Posts Tagged ‘Extreme Fire Behavior’

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

Figure 1. 132 Garden Avenue-Side Alpha

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

Firefighting Operations

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

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

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

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

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

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

Firefighter Rescue Operations

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

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

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

Questions

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

Developing & Case Studies

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

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

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

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

The Case

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

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

Building Information

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

Figure 2. Fire Unit and Exposure Bravo Floor 1

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

Figure 3. Fire Unit and Exposure Bravo Floor 2

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

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

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

Dispatch Information

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

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

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

Weather Conditions

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

Conditions on Arrival

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

Questions

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

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

What impact might weather conditions have on firefighting operations?

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

Ed Hartin, MS, EFO, MIFireE, CFO

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

Experienced Judgment

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

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

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

Riverdale Flashover

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

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

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

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

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

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

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

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

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

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

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

Things to Think About

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

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

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

Tactical Ventilation

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

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

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

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

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

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

Floor Plan Illustrating the Position of Captain Williams and Firefighter Cheek

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

Extreme Fire Behavior

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

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

NIOSH Recommendations

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

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

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

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

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

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

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

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

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

The Way Forward

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

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

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

Ed Hartin, MS, EFO, MIFireE, CFO

References

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

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

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

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

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

Public Stakeholder Meeting

On 19 November 2008, National Institute for Occupational Safety and Health (NIOSH) will conduct a public stakeholder meeting to gather input on the Firefighter Fatality Investigation and Prevention Program. This meeting has a similar focus to one held on 22 March 2006 in Washington DC. At the 2006 stakeholder meeting, NIOSH received Input from a diverse range of fire service stakeholders. Feedback was extremely supportive of the program, but provided input on potential improvements to this extremely important program. In 2006, I gave a brief presentation that focused on several key issues:

• The upward trend in the rate of firefighter fatalities due to trauma during offensive, interior firefighting operations.
• Failure of NIOSH to adequately address fire behavior and limited understanding of fire dynamics as a causal or contributing factor in these fatalities.

The issues that I raised at the 2006 stakeholder meeting continue to be a significant concern. In 2007, extreme fire behavior was a causal or contributing factor in 17 firefighter line of duty deaths (LODD) in the United States. Where these incidents were investigated by NIOSH, the investigations, subsequent reports, and recommendations did not substantively address the fire behavior phenomena involved nor did they provide recommendations focused on improving firefighters and fire officers understanding of practical fire dynamics.

Ongoing Challenges

In the 20 months since the 2006 stakeholder meeting, NIOSH has implemented a number of stakeholder recommendations. However, Death in the line of duty reports continue to lack sufficient focus on fire behavior and human factors issues contributing to traumatic fatalities during offensive, interior firefighting operations.

Where these reports could provide substantive recommendations for training and operations that would improve firefighter safety, they continue to provide general statements reflecting good practice. While the recommendations contained in NIOSH Death in the line of duty reports, are correct and critically important to safe and effective fireground operations, they frequently provide inadequate guidance and clarity.

In incidents involving extreme fire behavior, investigators frequently fail to adequately address the fire behavior phenomena involved and the implications of the action or inaction of responders. In addition, while training is addressed in terms of national consensus standards or standard state fire training curriculum, there is no investigation as to how the level of training in practical fire dynamics, fire control, and ventilation strategies and tactics may have impacted on decision making.

Presentation of these issues in general terms does not provide sufficient clarity to guide program improvement. Examination of a recent death in the line of duty report will be used to illustrate the limitations of these important investigations and reports in incidents where extreme fire behavior is involved in LODD.

Death in the line of duty… F2007-29

There are many important lessons to be learned from this incident and the limited information presented in this report. However, this analysis of Report F2007-29 focuses on fire behavior and related tactical decision-making. This analysis is completed with all due respect to the individuals and agencies involved in an effort to identify systems issues related to the identification and implementation of lessons learned from firefighter fatalities.

On August 3, 2007 Captain Kevin Williams and Firefighter Austin Cheek of the Noonday Volunteer Fire Department lost their lives while fighting a residential fire. Neither this information nor any reference to the report on Firefighter Fatality Investigation FY 07-02 released by the Texas State Fire Marshal’s Office was included in NIOSH Death in the line of duty report F2007-29. This is critical to locating additional information regarding the incident. Even more importantly, it is important to remember that firefighter LODD involve our brother and sister firefighters, not simply “Victim #1″� and “Victim #2”.

