Posts Tagged ‘flashover’

Weather, Topography, and Fuel

In S-190 Introduction to Wildland Fire Behavior, firefighters learn that weather, topography, and fuel and the principal factors influencing fire behavior in the wildland environment. How might this important concept apply when dealing with fires in the built environment? Factors influencing compartment fire behavior have a strong parallel to those in the wildland environment. Principal influences on compartment fire behavior include fuel, configuration (of the compartment and building), and ventilation.

Wind Driven Compartment Fires

As buildings are designed to minimize the influence of weather on their contents and occupants, weather is not generally considered a major factor in compartment fires. However, this is not always the case. As wildland firefighters recognize, wind can be a major influence on fire behavior and strong winds present a significant threat of extreme fire behavior.

Under fire conditions, unplanned ventilation involves all changes influencing exhaust of smoke, air intake, and movement of smoke within the building that are not part of the incident action plan. These changes may result from the actions of exiting building occupants, fire effects on the building (e.g., failure of window glass), or a wide range of other factors.

Changes in ventilation can increase fire growth and hot smoke throughout the building. Failure of a window in the fire compartment in the presence of wind conditions can result in a significant and rapid increase in heat release. If this is combined with open doors to corridors, unprotected stairwells, and other compartments, wind driven fire conditions have frequently resulted in firefighter injuries and fatalities (see Additional Reading).

NIST Research on Wind Driven Fires

From November 2007 to January 2008, the National Institute of Standards and Technology conducted a series of experiments examining firefighting tactics dealing with wind driven compartment fires. The primary focus of this research was on the dynamics of fire growth and intensity and the influence of ventilation and fire control strategies under wind driven fire conditions. The results of these experiments are presented in Fire Fighting Tactics Under Wind Driven Conditions, published by The Fire Protection Research Foundation.

Tests conducted at NIST’s Large Fire Test Facility (see Figure 1) included establishment of baseline heat release data for the fuels (bed, chairs, sofa, etc), full scale fire tests under varied conditions (e.g., no wind, wind), and experiments involving control of the inlet opening and varied methods of external water application.

Figure 1. NIST Large Fire Test Facility

Note: Photo adapted from Firefighting Tactics Under Wind Driven Conditions.

The objectives of this study were:

• To understand the impact of wind on a structure fire fueled with residential furnishings in terms of temperature, heat flux, heat release rate, and gas concentrations
• To quantify the impact of several novel firefighting tactics on a wind driven structure fire
• Improve firefighter safety

After conducting a series of tests to determine the heat release rate characteristics of the fuels to be used for the full scale tests, NIST conducted eight full scale experiments to examine the impact of wind on fire spread through the multi-room test structure (see Figure 2) and examine the influence of anti-ventilation using wind control devices and the impact of external water application.

Multi-Room Test Structure

All tests were conducted under the 9 m (30′) x 12 m (40′) oxygen consumption calorimetry hood at the NIST Large Fire Test Facility. The test structure was comprised of three compartments; Bedroom, Target Room (used to assess tenability in a compartment adjacent to the ventilation flow), and Living Room, along with an interconnecting hallway and exterior hallways. A large mechanical fan was positioned 7.9 m (26′) away from the window in the bedroom of the test structure (see Figure 2) to provide consistent wind conditions for the experiments.

Figure 2. Configuration of the Multi-Room Test Structure

Note: Adapted from Firefighting Tactics Under Wind Driven Conditions.

The structure was framed with steel studs and wood truss joist I-beams (TJIs) used to support the ceiling. The interior of the compartments were lined with three layers of 13 mm (1/2″) gypsum board. Multiple layers of gypsum board were used to provide the durability required for repetitive experiments (the inner layer was replaced and repairs made to other layers as needed between experiments).

Used furnishings were purchased from a hotel liquidator to obtain 10 sets of similar furniture to use in the heat release rate and full-scale, multi-compartment experiments. Fuel used in the tests included furniture, nylon carpet, and polyurethane carpet padding (the position major furniture items are illustrated in Figures 2 and 3).� Fuel load was 348.69 kg (768.73 lbs) in the bedroom, 21.5 kg (47.40 lbs) in the hallway, and 217.6 kg (479.73 lbs) in the living room (no contents were placed in the target room).

Figure 3. Bedroom and Living Room Fuel Load

Note: Photos adapted from Firefighting Tactics Under Wind Driven Conditions.

NIST researchers conducted a series of eight full-scale, multi-compartment fire tests. In each case, a fire was started in the Bedroom using a plastic trash container placed next to the bed (see Figure 3).

Figure 3. Placement of the Trash Container

Note: Photos adapted from Firefighting Tactics Under Wind Driven Conditions.

Experiments

The eight tests provided the opportunity to study the dynamics of wind driven compartment fires and several different approaches to limiting the influence of air intake and controlling the fire.

