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Buffalo, NY Three Alarm Fire and Double LODD Report

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8-26-2009 7-07-53 AMNIOSH released it’s report on the August 24, 2009 three alarm fire at 1815 Genesee Street in Buffalo, New York that resulted in the LODD of Lt. Charles McCarthy and FF Jonathan Croom. On August 24, 2009, 45-year-old career Lieutenant Charles McCarthy died following a partial floor collapse into a basement fire, and  34-year-old career fire fighter Jonathan Croom was fatally injured while attempting to rescue the Lieutenant.  The Buffalo Fire Department was dispatched for “an alarm of fire” with reported civilian(s) entrapment. Arriving units discovered a heavily secured mixed commercial/residential structure with smoke showing. Following failed initial attempts to locate an entry to the basement, crews located a door on Side 2 that provided access down a flight of stairs to a basement entry door. Repeated attempts were made to force open this basement door in order to search for trapped civilians, but crews had difficulty gaining access through this door because it was made of steel and locked and dead-bolted on both sides. Other crews on scene performed primary searches of the 1st and 2nd floors with no civilians found.

Approximately 30 minutes into the basement fire, command ordered all interior crews to exit the structure to regroup because crews were still unable to gain access into the basement from Side 2. Additional manpower was sent with special tools to assist in breaching the basement door on Side 2. Lieutenant Charles McCarthy and two fire fighters from his crew entered into the structure from Side 1 to verify all fire fighters had exited a 1st floor deli. Lt. McCarthy following a hoseline into the structure, was well ahead of the other two fire fighters when the 1st floor partially collapsed beneath him. McCarthy fell with the floor into the basement, exposing him to the basement fire. The other two fire fighters immediately exited the deli after fire conditions quickly changed and shelving and displays fell on them; they were unaware of what had just occurred. Lt. McCarthy made several Mayday calls from within the structure and activated his PASS device. Confusion erupted exteriorly on scene when trying to verify who was calling the Mayday, their exact location, and how they got into the basement.

The incident commander was aware that he had crews attempting to gain access into the basement from Side 2 but was unaware that there had been a floor collapse within the deli section of the structure. Simultaneously, FF Croom, a member of the fire fighter assistance and search team (FAST), was standing by outside  Lieutenant McCarthy’s point of entry when the Mayday calls came out. It is believed that FF Croom  knew where the Lt., was since he had gone in the structure with him earlier in the incident. FF Croom grabbed a tool, went on air, and rushed into the structure. The FAST and additional personnel on scene concentrated on Side 2 initially while other fire fighters followed an unmanned hoseline into the deli. Crews within the deli quickly discovered a floor collapse and reported hearing a PASS device alarming. Lt. McCarthy was immediately identified as missing during the first accountability check, but FF Croom was not accounted for as missing until the third accountability check, more than 50 minutes after Lt. McCarthy’s Mayday. After the fire was controlled, both victims were discovered side-by-side in the basement where the 1st floor had partially collapsed. They were found without their facepieces on and with SCBA bottles empty. the Lt’s. PASS device was still alarming. They were pronounced dead on scene. Four fire fighters and one lieutenant suffered minor injuries during the incident. No civilians were discovered within the structure.

Key contributing factors identified in this investigation include working above an uncontrolled, free-burning basement fire; interior condition reports not communicated to command; inadequate risk-versus-gain assessments; and, crew integrity not maintained.

NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should:

  • Ensure that all personnel are aware of the dangers of working above a fire, especially a basement fire, and develop, implement, and enforce a standard operating procedure (SOP) that addresses strategies and tactics for this type of fire.
  • Ensure that the incident commander (IC) receives interior status reports and performs/continues evaluating risk-versus-gain.
  • Ensure that crew integrity is maintained at all times on the fireground.
  • Ensure that the incident commander (IC) receives accurate personnel accountability reports (PAR) so that he can account for all personnel operating at an incident.
  • Ensure that a separate incident safety officer, independent from the incident commander, is appointed at each structure fire.
  • Ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.
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1815 Genesee Street 1815 Genesee Street

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that may have led to the fatalities:

  • Working above an uncontrolled, free-burning basement fire.
  • Interior condition reports not communicated to command.
  • Inadequate risk-versus-gain assessments.
  • Crew integrity not maintained.