Reading the Fire

This incident involved a 2700 ft², wood frame, single family dwelling. The fire was reported at 0136 and the first unit arrived on scene at 0150. The crew of the first arriving engine deployed a 1-3/4″� (45 mm) hoseline and positive pressure fan to the door on Side A. NIOSH Report F2007-29 reported that the attack team made entry at 0151 but backed out a few minutes later due to flames overhead just inside the front door and that positive pressure was initiated at 0156 prior to the attack team re-entering the building.

However, the Texas State Fire Marshal’s Report FY 07-02 indicated the following:

Flint-Gresham Engine 1 arrived on scene at 01:50:21 positioning short of Side A� and reported, “On location, flames visible.”�

Firefighters Joshua Rawlings and Ben Barnard of the Flint-Gresham VFD pulled rack line 2, a 200� long 1.3/4” (45 mm) � line, to the front door on Side A.� Flint-Gresham VFD Firefighter Robles conducted a quick survey of the north side and then positioned the vent fan at the front door to initiate Positive Pressure Ventilation (PPV). Robles stated that the PPV was set and operating prior to entry by the first attack team. Robles stated that he started to survey the south side and noted heavy black smoke from the top half of a broken window. He stated that he reported this to the IC.

Flint-Gresham Firefighters Barnard (nozzle) and Rawlings (backup) entered through the open front door and advanced 8-10 feet on a left hand search. This attack team noted flames rolling across the ceiling moving from their left to their right as if from the attic. Rawlings stated that flames were coming out of the hallway at the ceiling area and around the corner at a lower level. Barnard reported the hottest area at the hallway. The interior attack team then backed out to the front doorway and discussed their tactics. After a brief conversation, Rawlings took the nozzle with Barnard backing him and they re-entered. They entered approximately 10 feet and encountered flames rolling from their left to their right. They used a “penciling technique”� aimed at the ceiling to cool the thermal layer. Rawlings reported in interview that there was an increase in heat and decrease in visibility as the thermal layer was disrupted and heat began to drop down on top of them.

There is an inconsistency between the NIOSH and Texas State Fire Marshal’s reports regarding the timing of the positive pressure ventilation. The NIOSH report indicates that positive pressure was applied between the first and second entries by the attack team. However, in the Fire Marshal’s report, Firefighter Robles is quoted as stating that positive pressure was applied before entry. This seems to be a minor point, but if effective, positive pressure ventilation would have significantly changed the fire behavior indicators observed from the exterior and inside the building. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

The NIOSH report did not identify the fire behavior indicators initially observed by Firefighter Robles or the attack team, nor did they draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation.

NIOSH Report F2007-29 did not speak to the fact that none of the first arriving personnel verified the size and adequacy of the existing ventilation opening, the potential implications of inadequate exhaust opening size, and the need to verify that the positive pressure ventilation was effective prior to entry. In addition, the initial attack crew observed flames moving toward the point of entry, which would not be likely if the positive pressure ventilation was effective. However, no mention was made in the NIOSH report regarding conditions inside building and the observations of the attack team.

Window size is not specified, but it is likely that the opening was significantly less than the area of the inlet being pressurized by the fan. Inadequate exhaust opening area leads to excessive turbulence, mixing of hot smoke (fuel) and air, and can lead to extreme fire behavior such as vent induced flashover or backdraft. Recognition of this discrepancy along with a sound understanding of practical fire dynamics would have pointed to the ineffectiveness of tactical ventilation and potential for extreme fire behavior.

In reading this case study, it would be useful for the reader to be able to make a connection between key fire behavior indicators, the decisions made by on-scene personnel, and subsequent fire behavior. The NIOSH report did not identify the indicators initially observed by interior or exterior crews, nor did it draw any conclusions regarding the stage of fire development, burning regime (fuel or ventilation controlled), or effectiveness of the positive pressure ventilation, all of which were likely factors influencing the outcome of this incident.

