Posts Tagged ‘Extreme Fire Behavior’

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

Brief Review

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

Figure 1. 3D Cutaway View of 62 Watts Street

Analysis and Computer Modeling

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

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

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

Figure 2. Upper and Lower Layers in Two Zone Models

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

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

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

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

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

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

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

Figure 4. Heat Release Rate

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

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

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

Figure 5. Oxygen Concentration

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

Figure 6. Temperature

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

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

Theory and Practice

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

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

Questions

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

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

Ed Hartin, MS, EFO, MIFIreE, CFO

References

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

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

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

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

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

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

The Case

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

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

Figure 1. 62 Watts Street-Side A

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

Building Information

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

Figure 2. Floor Plan-First Floor Apartment

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

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

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

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

The Fire

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

Weather Conditions

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

Conditions on Arrival

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

Firefighting Operations

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

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

Figure 3. 3D Cutaway View of 62 Watts Street

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

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

Questions

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

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

Analysis and Computer Modeling

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

Ed Hartin, MS, EFO, MIFIreE, CFO

Language is Important

Language has a substantial influence on what and how we think. “What a man cannot state he does not perfectly know, and conversely the inability to put his thoughts into words sets a boundary to his thought” (Newbolt, Bailey, Baines, Boas, Davies, Enright, et al., 1921, p. 20).

While the authors of this statement were focused on English language education in English schools in the 1920’s, the underlying concept applies equally well today. Language is the foundation of understanding. While this is true in day-to-day life, it is equally (or even more) important when dealing with scientific concepts and phenomena related to firefighting.

While construction and fuel loading vary to some extent, fire services around the world are challenged by similar fire problems in the built environment. Each of us faces the same processes of compartment fire development and extreme fire behavior phenomena such as flashover, backdraft, and smoke explosion. However, our understanding and communication about these important processes and phenomena are limited by lack of a common language. In many cases terms have more than one definition. In addition, definitions are often unclear and imprecise.

Shared Concepts

In philosophy, ontology is the study of the nature of reality, categories of being, and their relations; what entities can exist and how they can be grouped, related within a hierarchy, and divided based on their similarities and differences. Ontology is a system of concepts that provides a shared vocabulary that can be used to describe and think about a particular domain.

We do not really have an ontology that encompasses fire behavior phenomena such as flashover, backdraft, smoke explosion, and the like. As Dr. Stefan Svennson so astutely observes, it is complicated and there may not always be a clearly defined differences between phenomena. However, going back to the opening paragraph of this post, I contend that a shared language is necessary for us to understand and mitigate the hazards we face as a result of rapid fire progress. Hopefully this post will engage you in this ongoing effort.

Extreme Fire Behavior

Terms such as flashover, backdraft, and smoke explosion are often used to describe phenomena involving rapid fire progression in compartment fires. Currently accepted definitions provide a starting point for developing improved clarity. As a starting point, I have examined definitions of extreme fire behavior phenomena from the following sources:

1. International Standards Organization (ISO)
2. National consensus standards organizations (e.g., National Fire Protection Association, Fire Protection Association)
3. International or national professional associations (e.g., Institution of Fire Engineers, Society of Fire Protection Engineers)
4. Recognized texts

Consider the similarities and differences in the following definitions and give some thought to the questions that follow.

Flashover: 1) Stage of fire transition to a state of total surface involvement in a fire of combustible materials within an enclosure’ (ISO 13943, 2008, 4.156). 2) A transitional phase in the development of a compartment fire in which surfaces exposed to thermal radiation reach ignition temperature more or less simultaneously and fire spreads rapidly throughout the space resulting in full room involvement or total involvement of the compartment or enclosed area (NFPA 921-2007).

Discussion: This transition is often assumed to take place between the growth and fully developed stages. However, neither the ISO nor NFPA definition specifies this. In addition, while the NFPA definition indicates that this transition is extremely rapid (i.e., more or less simultaneously), the ISO definition does not describe the speed with which the transition to total surface involvement occurs.

• Is the occurrence of flashover limited to the transition between growth and fully developed stages of fire development?
• Can flashover result from increasing ventilation to a ventilation controlled fire (vent induced flashover)? If yes, how does this differ from backdraft?
• Can a fire reach the fully developed stage without transitioning through flashover?

Backdraft: 1) Rapid flaming combustion caused by the sudden introduction of air into a confined oxygen-deficient space that contains hot products of incomplete combustion. In some cases, these conditions can result in an explosion (ISO 13943, 2008, 4.21). 2) A deflagration resulting from the sudden introduction of air into a confined space containing oxygen-deficient products of incomplete combustion (NFPA 921, 2008, 3.3.14).� 3) A phenomenon that occurs when a fire takes place in a confined area such as a sealed aircraft fuselage and burns undetected until most of the oxygen within is consumed. The heat continues to produce flammable gases, mostly in the form of carbon monoxide. These gases are heated above their ignition temperature and when a supply of oxygen is introduced, as when normal entry points are opened, the gases could ignite with explosive force (NFPA 402, 2008).

