Posts Tagged ‘accident investigation’

NIOSH F2009-11: The Minority Report

Tuesday, May 4th, 2010

As a critical friend of the NIOSH Firefighter Fatality Investigation and Prevention Program, I have provided testimony at public hearings and engaged in discussions with NIOSH staff regarding improvement of the quality of information provided in Death in the Line of Duty Reports, particularly in incidents involving extreme fire behavior. In addition, I have provided expert review on a number of Death in the Line of Duty Reports (including F2009-11). The discussion of fire dynamics, fire behavior indicators, and influence of ventilation and wind effects in Report F2009-11 is evidence that this feedback has been heard! I would like to thank Tim Merinar and the other NIOSH staff for their efforts in this area.

However, more work is needed. Just over a year ago, I read a news report about the deaths of Captain James Harlow and Firefighter Damion Hobbs of the Houston Fire Department during operations at a residential fire. I recalled Houston had seen a number of fatalities during structural firefighting over a reasonably short period of time. Curious, I reviewed reports on these incidents developed by NIOSH and the Texas State Fire Marshal’s Office. Seeing some commonality in the circumstances surrounding these incidents, I called a colleague at NIOSH and recommended that the investigation of the incident in which Captain Harlow and Firefighter Hobbs lost their lives, include review of prior incidents (and near miss data if available) to identify underlying causal or contributing factors that may not be evident from examination of a single incident.

While we often want to know the cause of a tragic event, the reality is that it is often much more complicated that we would like. Investigative reports such as those prepared by NIOSH focus a bright light on the what and how, but often leave the question of why hidden in the shadows. Observations and questions in this post are not presented as an indictment of the Houston Fire Department, or to question the commitment and bravery of Captain Harlow and Firefighter Hobbs, but simply to encourage each and every one of us to look more deeply; more deeply at our profession, at our own organizations, and at ourselves.


Epidemiology is the study of factors affecting the health and illness of populations. Epidemiological research is the foundation of public health intervention and preventative medicine. This research is focused at identifying relationships between exposures and disease or death. Identification of causal relationships between exposures and outcomes is critical. However, correlation does not determine cause, and identification of causality is often complex and tentative.

For the fire service, epidemiological study has and continues to focus on heart disease, stress, and cancer (see USFA, NIOSH Launch Cancer Study). However, these same concepts can be applied to traumatic fatalities as well.

R-Fire 7811 Oak Vista, Houston TX

On April 12, 2009 Captain James Harlow and Firefighter Damion Hobbs lost their lives in a residential fire at 7811 Oak Vista in Houston, Texas. On April 9, 2010, the National Institute for Occupational Safety and Health released Death in the Line of Duty Report F2009-11 summarizing their investigation of this incident. Overall, this report is well written and provides an excellent examination of the events involved in this incident. The Texas State Fire Marshal’s Office also conducted an investigation of this incident and released a report a short time prior to release of NIOSH Report F2009-11.

Contributing Factors

NIOSH identified eight items as key contributing factors in the deaths of Captain Harlow and Firefighter Hobbs:

  • An inadequate size-up prior to committing to tactical operations
  • Lack of understanding of fire behavior and fire dynamics
  • Fire in a void space burning in a ventilation controlled regime
  • High winds
  • Uncoordinated tactical operations, in particular fire control and tactical ventilation
  • Failure to protect the means of egress with a backup hose line
  • Inadequate fireground communications
  • Failure to react appropriately to deteriorating conditions.

What is missing from this list? Six of the seven items on this list relate to human action or inaction. The report points out the need for policy, procedures, and additional training to address the contributing factors. While this is undoubtedly necessary, does this provide the entire answer?

The Remaining Question

As with all NIOSH firefighter fatality investigations, the focus of this report is on the circumstances and events surrounding a single incident. In this report, there is a brief mention of investigation of the deaths of other firefighters from this department, but no analysis of commonality or underlying contributing factors is provided. This leaves the question, to what extent did organizational culture impact on the circumstances and events involved in this tragic incident?

In his keynote presentation at the 2010 Fire Department Instructor’s Conference, Lieutenant Frank Ricci of the New Haven (CT) Fire Department indicated that the culture of the fire service is wrongly blamed for many of it’s problems. Lieutenant Ricci indicated that a large percentage of firefighter injuries and deaths are not due to inherent risks, but to an “unwillingness to take personal responsibility for safety” (Thompson, 2010). I would ask, why are firefighters unwilling to take personal responsibility? What factors influence this pattern of behavior? I suspect that it is our unquestioned assumptions about the way that things are (part of our culture). In this sense, culture is not to blame, but is simply one of a number of contributing and causal factors in many firefighter fatalities.