Experiment 1: This test was performed to establish baseline conditions with no wind

Experiment 2: Evaluation of anti-ventilation using a large wind control device placed over the window

Experiment 3: Evaluation of anti-ventilation using a large wind control device placed over the window (second test with a longer pre-burn before deployment of the wind control device).

Experiment 4: Evaluation of anti-ventilation and water application using a small wind control device and 30 gpm (113.6 lpm) spray nozzle from under the wind control device.

Experiment 5: Evaluation of anti-ventilation and water application using a small wind control device and 30 gpm (113.6 lpm) spray nozzle from under the wind control device (second test with a lower wind speed)

Experiment 6: No wind control device, application of water using a hoseline equipped with a combination nozzle at 90 psi (621 kPa) nozzle pressure, providing a flow rate of 80 gpm (303 lpm).

Experiment 7: No wind control device, application of water using a hoseline equipped with a 15/16″ smooth bore nozzle at 50 psi (345 kPa) nozzle pressure, providing a flow rate of 160 gpm (606 lpm) (test was conducted with the living room corridor door closed).

Experiment 8: No wind control device, application of water using a hoseline equipped with a 15/16″ smooth bore nozzle at 50 psi (345 kPa) nozzle pressure, providing a flow rate of 160 gpm (606 lpm) (second test with the living room corridor door open).

Note: The nozzles for these tests (100 gpm at 100 psi combination nozzle and 15/16″ solid stream nozzle were selected as to be representative of those used by the fire service in the United States (personal correspondence, S. Kerber, February 28, 2009). However, it is important to note that in comparing the results, that the combination nozzle was under pressurized (80 psi, rather than 100 psi) resulting in large droplet size. In addition, the 100 gpm flow rate was 50% of that applied through the solid stream nozzle and is likely considerably lower than the flow capability of combination nozzles typically used with 1-3/4″ (45 mm) hose.

Important Findings

The first experiment was conducted without any external wind or tactical intervention. The baseline data generated during this test was critical to evaluating the outcome of subsequent experiments and demonstrated a number of concepts that are critical to firefighter safety:

Smoke is fuel. A ventilation limited (fuel rich) condition had developed prior to the failure of the window. Oxygen depleted combustion products containing carbon dioxide, carbon monoxide and unburned hydrocarbons, filled the rooms of the structure. Once the window failed, the fresh air provided the oxygen needed to sustain the transition through flashover, which caused a significant increase in heat release rate.

Venting does not always equal cooling. In this experiment, post ventilation temperatures and heat fluxes all increased, due to the ventilation induced flashover.

As discussed in early posts, Fuel & Ventilation and Myth of the Self Vented Fire understanding the relationship between oxygen and heat release rate, the hazards presented by ventilation controlled fires, and the influence of ventilation on fire development is critical to safe and effective fireground operations.

Fire induced flows. Velocities within the structure exceeded 5 m/s (11 mph), just due to the fire growth and the flow path that was set-up between the window opening and the corridor vent.

Avoid the flow path. The directional nature of the fire gas flow was demonstrated with thermal conditions, both temperature and heat flux, which were twice as high in the “flow” portion of the corridor as opposed to the “static” portion of the corridor in Experiment 1 [not wind driven]. Thermal conditions in the flow path were not consistent with firefighter survival.

Previous posts have presented case studies based on incidents in Loudoun County Virginia and Grove City, Pennsylvania in which convective flow was a significant factor rapid fire progress that entrapped and injured firefighters, in one case fatally. Previous NIST research investigating a multiple line-of-duty death that occurred in a townhouse fire at 3146 Cherry Road in Washington, DC in 1999 also emphasized the influence of flow path on fire conditions and tenability.

More to Follow

Subsequent posts will examine the NIST wind driven fire tests in greater detail.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Madrzykowski, D. & Kerber, S. (2009). Fire Fighting Tactics Under Wind Driven Conditions. Retrieved (in four parts) February 28, 2009 from http://www.nfpa.org/assets/files//PDF/Research/Wind_Driven_Report_Part1.pdf; http://www.nfpa.org/assets/files//PDF/Research/Wind_Driven_Report_Part2.pdf;http://www.nfpa.org/assets/files//PDF/Research/Wind_Driven_Report_Part3.pdf;http://www.nfpa.org/assets/files//PDF/Research/Wind_Driven_Report_Part4.pdf.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999. Retrieved March 1, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

Additional Reading

The following investigative reports deal with firefighter line of duty deaths involving wind driven fire events during structural firefighting.