NIOSH Report F2007-29 indicated that the attack team exited the building at 0213 due to low air and reported that the fire was knocked down, identified the location of a few hot spots, and that smoke conditions were light. The report follows to indicate that one of the chief officers did a walk around two minutes later and observed smoke in all the windows and smoke coming from the B/C and C/D corners of the structure. However the Texas State Fire Marshal’s Report 07-02 stated:

Firefighters Rawlings and Barnard penciled the rolling flames in the thermal layer until Rawlings’s low air alarm sounded. The Incident Commander, Captain Williams and Firefighter Cheek met Firefighters Rawlings and Barnard at the front door and a briefing occurred. Firefighters Rawlings and Barnard reported to Asst. Chief Baldauf they had the hot spots out. Rawlings stated in a later interview that they told Williams and Cheek they knocked down the fire and only overhaul was needed.

At 02:13, Captain Williams and Firefighter Cheek entered the structure as attack team 2, using the same line previously utilized by Firefighters Rawlings and Barnard.

Exterior crews from Noonday and Bullard started horizontal ventilation by breaking a window out on Side C (north side). Noonday Chief Gary Aarant performed a walk around, then reported heavy smoke from the B/C,and C/D� corners and at 02:15:51 asked if vertical ventilation had been started. Command then gave the order to begin vertical ventilation.

Understanding what occurred in this incident requires more than the cursory information provided in the NIOSH report. Developing the understanding of critical fire behavior indicators is essential to situational awareness. Discussion of fire behavior indicators and their significance in NIOSH reports would provide an excellent learning opportunity. For example, in this incident, the difference between “smoke” as described in the NIOSH report and “heavy smoke” as reported in the Texas State Fire Marshal’s report is likely a significant difference in assessment of conditions from the exterior of the building (particularly if this is a change in conditions).

NIOSH Report F2007-29 made brief mention of smoke discharge from the point of entry which was being used as the inlet for application of positive pressure. “At 0236 hours, heavier and darker smoke began pushing out of the entire front door opening and overriding the PPV fan”. However, the report does not speak to the significance of this indicator of impending extreme fire behavior.

The Texas State Fire Marshal’s Report 07-02 included a series of photographs provided by the Bullard Fire Department which provided a dramatic illustration of these key smoke and air track indicators. Inclusion of these photographs in the NIOSH report would have aided the reader in recognizing this key indicator of ineffective tactical ventilation and imminent potential for extreme fire behavior.

Photo of Conditions on Side A at 0210

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0217

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

Photo of Conditions on Side A at 0223

Bullard Fire Department Photo/Texas State Fire Marshal’s Report

NIOSH Report F2007-29 addresses the need for the incident commander to conduct a risk versus gain analysis prior to and during interior operations. However, the report does not address the foundational skill of being able to read fire and predict likely fire behavior as a part of that process. In addition, reading the fire and dynamic risk assessment are not solely the responsibility of the incident commander. Everyone on the fireground must be involved in this process within the scope of their role and work assignment. For example, the initial and subsequent attack teams were in a position to observe critical indicators that were not visible from the exterior.

While there is no way to tell, it is likely that if Captain Williams and Firefighter Cheek recognized the imminent probability of extreme fire behavior or the significance of changing conditions they would have withdrawn the short distance from their operating position to the exterior of the building. Likewise, if the incident commander or others operating on the exterior recognized deteriorating conditions earlier in the incident it is likely that they would have taken action sooner to withdraw the crew working on the interior.

Understanding practical fire dynamics, recognition of key indicators and predicting likely fire behavior is a critical element in situational awareness and dynamic risk assessment. Fire behavior and fire dynamics receive limited focus in most standard fire training curricula. It is important that NIOSH examine this issue when extreme fire behavior is a causal or contributing factor in LODD.

My next post will continue with the analysis of NIOSH Report F2007-29 and will make specific recommendations for program improvement.

Ed Hartin, MS, EFO, MIFireE, CFO

What is a smoke explosion? Is it the same thing as a backdraft or is it a completely different phenomenon? In one form or another I have encountered this question several times during the last week. In one case, I was asked to review a short article about an incident involving a smoke explosion that was submitted to FireRescue magazine. In another case, I was surfing the web and came across the following video titled large smoke explosion close call on firevideo.net. What happened in this incident? Was it a smoke explosion or a backdraft?

