Posts Tagged ‘NIOSH’

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

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

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

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

Historical Perspective

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

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

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

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

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

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

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

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

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

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

NFPA 1403

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

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

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

Learning from the Past

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

References

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

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

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

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

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

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

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

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

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

Applying NIOSH Recommendations

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

Brief Review of the Incident

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

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

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

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

Recommendations

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

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

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

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

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

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

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

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

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

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

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

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

The report also quotes Chief Dunn regarding defensive search tactics.

Three defensive search tactics are as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Detailed Case Study

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

Now What?

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

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

Have a safe and happy new year!

Ed Hartin, MS, EFO, MIFIreE, CFO

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

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

Analysis and Critique

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

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

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

A Brief Review of the Incident

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

Figure 1. 132 Garden Avenue-Side Alpha

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

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

Contributory Factors

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure 1. 132 Garden Avenue-Side Alpha

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

Firefighting Operations

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

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

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

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

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

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

Firefighter Rescue Operations

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

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

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

Questions

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

Developing & Case Studies

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

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

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

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

The Case

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

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

Building Information

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

Dispatch Information

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

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

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

Weather Conditions

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

Conditions on Arrival

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

Questions

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

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

What impact might weather conditions have on firefighting operations?

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

Ed Hartin, MS, EFO, MIFireE, CFO

Relevance, Quality, & Impact

The National Institute for Occupational Safety and Health (NIOSH) conducted a public stakeholder meeting in Chicago, IL on 19 November 2008 to hear input and recommendations on the Firefighter Fatality Investigation and Prevention Program. Dr. Christine Branche, Acting Director of NIOSH opened the meeting by emphasizing that this program must be relevant, have high scientific quality, and impact on firefighter health and safety. Dr. Branche requested the participants to review and provide input on Draft strategic Plan for the NIOSH Firefighter Fatality Investigation and Prevention Program.

Tim Firefighter Fatality Investigation Program Project Officer Tim Merinar and Dr. Tom Hales who manages the Cardiovascular Disease and Medical elements of the program provided a program overview and outlined future directions that were identified on the basis of the 2006 stakeholder meeting and other program review efforts. One key area was an increased emphasis on fire dynamics. NIOSH has taken some steps in this direction through staff training and recruitment of investigators with a fire service background. However, much more remains to be done!

Strategic Plan

Paul Moore, Chief of the Fatality Investigations Team provided an overview of the Firefighter Fatality Investigation and Prevention Program Strategic Plan. This plan includes strategic goals (top level goals that state a specific desired change), intermediate goals (activities that NIOSH believes should be taken by stakeholders), activity/output goals (statements of NIOSH program activities), and performance measures (metrics indicating progress).

I was encouraged by a number of the goals identified in the strategic plan related to reducing deaths and injuries associated with structural firefighting.

Strategic Goal 2: Reduce deaths and injuries associated with structural firefighting operations by 2015.

Intermediate Goal 2.1: Fire Service agencies and labor organizations will develop safety interventions based on fatality investigation findings.

Intermediate Goal 2.2: Fire departments will modify training, policies and practices based on investigation findings

These goals are a good starting point. However, if investigation findings do not clearly identify causal and contributing factors, accomplishment will be difficult.

One of the intermediate goals in this section was a bit more problematic.

Intermediate Goal 2.3: Standards setting agencies will modify standards that apply to the design, maintenance, operation, and training regarding fire fighter personal protective technology based on investigation findings.

What could be wrong with this? It sounds perfectly reasonable. It is, but it does not go far enough. Standards setting agencies such as the National Fire Protection Association (NFPA) develop standards for many aspects of our work, including those related to professional qualifications which frequently determine the content of fire service training programs. I believe that this goal should be expanded beyond personal protective technology to include professional qualifications and operational practices.

Some of the activity/output goals identified in the strategic plan were similarly encouraging:

Activity/Output Goal C: Seek peer and stakeholder input to improve the quality of products and impact of the program.

Performance Measure C.1: 75% of fatality investigation reports will be reviewed by external experts prior to finalization and 100% of other publications will be reviewed by peer and/or stakeholder reviewers prior to finalization.

Performance Measure C.2: Expert consultation and/or equipment testing will be sought on all investigations suggestive of personal protective technology malfunctions or failures.

Performance Measure C.3: Stakeholder input will be sought at least every two years through a public meeting and/or docket.

I would encourage NIOSH to examine the process by which they select peer or stakeholder reviewers for specific types of incidents to ensure the greatest technical expertise is brought to bear. In addition, it would be useful to expand Performance Measure C.2 to include more than equipment. In depth fire behavior analysis and in some cases fire modeling would provide extremely useful information to development of effective intervention strategies. Ongoing feedback from the stakeholder community is critical. However, the turnout at this meeting was disappointing with few stakeholder presentations outside those made by national fire service organizations such as the International Association of Firefighters (IAFF), International Association of Fire Chiefs (IAFC), IAFC Health, Safety, & Survival Section, and NFPA.

The strategic plan also spoke to the need to increase the fire service expertise of the NIOSH staff involved in firefighter fatality investigations.

Activity/Output Goal D: Increase the fire service expertise of FFFIPP personnel.

Performance Measure D.1: Each fatality investigator will take at least one fire service training course or attend a fire service conference specifically for training purposes annually.

Performance Measure D.2: Any announcements seeking to fill investigator positions will require previous fire service expertise in addition to occupational safety and health training and experience.

These are positive steps, but it would be useful to provide a bit more direction with regards to what type of fire service expertise should be developed. For example, if the investigators will be examining incidents involving structural firefighting operations, developing competence in fire dynamics and the impact of tactical operations would be a high priority. In considering the experience of potential investigators, it is essential to examine both the breadth and depth of that experience, particularly in relation to understanding of fire dynamics and influence of tactical operations on fire behavior.

Feedback on the Firefighter Fatality Investigation and Prevention Program Strategic Plan can be submitted until 19 December 2008 via e-mail to niocindocket@cdc.gov (attachments should be formatted in Microsoft Word). I would encourage all of you to take the time to review this document and provide your input on this essential program.

Continuing Concerns

My feedback on the limitations of NIOSH death in the line of duty reports dealing with incidents where fire behavior and/or limited understanding of fire dynamics were causal or contributing factors in line-of-duty deaths was well received. In addition, my observations were supported by several of the other stakeholders, most strongly by Rich Duffy, Assistant to the General President of the IAFF.

While constrained by limited resources, the NIOSH staff is committed to serving the needs of the nation’s fire service and truly desires to provide quality information that is relevant, and most importantly has a positive impact on firefighter safety and health.

I will continue my efforts to ensure that this becomes a reality in fire behavior related incidents.

Ed Hartin, MS, EFO, MIFireE, CFO

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

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

Tactical Ventilation

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

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

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

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

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

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

Floor Plan Illustrating the Position of Captain Williams and Firefighter Cheek

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

Extreme Fire Behavior

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

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

NIOSH Recommendations

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

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

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

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

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

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

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

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

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

The Way Forward

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

References

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

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

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

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

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