Posts Tagged ‘firefighter injury’

The Problem

NIOSH has investigated a number of incidents in which firefighters trapped by rapid fire progress did not take appropriate survival action. Last September, I was reading NIOSH Report F2007-02, which outlined the circumstances surrounding the death of Firefighter Steven Solomon in Atlanta, Georgia. Firefighter Solomon was severely burned after being caught by rapid fire development while advancing an attack line in a vacant structure (see Figure 1).

Figure 1. Rapid Fire Development

Note: Atlanta Fire Department photo from NIOSH Report F2007-02

Firefighter Solomon was on the nozzle as the first arriving truck removed the plywood covering the front door and thick, black smoke came rolling out the top of the doorway. Firefighter Solomon and the crew of Engine 16 advanced the line into the building as the truck continued horizontal ventilation. After advancing a short distance, fire conditions quickly worsened and the crew attempted to back out, but collided with another company who was advancing a backup line. After exiting the building the crew of Engine 16 realized that Firefighter Solomon was still inside. Crews outside the door on Side A observed the silhouette of a firefighter running through the flames inside the building.

As I read the report, I asked myself how a firefighter on a hoseline that was just a short distance could have been killed by rapid fire development. The NIOSH report identified four contributing factors:

• Initial size-up not conducted.
• Failure to recognize the signs of an impending flashover/flameover.
• Inadequate communication on the fireground.
• Possibility of ventilation induced rapid fire progression.

While these factors likely contributed to Firefighter Solomon’s death, I still did not have a solid answer to my question of how a firefighter on a hoseline just a short distance inside the doorway could have died in this type of event.

Predictability

The best way to avoid being injured or killed in an extreme fire behavior event is to read the fire, anticipate likely fire behavior, and control your operating environment. A majority of our effort should be spent on mastering these skills.

There is no unpredictable fire behavior. Under the same conditions, a compartment fire will develop and behave consistently. However, conditions are not always the same! In addition, firefighters operate with limited information, imperfect skill in anticipating likely fire behavior, and often under pressure to take rapid action. When making decisions under pressure, in a complex and dynamic environment, and with limited information, potential for error increases.

Improved understanding of fire dynamics and development of a high level of skill reduces, but does not eliminate your risk of encountering extreme fire behavior. When this occurs it is essential that firefighters understand the fire behavior, their own reactions to stress, and have well practiced (to automaticity) responses to increase the chance of survival.

Training for Survival

What exactly are firefighter survival skills? Firefighters may encounter a number of life threatening problems while operating in the hazardous environment of as structure fire. Threats include breathing apparatus emergencies (e.g., malfunctions, running out of air), becoming disoriented, and being trapped by collapse or rapid fire progress.

A quick survey of survival skills training programs from around the United States shows a fair degree of consistency in curriculum content:

• Emergency Communications Procedures (Mayday, Radio Emergency Distress Button)
• Personal Alert Safety System (PASS) Activation
• Reorientation, Searching for an Exit & Following a Hoseline to Safety
• Air Conservation Techniques
• Assuming a Horizontal Position to Enhance Thermal Protection and Audibility of the PASS
• Escape to a Place of Refuge
• Use of Visual and Audible Signals (Flashlight, Tapping with a Tool)
• Reduced Profile Maneuvers to Escape Through Small Openings
• Emergency Window Egress (Ladder Bail, Rope Systems)

These techniques may provide useful in dealing with a number of the threats that may be encountered in a structure fire. Taking refuge in an uninvolved compartment (with the door closed) may buy time for firefighters to escape through a window. However, the other elements will have little impact on increasing survival potential when encountering extreme fire behavior phenomena.

What is the missing element in the typical survival skills curriculum? In some cases, firefighters are taught breathing techniques to control their respiratory rate and conserve air, but little emphasis is provided on the psychological and physiological effects of the stress encountered in life threatening situations. This is critical to survival regardless of the nature of the threat. When faced with extreme fire behavior, particularly wind driven flames, flashover, and flash fire, appropriate nozzle technique and immediate tactical withdrawal to a safer area is absolutely critical. However, most survival skills curriculums do not address these critical skills.

When was the last time you practiced withdrawing a hoseline while operating the nozzle in the context of offensive, interior firefighting operations?

Performance Under Stress

There has been little if any research has been done to identify factors influencing firefighters’ performance under the extreme stress of a life threatening situation. However, there has been considerable investigation in other domains, particularly in the military and law enforcement

Increased psychological and physiological arousal prepare the human body for action. As this occurs, the sympathetic nervous system increases heart rate and blood pressure to maximize the body’s physical capacity. However, extreme levels of stress can result in significant deterioration in performance.

In On-Combat: The Psychology and Physiology of Deadly Conflict in War and Peace, LT COL Dave Grossman (2008) identifies five levels of arousal designated Conditions White, Yellow, Red, Grey, and Black. While cautioning against fixing specific heart rate numbers (or other precise physiological measures) to these levels of arousal, heart rate can be used as an indicator (see Figure 2).

Figure 2. Effects of Hormonal or Fear Induced Increases in Heart Rate

Note. Adapted from On-Combat: The Psychology and Physiology of Deadly Conflict in War and Peace (p. 31), by Dave Grossman, 2008, Millstadt, IL: Warrior Science Publications Copyright 2008 by David A. Grossman.

When face with an immediately life threatening situation, the resulting stress can significantly impact an individual’s ability to respond appropriately. In addition to the physiological responses (e.g. increased heart rate, visual and auditory distortion) decreased cognitive processing may delay appropriate response or result in freezing, with the inability to act (Wallenius, Johansson, & Larsson, 2002).

Recently a colleague related the experience of a firefighter who had been trapped by a wind driven fire. The firefighter dropped to the floor, went into the fetal position, said goodby to his wife and children and thought he was dead. Fortunately, the firefighter was rescued, but this illustrates the potentially incapacitating effects of stress in life threatening situations.

What is the answer? Military research points to the need for a highly trained (to automaticity) response. Battle drills integrate these immediate individual actions in the context of small unit operations.

Battle Drill

In a military context, battle drills are an immediate response to enemy contact that requires fire and maneuver in order to succeed. Battle drills are initiated with minimal commands from the unit leader. Soldiers or marines execute preplanned, sequential actions in response to enemy contact.

The battle drill concept has direct applicability to training firefighters to react appropriately on contact with our enemy (the fire) which requires fire (application of water) and maneuver (movement to a safer location) in order to succeed.

Unless a barrier (such as a door) is available to block the flow of flames and hot gases towards the firefighters position, attempts to escape without protection from a hoseline are likely to fail as fire can spread far more quickly than you can move.

Remember: The key elements of a battle drill are fire and maneuver! This requires the ability to operate and maintain control of the hoseline while moving backward.

The next post in this series will return to hose and nozzle drills with development of a battle drill for response to rapid fire progression.

Ed Hartin, MS, EFO, MIFireE, CFO.

References

Grossman, D. (2008). On-combat: The psychology and physiology of deadly conflict in war and peace. Millstadt, IL: Warrior Science Publications.

Wallenius, C. Johansson, C. & Larsson, G. (2002). Reactions and performance of Swedish peacekeepers in life-threatening situations. International Peacekeeping, 9(1), 133-152.