Common Elements

A cursory examination of the facts presented in the reports of NIOSH investigation of traumatic fatalities in the Houston Fire Department since 2000 shows a distinct pattern. Each of the fatalities involved members of the first arriving company where a fast attack was initiated without adequate size up and in most (and likely all) cases failure to assess risk versus gain. A more detailed examination of these events would likely provide a more finely grained picture of organizational expectations that make extremely aggressive fire attack without adequate size-up and risk assessment the norm, rather than the exception.

Table 1. Traumatic Line-of-Duty-Deaths in Houston, Texas 2000-2009

Report Event Type Commonality
F2000-13 Collapse (2 LODD)
Commercial Fire-Collapse
Victims were part of first in company

Inadequate size-up

Failure to assess risk versus gain

F2001-33 Rapid Fire Progress (1 LODD)
High-Rise Apartment Fire-Wind Driven Fire
Victim was part of the first in company

Inadequate size-up (consideration of wind)

F2004-14 Rapid Fire Progress (1 LODD)
Commercial Fire-Disorientation Subsequent to Rapid Fire Progress
Victim was part of the first in company

Inadequate size-up

Failure to assess risk versus gain

F2005-09 Collapse & Rapid Fire Progress (1 LODD) Residential Fire (Vacant)-Rapid Collapse Subsequent to Fire Progress Victim was part of the first in company

Inadequate size-up

Failure to assess risk versus gain

F2009-11 Rapid Fire Progress (2 LODD) Residential Fire-Wind Driven Fire Victim was part of the first in company

Inadequate size-up

Failure to assess risk versus gain

A Comparison

On September 11, 1991, Continental Express Flight 2574 crashed in Eagle Lake Texas killing all 14 people aboard. As with all commercial aircraft accidents, this incident was investigated by the National Transportation Safety Board.  The board identified the cause as failure of maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures. However, the board also identified failure of management to ensure compliance with approved procedures and failure of Federal Aviation Administration to detect and correct this problem as contributing factors. Board member John K. Lauber, filed a dissenting statement. “It is clear based on this record alone, that the series of failures which led directly to the accident were not the result of an aberration, but rather resulted from the normal accepted way of doing business at Continental Express” (NTSB, 1992, p. 53). Lauber advocated restating the probable cause of this accident as “the failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures” (NTSB, 1992, p. 54).

It is essential to look at the five events identified in reports F2000-13, F2001-33, F2004-14, F2005-09, and F2009-11 (NIOSH, 2001, 2002, 2005a, 2005b, 2010) from a longitudinal perspective to identify in greater detail and understand the common elements and potential systemic cultural issues that influenced the actions of those involved. While the influence of organizational culture is more difficult to identify than failure to comply with good practice, failure to recognize a hazardous condition, or an error in decision-making, it has a far more pervasive influence on fire fighter safety than these specific, individual acts.

Based on limited research, it is apparent that the Houston Fire Department (like many others) places an extremely high value on rapid and aggressive offensive firefighting operations. While the outcome of this incident resulted from a wide range of interrelated contributing factors, organizational culture and lack of knowledge regarding fire behavior and the influence of tactical operations were likely the most significant.

Identification of organizational culture as a contributing factor in this incident is based on data included in the DRAFT report as well as review of NIOSH Reports F2000-13, F2001-33, F-2004-14, F2005-09, and F2009-11 (NIOSH, 2001, 2002, 2005a, 2005b, 2010) as well as review of the Houston Fire Department Strategic Plan FY2008-2012 (n.d., HFD) and Philosophy of Firefighting (2003, HFD).

A memorandum from the Office of the Fire Chief defining the Houston Fire Department’s philosophy of firefighting (HFD, 2003) after the McDonald’s (NIOSH, 2001) and Four Leaf Tower (NIOSH, 2002) fires reinforced the importance of risk assessment in selecting strategies and tactics. In this memo, the chief identified the importance of organizational culture, stating “we pride ourselves in being very aggressive interior fire fighters and look down on those that fight fire from the street” (p. 1). While this memorandum was written in 2003, lack of adequate size up and risk assessment was a contributing factor in three incidents resulting in four line-of-duty deaths involving Houston Fire Department members in subsequent six years.

The Houston Fire Department Strategic Plan for FY2008-2012 (n.d., HFD) identifies safety as a core organizational value, stating: “preservation of life remains the number one goal of the HFD beginning with the responder and extending to the public” (p. 5). This focus continues with enhancement of the health and safety of HFD members as the first goal within the strategic plan. However, while the strategic plan provides a detailed blueprint for action, no objective or action plan element addresses the predominant contributory factors that are common in the seven line-of-duty deaths of Houston Fire Department members resulting from traumatic cause between 1999 and 2009. For example, Objective 1.5 of the strategic plan focuses on National Fallen Fire fighter Initiative #1 which states “define and advocate the need for cultural change within the fire service relating to safety; incorporating leadership, management, supervision, accountability and personal responsibility (HFD, n.d., p. 8). However, the sub elements of this objective focus on near miss reporting, roadway emergency safety, and response to violent incidents.