Find more videos like this on firevideo.net

What’s in a Name?

For many years, the term smoke explosion was a synonym for backdraft. In fact, if you look up the definition of smoke explosion in the National Fire Protection Association (NFPA) 921 (2007) Guide for Fire and Explosion Investigation, it says “see backdraft“. However, smoke explosion is actually a different, and in many respects more dangerous extreme fire behavior phenomenon.

Smoke explosion is described in a number of fire dynamics texts including Enclosure Fire Dynamics (Karlsson and Quintiere) and An Introduction to Fire Dynamics (Drysdale). However, Enclosure Fires by Swedish Fire Protection Engineer Lars-G�ran Bengtsson provides the most detailed explanation of this phenomenon. Paraphrasing this explanation:

A smoke or fire gas explosion occurs when unburned pyrolysis products and flammable products of combustion accumulate and mix with air, forming a flammable mixture and introduction of a source of ignition results in a violent explosion of the pre-mixed fuel gases and air. This phenomenon generally occurs remote from the fire (as in an attached exposure) or after fire control.

In some cases, the fire serves as a source of ignition as it extends into the void or compartment containing the flammable mixture of smoke(fuel) and air. This was the case in Evanston, Wyoming, where two firefighters died as the result of a smoke explosion in a two-story wood frame townhouse (see National Institute for Occupational Safety and Health (NIOSH) Report F2005-13). In other cases, firefighters may unintentionally provide the source of ignition. On 26 March 2008, a Los Angeles City firefighter was killed when he attempted to force entry into an electrical room filled with smoke from a manhole fire in the adjacent street. (see LAFD News and Information). Battalion Chief John Miller, Commanding Officer of the LAFD Arson/Counter-Terrorism Section reported:

This combustible smoke accumulated in the confined area of the electrical room. When Firefighter Lovrien attempted entry into the room, a spark was generated when the composite blade of the rotary saw struck the locking mechanism of the door… Investigators have concluded that unburned combustible gases, from a fire in the electrical vault located in the street at the front of the building, accumulated in the electrical room. These products of combustion reached its explosive limit and was ignited by a spark from the forcible entry attempts

Conditions Required for a Smoke Explosion

The risk of a smoke explosion is greatest in compartments or void spaces adjacent to, but not yet involved in fire. Infiltration of smoke through void spaces or other conduits can result in a well mixed volume of smoke (fuel) and air. Smoke explosion creates a significant overpressure as the fuel and air are premixed and ignition results in a very large energy release. Several factors influence the violence of this type of explosion:

• The degree of confinement (more confinement results in increased overpressure)
• Mass of premixed fuel and air within the flammable range (more premixed fuel results in a larger energy release)
• How close the mixture is to a stoichiometric concentration (the closer to an ideal mixture the faster the deflagration)

Potential Smoke Explosion Indicators

It is very difficult to predict a smoke explosion. However, the following indicators point to the potential for this phenomenon to occur:

• Ventilation controlled fire (inefficient combustion producing substantial amounts of unburned pyrolysis products and flammable products of incomplete combustion)
• Relatively cool (generally less than 600^o C or 1112^o F) smoke
• Presence of void spaces, particularly if they are interconnected
• Combustible structural elements
• Infiltration of significant amounts of smoke into uninvolved compartments in the fire building or into exposures

Smoke Explosion and Backdraft

A smoke explosion requires a relatively cool mixture of fuel (smoke) and air within its flammable range to come into contact with a source of ignition. On the other hand a backdraft requires introduction of air to an hot, extremely ventilation controlled fire where the concentration of gas phase fuel (smoke) is high and oxygen concentration is low. Both result in an explosion, but the initiating event and indicators that may be observed by firefighters and fire officers are considerably different.

Have another look at the video and see what you think: Smoke explosion or backdraft? Remember that both of these phenomena can occur in a building, a compartment, or even a small void space. Look closely at the building, smoke, air track, heat, and flame (B-SAHF) indicators. Check CFBT-US Resources more information on extreme fire behavior and reading the fire.

Ed Hartin, MS, EFO, MIFireE, CFO

Quantitative Analysis

Quantitative analysis of firefighter injuries and fatalities uses statistics to describe what has occurred and identify patterns and trends. Annual reports and longitudinal (multi-year) quantitative studies provide one way to examine firefighter safety performance.