This post continues study of an incident in a townhouse style apartment building in Washington, DC with examination of the extreme fire behavior that took the lives of Firefighters Anthony Phillips and Louis Mathews. As discussed in Townhouse Fire: Washington, DC-Computer Modeling Part I, this was one of the first cases where the NIST Fire Dynamics Simulator (FDS) software was used in forensic fire scene reconstruction (Madrzykowski and Vettori, 2000).

Quick Review

As discussed in prior posts, crews working on Floor 1 to locate the fire and secure the door to the stairwell were trapped and burned as a result of rapid progression of a fire in the basement up the open interior stairway after an exterior sliding glass door was opened to provide access to the basement. For detailed examination of incident operations and fire behavior, see:

• Fire Behavior Case Study Townhouse Fire: Washington, DC
• Townhouse Fire: Washington DC-What Happened
• Townhouse Fire: Washington DC-Extreme Fire Behavior
• Townhouse Fire: Washington DC-Computer Modeling

Figure 1. Conditions at Approximately 00:28

Note: From Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 29 & 32. District of Columbia Fire & EMS, 2000.

Smokeview

Smokeview is a visualization program used to provide a graphical display of a FDS model simulation in the form of an animation or snapshot. Snapshots illustrate conditions in a specific plane or slice within the building. Three vertical slices are important to understanding the fire dynamics involved in the Cherry Road incident: 1) midline of the door on Floor 1, Side A, 2) midline of the Basement Door, Side C, and midline of the Basement Stairwell (see Figure 2). Imagine that the building is cut open along the slice and that you can observe the temperature, oxygen concentration, or velocity of gas movement within that plane.

Figure 2. Perspective View of 3146 Cherry Road and Location of Slices

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 15) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

In addition to having an influence on heat release rate, the location and configuration of exhaust and inlet openings determines air track (movement of smoke and air) and the path of fire spread. In this incident, the patio door providing access to the basement at the rear acted as an inlet, providing additional air to the fire. The front door and windows on the first floor opened for ventilation served as exhaust openings and provided a path for fire travel when the conditions in the basement rapidly transitioned to a fully developed fire.

Figures 3-10 illustrate conditions at 200 seconds into the simulation, which relates to approximately 00:27 during the incident, the time at which the fire in the basement transitioned to a fully developed stage and rapidly extended up the basement stairway to Floor 1. Data is presented as a snapshot within a specific slice. Temperature and velocity data are provide for each slice (S1, S2, & S3 as illustrated in Figure 2).

Figure 3. Temperature Along Centerline of Basement Door Side C (S1) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 17) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 4. Vector Representation of Velocity Along Centerline of Basement Door Side C (S1) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 18) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 5. Oxygen Concentration Along Centerline of Basement Door Side C (S1) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 23) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 6. Temperature Slice Along Centerline of Basement Stairwell (S2) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 21) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 7. Vector Representation of Velocity Along Centerline of Basement Stairwell (S2) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 22) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 8. Oxygen Concentration Along Centerline of Basement Stairwell (S2) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 24) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 9. Temperature Slice Along Centerline of Floor 1 Door Side A (S3) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 19) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 10. Vector Representation of Velocity Along Centerline of Floor 1 Door Side A (S3) at 200 s

Note: From Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 20) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Figure 11. Perspective Cutaway, Flow/Temperature, Velocity, and O₂ Concentration

Figure 12. Thermal Exposure Limits in the Firefighting Environment

Note: Adapted from Measurements of the firefighting environment. Central Fire Brigades Advisory Council Research Report 61/1994 by J.A. Foster & G.V. Roberts, 1995. London: Department for Communities and Local Government and Thermal Environment for Electronic Equipment Used by First Responders by M.K. Donnelly, W.D. Davis, J.R. Lawson, & M.J. Selepak, 2006, Gaithersburg, MD: National Institute of Standards and Technology.

Compartment Fire Thermal Hazards

The temperature of the atmosphere (i.e., smoke and air) is a significant concern in the fire environment, and firefighters often wonder or speculate about how hot it was in a particular fire situation. However, gas temperature in the fire environment is a bit more complex than it might appear on the surface and is only part of the thermal hazard presented by compartment fire.

Tissue temperature and depth of penetration determine the severity of a thermal burn. Temperature and penetration are dependent on the amount of energy absorbed and the duration of the thermal insult as well as the properties of human tissue. In a compartment fire, firefighters absorb energy from any substance that has a temperature above 37^o C (98.6^o F), including hot compartment linings, contents, the hot gas layer, and flames. The dominant mechanisms of heat transfer involved in this process are convection and radiation (although conduction through personal protective equipment is also a factor to be considered).

The total thermal energy received is described in joules per unit area. However, the speed or rate of energy is transferred may be more important when assessing thermal hazard. Heat (thermal) flux is used to define the rate of heat transfer and is expressed in kW/m² (Btu/hr/ft²).

One way to understand the interrelated influence of radiant and convective heat transfer is to consider the following scenario. Imagine that you are standing outside in the shade on a hot, sunny day when the temperature is 38^o C (100^o F). As the ambient temperature is higher than that of your body, energy will be transferred to you from the air. If you move out of the shade, your body will receive additional energy as a result of radiant heat transfer from the sun.

Convective heat transfer is influenced by gas temperature and velocity. When hot gases are not moving or the flow of gases across a surface (such as your body or personal protective equipment) is slow, energy is transferred from the gases to the surface (lowering the temperature of the gases, while raising surface temperature). These lower temperature gases act as an insulating layer, slowing heat transfer from higher temperature gases further away from the surface. When velocity increases, cooler gases (which have already transferred energy to the surface) move away and are replaced by higher temperature gases. When velocity increases sufficiently to result in turbulent flow, hot gases remain in contact with the surface on a relatively constant basis, increasing convective heat flux.

Radiant heat transfer is influenced by proximity and temperature of the radiating body. Radiation increases by a factor of four when distance to the hot material is reduced by half. In addition, radiation increases exponentially (as a function of the fourth power) as absolute temperature increases.

Thermal hazard may be classified based on hot gas temperature and radiant heat flux (Foster & Roberts, 1995; Donnelly, Davis, Lawson, & Selpak, 2006) with temperatures above 260^o C (500^o F) and/or radiant heat flux of 10 kW/m² (3172 Btu/hr/ft²) being immediately life threatening to a firefighter wearing a structural firefighting ensemble (including breathing apparatus). National Institute of Standards and Technology (NIST) experiments in a single compartment show post flashover gas temperatures in excess of 1000^o C (1832^o F) and heat flux at the floor may exceed 170 kW/m² (Donnelly, Davis, Lawson, & Selpak, 2006). Post flashover conditions in larger buildings with more substantial fuel load may be more severe!

Figure 11 integrates temperature, velocity, and oxygen concentration data from the simulation (Figures 3-10). Detail and accuracy is sacrificed to some extent in order to provide a (somewhat) simpler view of conditions at 200 seconds into the simulation (approximately 00:27 incident time). Note that as in individual slices, data is presented as a range due to uncertainty in the computer model.

Alternative Model

In addition to modeling fire dynamics based on incident conditions and tactical operations as they occurred, NIST also modeled the incident with a slightly different ventilation profile.

The basic input for the alternate simulation was the same as the simulation of actual incident conditions. Ventilation openings and timing was the same, with one exception; the sliding glass door on Floor 1, Side C was opened at 120 s into the simulation. Conditions in the basement during the alternative simulation were similar to the first. However, on Floor 1, the increase in ventilation provided by the sliding glass door on Side C resulted in a shallower hot gas layer and cooler conditions at floor level. A side-by-side comparison of the temperature gradients in these two simulations is provided in Figure 13.