Discussion: The ISO definition is considerably more broad than that specified in NFPA 921 and as such would be inclusive of phenomena such as ventilation induced flashover as well deflagration resulting from introduction of air to an extremely ventilation controlled fire. The definition of backdraft in NFPA 402, Guide for Aircraft Rescue and Firefighting Operations illustrates the common misconception that carbon monoxide is the primary gas phase fuel in a backdraft. There is no scientific evidence that this is the case. Both NFPA definitions indicate that backdraft is explosive in nature (e.g., deflagration) while the ISO definition indicates that this is a possibility, but not a requisite outcome.

• How does backdraft differ from a vent induced flashover? This is essentially the same question as before, but this time, think about it from the backdraft perspective.
• If there is a difference between vent induced flashover and backdraft, what is different (about the nature of the phenomena, requisite conditions, and initiating event(s))?
• Many firefighters believe that backdraft requires high temperature (resulting in auto-ignition following an increase in ventilation), yet this is not mentioned in any of the definitions. Is this the case?
• Is a backdraft always an explosive event?

Fire Gas Ignition: Ignition of accumulated unburned pyrolysis products and flammable products of incomplete combustion existing in or transported into a flammable state (Grimwood, Hartin, McDonough, & Raffel, 2005)

Discussion: In 3D Firefighting, Grimwood uses the term Fire Gas Ignition as a broad category of phenomena including smoke (fire gas) explosion, flash fire, and a number of other fire behavior phenomena.

• What differentiates phenomena classified as fire gas ignitions from backdraft, or for that matter flashover?
• If there is a common theme, is it useful to have an overarching category such as fire gas ignition?

Smoke Explosion: 1) See Backdraft (NFPA 921, 2008). 2) When unburnt gases from an under-ventilated fire flow through leakages into a closed space connected to the fire room, the gases there can mix very well with air to form a combustible gas mixture. A small spark is then enough to cause a smoke gas explosion (Karlsson & Quintiere, 2000). 3) A smoke gas explosion results from ignition of a confined mass of smoke gases and air that fall within the flammable range. This may result in a significant increase in pressure within the compartment (paraphrased from Bengtsson, 2001).

Discussion: In the past, the terms smoke explosion and backdraft were frequently used synonymously (and still used this way within NFPA 921). However, smoke explosion is a substantively different phenomenon as evidenced by the definitions provided by Karlsson & Quintiere (2000) and Bengtsson (2001). Drysdale (1998) also discusses this phenomenon, and while not providing a definition per say, delineates the difference between smoke explosion and backdraft as different phenomena.

• How are smoke explosion and backdraft different?
• What differentiates smoke explosion from flash fire?
• The phenomenon of smoke explosion as defined in various texts requires a mixture of fuel and air within the flammable range. If this flammable mixture is achieved by an increase in ventilation (adding air to a rich mixture of air and fuel), would piloted ignition result in a smoke explosion or backdraft?

Flash Fire: A fire that spreads rapidly through a diffuse fuel, such as dust, gas, or the vapors of an ignitable liquid, without the production of damaging pressure (NFPA 921, 2008, 3.3.72)

Discussion: While this definition appears reasonably clear when taken by itself, how does this differ from rollover, or for that matter flashover?

• What differentiates flash fire from other phenomena such as rollover (flameover) where fire spread rapidly through gas phase fuel in the upper layer?
• While the term “flash” infers a brief occurrence, the definition does not clearly define the duration of this phenomenon. Is this different from the rapid transition to a fully developed fire that results from flashover?
• What differentiates flash fire from a smoke explosion (the NFPA definition of flash fire provides a fuzzy hint, but is this clear enough)?

For a longer and more detailed examination of the definitions of flashover and backdraft, see The Current Knowledge and Training Regarding Flashover, Backdraft, and Other Rapid Fire Progression Phenomenon (Gorbett & Hopkins, 2007).

What Next?

Over the next couple of months, I will be working to develop a discussion (in a variety of formats) to develop a common framework and working definitions that will aid us in talking about fire behavior phenomena that present a significant threat to firefighters (i.e., extreme fire behavior). I invite you to be part of this process! More information will be provided in subsequent posts.

Ed Hartin, MS, EFO, MIFireE, CFO

References

Bengtsson, L. (2001). Enclosure Fires. Karlstad, Sweden: R�ddnings Verket.

Drysdale, D. (2000). An introduction to fire dynamics. Chichester, England: John Wiley & Sons.

Gorbett, G. & Hopkins, R. (2007). The Current Knowledge and Training Regarding Flashover, Backdraft, and Other Rapid Fire Progression Phenomenon. Retrieved March 19, 2009 from http://www.kennedy-fire.com/backdraft%20paper.pdf.

Grimwood, P., Hartin, E., McDonough, J., & Raffel, S. (2005). 3D firefighting: Training , techniques, and tactics. Stillwater, OK: Fire Protection Publications.

Karlsson, B. & Quintiere, J.G. (2000). Enclosure fire dynamics. Boca Raton, FL: CRC Press.

National Fire Protection Association. (2008) NFPA 402 Guide for aircraft rescue and fire-fighting operations. Quincy, MA: Author.

National Fire Protection Association. (2008) NFPA 921 Guide for fire and explosion investigations. Quincy, MA: Author.