• Firefighter Fatalities in the United States 2007, National Fire Protection Association (NFPA)
• U.S. Fire Service Fatalities in Structure Fires, 1977-2000, NFPA
• Firefighter Fatalities in the US in 2007, United States Fire Administration (USFA)
• Firefighter Fatality Retrospective Study, USFA

Examination of firefighter fatalities and injuries over time requires consistency of method when comparing data from year to year. However, dividing fatalities and injuries into a small number of causes or injury or death provides a coarse grained picture of the problem. This is useful, but not sufficient.

Reporting system limitations in dealing with multiple causal and contributing factors also limits firefighter injury and fatality statistical analysis and reporting. Quantitative analysis is extremely useful in identifying trends and pointing to issues needing further examination. Identification of the increasing rate of firefighter fatalities inside buildings during structural firefighting is one example. However data and system limitations may preclude a fine grained quantitative analysis of this issue.

Qualitative Analysis

Qualitative analysis of firefighter injuries and fatalities often involves examination of individual incidents, describing in detail what happened in that specific case and identifying causal and contributing factors. The limited information provided by annual reports and longitudinal analysis of firefighter injuries and fatalities can be enhanced by examining individual cases.

The NIOSH Firefighter Fatality Investigation and Prevention Program investigates many firefighter fatalities as a result of trauma (see the NIOSH Decision Matrix). However, they do not generally investigate non-fatal incidents and do not investigate near miss events. In addition to not examining all traumatic fatalities there is often a considerable delay in beginning the investigative process. This delay may result in the building involved being demolished and loss of important detail in witness interviews.

My last two posts looked at the US Forest Service approach to Investigating Wildland Fire Entrapments and Peer Review Process to identify lessons learned. Application of these methods in structural firefighting would provide an excellent method for improving our understanding of applied fire dynamics, tactical operations, and decision-making as well as other hazards such as structural collapse, and firefighter disorientation.

The Way Forward

Fire service organizations should examine all events that involve structural fire entrapment, collapse entrapment, and disorientation. There are no commonly accepted definitions for these types of events. However, the US Forest Service definition for wildland fire entrapment could serve as a starting point for defining entrapment and disorientation in the structural environment.

• Structural Fire Entrapment: a fire behavior related event involving compromise of normal (planned) means of egress; or thermal exposure resulted in, or had significant potential for death, injury, or damage to personal protective equipment.
• Collapse Entrapment: A structural failure related event involving compromise of normal (planned) means of egress, or impact resulting from structural failure (load bearing or non-load bearing) that resulted in, or had significant potential for death, injury, or damage to personal protective equipment.
• Disorientation Entrapment: Loss of spatial orientation while operating in a hazardous atmosphere that resulted in, or had significant potential for death or injury.

Note that like the US Forest Service definition of wildland fire entrapment; these events are inclusive of fatalities, injuries, and near miss events.

Investigating a near miss or accident involving a serious injury or fatality may present significant challenges to an individual agency in terms of resources and expertise. Individuals and organizations also filter information through cultural norms which define “the way we do things”. Use of a multi-agency team reduces these potential challenges. However, as in emergency response, it is important to define the process and develop effective working relationships prior to facing a serious injury or fatality investigation.

Who should be involved? Adapting from the US Forest Service Investigating Wildland Fire Entrapments individuals with the following skill sets should be involved in structural fire, collapse, or disorientation entrapment events.

• Command Officer
• Safety Officer
• Fire Behavior Specialist
• Structural Specialist (collapse entrapment)
• Fire Investigator
• Personal Protective Equipment Specialist (may be an external resource)
• Photographer/Videographer

There are a number of considerations in determining the makeup of the investigative team. Depending on the nature of the investigation, some of these skill sets may not be as critical or a single individual may fill more than one role (e.g., fire investigator and photographer). Unlike the wildland community, there is considerably less clarity to specialization in structural fire behavior. In some cases this may be a fire investigator with specific training in fire dynamics and fire modeling, in others it may be a compartment fire behavior instructor. This will depend on the nature of the incident and available resources. In addition, the technical complexity of assessing personal protective equipment performance (particularly self-contained breathing apparatus) may require specialized external expertise.