Time Line from the Buffalo (NY) Fire Department Investigative Report

3:51 a.m. – fire crews were sent to 1815 Genesee Street in Buffalo. When they arrived, they were met by a resident who said he heard people trapped inside. Crews began searching the building, but were eventually ordered out as conditions deteriorated.

4:22 a.m. – Members of Rescue 1 entered the building to make sure all firefighters had evacuated the building. Less than two minutes later the floor in the rear of the building collapsed. Lt. McCarthy of Rescue 1 fell into the basement as the floor collapsed. according to the report, other members of Rescue 1 were unaware of the collapse and only reported hearing a loud noise. McCarthy began calling for help on his radio, but other members of Rescue 1 were unable to determine where the calls were coming from and left the building unaware that Lt. McCarthy was trapped.

4:23 a.m. – Firefighter Croom entered the building after hearing the calls for help. the report says he did not exit the building, apparently falling into the basement near Lt. McCarthy.

4:31 a.m. – An emergency head count was ordered to determine the identity of the missing firefighter. Lt. McCarthy was reported missing at that time, but FF Croom was not. Firefighters in the front of the store reported hearing a pass alarm, but could not reach it due to extreme fire conditions, a weakened floor and continuing collapse.

4:48 a.m. – all crews were ordered out of the building because it had become unsafe.

Later, concerns began to arise that FF Croom was missing. the report says he was erroneously reported in a remote area.

5:46 a.m. – On scene personal realize FF Croom is missing and likely inside the building.

6:10 a.m. – Another head count is taken and FF Croom is reported missing.

9:18 a.m. – the Recovery Group reports that the two missing firefighters had been located in the basement, covered in fallen debris.

9:32 a.m. – the debris is cleared and Recovery Group firefighters reach Lt. McCarthy and FF Croom.

Buffalo (NY) Fire Department Investigative Report, issued December 2, 2009, HERE

For a comprehensive Power Point Program on Operational Safety at Heavy Timber and Ordinary Construction Occupancys that you can down load, go to the National Firefighter Near Miss Reporting Web Site HERE.

I produced an informational training PPT program and support information that aligned with a previoulsy reported Near Miss Event Report. You can download the PPT Training Program HERE and the PDF File HERE

NIOSH Fire Fighter Fatality Investigative Report 2009-23, HERE

Buildingsonfire reaches Milestone

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Buildingsonfire on Face Book reaches 3,000 fan milestone, are you one? Sign up and follow Buildingsonfire on Facebook today

Remember, Building Knowledge=Firefighter Safety

Follow Commandsafety on Twitter, HERE and Buildingsonfire on Twitter, HERE

3-26-2010 9-31-01 PM

Operational Safety at Buildings Under Renovation

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A multiple alarm fire consumed the county courthouse in downtown Pittsboro, North Carolina yesterday. The building was undergoing renovations at the time of the fire and was occupied and operational. The fire started in the clock tower of the 130-yr.-old building and is believed to have been caused by welders.  The entire building was undergoing renovation with the outside enclosed with scaffolding. 

The clock tower had a protective tarp wrapped around it that preventing outside hose streams from reaching the seat of the fire. The fire broke out at 4:45 p.m., according to county and court officials, shortly after court sessions had ended. All who worked in the building were evacuated safely, according to county officials, and no injuries had been reported late Thursday. According to published reports, the courthouse, the centerpiece of the Pittsboro downtown, was built in stages. It was initially constructed in 1881 at a cost of $10,666, according to Paul Shield Crane’s first edition of “North Carolina Taproots: Courthouses of North Carolina.” In 1930, another story was added to the brick building and, in 1959, there was an extensive renovation that cost $130,000.