Figure 13. Comparison of Temperature Gradients Along Centerline of Basement Stairwell (S2) at 200 s

Note: Adapted from Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 21 & 27) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

The NIST Report (Madrzykowski & Vettori, 2000) identified that the significant difference between these two simulations is in the region close to the floor. In the alternative simulation (Floor 1, Side C Sliding Glass Door Open) between the doorway to the basement and the sofa, the temperatures from approximately 0.6 m (2 ft) above the floor, to floor level are in the range of 20 �C to 100 �C (68�F to 212 �F), providing at least an 80 �C (176 �F) temperature reduction.

While this is a considerable reduction in gas temperature, it is essential to also consider radiant heat flux from the hot gas layer. Given the temperature of the hot gases from the ceiling level to a depth of approximately 3′ (0.9 m), the heat flux at the floor would likely have been in the range of 15-20 kW/m² (or greater).

Questions

1. Temperatures vary widely at a given elevation above the floor. Consider the slices illustrated in Figures 3, 6, and 9, and identify factors that may have influenced these major differences in temperature.
2. How might the variations in temperature illustrated in Figures 3, 6, and9 and location of Firefighters Phillips (basement doorway), Mathews (living room, C/D corner), and Morgan (between Phillips & Mathews) have influenced their injuries?
3. Examine the velocity of gas movement illustrated in Figures 4, 7, and 10 and integrated illustration conditions in Figure 11. How does this correlate to the photos in Figure 1 illustrating incident conditions at approximately 00:28?
4. Explain how the size and configuration of ventilation openings resulted in a bi-directional air track at the basement door on Side C.
5. How did the velocity of hot gases in the stairwell and living room influence the thermal insult to Firefighters Phillips, Mathews, and Morgan? What factors caused the high velocity flow of gases from the basement stairwell doorway into the living room?
6. Rescue 1B noted that the floor in the living room was soft while conducting primary search at approximately 00:30. Why didn’t the parallel chord trusses in the basement fail sooner? Is there a potential relationship between fire behavior and performance of the engineered floor support system in this incident?
7. How might stability of the engineered floor support system have differed if the sliding glass door in the basement had failed prior to the fire departments arrival? Why?
8. How might the double pane glazing on the windows and sliding glass doors have influenced fire development in the basement? How might fire development differed if these building openings had been fitted with single pane glazing?
9. What was the likely influence of turbulence in the flow of hot gases and cooler air on combustion in the basement? What factors influenced this turbulence (examine Figures 4, 7, and 10) illustrating velocity of flow and floor plan illustrated in conjunction with the second question)?
10. How did conditions in the area in which Firefighters Phillips, Mathews, and Morgan were located correlate to the thermal exposure limits defined in Figure 12? How did this change in the alternate scenario? Remember to consider both temperature and heat flux.

Extended Learning Activity

The Cherry Road case study provides an excellent opportunity to develop an understanding of the influence of building factors, burning regime, ventilation, and tactical operations on fire behavior. These lessons can be extended by comparing and contrasting this case with other cases such as the 1999 residential fire in Keokuk, Iowa that took the lives Assistant Chief Dave McNally, Firefighter Jason Bitting, and Firefighter Nathan Tuck along with three young children. For information on this incident see NIOSH Death in the Line of Duty Report F2000-4, NIST report Simulation of the Dynamics of a Fire in a Two Story Duplex, NIST IR 6923.and video animation of Smokeview output from modeling of this incident

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

This post continues study of an incident in a townhouse style apartment building in Washington, DC with examination of the extreme fire behavior that took the lives of Firefighters Anthony Phillips and Louis Mathews.

A Quick Review

Prior posts in this series, Fire Behavior Case Study of a Townhouse Fire: Washington, DC, Townhouse Fire: Washington, DC-What Happened,and Townhouse Fire: Washington, DC-Extreme Fire Behavior examined the building and initial tactical operations at this incident. The fire occurred in the basement of a two-story, middle of building, townhouse apartment with a daylight basement. This configuration provided at grade entrances to Floor 1 on Side A and the Basement on Side C.

Engine 26, the first arriving unit reported heavy smoke showing from Side A and observed a bi-directional air track at the open front door. Engines 26 and 10 operating from Side A deployed hoselines into the first floor to locate the fire. Engine 17, the second due engine, was stretching a hoseline to Side C, but had insufficient hose and needed to extend their line. Truck 4, the second due truck, operating from Side C opened a sliding glass door to the basement to conduct search and access the upper floors (prior to Engine 17’s line being in position). When the door on Side C was opened, Truck 4 observed a strong inward air track. As Engine 17 reached Side C (shortly after Rescue 1 and a member of Truck 4 entered the basement) and asked for their line to be charged. Engine 17 advised Command that the fire was small.

Conditions changed quickly after the door on Side C was opened, as conditions in the basement rapidly transitioned to a fully developed fire with hot gases and flames extending up the interior stairway trapping Firefighters Phillips, Mathews, and Morgan. Confusion about building configuration (particularly the number of floors and location of entry points on Side A and C) delayed fire attack due to concern for opposing hoselines.

Modeling of the Cherry Road Incident

National Institute for Standards and Technology (NIST) performed a computer model of fire dynamics in the fire at 3146 Cherry Road (Madrzykowski and Vettori, 2000) using the NIST Fire Dynamics Simulator (FDS) software. This is one of the first cases where FDS was used in forensic fire scene reconstruction.

Fire Modeling

Fire modeling is a useful tool in research, engineering, fire investigation, and learning about fire dynamics. However, effective use of this tool and the information it provides requires understanding of its capabilities and limitations.

Models, such as the National Institute of Standards and Technology (NIST) Fire Dynamics Simulator (FDS) relay on computational fluid dynamics (CFD). CFD models define the fire environment by dividing it into small, rectangular cells. The model simultaneously solves mathematical equations for combustion, heat transfer, and mass transport within and between cells. When used with a graphical interface such as NIST Smokeview, output can be displayed in a three-dimensional (3D) visual format.

Models must be validated to determine how closely they match reality. In large part this requires comparison of model output to full scale fire tests under controlled conditions. When used for forensic fire scene reconstruction, it may not be feasible to recreate the fire to test the model. In these situations, model output is compared to physical evidence and interview data to determine how closely key aspects of model output matched events as they occurred. If model output reasonably matches events as they occurred, it is likely to be useful in understanding the fire dynamics involved in the incident.

It is crucial to bear in mind that fire models do not provide a reconstruction of the reality of an event. They are simplified representation of reality that will always suffer from a certain lack of accuracy and precision. Under the condition that the user is fully aware of this status and has an extensive knowledge of the principles of the models, their functioning, their limitations and the significance attributed to their results, fire modeling becomes a very powerful tool (Dele�mont & Martin, J., 2007, p. 134).

FDS output included data on heat release rate, temperature, oxygen concentration, and velocity of gas (smoke and air) movement within the townhouse. As indicated above, model output is an approximation of actual incident conditions.

In large scale fire tests (McGrattan, Hamins, & Stroup, 1998, as cited in Madrzykowski and Vettori, 2000), FDS temperature predictions were found to be within 15% of the measured temperatures and FDS heat release rates were predicted to within 20% of the measured values. For relatively simple fire driven flows such as buoyant plumes and flows through doorways, FDS predictions are within experimental uncertancies (McGrattan, Baum, & Rehm, 1998, as cited in Madrzykowski and Vettori, 2000).