As in wildland incidents, there is also great value in peer review of structural incidents. Like the more formal investigation, peer review is a team based process, but the team is comprised of a small group of experienced firefighters and fire officers who are known to be insightful, fair, just, and honest.

A Call to Action

There is not a simple cookbook approach to developing processes for entrapment investigation and peer review. The first step is to identify how your organization can effectively identify and communicate lessons learned. While serious accidents and injuries present a significant challenge, near miss events occur much more frequently and provide an opportunity for individual and organizational learning as well as an opportunity to develop the entrapment investigation and peer review processes. The following two actions provide the opportunity to improve firefighter safety while operating offensively at structure fires:

• Members submit near miss reports to the National Firefighter Near Miss Program
• Agencies use a team based, multi-agency approach to investigate structure fire, collapse, and disorientation entrapments (inclusive of near miss events).
• Agencies widely share their lessons learned with other fire service agencies and organizations

Please post your thoughts on this process and how we can best develop and communicate lessons learned from entrapment events occurring during structure fires.

Ed Hartin, MS, EFO, MIFireE, CFO

Structural firefighting agencies can draw some valuable lessons from the wildland firefighting community. Fire behavior training in many structural agencies often begins and ends in recruit academy. For wildland firefighters, fire behavior training involves an extensive, multi-level curriculum (S-190, S290, S-390, S-490 and so on). The wildland community is also more substantively engaged in analysis of fatalities, accidents, and near miss events with the intention of impacting policy, procedure, and performance. This is not to say that they have a perfect safety record, far from it. However, this ongoing effort to identify and implement best practice based on lessons learned is worthy of emulation.

The US Forest Service Technology & Development Program produced a document titled Investigating Wildland Fire Entrapments which outlines the process that should be used and documentation required for entrapment related incidents. Entrapments are:

A situation where personnel are unexpectedly caught in a fire behavior related, life-threatening position where planned escape routes and safety zones are absent, inadequate, or have been compromised…These situations may or may not result in injury. They include”near misses”�.

The concept of entrapment applies equally in the structural firefighting environment. I read news accounts of extreme fire behavior related events (e.g., flashover, backdraft) from around the United States on a weekly basis. Flashover, backdraft, or other extreme fire behavior often results in a near miss or minor injury and less frequently in serious injury or fatality. Some (actually very few) of these incidents are documented in the National Firefighter Near Miss Program. As discussed in my last post, the near miss program uses self-reported data. This is extremely useful in determining the individual’s perception of the event and what lessons they took away from the experience. However, the individual reporting the event may or may not have the training or education to recognize what actually happened, determine multiple causal factors, and provide a reasonably objective analysis.

Formal Investigation

If a significant injury occurs, some level of investigation is likely to take place (even if it is limited to a cursory examination of circumstances and conditions by the individual’s supervisor). Traumatic fatalities result in more significant and in many cases multiple investigations by the agency involved, law enforcement agencies, Occupational Safety and Health Administration (state or federal), and potentially the National Institute for Occupational Safety and Health (NIOSH). The purpose of these various investigations is different and not all focus on identifying lessons learned and opportunities for improving organizational performance. However, some reports by the agencies involved, state fire service agencies, and NIOSH take positive steps in this direction. For example:

• Prince William County (Virginia) Department of Fire & Rescue
  Line of Duty Death (LODD) Report for Technician I Kyle Robert Wilson
• Texas State Fire Marshal’s LODD Investigation Program
• New Jersey Division of Fire and Life Safety Firefighter Fatality and Serious Injury Report Series
• NIOSH Fire Fighter Fatality Investigation and Prevention Program

Limitations

Near miss events and events involving extreme fire behavior resulting in minor injuries or damage to equipment frequently are not or are inadequately investigated to identify causal factors and lessons learned. Investigation of serious injuries and fatalities in many cases do not adequately address fire behavior and interrelated human factors that may be directly or indirectly related to the cause of the incident. This results in lost opportunities for individual and organizational learning.

Two interrelated challenges make investigating extreme fire behavior events or structural fire entrapments difficult. First is the lack of a formal process or framework for this specific type of investigation and second is potential for investigators lack of specific technical expertise in the area of fire behavior.