Newbolt, H., Bailey, J., Baines, K., Boas, F., Davies, H., Enright, D., et al. (1921). Teaching of English in England.� Retrieved March 17, 2009 from http://ia340921.us.archive.org/2/items/teachingofenglis00greaiala/teachingofenglis00greaiala.pdf

What is Extreme?

There is some debate about the use of the term extreme fire behavior (some of my colleagues indicate that processes such as flashover is not “extreme” but simply “normal” fire behavior). I contend that flashover would potentially be a normal part of fire development, but is also extreme, at least in the context that we are using the word. As defined in the wildland firefighting community:

“Extreme” implies a level of fire behavior characteristics that ordinarily precludes methods of direct control action. One or more of the following is usually involved: high rate of spread, prolific crowning and/or spotting, presence of fire whirls, strong convection column. Predictability is difficult because such fires often exercise some degree of influence on their environment and behave erratically, sometimes dangerously (National Wildfire Coordinating Group Glossary)

In the structural firefighting environment, occurrence of flashover (particularly while firefighters are operating inside the compartment) fits substantially with the description of extreme used by wildland firefighters.

Classification and Understanding

Ontology may be described as definition of a formal representation of concepts and the relationships between those concepts. An ontology provides a shared vocabulary. Unfortunately we do not have a well developed ontology of fire behavior phenomenon and many types of phenomena have more than one definition. As with the use of the word extreme, there is some debate about the need to classify phenomena as being this or that (e.g., flashover or backdraft). I take the position that it is useful (but difficult as we do not have a common classification scheme or ontology). But, I think that it is still worth the effort.

This is a substantive topic for a later post. This post will examine a type of fire gas ignition phenomena that has been involved in a number of incidents in recent years resulting in near misses, injuries, and fatalities.

Fire Gas Ignitions

In a previous post, I posed the question: Backdraft or Smoke Explosion?. This post used a video clip to open a discussion of the difference between these two phenomena. A smoke (or fire gas) explosion is a type of fire gas ignition, but there are a number of other types of fire gas ignition that present a hazard during firefighting operations.

All fire gas ignitions (FGI) involve combustion of accumulated unburned pyrolysis products and flammable products of incomplete combustion existing in or transported into a flammable state (Grimwood, Hartin, McDonough, & Raffel, 2005). In a smoke explosion, ignition of a confined mass of smoke gases and air that fall within the flammable range results in extremely rapid combustion (deflagration), producing an significant overpressure which can result in structural damage. However, what happens if the mass of gas phase fuel is not pre-mixed within its flammable range and does not burn explosively?

The general term Fire Gas Ignition, encompasses a number of phenomena that are related by the common characteristic that they involve rapid combustion of gas phase fuel consisting of pyrolizate and unburned products of incomplete combustion that are in or are transported into a flammable state. For now, let’s differentiate these phenomena from backdraft on the basis of the concentration of gas phase fuel (backdraft involving a higher concentration than fire gas ignition).

Fire gas ignition can involve explosive combustion (as in a smoke explosion) or rapid combustion that does not produce the same type of overpressure as an explosion. One such phenomenon is a flash fire. In this case, gas phase fuel ignites and burns for short duration, but does not release sufficient energy for the fire to transition to a fully developed stage (as occurs in flashover). While a flash fire may not result in flashover, the energy release is still significant and heat flux (energy transferred) can be sufficient result in damage to personal protective equipment, injury and death. This post uses a case study to examine the flash fire phenomenon.

Residential Fire

This case study is based on a near-miss incident involving extreme fire behavior during a residential fire that occurred on October 9, 2007 at 1119 William Street in Omaha, Nebraska. Special thanks to Captain Shane Hunter (Omaha Fire Department Training Officer) for sharing this post incident analysis and lessons learned.

Unlike many of the incidents used as case studies, no one died or was injured during incident operations. In this near miss incident, the firefighters and officers involved escaped without injury, but the outcome could easily have been quite different.

Weather Conditions

Weather was typical for early fall with a light breeze from the south (blowing towards Side C of the fire building).

Building Information

The fire building was a one and a half story, wood frame dwelling with a basement (see Figure 1). The attic space had been renovated into three separate compartments to provide additional living space.

Figure 1. Exterior View Side A

Figure 2. Floor 2 Layout

Conditions on Arrival

When the first company arrived they observed fire and smoke from the second floor window (see Figure 1) and reported a working fire. The doors and windows on the first floor were closed.

Firefighting Operations

What initial actions were taken? A 200′ hoseline was extended through the door located on Side A and through the living room and kitchen to the stairway to the second floor, which was located at the C/D corner of the structure (Figures 2 and 3).

Figure 5 & 6. Kitchen (view from Floor 1) and Stairwell (view from Floor 2)

What did the fire attack crew observe? The living room and kitchen were clear of smoke and the door to the second floor stairway was closed. When this door was opened and the line was advanced up the stairway to the second floor, the company assigned to fire attack encountered smoke down to floor level on the second floor. Making a left turn at the top of the stairs (see Figure 4) the Captain noted high temperature at the floor level and observed rollover at the ceiling level.