Results presented in the NIST report on the fire at 3146 Cherry Road were presented as ranges to account for potential variation between model output and actual incident conditions.

Heat release rate is dependent on the characteristics and configuration of the fuel packages involved and available oxygen. In a compartment fire, available oxygen is dependent on the ventilation profile (i.e., size and location of compartment openings). The ventilation profile can change over time due to the effects of the fire (e.g., failure of window glazing) as well as human action (i.e., doors left open by exiting occupants, tactical ventilation, and tactical anti-ventilation)

In this incident there were a number of changes to the ventilation profile. Most significant of which were, 1) the occupant opened the second floor windows on Side C (see Figure 3), 2) the occupant left the front door open as they exited (see Figures 1 &2 ), 3) tactical ventilation of the first floor window on Side A, and opening of the sliding glass door in the basement on Side C (see Figures 1-3). In addition, the open door in the basement stairwell and open stairwell between the Floors 1 and 2 also influenced the ventilation profile (see Figure 1).

Figure 1. Cross Section of 3146 Cherry Road NE

Figure 2. Side A 3146 Cherry Road NE

Figure 3. Side C 3146 Cherry Road NE

Figure 4 illustrates the timing of changes to the ventilation profile and resulting influence on heat release rate in modeling this incident. A small fire with a specific heat release rate (HRR) was used to start fire growth in the FDS simulation. In the actual incident it may have taken hours for the fire to develop flaming combustion and progression into the growth stage. Direct comparison between the simulation and incident conditions began at 100 seconds into the simulation which corresponds to approximately 00:25 during the incident.

Figure 4. FDS Heat Release Rate Curve

Note: Adapted from Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510 (p. 14) by Dan Madrzykowski and Robert Vettori, 2000, Gaithersburg, MD: National Institute for Standards and Technology.

Questions

The following questions are based on heat release rate data from the FDS model presented in Figure 4.

1. What was the relationship between changes in ventilation profile and heat release rate?
2. What would explain the rapid increase in heat release rate after the right side of the basement sliding glass door is opened?
3. Why might the heat release rate have dropped slightly prior to opening of the left side of the basement sliding glass door?
4. Why did the heat release rate again increase rapidly to in excess of 10 MW after the left side of the basement sliding glass door was opened?
5. How does data from the FDS model correlate to the narrative description of events presented in prior posts about this incident (Fire Behavior Case Study of a Townhouse Fire: Washington, DC, Townhouse Fire: Washington, DC-What Happened,and Townhouse Fire: Washington, DC-Extreme Fire Behavior)?

More to Follow

In addition to heat release rate data the computer modeling of this incident provided data on temperature, oxygen concentration, and gas velocity. Visual presentation of this data provides a more detailed look at potential conditions inside the townhouse during the fire. The next post in this series will present and examine graphic output from Smokeview to aid in understanding the fire dynamics and thermal environment encountered during this incident.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

This post continues study of an incident in a townhouse style apartment building in Washington, DC with examination of the extreme fire behavior that took the lives of Firefighters Anthony Phillips and Louis Mathews.

A Quick Review

Prior posts in this series, Fire Behavior Case Study of a Townhouse Fire: Washington, DC and Townhouse Fire: Washington, DC-What Happened examined the building and initial tactical operations at this incident. The fire occurred in the basement of a two-story, middle of building, townhouse style apartment with a daylight basement. This configuration provided an at grade entrance to the Floor 1 on Side A and at grade entrance to the Basement on Side C.

Engine 26, the first arriving unit reported heavy smoke showing from Side A and observed a bi-directional air track at the open front door. First alarm companies operating on Side A deployed hoselines into the first floor to locate the fire. Engine 17, the second due engine, was stretching a hoseline to Side C, but had insufficient hose and needed to extend their line. Truck 4, the second due truck, operating from Side C opened a sliding glass door to the basement to conduct search and access the upper floors (prior to Engine 17’s line being in position). When the door on Side C was opened, Truck 4 observed a strong inward air track. As Engine 17 reached Side C (shortly after Rescue 1 and a member of Truck 4 entered the basement) and asked for their line to be charged, and Engine 17 advised Command that the fire was small.

Extreme Fire Behavior

Proceeding from their entry point on Side C towards the stairway to Floor 1 on Side A, Rescue 1B and the firefighter from Truck 4 observed fire burning in the middle of the basement room. Nearing the stairs, temperature increased significantly and they observed fire gases in the upper layer igniting. Rescue 1B and the firefighter from Truck 4 escaped through the basement doorway on Side C as the basement rapidly transitioned to a fully developed fire.

Figure 1. Timeline Leading Up to the Extreme Fire Behavior Event

The timeline illustrated in Figure 1 is abbreviated and focuses on a limited number of factors. A detailed timeline, inclusive of tactical operations, fire behavior indicators, and fire behavior is provided in a subsequent section of the case.

After Engine 17’s line was charged, the Engine 17 officer asked Command for permission to initiate fire attack from Side C. Command denied this request due to lack of contact with Engines 26 and 10 and concern regarding opposing hoselines. Due to their path of travel around Side B of the building, Engine 17 had not had a clear view of Side A and thought that they were at a doorway leading to Floor 1 (rather than the Basement). At this point, neither the companies on Side C nor Command recognized that the building had three levels on Side C and two levels on Side A.

At this point crews from Engine 26 and 10 are operating on Floor 1 and conditions begin to deteriorate. Firefighter Morgan (Engine 26) observed flames at the basement door in the living room (see Figure 8 which illustrates fire conditions in the basement as seen from Side C). Firefighter Phillips (Engine 10) knocked down visible flames at the doorway, but conditions continued to deteriorate. Temperature increased rapidly while visibility dropped to zero.

As conditions deteriorated, Engine 26’s officer feels his face burning and quickly exits (without notifying his crew). In his rapid exit through the hallway on Floor 1, he knocked the officer from Engine 10 over. Confused about what was happening Engine 10’s officer exited the building as well (also without notifying his crew). Engine 26’s officer reports to Command that Firefighter Mathews was missing, but did not report that Firefighter Morgan was also missing. Appearing dazed, Engine 10’s officer did not report that Firefighter Phillips was missing.

Figure 2. Conditions on Side C at Aproximately 00:28

Note: From Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 32. District of Columbia Fire & EMS, 2000.

Figure 3. Conditions on Side A at Aproximately 00:28

Note: From Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 29. District of Columbia Fire & EMS, 2000.

Firefighter Rescue Operations

After the exit of the officers from Engine 26 and Engine 10, the three firefighters (Mathews, Phillips, and Morgan) remained on Floor 1. However, neither Command (Battalion 1) nor a majority of the other personnel operating at the incident recognized that the firefighters from Engines 26 and 10 had been trapped by the rapid extension of fire from the Basement to Floor 1 (see Figure 4).

While at their apparatus getting a ladder to access the roof from Side B, Truck 4B observed the rapid fire development in the basement and pulled a 350′ 1-1/2″ (107 m 38 mm) line from Engine 12 to Side C, backing up Engine 17.

Figure 4. Location of Firefighters on Floor 1

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 18 & 20. District of Columbia Fire & EMS, 2000 and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 12-13, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology.