A Solution

The US Forest Service uses a team approach to investigating entrapment incidents. The team may include (but is not limited to):

• Fire Operations Specialist (Operations Section Chief level)
• Fire Safety Officer
• Fire Behavior Analyst, with experience in the incident fuel type
• Fire Weather Meteorologist
• Fire Equipment Specialists who develop the personal protective equipment (including fire shelters) used on wildland fires
• Technical Photographer
• Fire Information Officer

This team is established and begins the investigation as soon as possible after the occurrence of the event to ensure that critical information and evidence is not lost. The investigative process and documentation focuses on accurately describing what happened, when it happened, causal and contributing factors, and recommendations to reduce the risk of future occurrence.

What might this look like in the structural firefighting environment?

Communicating Lessons Learned

Lessons learned must be integrated into appropriate training curriculum to ensure that the lessons are built into organizational culture.

Some agencies have taken steps in this direction. Following the line-of-duty death of Technician Kyle Wilson, Prince William County Department of Fire & Rescue conducted an in-depth investigation which integrated use of computational fluid dynamics (CFD) modeling to describe likely fire conditions and the influence of wind on fire behavior. Following the conclusion of this investigation, the report and related presentations have been distributed widely.

Investigating Wildland Fire Entrapments identifies timeliness as being essential in dissemination of the lessons learned. This presents a significant challenge when faced with a complex event involving a major injury or fatality. However, it is likely that timeliness in communicating lessons learned can be improved without compromising the thoroughness and quality of the investigation.

My next post will examine the US Forest Service’s less formal Peer Review Process which may be used following near miss events or significant events regardless of outcome (possibly concurrently with a formal investigation). Like the entrapment investigation procedure, there are likely some lessons here for the structural firefighting community!

Ed Hartin, MS, EFO, MIFireE, CFO

What is the difference between a fairy tale and a firehouse tale?

Fairy tales generally begin with once upon a time, while firehouse tales begin with you wouldn’t believe what happened last shift and no, this really happened. This post begins with a firehouse tale.

A crew of firefighters advances a 1 1/2″ (45 mm) hoseline up a stairwell in a large wood frame house. The second floor is well involved, and the smoke level is down close to the floor. The young firefighter with the nozzle indicates that it is too hot to advance onto the fire floor. The officer moves up close to the nozzle and evaluates conditions, finding that the firefighter is correct. The officer calls the incident commander and asks for ventilation to raise the smoke level and relieve some of the heat that is preventing advancement onto the fire floor and an attack on the fire. Moments later, the officer is enveloped in fire and feels himself flying backward through the air. This ends when he slams into a hard surface. Everything is black, and he is unable to see. It is not hot, and eventually, he sees a glimmer of sunlight. Attempting to remove his breathing apparatus facepiece, he experiences discomfort in both shoulders, but is able to pull the facepiece off, discovering that the darkness was caused by blackening of the exterior of his facepiece lens. The building is still well involved, the hoseline extended through the front door, but the crew of firefighters that was with the officer are nowhere to be seen. The officer pulls his facepiece back on and crawls back in along the hoseline, finding the firefighters frantically trying to make the fire floor, thinking that their officer had been blown down the hallway instead of up and over their heads, balling down the stairwell behind them and rolling out into the street. The officer withdraws his crew as other crews extend hoselines to the second floor, and extinguish the fire.

In this incident, the officer with the hoseline was unaware that significant indicators of a potential backdraft in an enclosed section of the second floor were visible from the rear of the structure (where the incident commander and the crew performing horizontal ventilation were located). The effects of the backdraft were serous but could have been much worse. The officer received minor burns, injured both shoulders, and severely damaged his facepiece and turnout coat. What made this incident worse was that it occurred during live fire training with a group of recruit firefighters.

I know that this firehouse tale really did happen as I was the officer in the story. This incident occurred in the late 1970s while I was working for the Massachusetts Firefighting Academy as a part-time instructor. Unfortunately, while academy staff investigated this incident, the outcome of this investigation did not impact substantively on training practices, and at the time, the academy staff did not widely communicate lessons learned.

How many of you have had a close encounter with extreme fire behavior? One where you said that was close or you suffered a minor injury? What did you learn and how did you share this information?