• How did the ventilation profile change when the door to second floor stairway was opened? How might this have changed fire behavior?
• What did the depth of the hot gas layer (from ceiling to floor) indicate about the ventilation profile?
• What did rollover in the center compartment indicate?

The Captain instructed the nozzle operator to apply water to the ceiling. The firefighter on the nozzle applied water in a 30^o fog pattern (continuous application). Simultaneously, a crew working on the exterior vented the second floor window on Side C (see Figures 4 and 6).

How did conditions change? The engine company working on floor 2 heard an audible, whoosh as the hot gas layer ignited producing flames down to floor level. Operation of the hoseline (30^o fog pattern) had no immediate effect. The Captain ordered the crew to retreat into the stairwell and continue water application.

• What extreme fire behavior phenomena occurred?
• What were the initiating events that caused this rapid fire progression?

Figure 4. Floor 2 Side A (Looking Towards Side A)

Figure 5. Floor 2 Side C (Looking Towards Side C)

What action was taken? While the engine company operated from the stairwell, vertical ventilation was completed over the center compartment (see Figures 4 and 5). After the creation of an exhaust opening in the roof, conditions on floor 2 became tenable and the engine crew was able to knock the fire down within several minutes.

• Why did conditions improve quickly after the creation of a vertical exhaust opening?
• What tactical options might have prevented this near miss?

Observations and Analysis

Captain Shane Hunter observed that the initial fire attack crew viewed this incident as an easy job. They thought that an attack from the unburned side would simply push the fire out the window where fire was initially showing on Side A. Why did things turn out so differently than anticipated?

In his analysis of this incident, Captain Hunter points out that there is a considerable difference between a “self-vented” fire and an adequately ventilated fire. As discussed in the April 2008 Officer’s Corner (GFES), horizontally ventilated fires are likely to remain ventilation-controlled. It is important to read the Building, Smoke, Air Track, Heat, and Flame (B-SAHF) indicators to determine the current burning regime (fuel or ventilation-controlled) and anticipate the effect of changes to the ventilation profile.

The fire in the compartment of origin reached flashover resulting in the extension of flames into the center compartment as evidenced by the observation of rollover by the Captain of the engine company performing fire attack. However, the center compartment and the compartment on Side C did not experience flashover (note the condition of contents in the center compartment in Figure 6.). If flashover did not occur in these two compartments, what happened?

In this incident, the fire gases ignited in a flash fire, but combustion did not rapidly transition to a fully developed state in the two compartments adjacent to the compartment of origin.

A flash fire rapidly increases heat release rate, temperature within the compartment and heat flux (as experienced by the fire attack crew in this incident). Like rollover, this phenomenon should not be confused with flashover as fuel in the lower region of the compartment may or may not ignite and sustain combustion. However, fire gas ignition can precede and precipitate flashover (should the fire quickly transition to the fully developed stage).

The concentration of fuel within the hot gas layer varies considerably, with higher concentrations at the ceiling. Concentrations within the flammable range most commonly develop at the interface between the hot gas layer and the cooler air below. Isolated flames (an indicator of a ventilation-controlled fire) are most commonly seen in the lower region of the hot gas layer (as there may be insufficient oxygen concentration in the upper level of the hot gas layer to support flaming combustion). Mixing of the hot gas layer and air due to turbulence increases the likelihood of a significant fire gas ignition.

• What was the ventilation profile and air track when the engine company reached the top of the stairs to begin their attack on the fire?
• How did the tactical ventilation performed from the exterior (removal of the window on floor 2, Side C) influence the ventilation profile and air track?
• What effect do you think that continuous operation of the 30^o fog stream had on conditions on floor 2?
• What combination of factors likely resulting in mixing of air and smoke (fuel) leading to the fire gas ignition that drove the fire attack crew off floor 2 and into the stairwell?

Key Considerations and Lessons Learned

This incident points to a number of key considerations and lessons learned.

• Beware the routine incident! Even what appears to be a simple fire in a small residential structure can present significant challenges and threats to your safety.
• Use the B-SAHF indicators to read the fire and consider both the stage of fire development and burning regime (fuel or ventilation-controlled) in strategic and tactical decision making.
• Flame showing is just that. Do not be lulled into a false sense of security by thinking that the fire is adequately ventilated. Read the air track indicators!
• Continue to read the fire after making entry. Smoke is fuel and hot gases overhead are a threat. Observation of isolated flames indicates a ventilation-controlled fire. Rollover often precedes flashover. Take proactive steps to mitigate the threat of extreme fire behavior.
• Recognize that ventilation-controlled fires will increase in heat release rate if additional air is introduced. Manage the ventilation profile using tactical ventilation and tactical anti-ventilation. Anticipate unplanned ventilation due to fire effects.
• Recognize that both horizontal and vertical ventilation are effective when used appropriately and coordinated with fire control. Consider the influence of inlet and exhaust opening location and size when anticipating the influence of tactical ventilation on fire behavior and conditions within the building.

Again special thanks to Captain Shane Hunter and the Omaha Fire Department for sharing the information about this incident and their work to improve firefighter safety.