In the incident that took the lives of Captain Harlow and Firefighter Hobbs, several elements point to the focus on speed and aggressive action. Despite his seniority and experience, the captain of the first arriving engine quickly initiated an interior attack without adequate size-up and risk assessment (or performed a size-up and failed to recognize critical fire behavior indicators). In addition, he left his portable radio on the apparatus, E-26s thermal imaging camera (TIC) was left outside the front door. Any one of these elements alone might indicate a simple error, but in combination along with the context provided by previous LODD incidents (NIOSH, 2001, 2002, 2005a, 2005b) this is likely evidence of the cultural value of speed and aggressive action over deliberate assessment of conditions and decision-making based on risk assessment.

While increased protection through the use of the reed hood has significant potential benefits (similar technology is used by the Swedish fire service), it is quite possible that this type of personal protective clothing (which is somewhat unique to the Houston Fire Department) is used to permit fire fighters to penetrate deeper into hostile environments, rather than simply to provide improved protection with the ordinary or hazardous range of conditions encountered during structural firefighting.


Based on these factors identified in NIOSH Report F2009-11 (2010) as well Reports F2000-13, F2001-33, F2004-14, F2005-09 (2001, 2002, 2005a, 2005b), I recommend that fire service organizations assess the impact of their organizational culture on fire fighter safety and operational performance.

Note that this recommendation is not simply focused on the Houston Fire Department. It is a global recommendation, that each of us examine the influence of culture within our respective organizations.

Ed Hartin, MS, EFO, MIFireE, CFO


Houston Fire Department. (2003) Philosophy of firefighting. Retrieved January 24, from

Houston Fire Department. (n.d.) Houston Fire Department Strategic Plan FY2008-2012. Retrieved January 24 from

National Transportation Safety Board (NTSB). Aircraft accident report: Britt Airways, Inc. d/b/a/ Contenental Express Flight 2474 in flight structural breakup, EMB-120RT, N33701, Eagle Lake, Texas, September 11, 1991, NTSB/AAR-92/04. Washington, DC: Author.

National Institute for Occupational Safety and Health (NIOSH). (2001). Death in the line of duty, Report F2000-13. Retrieved January 24, 2010 from

National Institute for Occupational Safety and Health (NIOSH). (2002). Death in the line of duty, Report F2001-33. Retrieved January 24, 2010 from

National Institute for Occupational Safety and Health (NIOSH). (2005a). Death in the line of duty, Report F2004-14. Retrieved January 24, 2010 from

National Institute for Occupational Safety and Health (NIOSH). (2005b). Death in the line of duty, Report F2005-09. Retrieved January 24, 2010 from

National Institute for Occupational Safety and Health (NIOSH). (2010). Death in the line of duty, Report F2009-11. Retrieved April 25, 2010 from

Thompson, J. (2010) FDIC keynote: Fire service culture not to blame for problems. Retrieved May 3, 2010 from

Contra Costa County LODD: What Happened?

Thursday, May 14th, 2009

My last two posts (Contra Costa County Line of Duty Deaths (LODD) Part 1 & Part 2) examined the conditions and circumstances involved in the incident that took the lives of Captain Matthew Burton and Engineer Scott Desmond while conducting primary search in a small residential structure in San Pablo, California early on the morning of July 21, 2007.

As identified in the Contra Costa County Investigation and NIOSH Death in the Line of Duty Report F2007-28, these line of duty deaths were the result of a complex web of events, circumstances, and actions.

These two reports identify the rapid fire progression that trapped Captain Burton and Engineer Desmond as a fire gas ignition (county and NIOSH reports) or ventilation induced flashover (NIOSH report). Both reports also point to ineffective or inappropriate use of positive pressure ventilation as a contributing factor in the occurrence of extreme fire behavior. However, neither report provides a substantive explanation of how and why this extreme fire behavior occurred.

Investigative Approach

Developing a reasonable explanation of the extreme fire behavior that occurred in this incident involved application of the scientific method as outlined in NFPA 921 Standard on Fire and Explosion Investigations (2008).

The following analysis is based on narrative data and photographic evidence provided in the Contra Costa County Fire Protection District Investigation Report: Michele Drive Line of Duty Deaths and the video taken by the Q76 Firefighter.