Bottom line, buildings undergoing construction, alterations, deconstruction, demolition and renovations can pose significant risk to suppression operations and lead to firefighter injuries and fatalities. This can not be stressed enough.

The unique and dangerous elements confronting incident commanders, company officers and operating forces demands a clear understanding that fire suppression operations in buildings during construction, alterations, deconstruction, demolition and renovations present significant risks and consequences, requires a methodical and conservative approach towards incident stabilization and mitigation. You cannot implement conventional tactical operations in these structures. Doing so jeopardizes all operating personnel and creates unbalanced risk management profiles that are typically not favorable to the safety and wellbeing of firefighters.

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The following are assessment considerations that may provide insights in the assessment, risk profile and development of pre-fire plans, operational procedures and field directives to prevent history repeating events (HRE) with similar conditions and attributes;

 Construction Type

  • What is the construction type or mixed application? How does this affect suppression, rescue, special operations and typical daily operations?
  • Stage and/or Phase of construction, alterations, deconstruction, demolition and renovations
  • The Stage and/or phase of construction, alterations, deconstruction, demolition and renovation has, SIGNIFICANT impact on firefighter safety and operational integrity.
  • Understanding these stages and phases can provide mission critical decision-making considerations to incident management teams and company officers.

 Site conditions and accessibility

  • Considerations for both horizontal, vertical and grade conditions.
  • Considerations during changes in stages and phases. Expect changes
  • Conduct periodic command and company level inspections and walk-through’s

 Exposures

  • These will be specific to the commonality or uniqueness of the structure and occupancy.

 Resources

  • Do you have enough of what’s going to be needed? Plan for it now, before you’re in the street needing it “yesterday”.
  • Think BIG, as the adage goes, you can always send the companies back. Don’t under estimate the types and kind of resources needs, based upon the structure profile and the potential of undetermined conditions. (reinforces need for pre-planning)
  • Share the Knowledge, Situational Awareness and Pre-planning inf
    ormation with other agencies (resources) you may call upon to support escalating or multiple alarm events.

 Operating procedures
Again, response and operations at these types of structures demands that pre-fire plan considerations, dialog, discussions, communications and what ever else is appropriate to you organization is identified and disseminated BEFORE an alarm response occurs. Take advantage of pre-gaming and table top a target occupancy, to increase preparedness and reduce risk potential.

  • Conduct periodic command and company level inspections and walk-through’s
  • Update the plans as conditions change
  • Share the information with other agencies (resources) you may call upon to support escalating or multiple alarm events.

 Knowledge and Situational Awareness

  • Understand, explore, research and obtain ALL the necessary information on the structure(s) undergoing construction, alterations, deconstruction, demolition and renovations
  • Conduct periodic command and company level inspections and walk-through’s
  • Communicate the observations, findings, conditions and considerations.

 Communications

  • What ever you identify- COMMUNICATE this throughout the organization.
    Share the information with other agencies (resources) you may call upon to support escalating or multiple alarm events.

 Special and Unique Conditions

  • Identify and plan for the Special and Unique Conditions that may exclusive to you jurisdiction’s structure undergoing construction, alterations, deconstruction, demolition and renovations.

 Contingency Plans

  • Plan of the unexpected and have contingent plans in place.

 The magnitude and complexity of an incident involving a structure undergoing construction, alterations, deconstruction, demolition and renovations will be directly proportional to the size of the building/construction site and corresponding age profile (vintage) of the existing building, if under renovation, and degree of construction. Operational deployment and the Incident Action Plan- IAP must be addressed during strategic and tactical incident management, risk profiling and pre-incident and on-scene intelligence, reconnaissance and planning considerations: More HERE

Shopping Center Explosion: Fluid Risk Assessment

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NIOSH recently released it’s report on the Penn-Mar Shopping Center Explosion that occured on May 7, 2008 in Prince George’s County, Maryland. Report Copy HERE. A number of mission critial lessons and insights can be gained regarding initial response, command management, operational safety, tactical deployment and effective situational awareness and dynamic risk assessment through an unstable progressing incident. Here are some of the insights and specifics.