Ed Hartin, MS, EFO, MIFireE, CFO

25 Years Later

Firefighters Scott Smith and William Duran died as a result of flashover during a search and rescue drill in Boulder, Colorado on January 26, 1982 (Demers Associates, 1982, August). This incident has particular significance in that it was one of the major influences in the development of National Fire Protection Association (NFPA) Standard 1403 Live Fire Training Evolutions in Structures (NFPA, 1986). 25 years after the deaths of the two firefighters in Boulder, rapid fire progress during live fire training claimed the life of Firefighter Paramedic Apprentice Rachael Wilson in Baltimore, Maryland (Shimer, 2007; NIOSH, 2008)

What makes this even more tragic is that unlike the incident in Boulder, for the last 20 years the fire service has had a national consensus standard that defines minimum acceptable practice for live fire training.

Training Exercise on South Calverton Road

Information on the incident that resulted in the death of Firefighter Paramedic Apprentice Rachael Wilson was drawn from the Independent Investigation Report: Baltimore City Fire Department Live Fire Training Exercise 145 South Calverton Road February 9, 2007 (Shimer, 2007) and NIOSH Death in the Line of Duty Report F2007-09 (NIOSH, 2008).

On February 9, 2007 twenty-two members of Baltimore City Fire Department Firefighter Paramedic Apprentice Class 19 were participating in live fire training in an acquired structure. The objectives of this training exercise included practice in fire attack, primary search, forcible entry, and ventilation. The building used for this training exercise was a three story, single family row house of ordinary (masonry and wood joist) construction. The building was of somewhat unusual design with the front (A Side) of the building constructed at an angle (parallel to the street) resulting in a trapezoidal floor plan as illustrated in Figure 1. The third floor was considerably smaller than the first two floors with third floor windows on Side C looking out over the second floor roof. The building had previously been used for training and ceilings and portions of the walls on the second and third floors had been opened up during ventilation and forcible entry practice.

Five instructors assigned to the Training Academy and six adjunct instructors were responsible for managing the live fire training exercise and providing instruction. Lieutenant Crest (Training Academy staff) served as Incident Commander and Division Chief Hyde served as the Safety Officer. Two instructors were assigned as the ignition team and others were assigned to supervise assigned crews of Firefighter Paramedic Apprentices. An engine and truck from the Training Academy were positioned on the A Side of the building. The engine was supplied by a hydrant through a single large diameter hoseline.

The plan for the training exercise called for eight separate fuel packages on Floors 2 (two fuel packages) and 3 (six fuel packages) to be ignited. Each fuel package consisted of one or three pallets and excelsior (soft shredded wood packing material). Crews would be assigned to fire attack on floors two and three while other crews performed forcible entry (in support of fire attack) primary search, ventilation. The trainees were divided into five companies, designated Engine 1 (fire attack on Floor 3), Engine 2 (fire attack on Floor 2), Truck 1 (placement of ladders and then search and rescue), Truck 2 (assist with forcible entry on Side C), and Truck 3 (vertical ventilation). While the Incident Commander outlined the plan for the instructors, the trainees were not provided with a walkthrough of the building or safety briefing prior to the start of the live fire exercise.

The Incident Commander (Lieutenant Crest) accompanied the ignition team into the building and supervised ignition of the fires on Floors 3 and 2. While none of the instructors indicated doing so, a fire was also lit in debris (three mattresses, automobile tire, upholstered chair, and other combustible materials) located just inside the doorway on Floor 1 Side C.

Fire Attack

The crew designated Engine 1 consisted of Emergency Vehicle Driver Wenger (Instructor) and Firefighter Paramedic Apprentice Wilson (nozzle), Paramedic Cisneros (2^nd on the line), and Firefighter Paramedic Apprentices Perez, and Lichtenberg. Engine 1 was tasked with fire attack on Floor 3. None of the crew from Engine 1 was equipped with a portable radio and received their orders face-to-face from Command. When the instructor questioned passing the fire on Floor 2, Command indicated that another line would be coming in right behind them and to go directly to Floor 3. Engine 1 entered from Side A with a 1-3/4″ (45 mm) hoseline and proceeded up the interior stairwell. None of the members of this crew indicated seeing fire on Floor 1 at the time they made entry.

Figure 1. Baltimore Floor Plan.

Note: Adapted from City of Baltimore.� Independent investigation report: The Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007, (Shimmer, 2007, pp. 13)

Upon reaching Floor 2, Engine 1 encountered severe fire conditions and the instructor did not feel comfortable proceeding to Floor 3 without controlling the fire on Floor 2. He instructed Apprentice Wilson to open the nozzle and put water on the fire. In the process of doing so, she fell and the instructor took over the nozzle. He (the instructor) knocked the fire down to the point where he felt that his crew could advance to Floor 3 (bud did not completely control or extinguish the fire on Floor 2). At this point he returned the nozzle to Wilson. Wilson and Cisneros and the instructor proceeded to Floor 3 while Perez, and Lichtenberg remained in the stairwell pulling hose.

Trapped Above the Fire

After reaching Floor 3, Cisneros (2^nd on the line behind Wilson) advised the instructor that Floor 2 was well involved. He instructed her to go into the stairwell and pull up additional hose. She felt intense heat on her legs and advised the instructor that she needed to get out of the building. The instructor climbed through the egress window (see Figure 2) and assisted Cisneros out the window and onto the second floor roof. At this point, Wilson was maintaining a position at the egress window (located at the top of the stairwell) with the nozzle.