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report F99-01. Retrieved February 28, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face9901.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report F98-26. Retrieved February 28, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face9826.pdf

National Institute for Occupational Safety and Health (NIOSH). (2002). Death in the line of duty, Report F2001-33. Retrieved February 28, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200133.pdf

National Institute for Occupational Safety and Health (NIOSH). (2007). Death in the line of duty, Report F2005-03. Retrieved February 28, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200503.pdf

National Institute for Occupational Safety and Health (NIOSH). (2008). Death in the line of duty, Report F2007-12. Retrieved February 28, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200712.pdf

Prince William County Department of Fire and Rescue (2007). Line of duty investigative report: Technician I Kyle Wilson. Retrieved February 28, 2009 from http://www.pwcgov.org/default.aspx?topic=040061002930004566

Texas State Fire Marshal’s Office. (2001). Firefighter Fatality Investigation, Investigation Number 02-50-10. Retrieved February 28, 2009 from http://www.tdi.state.tx.us/reports/fire/documents/fmloddjahnke.pdf

Applying NIOSH Recommendations

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

Brief Review of the Incident

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

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

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

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

Recommendations

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

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

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

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

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

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

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

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

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

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

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

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

The report also quotes Chief Dunn regarding defensive search tactics.

Three defensive search tactics are as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Detailed Case Study

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

Now What?

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

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

Have a safe and happy new year!

Ed Hartin, MS, EFO, MIFIreE, CFO

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

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

Analysis and Critique

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

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

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

A Brief Review of the Incident

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

Figure 1. 132 Garden Avenue-Side Alpha

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

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

Contributory Factors

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure 1. 132 Garden Avenue-Side Alpha

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

Firefighting Operations

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

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

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

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

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

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

Firefighter Rescue Operations

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

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

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

Questions

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

Developing & Case Studies

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

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

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

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

The Case

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

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

Building Information

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

Dispatch Information

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

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

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

Weather Conditions

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

Conditions on Arrival

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

Questions

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

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

What impact might weather conditions have on firefighting operations?

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

Ed Hartin, MS, EFO, MIFireE, CFO

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

Experienced Judgment

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

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

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

Riverdale Flashover

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

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

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

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

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

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

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

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

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

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

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

Things to Think About

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

In the Grading the Fireground on a Curve, published in the September issue of Firehouse magazine, Battalion Chief Mark Emery warned of the hazards of assuming that limited volume and velocity of visible smoke indicates a growth stage fire. He correctly identified that compartment fires may enter the decay phase as fuel is consumed or due to a lack of oxygen.

Emery cites National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty reports 98-F07 and F2004-14, in which firefighters initiated offensive fire attack in commercial buildings and encountered rapidly deteriorating fire conditions due to changes in the ventilation profile. Concluding the introduction to his article, Emery observes “Unless you know which side of the fire growth curve you are entering, advancing into zero-visibility conditions is really a bad idea”.

I agree with BC Emery’s basic premise that appearances can be deceiving. However, this article points to two interrelated issues. The hazards presented by ventilation controlled fires and the dangerous conditions presented by enclosed buildings. In Smoke Burns,originally published on Firehouse.com I discussed the hazards of ventilation controlled fire and the relationship of burning regime to extreme fire behavior phenomena such as flashover and backdraft. The hazards presented by ventilation controlled fires are compounded when the fire occurs in an enclosed structure (a building with limited means of access and egress). Captain Willie Mora has written extensively on Enclosed Structure Disorientation on Firehouse.com.

BC Emery illustrated how appearances can be deceiving using data and still images from a full scale fire test in a warehouse in Phoenix, Arizona conducted by the National Institute for Standards and Technology (NIST). NIST conducted these tests as part of a research project on structural collapse. However, the video footage and temperature data from this test is extremely useful in studying the influence of ventilation on fire behavior and fire behavior indicators (Building, Smoke, Air Track, Heat, and Flame (B-SAHF)). The full report and video from this test is available on-line from the NIST Building Fire Research Laboratory (BFRL).

As an oxidation reaction, combustion requires oxygen to transform the chemical potential energy in fuel to thermal energy. If a developing compartment fire becomes ventilation controlled, with heat release rate limited by the oxygen available in the compartment, pyrolysis will continue as long as temperature in the compartment is above several hundred degrees Celsius. Pyrolysis products in smoke are gas phase fuel ready to burn. Increased ventilation at this point, may cause the fire to quickly transition to the fully developed stage (ventilation induced flashover). However, if the fire continues to burn in a ventilation controlled state and the concentration of gas phase fuel (pyrolysis products and flammable products of incomplete combustion) increases sufficiently, increased ventilation may result in a backdraft.

I take issue with BC Emery’s illustration of the growth side of the fire development curve as the value side of the cure and the decay side of the curve as the no value side of the curve. Depending on resources, a fire on the growth side of the curve may exceed the offensive fire control capability of the fire department. Conversely, a fire on the decay side of the curve which is limited to a single compartment or series of compartments may be effectively controlled using an appropriate tactics in an offensive strategic mode. However, Emery’s discussion of the more subtle indicators of burning regime that may warn firefighters of a ventilation controlled fire is right on track. For more information on fire behavior indicators and fire development, see Fire Behavior Indicators and Fire Development Parts I and II on Firehouse.com.

Ed Hartin, MS, EFO, MIFireE, CFO

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

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

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

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

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

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

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

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

Read the report for additional detail on this incident.

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read the report for additional detail on this incident.

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

Ed Hartin, MS, EFO, MIFireE, CFO