Engine 17 again contacted Command (Battalion 1) and requested permission to initiate an exterior attack from Side C. However, the officer of Engine 17 mistakenly advised Command that there was no basement entrance and that his crew was in position to attack the fire on Floor 1. Unable to contact Engines 10 and 26, Command denied this request due to concern for opposing hoselines. With conditions worsening, Command (Battalion 1) requested a Task Force Alarm at 00:29, adding another two engine companies, truck company, and battalion chief to the incident.

Firefighter Phillips (E-10) attempted to retreat from his untenable position at the open basement door. He was only able to travel a short distance before he collapsed. Firefighter Morgan (E-26) heard a loud scream to his left and then a thud as if someone had fallen to the floor (possibly Firefighter Mathews (E-26)). Firefighter Morgan found the attack line and opened the nozzle on a straight stream, penciling the ceiling twice before following the hoseline out of the building (to Side A). Firefighter Morgan exited the building at approximately 00:30.

Rescue 1B entered the structure on Floor 1, Side A to perform a primary search. They crawled down the hallway on Floor 1 towards Side C until they reached the living room and attempted to close the open basement door but were unable to do so. Rescue 1 B did not see or hear Firefighters Mathews (E-26) and Phillips (E-10) while working on Floor 1. Rescue 1B noted that the floor in the living room was spongy. The Rescue 1 Officer ordered his B Team to exit, but instead they returned to the front door and then attempted to search Floor 2, but were unable to because of extremely high temperature.

Unaware that Firefighter Phillips (E-10) was missing, Command tasked Engine 10� and Rescue 1A, with conducting a search for Firefighter Mathews (E-26). The Engine 10 officer entered Floor 1 to conduct the search (alone) while instructing another of his firefighters to remain at the door. Rescue 1A followed Engine 26’s 1-1/2″ (38 mm) hoseline to Floor 1 Slide C. Rescue 1B relocated to Side B to search the basement for the missing firefighter.

The Engine 26 Officer again advised Command (Battalion 1) that Firefighter Mathews was missing. Engine 17 made a final request to attack the fire from Side C. Given that a firefighter was missing and believing that the fire had extended to Floor 1, Command instructed Engine 17 to attack the fire with a straight stream (to avoid pushing the fire onto crews working on Floor 1). At approximately 00:33, Battalion 2 reported (from Side C) that the fire was darkening down. Engine 14 arrived and staged on Bladensburg Road.

Command ordered a second alarm assignment at 00:34 hours. At 00:36, Command ordered Battalion 2 (on Side C) to have Engine 17 and Truck 4 search for Firefighter Mathews in the Basement. Engine 10’s officer heard a shrill sound from a personal alert safety system (PASS) and quickly located Firefighter Phillips (E-10). Firefighter Phillips was unconscious, lying on the floor (see Figure 4) with his facepiece and hood removed. Unable to remove Firefighter Phillips by himself, the officer from Engine 10 unsuccessfully attempted to contact Command (Battalion 1) and then returned to Side A to request assistance.

Command received a priority traffic message at 00:37, possibly attempting to report the location of a missing firefighter. However, the message was unreadable.

The Hazmat Unit and Engine 6 arrived and staged on Bladensburg Road and a short time later were tasked by Command to assist with rescue of the downed firefighter on Floor 1. Firefighter Phillips (E-10) was removed from the building by the Engine 10 officer, Rescue 1A, Engine 6, and the Hazardous Materials Unit at 00:45. After Firefighter Phillips was removed to Side A, Command discovered that Firefighter Mathews (E-26) was still missing and ordered the incident safety officer to conduct an accountability check. Safety attempted to conduct a personnel accountability report (PAR) by radio, but none of the companies acknowledged his transmission.

The Deputy Chief of the Firefighting Division arrived at 00:43 and assumed Command, establishing a fixed command post at the Engine 26 apparatus. Battalion 4 arrived a short time later and was assigned to assist with rescue operations along with Engines 4 and 14.

Firefighter Mathews was located simultaneously by several firefighters. He was unconscious leaning over a couch on Side C of the living room (see Figure 4). Firefighter Mathews breathing apparatus was operational, but he had not activated his (non-integrated) personal alert safety system (PASS). Firefighter Mathews was removed from the building by Engine 4, Engine 14, and Hazardous Materials Unit at 00:49.

Command (Deputy Chief) ordered Battalions 2 and 4 to conduct a face-to-face personnel accountability report on Sides A and C at 00:53.

Questions

1. Based on the information provided in the case to this point, answer the following questions:
2. National Institute for Occupational Safety and Health (NIOSH) Death in the Line of Duty Reports examining incidents involving extreme fire behavior often recommend close coordination of fire attack and ventilation.
3. Did the fire behavior in this incident match the prediction you made after reading the previous post (Towhouse Fire: Washington DC-What Happened)?
4. What type of extreme fire behavior occurred? Justify your answer?
5. What event or action initiated the extreme fire behavior? Why do you believe that this is the case?
6. How did building design and construction impact on fire behavior and tactical operations during this incident?
7. How might a building pre-plan and/or 360^o reconnaissance have impacted the outcome of this incident? Note that 360^o reconnaissance does not necessarily mean one individual walking completely around the building, but requires communication and knowledge of conditions on all sides of the structure (e.g., two stories on Side A and three stories on Side C).
8. How might the outcome of this incident have changed if Engine 17 had been in position and attacked the fire in the basement prior to Engines 26 and 10 committing to Floor 1?
9. What strategies and tactics might have been used to mitigate the risk of extreme fire behavior during this incident?

More to Follow

This incident was one of the first instances where the National Institute of Standards and Technology (NIST) Fire Dynamics Simulator (FDS) was used in forensic fire scene reconstruction (Madrzykowski & Vettori, 2000). Modeling of the fire behavior in this incident helps illustrate what was likely to have happened in this incident. The next post in this series will examine and expand on the information provided by modeling of this incident.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

This post continues study of an incident that resulted in two line-of-duty deaths as a result of extreme fire behavior in a townhouse style apartment building in Washington, DC.

A Quick Review

The previous post in this series, Fire Behavior Case Study of a Townhouse Fire: Washington, DC examined building construction and configuration that had a significant impact on the outcome of this incident. The fire occurred in the basement of a two-story, middle of building, townhouse style apartment with a daylight basement. This configuration provided an at grade entrance to the Floor 1 on Side A and an at grade entrance to the Basement on Side C.

The fire originated in an electrical junction box attached to a fluorescent light fixture in the basement ceiling (see Figures 1 and 2). The occupants of the unit were awakened by a smoke detector. The female occupant noticed smoke coming from the floor vents on Floor 2. She proceeded downstairs and opened the front door and then proceeded down the first floor hallway towards Side C, but encountered thick smoke and high temperature. The female and male occupants exited the structure, leaving the front door open, and made contact with the occupant of an adjacent unit who notified the DC Fire & EMS Department at 0017 hours.

Dispatch Information

At 00:17, DC Fire & EMS Communications Division dispatched a first alarm assignment consisting of Engines 26, 17, 10, 12, Trucks 15, 4, Rescue Squad 1, and Battalion 1 to 3150 Cherry Road NE. At 0019 Communications received a second call, reporting a fire in the basement of 3146 Cherry Road NE. Communications transmitted the update with the change of address and report of smoke coming from the basement. However, only one of the responding companies (Engine 26) acknowledged the updated information.