In that the district and NIOSH had already collected data, this effort focused on 1) analysis of the data contained in the incident reports, photographs, and video; 2) development of a hypothesis that provided an explanation for what occurred (deductive reasoning), 3) testing this hypothesis (inductive reasoning); 4) revising the hypothesis as necessary; and 5) selecting a final hypothesis.

Figure 1. Fire Development in Bedroom 2



The fire originated in Bedroom 2, likely on or near the bed. In the growth stage, the fire extended through the hallway into the living room (see Figure 1). The fuel load in the living room and ventilation provided by the open front door permitted the fire to progress through flashover and become fully developed (see Figure 2).

Figure 2. Extension and Fire Development in the Living Room


The extent of fire in the living room consumed the oxygen supplied through the front door, resulting in an extremely ventilation controlled fire in the hallway and bedroom. Unburned flammable products of combustion and pyrolysis products from contents and structural materials accumulated in the upper layer in the bedrooms and hallway.

Figure 3. Fire Control and Development of a Gravity Current


Extinguishment of the fire in the living room allowed development of a gravity current and movement of oxygen through the living room to the hallway and bedrooms allowing flaming combustion in these areas to resume.

Figure 4. Positive Pressure Ventilation


Flaming combustion in the hallway or bedroom resulted in piloted ignition of a substantive accumulation of pyrolysis products and flammable products of incomplete combustion in the upper layer within the hallway and bedrooms. Application of positive pressure at the door on Side A influenced (or speeded up) this phenomena and may have increased the violence of this ignition (due to increased pressure and confinement) but likely aided in limiting the spread of flaming combustion from the hallway into the living room.

Figure 5. Fire Gas Ignition


Supporting Information

Information supporting the preceding hypothesis is divided into three categories: Known, suspected, and assumptions.


The cause and origin  and line of duty death investigation conducted by the Contra Costa Fire Protection District and line of duty death investigation conducted by NIOSH identified and documented a range of data supporting this hypothesis. These data elements include physical evidence, and narrative data obtained from interviews with individuals involved in the incident.

  • The fuel load in the bedroom included a bed, dresser, and other contents, exposed wood ceiling, carpet, and carpet pad.
  • Fire originated in Bedroom 2 (on or near the bed)
  • The female occupant exited the structure prior to making a 911 call to report the fire (via cell phone).
  • The female occupant then reentered the building prior to the arrival of the first fire unit in an effort to rescue her husband. [Observations by bystanders included in the report]
  • The fire in Bedroom 2 entered the growth stage and extended into the hallway and subsequently the living room. This fire spread was in part due to the combustible wood ceiling. [Information on the cause and origin investigation provided in the report]
  • Windows other than the living room window on Side A were substantively intact until the occurrence of the extreme fire behavior event. [Observation by firefighters included in the report]
  • E70 knocked down the fire in the living room prior to initiating primary search (without a hoseline). E70 used a left hand search pattern in which they would have moved into the hallway and bedrooms located on Side B of the residence.
  • A blower was placed at the front door while E70 and E73 were conducting primary search. Due to the placement of the blower close to the door, it is possible that the air cone did not fully cover the door opening. There is no mention in the report regarding the air track at the door or living room window following placement of the blower. However, E73 reported increased visibility and temperature in the kitchen a short time after the blower was placed, and observed rollover from the hallway leading to the bedrooms.]
  • The large window in the living room (if fully cleared of glass) would provide approximately equal area as the door on Side A used as an inlet. Given an equal sized inlet and outlet, efficiency of PPV is likely to be approximately 70%. However, given the location of the exhaust opening next to the inlet, the effectiveness of this ventilation at clearing smoke from compartments beyond the living room and kitchen would have been limited.
  • Vertical ventilation was not completed until after the occurrence of the extreme fire behavior phenomena that trapped and killed Captain Burton and Engineer Desmond. The exhaust opening created in the roof had limited impact on interior conditions when it was completed due to the presence of the original roof.
  • Fuel load in this compartment was more than sufficient to provide the heat release rate necessary to allow fire development to flashover. [This assessment is based on post-fire photos, room dimensions, and ventilation openings at the time of the ignition].
  • Other bedrooms contained a similar fuel load.


Several factors supporting the stated hypothesis are not directly supported by physical evidence or narrative data. These elements are deduced based on the design, construction, and configuration of the building and principles of fire dynamics in conjunction with known information.