Often, as in this backdraft incident, those involved learn a valuable lesson, but do not share the information beyond the firefighters and officers they work with. Many things have changed since the 1970s. One is the existence of National Fire Protection Association 1403 Standard on Live Fire Training Evolutions. While not perfect (but that is another topic for discussion), it identifies systems of work that increase the safety of participants engaged in live fire training. Another, more recent change was the development of the National Firefighter Near Miss Reporting System. This system leverages the advantage of the World Wide Web to provide the ability to report near miss incidents and widely share our lessons learned. If you have been involved in or witnessed a near miss incident or have been told of the event, you can anonymously submit a report and share what you have learned.

The data submitted to the Near Miss Reporting System does not go into a vacuum. Following review, and removal of information which would identify the agency involved, reports are posted in a searchable database on the firefighternearmiss.com website.

This program is a tremendous resource! Visit the site and search on flashover (38 reports), backdraft (9 reports), rapid fire progress (4 reports), or smoke explosion (33 reports). Remember, this database contains self-reported information. This does not make it less useful. In many ways it is more useful than distilled and analyzed information presented in other types of reports (particularly when the individual was involved in or witnessed the event). However, there may be technical inaccuracies (particularly with regards to extreme fire behavior phenomena) and the lessons learned by the individual who submitted the report may or may not be what you want to take away. Read the reports, think about the factors that influenced the occurrence of the event, how it could have been prevented, trapped or mitigated, and draw your own conclusions.

If you are involved in, witness, or are told about a near miss event, report it. The more information in the database, the greater the potential to identify patterns of causal factors and develop strategies for improving firefighter safety.

Ed Hartin, MS, EFO, MIFireE, CFO

In 2007, twenty firefighters in North America lost their lives due to extreme fire behavior while engaged in interior structural firefighting operations. The United States Fire Administration Report 2007 Firefighter Fatalities in the United States and the NFPA Report Firefighter Fatalities in the United States-2007 provide analysis of firefighter fatalities that occurred during this year. Neither report specifically addressed the issue of firefighter fatalities as a result of extreme fire behavior. In fact the NFPA report classified a significant number of these fatalities as being the result of structural collapse (despite the fact that collapse occurred some time after rapid fire development trapped the firefighters involved).

Thus far in 2008, eight more firefighters have died due to extreme fire behavior while working inside burning buildings. This is the tip of the iceberg! Since January 2008, there have been several incidents in which rapid fire progress trapped multiple firefighters. In each of these incidents the firefighters escaped with serious injuries.

• May 25, 2008 – Four firefighters trapped on the second floor by a flashover, Loudon County, Virginia
• October 7, 2008 – Four firefighters trapped on the second floor by a flashover, Sacramento, California

In What’s Changed Over the Last 30 Years, Fahy, LaBlanc, and Molis state that the rate of traumatic fatalities while engaged in offensive firefighting operations inside burning building has been increasing.

In many cases, extreme fire behavior is a causal or contributing factor. It is critical that firefighters understand compartment fire behavior and can apply that knowledge to maintain situational awareness and make effective decisions on the fireground. Fire behavior training for most firefighters and fire officers is limited to a few hours during recruit academy and possibly brief mention during tactical training. This is not adequate!

At the 2008 International Association of Fire Chiefs Conference in Denver, Colorado, Chief Fire Officer Charlie Hendry of Kent Fire Rescue Service and President of the United Kingdom (UK) Chief Fire Officers Association discussed a number of significant incidents that impacted his nation’s fire service. One of these incidents was a backdraft in townhouse apartment in rural Wales that killed Firefighters Kevin Lane and Stephen Griffin. This incident and the subsequent investigation by the British Fire Brigades Union and the Health and Safety Executive identified major training deficiencies, resulting in changes in fire behavior training across the UK. For a brief overview of the incident and discussion of its impact on the UK fire service, see Blaina: A Perpetual Legacy.

Where is the recognition that the American fire service faces the same problem on an even larger scale?

What can we do, individually and collectively to address this issue? I will be writing about this topic for the next couple of weeks. Add a comment to this post with your ideas!

Ed Hartin, MS, EFO, MIFireE, CFO