Weather Conditions

Temperature was approximately 66^o F (19^o C) with south to southwest winds at 5-10 mi/hr (8-16 km/h), mostly clear with no precipitation.

Conditions on Arrival

Approaching the incident, Engine 26 observed smoke blowing across Bladensburg Road. Engine 26 arrived at a hydrant at the corner of Banneker Drive and Cherry Road at 00:22 hours and reported smoke showing. A short time later, Engine 26 provided an updated size-up with heavy smoke showing from Side A of a two story row house. Based on this report, Battalion 1 ordered a working fire dispatch and a special call for the Hazmat Unit at 00:23. This added Engine 14, Battalion 2, Medic 17 and EMS Supervisor, Air Unit, Duty Safety Officer, and Hazmat Unit.

Firefighting Operations

DC Fire and EMS Department standard operating procedures (SOP) specify apparatus placement and company assignments based on dispatch (anticipated arrival) order. Note that dispatch order (i.e., first due, second due) may de different than order of arrival if companies are delayed by traffic or are out of quarters.

Standard Operating Procedures

Operations from Side A

The first due engine lays a supply line to Side A, and in the case of basement fires, the first line is positioned to protect companies performing primary search on upper floors by placing a line to cover the interior stairway to the basement. The first due engine is backed up by the third due engine. The apparatus operator of the third due engine takes over the hydrant and pumps supply line(s) laid by the first due engine, while the crew advances a backup line to support protection of interior exposures and fire attack from Side A.

The first due truck takes a position on Side A and is responsible for utility control and placement of ladders for access, egress, and rescue on Side A. If not needed for rescue, the aerial is raised to the roof to provide access for ventilation.

The rescue squad positions on Side A (unless otherwise ordered by Command) and is assigned to primary search using two teams of two. One team searches the fire floor, the other searches above the fire floor. The apparatus operator assists by performing forcible entry, exterior ventilation, monitoring search progress, and providing emergency medical care as necessary.

Operations from Side C

The second due engine lays a supply line to the rear of the building (Side C), and in the case of basement fires, is assigned to fire attack if exterior access to the basement is available and if it is determined that the first and third due engines are in a tenable position on Floor 1. The second due engine is responsible for checking conditions in the basement, control of utilities (on Side C), and notifying Command of conditions on Side C. Command must verify that the first and third due engines can maintain tenable positions before directing the second due engine to attack basement fires from the exterior access on Side C.

The second due truck takes a position on Side C and is responsible for placement of ladders for access, egress, and rescue on Side C. The aerial is raised to the roof to provide secondary access for ventilation (unless other tasks take priority).

Command and Control

The battalion chief positions to have an unobstructed view of the incident (if possible) and uses his vehicle as the command post. On greater alarms, the command post is moved to the field command unit.

Notes: This summary of DC Fire & EMS standard operating procedures for structure fires is based on information provided in the reconstruction report and reflects procedures in place at the time of the incident. DC Fire & EMS did not use alpha designations for the sides of a building at the time of this incident. However, this approach is used here (and throughout the case) to provide consistency in terminology.

First due, Engine 26 laid a 3″ (76 mm) supply line from a hydrant at the intersection of Banneker Drive and Cherry Road NE, positioned in the parking lot on Side A, and advanced a 200′ 1-1/2″ ( 61 m 38 mm) pre-connected hoseline to the first floor doorway of the fire unit on Side A (see Figures 1 and 2). A bi-directional air track was evident at the door on Floor 1, Side A , with thick (optically dense) black smoke from the upper area of the open doorway. Engine 26’s entry was delayed due to a breathing apparatus facepiece malfunction. The crew of Engine 26 (Firefighters Mathews and Morgan and the Engine 26 Officer) made at approximately 00:24.

Figure 1. Plot and Floor Plan-3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 18 & 20. District of Columbia Fire & EMS, 2000; Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 12-13, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology, and NIOSH Death in the Line of Duty Report 99 F-21, 1999, p. 19.

Engine 10, the third due engine arrived shortly after Engine 26, took the hydrant at the intersection of Banneker Drive and Cherry Road, NE, and pumped Engine 26’s supply line. After Engine 10 arrived at the hydrant, the firefighter from Engine 26 who had remained at the hydrant proceeded to the fire unit and rejoined his crew. Engine 10, advanced a 400′ 1-1/2″ (122 m 38 mm) line from their own apparatus as a backup line. Firefighter Phillips and the Engine 10 officer entered through the door on Floor 1, Side A (see Figure 2) while the other member of their crew remained at the door to assist in advancing the line.

Truck 15, the first due truck arrived at 00:23 and positioned on Side A in the parking lot behind Engine 26. The crew of Truck 15 began laddering Floor 2, Side A, and removed kitchen window on Floor 1, Side A (see Figure 2). Due to security bars on the window, one member of Truck 15 entered the building and removed glass from the window from the interior. After establishing horizontal ventilation, Truck 15 accessed the roof via a portable ladder and began vertical ventilation operations.

Engine 17, the second due engine, arrived at 00:24, laid a 3″ (76 mm) supply line from the intersection of Banneker Drive and Cherry Road NE, to a position on Cherry Road NE just past the parking lot, and in accordance with department procedure, stretched a 350′ 1-1/2″ (107 m 38 mm) line to Side C (see Figure 2).

Approaching Cherry Road from Banneker Drive, Battalion 1 observed a small amount of fire showing in the basement and assigned Truck 4 to Side C. Battalion 1 parked on Cherry Road at the entrance to the parking lot, but was unable to see the building, and proceeded to Side A and assumed a mobile command position.

Second due, Truck 4 proceeded to Side C and observed what appeared to be a number of small fires in the basement at floor level (this was actually flaming pieces of ceiling tile which had dropped to the floor). The officer of Truck 4 did not provide a size-up report to Command regarding conditions on Side C. Truck 4, removed the security bars from the basement sliding glass door using a gasoline powered rotary saw and sledgehammer. After clearing the security grate Truck 4, broke the right side of the sliding glass door to ventilate and access the basement (at approximately 00:27) and then removed the left side of the sliding glass door. The basement door on Side C was opened prior to Engine 17 getting a hoseline in place and charged. After opening the sliding glass door in the basement, Truck 4 attempted to ventilate windows on Floor 2 Side C using the tip of a ladder. They did not hear the glass break and believing that they had been unsuccessful; they left the ladder in place at one of the second floor windows and continued with other tasks.

Figure 2. Location of First Alarm Companies and Hoselines

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 27. District of Columbia Fire & EMS, 2000.

Unknown to Truck 4, these windows had been left open by the exiting occupants. Truck 4B (two person team from Truck 4) returned to their apparatus for a ladder to access the roof from Side C. Rescue 1 arrived at 00:26 and reported to Side C after being advised by the male occupant that everyone was out of the involved unit (this information was not reported to Command). Rescue 1 and Truck 4 observed inward air track (smoke and air) at the exterior basement doorway on Side C and an increase in the size of the flames from burning material on the floor.

Engines 26 and 10 encountered thick smoke and moderate temperature as they advanced their charged 1-1/2″ (38 mm) hoselines from the door on Side A towards Side C in an attempt to locate the fire. As they extended their hoselines into the living room, the temperature was high, but tolerable and the floor felt solid. It is important to note that engineered, lightweight floor support systems such as parallel chord wood trusses do not provide reliable warning of impending failure (e.g., sponginess, sagging), failure is often sudden and catastrophic (NIOSH, 2005; UL, 2009).