  • The front door remained open after the female occupant reentered. [E70 reported fire and smoke showing from the door and living room window on arrival, but no information provided in the report regarding the position of the door or extent to which the window had failed (fully or partially)]
  • Use of the blower is likely to have increased mixing of air and hot, fuel rich fire gases in the hallway, particularly near the opening between the hallway and the living room. Ventilation of smoke from the living room and kitchen through the window on Side A, likely reduced the potential for flaming combustion to have extended from the hallway into the living room.
  • Heat conducted through the tongue and groove wood roof/ceiling may have resulted in melting and gasification of asphalt roofing which may have been forced through gaps between the planks to add to the gas phase fuel resulting from pyrolysis and incomplete combustion of contents and structural surfaces within the involved compartments.
  • The primary source of air for the fire was through the front door and the living room window. The bottom of the doorway was the lowest opening in the building, likely resulting in a bi-directional air track with smoke exiting out the top of the door and air entering at the bottom. While the sill of the living room window was higher than the door, a bi-directional air track likely developed at this opening as well, with the extreme lower portion of the window opening serving as an inlet while the top of the window functioned as an outlet for flames and smoke [No information about air track at the front door was provided in the report.]
  • The fire in the living room reached the fully developed stage after the civilian occupant reentered and prior to the arrival of E70 [This deduction is based on the ability of the female occupant to enter and make her way to the kitchen and the presence of flames exiting the door and living room window on Side A when E70 arrived]


In addition to known and deduced information, the hypothesis is based on the following assumptions.

  • The fully developed, ventilation controlled fire in the living room substantively utilized the atmospheric oxygen provided by the air entering through the front door, causing the fire in Bedroom 2 and the hallway to enter ventilation controlled decay. The decay stage fire and heat from the hot gas layer present in the hallway and adjacent rooms continued pyrolysis of fuel packages in this area, resulting in accumulation of a substantial concentration of gas phase fuel in the smoke.
  • Control of the fully developed fire in the living room reduced oxygen demand from the fire. The bi-directional air track would have continued and gravity current would have increased air supply to the ventilation controlled decay stage fire in the hallway and bedroom(s).
  • Establishment of positive pressure ventilation with the door on Side A serving as the inlet (or inlet and outlet) and the living room window serving as an outlet would have cleared smoke from the living room, but would not have influenced smoke movement from the hallway and bedrooms (as quickly).


Special thanks to Dr. Stefan Svensson of the Swedish Civil Contingencies Agency and Assistant Professor Greg Gorbett of Eastern Kentucky University for serving as critical friends and providing useful feedback in development of this analysis.

This hypothesis is supported by a range of evidence, deductions and assumptions. However, further validation would require use of other methods such as development of a computational fluid dynamics model and small or full scale fire tests.

More to Follow

My next post will examine the potential influence of positive pressure ventilation (PPV) in this incident as well as a broader look at potential hazards when PPV is used incorrectly or under inappropriate circumstances.

Master Your Craft

Ed Hartin, MS, EFO, MIFireE, CFO


Contra Costa County Fire Protection District.  (2008). Investigation report: Michele drive line of duty deaths. Retrieved February 13, 2009 from

National Institute for Occupational Safety and Health (2009).  Death in the line of duty report 2007-28. Retrieved May 5, 2009 from

National Fire Protection Association (NFPA) (2008) NFPA 821 Standard on fire and Explosion Investigations. Quincy, MA: Author.

Contra Costa County LODD: Part 2

Monday, May 11th, 2009

This post continues examination of the incident that took the lives of Captain Matthew Burton and Engineer Scott Desmond early on the morning of July 21, 2007. Captain Burton and Engineer Desmond died while conducting primary search in a small, one-story, wood frame dwelling with an attached garage at 149 Michele Drive in San Pablo (Contra Costa County), California.

This post focuses on firefighting operations, key fire behavior indicators, and firefighter rescue operations implemented after Captain Burton and Engineer Desmond were discovered after rapid fire progression in the area in which they were searching.

Firefighting Operations

Based on the report of trapped occupants, E70 immediately placed a 150′ preconnected 1-3/4″ (45 m 45 mm) line into service using apparatus tank water. The officer of E70, seeing what he believed to be E74 arriving he passed command to the E74 officer. Unfortunately, the second arriving engine was E73 (using apparatus normally assigned to Station 74 and marked E74).

Note: This incomplete passing of command resulted in loss of command, control, and coordination of tactical operations until the arrival of BC7 at 0202 and formally assumed command at 0205. All tactical operations prior to 0205 were the result of independent action by first alarm companies.

The crew of E70 (officer and firefighter) initiated fire attack through the door on Side A and advanced 3′-5′ (0.9-1.5 m) through the door and quickly knocked down flaming combustion in the living room and through dispatch, requested the first arriving truck to establish vertical ventilation. Retrieving a thermal imaging camera (TIC) from the apparatus, the crew of E70 began a left hand search (towards the bedrooms), but left the hoseline just inside the door on Side A (see Figure 1)

Figure 1. Floor Plan-149 Michelle Drive


E73 hand stretched 200′ of 5″ (127 mm) supply line to a nearby hydrant. As he returned from the hydrant the firefighter from E73 observed a large volume of smoke from Side B. E73 officer tasked E70 engineer with placing a blower at the door on Side A. E73 (officer and firefighter) entered through the door on Side A and began a right hand search (taking the opposite direction from E70). E73 encountered poor visibility, but moderate temperature. While E73 conducted the search, E73 engineer shut off the natural gas service to the house.