Figure 2. Baltimore Cross Section of Floor 3

Note: Adapted from City of Baltimore. Independent investigation report: The Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007, (Shimmer, 2007, pp. 13 & 21-27)

While Engine 1 was making their way to Floor 3, Engine 2 entered from Side C with a 1-3/4″ (45 mm) hoseline, intending to proceeding to Floor 2 as ordered, but encountered a significant fire on Floor 1 with flames beginning to roll across the ceiling. Engine 2 attacked the fire on Floor 1 (which delayed their advancement to Floor 2).

Perez and Lichtenberg (members of Engine 1’s crew pulling hose in the stairwell) felt a rush of air followed by flames rapidly extending up the stairwell from Floor 2 to Floor 3. They moved to the top of the stairs and observed Wilson trying to climb through the egress window. Wilson warned them to get out of the building. Heeding her warning, they proceeded down the stairway with the hoseline and controlled the fire on Floor 2 sufficiently to permit them to exit the building, meeting the crew of Engine 2 who were making their way to Floor 2.

Wilson advised Wenger (instructor with Engine 1) that she needed to get out. She had dropped the nozzle (still operating) and was trying to climb out the window. Wenger tried unsuccessfully to pull her out the window (note the height of the window sill in Figure 2). Wenger asked Wilson if she could help him get her out the window. She replied that she could not and that she was burning up. Wenger lost his grip on Wilson and she fell back into the building. Regaining his grip he pulled her partially out the window again, noticing that her breathing apparatus facepiece was partially displaced. Wenger called for help (shouting as he had no radio). Three members of Truck 3 who were working on the third floor roof dropped down to the second floor roof to assist, but were unable to pull Wilson from the window.

Emergency Vehicle Driver Hiebler (instructor with Engine 2) heard a commotion on Floor 3. He ordered one of his crew to accompany him to Floor 3 with the hoseline and the others to remain in place on Floor 2. Reaching Floor 3, they observed Wilson at the window and Wenger (instructor from Engine 1) working from the second floor roof trying unsuccessfully to pull her out the window. Concerned about the fire on Floor 3, Hiebler instructed the trainee to extinguish the fire while he assisted in getting Wilson out the window.

Wilson was unconscious, pulseless and apnic when she was removed from Floor 3. Her breathing apparatus and protective clothing was removed and cardio pulmonary resuscitation (CPR) was initiated while she was on the second floor roof. At the Incident Commander’s direction she was moved up to the third floor roof so that she could be brought down an aerial ladder that had been placed to the roof from Side A. Prior to being brought down from the third floor roof, Wilson was packaged on a backboard and placed in a stokes basket. On reaching the ground advanced life support medical care was initiated and Wilson was transported to the local trauma center where she was pronounced dead. Firefighter Paramedic Apprentice Rachael Wilson died as a result of thermal injuries and asphyxia.

The Aftermath

The initial investigation of this incident was conducted by the Baltimore City Fire Department, Baltimore City Police Department Arson Unit, and United States Bureau of Alcohol Tobacco and Firearms. Subsequently, Mayor Sheila Dixon commissioned an independent investigation into the circumstances surrounding the death of Rachael Wilson lead by Deputy Chief Chris Shimer of the Howard County Department of Fire and Rescue Services. This investigation concluded that there were in excess of 50 deviations from accepted practice as defined by National Fire Protection Association (NFPA) 1403 Standard on Live Fire Training Evolutions (2002). In addition, the investigators identified significant issues related to the organizational culture of the Baltimore City Fire Department that resulted in a lack of accountability compliance with accepted safety practices (Shimer, 2007)

The Maryland Department of Labor, Licensing, and Regulation cited the Baltimore City Fire Department for 33 safety violations and singled out the fire officers who served as Incident Commander and Safety Officer for the haphazard planning and execution of this live fire training exercise (Linskey, 2007a)

The Baltimore City Fire Department fired Training Division Chief Kenneth Hyde who was the Safety Officer and senior fire officer present at the fatal incident. Citing negligence and incompetence in their roles as Incident Commander (Crest) and supervisor of the rapid intervention team (Broyles) during this incident (Linskey, 2007b) Lieutenants Joseph Crest and Barry Broyles were also terminated.

Following votes of no confidence from the Baltimore City Firefighters and Fire Officers unions and continuing criticism, Fire Chief William Goodwin resigned in November 2007, ten months after the death of Firefighter Paramedic Apprentice Rachael Wilson (Fritze & Reddy, 2007)

Now What?

Rachael Wilson’s death was the result of a complex web of contributing factors. It is easy to say that failure to comply with the provisions of standards and regulations regarding live fire training was the problem. But it is more complex than that.� It is essential that we examine our organizational culture and training practices on an ongoing basis and ask hard questions regarding the safety and effectiveness of what we do.