Prior to reaching Side C of the involved unit, Engine 17 found that their 350′ 1-1/2″ (107 m 38 mm) hoseline was of insufficient length and needed to extend the line with additional hose.

Engine 12, the fourth arriving engine, picked up Engine 17’s line, completed the hoselay to a hydrant on Banneker Drive (see Figure 2). The crew of Engine 12 then advanced a 200′ 1-1/2″ (61 m 38 mm) hoseline from Engine 26 through the front door of the involved unit on Side A and held in position approximately 3′ (1 m) inside the doorway. This tactical action was contrary to department procedure, as the fourth due engine has a standing assignment to stretch a backup line to Side C.

Rescue 1’s B Team (Rescue 1B) and a firefighter from Truck 4 entered the basement without a hoseline in an effort to conduct primary search and access the upper floors via the interior stairway. Engine 17 reported that the fire was small and requested that Engine 17 apparatus charge their line.

Questions

Consider the following questions related to the interrelationship between strategies, tactics, and fire behavior:

1. Based on the information provided to this point, what was the stage of fire development and burning regime in the basement when Engine 26 entered through the door on Floor 1, Side A? What leads you to this conclusion?
2. What impact do you believe Truck 4’s actions to open the Basement door on Side C will have on the fire burning in the basement? Why?
3. What is indicated by the strong inward flow of air after the Basement door on Side C is opened? How will this change in ventilation profile impact on air track within the structure?
4. Did the companies at this incident operate consistently with DC Fire & EMS SOP? If not, how might this have influenced the effectiveness of operations?
5. Committing companies with hoselines to the first floor when a fire is located in the basement may be able to protect crews conducting search (as outlined in the DC Fire & EMS SOP). However, what building factors increased the level of risk of this practice in this incident?

More to Follow

My next post will examine the extreme fire behavior phenomena that trapped Firefighters Phillips, Mathews, and Morgan and efforts to rescue them.

Remember the Past

This week marked the anniversary of the largest loss of life in a line-of-duty death incident in the history of the American fire service. Each September, we stop and remember the sacrifice made by those 343 firefighters. However, it is also important to remember and learn from events that take the lives of individual firefighters. In an effort to encourage us to remember the lessons of the past and continue our study of fire behavior, each month I include brief narratives and links to NIOSH Death in the Line of Duty reports and other documentation in my posts.

September 9, 2006
Acting CAPT Vincent R. Neglia
North Hudson Regional Fire & Rescue Department, NJ

Captain Neglia and other firefighters were dispatched to a report of fire in a three-story apartment building in Union City. Upon their arrival at the scene, firefighters found light smoke and no visible fire. Based on reports that the structure had not been evacuated, Captain Neglia and other firefighters entered the building to perform a search. Due to the light smoke conditions, Captain Neglia was not wearing his facepiece.

Captain Neglia was the first firefighter to enter an apartment. Conditions deteriorated rapidly as fire in the cockloft broke through a ceiling . Captain Neglia was trapped by rapid fire progress and subsequent collapse. Other firefighters came to his aid and removed him from the building. Captain Neglia was transported to the hospital but later died of a combination of smoke inhalation and burns.

NIOSH did not investigate and prepare a report on the incident that took the life of Captain Neglia.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

National Institute for Occupational Safety and Health (NIOSH). (2005). NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters Due to Truss System Failures. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

This series of posts focused on Understanding Flashover has provided a definition of flashover; examined flashover in the context of fire development in both fuel and ventilation controlled fires; and looked at the importance of air track on rapid fire progression through multiple compartments. To review prior posts see:

• Myths and Misconceptions
• Myths and Misconceptions: Part 2
• The Ventilation Paradox
• The Importance of Air Track

This post begins study of an incident that resulted in two line-of-duty deaths as a result of extreme fire behavior in a townhouse style apartment building in Washington, DC. This case study provides an excellent learning opportunity as it was one of the first times that the National Institute of Standards and Technology (NIST) Fire Dynamics Simulator (FDS) and Smokeview were used in forensic fire scene reconstruction to investigate fire dynamics involved in a line-of-duty death. Data development of this case study was obtained from Death in the line of duty, Report 99-21 (NIOSH, 1999), Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999 (District of Columbia (DC Fire & EMS, 2000), and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999 (Madrzykowski & Vettori, 2000).

The Case

In 1999, two firefighters in Washington, DC died and two others were severely injured as a result of being trapped and injured by rapid fire progress. The fire occurred in the basement of a two-story, middle of building, townhouse apartment with a daylight basement (two stories on Side A, three stories on Side C).

Figure 1. Cross Section of 3146 Cherry Road NE

The first arriving crews entered Floor 1 from Side A to search for the location of the fire. Another crew approached from the rear and made entry to the basement through a patio door on Side C. Due to some confusion about the configuration of the building and Command’s belief that the crews were operating on the same level, the crew at the rear was directed not to attack the fire. During fireground operations, the fire in the basement intensified and rapidly extended to the first floor via the open, interior stairway.

Building Information

The unit involved in this incident was a middle of row 18′ x 33′ (5.6 m x 10.1 m) two-story townhouse with a daylight basement (see Figures 1 and 3). The building was of wood frame construction with brick veneer exterior and non-combustible masonry firewalls separating six individual dwelling units. Floors were supported by lightweight, parallel chord wood trusses. This type of engineered floor support system provides substantial strength, but has been demonstrated to fail quickly under fire conditions (NIOSH, 2005). In addition, the design of this type of engineered system results in a substantial interstitial void space between the ceiling and floor as illustrated in Figure 2.

Figure 2. Parallel Chord Truss Construction

Note: This is not an illustration of the floor assembly in the Cherry Road Townhouse. It is provided to illustrate the characteristics of wood, parallel chord truss construction.

The trusses ran from the walls on Sides A and C and were supported by steel beams and columns at the center of the unit (See Figure 3). The basement ceiling consisted of wood fiber ceiling tiles on wood furring strips which were attached to the bottom chord of the floor trusses. Basement walls were covered with gypsum board (sheetrock) and the floor was carpeted. A double glazed sliding glass door protected by metal security bars was located on Side C of the basement, providing access from the exterior. Side C of the structure (see Figure 3) was enclosed by a six-foot wood and masonry fence. The finished basement was used as a family room and was furnished with a mix of upholstered and wood furniture.

The first floor of the townhouse was divided into the living room, dining room, and kitchen. The basement was accessed from the interior via a stairway leading from the living room to the basement. The door to this stairway was open at the time of the fire (see Figures 1 and 3). The walls and ceilings on the first floor were covered with gypsum board (sheetrock) and the floor was carpeted. Contents of the first floor were typical of a residential living room and kitchen. A double glazed sliding glass door protected by metal security bars similar to that in the basement was located on Side C of the first floor. An entry door and double glazed kitchen window were located on Side A (see Figure 3). A stairway led to the second floor from the front entry. The second floor contained bedrooms (but was not substantively involved in this incident). There were double glazed windows on Sides A and C of Floor 2.

Figure 3. Plot and Floor Plan-3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 18 & 20. District of Columbia Fire & EMS, 2000; Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 12-13, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology, and NIOSH Death in the Line of Duty Report 99 F-21, 1999, p. 19.

Figure 4. Side A 3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 17. District of Columbia Fire & EMS, 2000 and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 5, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology.