E69 arrived at 0157 and prepared to perform vertical ventilation. The officer performed a size-up while the engineer obtained a chain saw and the firefighter placed a 14 ladder to provide access to the roof at the A/D corner. E70 engineer, asked the E69 officer about placing a blower to the front door (as previously ordered by the officer of E73) and he answered in the affirmative. The engineers from E70 and E73 placed a blower into operation 3′ (0.9 m) from the front door due to a half wall that partially enclosed the porch.

Note: No information is provided in the report regarding air track prior to or following pressurization of the building. The only substantive exhaust opening at the time the blower was placed into operation was the window in the living room immediately adjacent to the door on Side A.

E73 located the first civilian casualty, a female occupant in the kitchen (see Figures 2 and 5). As they removed the victim, both visibility and temperature increased dramatically. As they move the victim through the living room, they observed rollover coming from the hallway leading to the bedrooms (see Figures 2 and 5). The E73 officer briefly operated the hoseline left in the living room by E70 to control flaming combustion in the upper layer. The blower was turned 90o to permit removal of the victim, but was then returned to its original operating position. E69 officer assigned the E69 firefighter to assist E73 with patient care on Side A.

The E69 officer and engineer proceeded to the roof and began making a vertical ventilation opening on Side A roof, over the hallway. At 0159 Q76 arrived and while the officer was donning his breathing apparatus (BA), the window in Bedroom 1 failed suddenly followed by a significant increase in flaming combustion from the windows in Bedroom 1 and 2 on Sides A and B.

The firefighter from E73 who was providing emergency medical care to the civilian fire victim observed that the window in Bedroom 1 which had been cracked with some discharge of smoke, failed violently with glass blowing out onto the lawn and a large volume of flames venting from the window for a period of 10 to 15 seconds (see Figure 2).

Figure 2. Extreme Fire Behavior


Note: Adapted from eight seconds of video was shot by Q76 firefighter from in front of Exposure D, looking towards the A/D corner of the fire building.

Figure 3. Post Fire Photo from in Front of Exposure D


Note: This screenshot from Google Maps Street View is from a similar angle as the video taken by Q76 firefighter and is provided to provide a point of reference and perspective for the video.

The E73 officer reentered the building and initiated fire attack using the hoseline left in the living room. E70 engineer stretched a second 150′ 1-3/4″ (45 m 45 mm) line to the front door. The second line was stretched into the building by Q76. Immediately after entering through the door on Side A, the Q76 met E73 officer who was exiting with low air alarm activation. Q76 took over the initial hoseline and worked their way down the hallway leading to the bedrooms, leaving the second line in the living room (see Figure 2) Q76 encountered poor visibility and high temperature with flames extending out of Bedrooms 1 and 2 and rollover in the hallway.

Shortly after exiting the building E73 officer advised E73 engineer that he was “out of air” [he was likely in a low air condition with low air alarm sounding rather than completely out of air] and expressed concern regarding E70’s air status.

Battalion 7 (BC7) arrived at 0202 and attempted to make face-to-face contact with Command (E70) as he had not heard E70 attempt to pass command to E74. At 0203, BC7 confirmed that a medic unit was responding and requested that the medic upgrade from Code 2 to Code 3. (Code 2 is a non-life threatening medical emergency requiring immediate response without the use of red lights or siren. Code 3 is a a medical emergency requiring immediate response with red lights and siren.) BC7 then attempted to contact E70 on the tactical channel and asked other crews operating at the incident about the status of E70. At 0205, BC7 ordered a second alarm and attempted to contact E70 on non-assigned tactical channels (in the event that their radios were inadvertently on the wrong channel). The second alarm added three engines (E74, E75, and E73) and a battalion chief (BC71) to the incident.

While BC7 was attempting to locate E70, Q76 was operating in the hallway and bedrooms in an effort to control the fire. They knocked the fire down in Bedroom 2 and controlled the rollover extending from Bedroom 1 down the hall. Q76 officer scanned Bedroom 2 with a TIC, but did not observe any victims. Q76 then advanced to Bedroom 1.

E69 completed a 6′ x 6′ (1.8 m x 1.8 m) ventilation opening in the roof on Side A, two thirds of the way from their access point at the A/D corner to Side B. Immediately after making the opening, they observed minimal smoke discharge (and were able to see items stored in the attic and the attic floor (original roof). They attempted to breach the attic floor, but were unable to do so (as it was constructed of 2″ x 6″ (51 mm x 152 mm) tongue and groove planks).