Ed Hartin, MS, EFO, MIFireE, CFO

References

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

Fritze, J. & Reddy, S. (2007) City’s fire chief resigns. Retrived June 5, 2008 from http://baltimoresun.com/recruit

Linsky, A. (2007c) Baltimore fire department cited in cadet’s death. Retrieved June 4, 2008 from http://baltimoresun.com/recruit

Linsky, A. (2007d) City dismisses two more fire officials. Retrieved June 4, 2008 from http://baltimoresun.com/recruit

National Fire Protection Association. (1986). Standard on live fire training evolutions in structures. Quincy, MA: Author.

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

National Institute for Occupational Safety and Health (NIOSH). (2002). Death in the line of duty, F2007-09. Retrieved February 19, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200709.pdf

Shimer, R. (2007) Independent investigation report: Baltimore city fire department live fire training exercise 145 South Calverton Road February 9, 2007. Retrieved February 19, 2009 from http://www.firefighterclosecalls.com/pdf/BaltimoreTrainingLODDFinalReport82307.pdf.

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

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

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

Historical Perspective

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

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

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

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

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

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

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

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

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

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

NFPA 1403

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

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

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

Learning from the Past

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

References

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

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

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

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

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

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

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

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

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

The Incident

Kernersville Fire Rescue and responded to a residential in the 1300 block of Union Cross Road shortly after 0200 hours on January 14, 2009. Occupants had been evacuated by two civilians returning home from work at a nearby Dell computer plant. First arriving units initiated offensive operations and began primary search to ensure that all occupants were out of the residence.

Less than 15 minutes into initial operations, an explosion occurred resulting in partial collapse of the building. Kernersville Firefighter Jay Coleman and three firefighters from the Winston-Salem Fire Department were caught in the collapse, but were able to self-extricate. Firefighter Coleman suffered minor injuries.

Chief Walt Summerville of Kernersville Fire Rescue reported “as we entered the building and began to ventilate and to flow air by moving hose lines, the heated gases got the air it needed”.� Chief Summerville believes the explosion was a backdraft, which was caused by a build-up of smoke in the crawl space of the home.

Explosion Captured on Video

A Kernersville police officer’s dashboard camera caught a burning home as it suddenly exploded. The police car was (appropriately) positioned a considerable distance from the house and provides a view of Side A from the Alpha/Delta corner. Watch the video several times to get a general sense of what happened Then download and print the B-SAHF Worksheet and identify any key indicators that might have be visible in the video.

Post fire video and an interview with Firefighter Coleman are available on the WGHP Fox Channel 8 web site.

At this point, information available about this incident is limited to news reports and video. However, we will be in touch with Kernersville Fire Rescue in an effort to obtain more detailed and fire behavior focused information about this incident. More to follow!

Important Lessons

An initial look at the limited information available about this incident points to several important considerations:

• Conditions can vary widely in different compartments. In this incident (like many others) flaming combustion is visible in one location, while extremely under-ventilated backdraft conditions exist elsewhere.
• Backdraft can occur in an entire building, one or more habitable compartments, or in a void space.
• Backdraft indicators may be pronounced, they may be subtle, or may not be visible from firefighters working positions.

Ed Hartin, MS, EFO, MIFireE, CFO

LODD in 2008

In 2008, six firefighters in the United States lost their lives in extreme fire behavior events occurring while they were engaged in interior firefighting operations. In 2008 there was only one multiple fatality line of duty death as the result of extreme fire behavior. Of this six, three were career, two were volunteers, and one was paid on call. They ranged in age from 19 to 54 years of age with an average age of 34.8 years. However, this does not give us the real picture, it is important to look at each of these events.

Firefighter Rick Morris (54, Career), Sedalia, Missouri: Firefighter Morris died April 8, 2008, nine days after being burned in a flashover that occurred while attempting to locate the fire in a small single family dwelling He was survived by his wife and four children.

Firefighter Bret Lovrien (35, Career), Los Angeles, California: Firefighter Lovrien died and Engineer Anthony Guzman was seriously injured March 26, 2008 from traumatic injuries occurring as the result of a smoke explosion while forcing entry into a commercial building to investigate smoke from a fire in a utility vault. Firefighter Lovrien was survived by his brother, parents, stepmother, and grandfather.

Firefighter Justin Monroe (19, Paid On-Call) and Firefighter Victor Isler (40, Career), Salisbury, North Carolina: Firefighters Monroe and Isler died March 7, 2008 of thermal insult and carbon monoxide exposure following rapid fire progress (likely flashover) in a commercial fire. Three other firefighters also suffered burns in this incident. Firefighter Monroe was survived by his parents and brother. Firefighter Isler was survived by his wife and two children.

Lieutenant Nicholas Picozzi (35, Volunteer), Linwood, Pennsylvania: Lieutenant Picozzi died March 5, 2008 as a result of injuries received due to rapid fire progress (likely flashover) while searching for the seat of the fire in the basement of a small single-family dwelling. Assistant Chief Kenny Dawson Jr., Assistant Chief Chris Durbano, and Firefighter Tom Morgan Jr. were injured while attempting to rescue Lieutenant Picozzi. Lieutenant Picozzi was survived by his wife and two children.

Firefighter Brad Holmes (21, Volunteer) , Grove City, Pennsylvania: Firefighter Holmes died three days after he and and Lieutenant Scott King were burned as the result of flashover while conducting primary search on the second floor of a small two-family home on February 29, 2008. Firefighter Holmes is survived by his parents and brother.