Figure5. Side C 3146 Cherry Road NE

Note: Adapted from Report from the Reconstruction Committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999, p. 19. District of Columbia Fire & EMS, 2000 and Simulation of the Dynamics of the Fire at 3146 Cherry Road NE, Washington D.C., May 30, 1999, p. 5, by Daniel Madrzykowski & Robert Vettori, 2000. Gaithersburg, MD: National Institute of Standards and Technology.

The Fire

The fire originated in an electrical junction box attached to a fluorescent light fixture in the basement ceiling (see Figures 1 and 3). The occupants of the unit were awakened by a smoke detector. The female occupant noticed smoke coming from the floor vents on Floor 2. She proceeded downstairs and opened the front door and then proceeded down the first floor hallway towards Side C, but encountered thick smoke and high temperature. The female and male occupants exited the structure, leaving the front door open, and made contact with the occupant of an adjacent unit who notified the DC Fire & EMS Department at 0017 hours.

Questions

It is important to remember that consideration of how a fire may develop and the relationship between fire behavior and your strategies and tactical operations must begin prior to the time of alarm. Assessment of building factors and fire behavior prediction should be integrated with pre-planning.

1. Based on the information provided about the fire and building conditions, how would you anticipate that this fire would develop?
2. What concerns would you have if you were the first arriving company at this incident?

More to Follow

My next post will examine dispatch information and initial tactical operations by first alarm companies.

Ed Hartin, MS, EFO, MIFireE, CFO

References

District of Columbia (DC) Fire & EMS. (2000). Report from the reconstruction committee: Fire at 3146 Cherry Road NE, Washington DC, May 30, 1999. Washington, DC: Author.

Madrzykowski, D. & Vettori, R. (2000). Simulation of the Dynamics of the Fire at 3146 Cherry Road NE Washington D.C., May 30, 1999, NISTR 6510. August 31, 2009 from http://fire.nist.gov/CDPUBS/NISTIR_6510/6510c.pdf

National Institute for Occupational Safety and Health (NIOSH). (1999). Death in the line of duty, Report 99-21. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

National Institute for Occupational Safety and Health (NIOSH). (2005). NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters Due to Truss System Failures. Retrieved August 31, 2009 from http://www.cdc.gov/niosh/fire/reports/face9921.html

Unanticipated smoke explosion and building collapse nearly kills three firefighters.

Portsmouth, VA Near-Miss Incident

Firefighter Eric Kirk gives a firsthand account of a near-miss incident involving a smoke explosion in the June 2009 issue of FireRescue magazine. On a December morning in 2007, firefighters in Portsmouth, Virginia responded to a fire in a church. On arrival, the building was well involved and defensive operations were initiated to protect exposures and confine the fire. Over the course of the fire, smoke extended into an attached, three-story, brick building and formed a flammable fuel/air mixture. Subsequent extension of flames from the church to the interior of the exposure resulted in ignition and explosive combustion of this fuel (smoke)/air mixture.

Incident Photos from PilotOnline.com

Smoke Explosion

This post expands on Smoke is Fuel (Hartin, 2009), a sidebar that I wrote for FireRescue that accompanies Eric’s article examining the Portsmouth, VA smoke explosion incident.

Smoke explosions have resulted in three firefighter fatalities in the United States since 2005, two in Wyoming (see NIOSH Report F2005-13) and one last year in Los Angeles California (NIOSH report pending). In addition, there have been a number of near miss incidents including this one in Virginia and another in Durango, Colorado (see NIOSH Report F2008-02)However, many firefighters have not heard of or misunderstand this fire behavior phenomenon.

The terms backdraft and smoke explosion have typically been used to describe explosions resulting results from confined and rapid combustion of pyrolysis and unburnt products of incomplete combustion. Describing a backdraft incident at a Chatham, England Mattress Store in 1975, Croft (1980) states “this is not an entirely new phenomenon, the first formal description of what have been called ‘smoke explosions’ having been given in 1914” (p. 3).

As an explanation of many contradictory statements in reference to explosions that are reported to have occurred in burning buildings, where it is also testified that explosives were non-existent, we may cite so-called “smoke explosions.”

Distinct from, yet closely allied with explosions of inflammable dust, are explosions caused by the ignition of mixtures of air with the minute particles of unconsumed carbon and invisible gaseous matter in smoke from the imperfect combustion of organic substances…

These “smoke explosions” frequently occur in burning buildings and are commonly termed “back draughts” or “hot air explosions” (Steward, 1914).

As discussed in my earlier post, Fires and Explosions, 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 (2008) Guide for Fire and Explosion Investigation, it says “see backdraft” (p. 921-15). However, today it identifies a different, and in many respects more dangerous extreme fire behavior phenomenon. Smoke (or Fire Gas) Explosion is described in fire dynamics textbooks such as Enclosure Fire Dynamics (Karlsson and Quintiere) and An Introduction to Fire Dynamics (Drysdale) and Enclosure Fires (Bengtsson). Of these, the text Enclosure Fires by Swedish Fire Protection Engineer Lars-G�ran Bengtsson provides the best explanation of how conditions for a smoke explosion develop. However, this phenomenon is less well known among firefighters and fire officers. In fact many well known fire service authors continue to use backdraft and smoke explosion interchangeably.

A smoke or fire gas explosion occurs when unburned pyrolysis products 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.

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 within its flammable range, requiring only a source of ignition.

Smoke explosions create a significant overpressure as the fuel and air are premixed. 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 in the compartment (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)

For additional information on transient, explosive, fire phenomena see earlier posts: Gas Explosions and Gas Explosions Part 2.

Indicators Smoke Explosion Potential

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 exposures

Mitigating the Hazard

As with recognizing the potential for a smoke explosion, mitigation can also be difficult. The gases are relatively cool, so application of water into the gas layer may have limited effect. Tactical ventilation to remove the smoke is the only way to fully mitigate the hazard and establish a safe zone. However, use care not to create a source of ignition (such as the sparks created when using an abrasive blade on a rotary saw).

The best course of action is to prevent infiltration of smoke into uninvolved spaces using anti-ventilation (confinement) tactics. Anti-ventilation is the planned and systematic confinement of heat, smoke, and fire gases, and exclusion of fresh air (from the fire). In this case, anti-ventilation may involve pressurizing the uninvolved are to prevent the spread and accumulation of smoke.

Ed Hartin, MS, EFO, MIFIreE, CFO

References

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

Croft, W. (1980) Fires involving explosions-a literature review. Fire Safety Journal, 3(1), 3-24.

Drysdale, D. (1998). An introduction to fire dynamics (2^nd ed.). New York: John Wiley & Sons.

Hartin, E. (2009, June). Smoke is fuel. FireRescue, 27(6), 54.

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

Kirk, E. (2009, June). Sudden blast: Unanticipated smoke explosion & building collapse nearly kills 3 firefighters. FireRescue, 27(6), 52-54.

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

National Institute for Occupational Safety and Health (NIOSH). (2006) Death in the Line of Duty Report F2005-13. Retrieved June 22, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200513.pdf

National Institute for Occupational Safety and Health (NIOSH). (2009) Death in the Line of Duty Report F2008-02. Retrieved June 22, 2009 from http://www.cdc.gov/niosh/fire/pdfs/face200803.pdf

Steward, P. (1914). Dust and smoke explosions, NFPA Quarterly 7, 424-428.

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

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