At 0206, after repeated unsuccessful attempts to contact E70, BC7 transmitted a report of a missing firefighter and assumed Command. Command requested an additional engine (E68) be added to the second alarm assignment. Battalion 64 (BC64) added himself to the incident and advised dispatch.

As E69 exited the roof they heard a loud pop and observed flames exiting the roof ventilation opening a distance of 8′-10′ (2.4-3.0 m). After knocking down the fire in Bedroom 1 Q76 moved back to Bedroom 2. Failure of the gypsum board on the wall between Bedrooms 1 and 2 allowed operation of the stream from their hoseline into both bedrooms.

While at the doorway of Bedroom 2, Q76 observed a substantial volume of fire in the attic through a small hole in the hallway ceiling (see Figure 4) and attempted to apply water into the attic. However, their stream was ineffective.

Figure 4. Hallway Ceiling.


Note: Adapted from Contra Costa Fire Protection District Photos, Investigation Report: Michele Drive Line of Duty Deaths. Brightness and contrast adjusted to increase clarity.

After exiting the roof, E69 proceeded counter clockwise around the building to Side C where they removed window screens and broke out several panes of glass, but did not observe an appreciable discharge of smoke. Continuing around the B/C corner, E69 observed flames from the window of Bedroom 2 and the attic.

At 0208 Command (BC7) repeatedly attempted to contact E70 by radio on the tactical channel. Unsuccessful, he requested an additional Code 3 ambulance and advised that the status of the missing firefighters was unknown.

E69 met with Command (BC7) and was assigned to continue primary search for the second reported occupant. E69 firefighter and engineer began the search while the officer replaced his SCBA cylinder. As they entered, they picked up a hoseline (second 1-3/4″ (45 mm) hoseline) and used it to extinguish small areas of fire as they moved towards the kitchen. Q76 handed off their TIC to E69 as they exited the building with low air alarms sounding.

Q76 replaced SCBA cylinders and was tasked with search for E70 on the exterior. While conducting this search, they observed flames 10′-15′ (3.0-4.6 m) in length issuing from the gable vent on Side B.

After E69 officer rejoined his crew in the kitchen, they located the second civilian casualty who was determined to be diseased (see Figure 2). Command (BC7) ordered E69 to defer removing the victim and continue searching for E70.

Firefighter Rescue Operations

E69 walked through the interior of the dwelling looking for E70 and used a hoseline to knock down fire still burning in the closet of Bedroom 2. E69 advised command that E70 was not inside, but was instructed to conduct a second search of the interior.

At 0127, Command (BC7) asked dispatch to conduct a “head count” [personnel accountability report (PAR)]. Second alarm resources arrived between 0218 and 0221.

E69 reentered the building and conducted a thorough search for E70. At 0221, Command (BC7) ordered companies to “evacuate” [withdraw from] the building. Based on the urgency of his assignment to locate E70, E69 officer decided to continue the search into Bedroom 2. At approximately 0222, E69 located Captain Burton (fire service casualty 1) under debris on the right side of the bed (see Figure 2). His facepiece was still in place and his low air alarm was ringing slowly. E69 attempted to remove the Captain, but were only able to move him to the doorway to Bedroom 2 before smoke conditions worsened and visibility decreased. Near exhaustion, one member of the crew experience low air alarm activation and became disoriented requiring assistance to exit to the door on Side A.

Command (BC7) assigned Q76 to assist with the search. As E69 exited, they advised Q76 that they had located one member of E70 in the bedroom. After exiting, E69 advised Command (BC7) that they had located one member of E70 and that he appeared to be diseased and that they were having difficulty in removing him. Q76 quickly located Captain Burton inside the doorway of Bedroom 2 and removed him to Side A at 0228. E73 attempted resuscitation, but quickly determined that the Captain’s injuries were fatal.

BC64 and E76 officer continued the search in Bedroom 2 and located Engineer Desmond (fire service casualty 2) on the left side of the bed (see Figure 2). E72 assisted in controlling the fire in Bedroom 2 and the removal of the second member of E70 on a backboard. Engineer Desmond was removed from the building at approximately 0224. After both members of E70 were removed, crews removed the deceased civilian occupant.


Review the Michelle Drive Timeline (PDF format) to gain perspective of sequence and the relationship between tactical operations and fire behavior.


