of the early morning hour. A search of the upstairs bedroom was conducted by Technician Wilson and his officer. A rapid and catastrophic change of fire and smoke conditions occurred in the interior of the house within minutes of Tower 512’s crew entering the structure. Technician Wilson became trapped and was unable to locate an immediate exit. “Mayday” radio transmissions of the life-threatening situation were made by crews and by Technician Wilson. Valiant and repeated rescue attempts to locate and remove Technician Wilson were made by the firefighting crews during extreme fire, heat, and smoke conditions. Firefighters were forced from the structure as the house began to collapse on them and fire conditions worsened. Technician Wilson succumbed to the fire and the cause of death was reported by the medical examiner to be thermal and inhalation injuries.

An extensive report on this incident is available from the Prince William Department of Fire and Rescue: Technician Kyle Wilson LODD Report.

For additional information regarding this incident, please refer to NIOSH Fire Fighter Fatality Investigation and Prevention Program Report F2007-12.

Ed Hartin, MS, EFO, MIFireE, CFO

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

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.