Two of these incidents have been documented by an investigative report. NIOSH Report F2008-06 examines the incident in which Firefighter Brad Holmes died. The Post Incident Report on the Salisbury Millwork Fire by the Salisbury Fire Department examines the circumstances surrounding the deaths of Firefighters Justin Monroe and Victor Isler (NIOSH Report F2008-07 is pending). NIOSH is also investigating the deaths of Lieutenant Nick Pilozzi (NOSH F2008-08) and Firefighter Brett Lovrien (NIOSH F2008-11). The status of these reports is listed on the NIOSH Firefighter Fatality Investigation and Prevention Program Pending Investigations page.

Similarities and Differences

Three of these fatalities occurred in small residential structures. Of these, one occurred on the second floor, one on the first floor, and the other in the basement. Two of these fatalities occurred in an exposure, not initially involved in the fire. Three of these fatalities occurred in commercial occupancies. Two of the fatalities occurred at a major, greater alarm fire. In one of these incidents, firefighters were searching for a trapped occupant, in all other cases; the firefighters were searching for the fire.

It is critical to remember that extreme fire behavior can occur in any type of structure. In some cases, severe fire conditions are evident on arrival, but in others, there is little evidence of a significant fire. The sense of urgency resulting from persons reported, or a rapidly developing fire can result in tunnel vision and reduce focus on key fire behavior indicators (B-SAHF). It is essential to ensure that members have adequate training so that reading the fire is both second nature and a conscious part of their size-up and dynamic risk assessment process.

Are We Making Progress?

This number is considerably lower than the 18 firefighters who died in 2007 where extreme fire behavior was a causal or contributing factor (four events accounted for 15 of the 18 fatalities). Does this reduction indicate that we are doing a better job of recognizing potential for extreme fire behavior and are controlling the fire environment more effectively to reduce risk during offensive operations? Examining not only line of duty deaths, but department incident reports, data submitted to the National Firefighter Near Miss Program and news reports of fire incidents involving extreme fire behavior I have the feeling that this reduction is not completely due to improved safety and operational performance.
There have been a number of incidents over the last year that point to the need for continued efforts in the improvement of fire behavior training. Incidents in Loudoun County, Virginia (see Loudon County Virginia Flashover, Loudoun County Flashover: What Happened, Loudoun County Flashover: Escape from Floor 2, and Flashover & Survival Skills Training); Sacramento, California and Edmonton, Alberta resulted in multiple firefighters being trapped by rapid fire progress while working above the fire. In these incidents, a slight variation in circumstances or any delay in the action of those involved might have resulted in multiple line of duty deaths.

These three incidents do not necessarily make a trend, but examining near miss, injury, and line of duty death data points to lack of or loss of situational awareness as a factor in this type of incident. Situational awareness is inclusive of the ability to recognize key fire behavior indicators, prediction of likely fire development, and recognizing the impact (or lack of impact) of tactical operations on fire progression.

The Way Forward

In an earlier post, Outstanding Performance I discussed the importance of deliberate practice in developing expertise. Numerous studies have identified that world class performance requires 10,000 hours of intensive and deliberate practice. While engaging in deliberate practice several hours a day, every day for ten years might seem a bit excessive to the average firefighter, performance is strongly correlated with an individual’s level of deliberate practice. Hard work pays off!

Regardless of your level of knowledge and skill, I challenge you to increase your efforts to engage in deliberate practice. As a student of your craft it is critical to deepen your knowledge of fire behavior, examine incidents you respond to with a critical eye, and use case studies to gain insight into fire behavior, building construction, and the effect of tactical operations. Engage in safe and effective live fire training to provide an opportunity to apply your knowledge and skill in a realistic context.

CFBT-US is using the following logo to identify training materials and activities that promote deliberate practice.

Resolutions

Many people make New Year’s Resolutions to lose weight and exercise more. Given the firefighter fatality statistics related to heart disease and stress, these are important goals. I share these goals with many of you. However, I have a few other professional resolutions for 2009 (and beyond):

• Continue to be a student of my craft as a fire officer and educator, finding the time to engage in an increased level of deliberate practice.
• Continue working to reducing firefighter injuries and deaths due to extreme fire behavior by increasing firefighter’s knowledge of practical fire dynamics.
• Work to improve the quality of NIOSH Firefighter Death in the Line of Duty Reports by continuing to be a critical friend of the program.
• Work to improve the quality and focus of fire service training curriculum and training materials in the area of fire behavior.
• Work to ensure that professional qualifications and other consensus standards adequately identify the requisite fire behavior knowledge and skills for safe and effective operation on the fireground.
• Work to ensure that live fire training instructors have the knowledge and skills necessary to conduct safe and effective training.

I encourage you to join me in this effort. These improvements will not happen overnight, but we can accomplish a great deal if we persist and work together. It is easy to complain and find fault. It is much more difficult to step up and do the right thing to make things better, but that is what is needed.

Thanks for reading the CFBT Blog and best wishes for a safe and happy 2009.

Ed Hartin, MS, EFO, MIFIreE, CFO

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