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

  1. The E73 officer tasked E70 engineer with placement of a blower at the door on Side A (use of this tactic was reaffirmed by the E69 officer). What air track did this use of positive pressure create and what effect did this have on 1) conditions in the living room and kitchen and 2) in the hallway and bedrooms? Why do you think that this was the case?
  2. What type of extreme fire behavior phenomena occurred in this incident? Do you agree with the Contra Costa County Fire Protection District report conclusion that this was a fire gas ignition or do you suspect that some other phenomenon was involved?
  3. How did the conditions necessary for this extreme fire behavior event develop (address both the fuel and ventilation sides of the equation)?
  4. What was the initiating event(s) that lead to the occurrence of the extreme fire behavior that trapped Captain Burton and Engineer Desmond? How did the use of positive pressure ventilation influence the occurrence of the extreme fire behavior (if in fact it did)?
  5. What action could have been taken to reduce the potential for extreme fire behavior and maintain tenable conditions during primary search operations?
  6. How did building design and construction impact on fire behavior and tactical operations during this incident?

Deliberate Practice

Ed Hartin, MS, EFO, MIFireE, CFO


Contra Costa County Fire Protection District.  (2008). Investigation Report: Michele Drive Line of Duty Deaths. Retrieved February 13, 2009 from

National Institute for Occupational Safety and Health (2009).  Death in the Line of Duty Report 2007-28. Retrieved May 5, 2009 from

Lessons Learned: The Way Forward

Monday, October 27th, 2008

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.

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

Peer Review & Lessons Learned

Thursday, October 23rd, 2008

In May 2006 US Forest Service Fire and Aviation Management published a briefing paper on Peer Review Process. Later that year, a peer review team used the process to investigate a near miss incident in the Shoshone National Forest and issued a report titled Little Venus Fire Shelter Deployment. This report provides an interesting look at the peer review process and potential benefits of a similar approach to identifying and communicating lessons learned in the structural fire service.

The stated purpose of the peer review process is: reduce errors by correcting or reinforcing upstream behaviors and other factors. Peer reviews provide a means to learn from a variety of situations including close calls, significant events, and other routine performance evaluations. The objective is to create a culture that expects and values peer reviews as an important means to discover subtle indictors of potential future errors and as a catalyst for positive change.

Peer Review and Accident Investigation

Peer review is not limited to investigating accidents and near miss events; it examines organizational performance in a variety of circumstances. However, a peer review and formal accident investigation may run concurrently. As stated in the US Forest Service Peer Review Process Briefing Paper, “this approach helps to segregate human error from intentional disregard of rules and gives the opportunity to identify positive behaviors and decisions even when bad outcomes occur.”

It is important to emphasize that peer review goes well beyond the context of accident and near miss investigation. This process applies to a broader range of significant events.

Key Process Elements

Like entrapment investigation, peer review is a team based process, but the team is comprised of “a small group of operators known for their ability to perform the particular mission in the particular environment, and also known to be insightful, fair, just, and honest”ť. This approach is consistent with the focus of peer review on developing lessons learned.

Key questions addressed in peer review examine individual observations and perceptions and include:

  • Action Plan and Leaders Intent
  • Situational awareness
  • Actions Taken and Not Taken
  • Personal Lessons Learned

In many respects the peer review process gathers the same types of information as the National Firefighter Near Miss Program. However, there is a significant difference. In peer review, team members are encouraged to “continue questioning in areas where the reviewers feel disconnect, discomfort, confusion, or curiosity”.

Communicating Lessons Learned

The peer review team develops a report that provides a look from outside the element of the organization involved in the accident, near miss or significant event. This written report identifies the story of the event, reasons the situation developed as it did, and lessons learned. The Peer Review-Purpose and Process Briefing Paper outlines a number of potential benefits:

  • Provides feedback on performance and potential areas of improvement
  • Assists supervisors in employee development
  • Helps guide training strategies, organizational policy, and operating guidelines
  • Develops data higher level lessons learned analysis
  • Promotes long-term positive shifts in organizational culture

Peer review reports such as the Little Venus Fire Shelter Deployment take a middle ground between a comprehensive organizational assessment seen in some agency reports (see reports from Loudon County Fire and Emergency Management and Prince William County Department of Fire and Rescue) and more limited information provided in National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty reports.


Peer review requires a bit of organizational and individual courage and commitment. One element of the deliberate practice required to develop expertise in any field is feedback on results and engaging with that feedback to refine and improve performance. Individuals and organizations must have the courage to ask for feedback and accept performance related feedback, which may be uncomfortable or difficult when things do not go well.

A more fundamental and underlying challenge lies with our underlying assumptions about the nature of fire, firefighting, and the business that we are in. Future posts will address at these important issues.

Ed Hartin, MS, EFO, MIFireE, CFO

Entrapment Investigation & Lessons Learned

Monday, October 20th, 2008

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”ť.

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:


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