At 12:54 PM on Thursday, May 7, 2009, Prince George’s County Firefighter/Medics were dispatched to respond to the Penn-Mar Shopping Center, a large 1-story strip mall, in the 3400 Block of Donnell Drive in Forestville and arrived at 12:59 PM.  First arriving crews initiated an investigation into a strong odor of natural gas inside the businesses.  Firefighters evacuated 5 of the 6 stores that were in the area of the odor, a sixth store was vacant. 

  • Forty-five people were evacuated from the 5 stores and firefighters then started ventilation efforts and called for assistance of the Washington Gas Company.  Firefighters discovered natural gas bubbling up from the ground on the exterior rear of the vacant store and minutes later reported that there was a fire on the interior. 
  • Within a minute, at about 1:20 PM, a massive explosion occurred. 
  • A MAYDAY call was sounded and additional resources including paramedics and a second alarm of firefighters were summoned to the scene.

Large plate glass windows blew shattered glass and other debris 60-70 feet into the front parking lot, the roof assembly appeared to have been lifted up and then fell back into place and the rear brick and block wall was completely blown out.  Firefighters were in the direct line of the explosion and suffered burns and injuries from flying debris.  Firefighters were wearing their personal protective gear which is believed to have minimized injuries.  They quickly gathered themselves and checked on other crew members and civilians that may have been injured.  A total of eight firefighters sustained a variety of injuries ranging from lacerations to second degree burns.  Four Firefighters were transported to the Washington Hospital Center Burn Unit where two were treated and released and two were admitted for additional treatment.  While initially transported with serious injuries, the firefighter’s conditions have been upgraded to “good.”  Four other firefighters were transported to other area hospitals and were treated and released.  One civilian, an employee of the Washington Gas Company was also treated and released from an area hospital.  There were no injuries to any of the 45 evacuated civilians. 

 3-18-2010 9-29-48 PM

A small fire resulted from the explosion that was quickly contained and extinguished.  The investigation so far has determined that the release of natural gas occurred in the vacant store and reached an ignition point that resulted in the explosion.  The Fire/EMS Department’s Technical Rescue Team completed a through secondary post-blast search of the damaged stores confirming that everyone heeded the orders of first arriving firefighters to evacuate.  (Excerpt from PGFD Press Release 05.07.2009)

 3-18-2010 9-09-52 PM

Building Knowledge

The south side of the structure was comprised of 10 business spaces (three of which were vacant) in a strip mall designed and constructed as a Type II, noncombustible classification in the 1970s. The section of the commercial structure involved in the incident was comprised of a main 2 story building, which included 2 vacant businesses and a mall office, with an adjoining wing on the right consisting of 6 businesses (1 unoccupied) in a single story with high dropped ceilings, large attic void spaces, and a sprinkler system. In the wing along the C-side were utility rooms housing the electrical circuit panels, sprinkler system controls, and security panels. It was constructed of brick/block and mortar with large plate glass windows on the A-side, block and mortar exterior C and D-side walls, and a block and mortar interior B-side wall adjoining the rest of the structure. The roof was a commercial flat roof consisting of open web, steel bar flat roof trusses covered with corrugated metal “q-deck” with multi-layered plies of bitumen laminated roof felts and topped with a granule-surfaced cap sheet. The open web steel bar roof trusses were connected to a steel beam and column structural assembly system.

The interior walls separating the businesses were primarily light weight galvanized metal studs covered with a ½ inch gypsum wall board providing tenant separation and compartmentation. The ceiling was a suspended acoustic tile ceiling system which provided a common void space over the business occupied areas of the adjoining right wing. The businesses contained office furniture, partitions, restaurant equipment and supplies, and health and beauty equipment and products.

NIOSH Report Summary

On May 7, 2009, two captains, a lieutenant, and five fire fighters were injured during a natural gas explosion at a strip mall in Maryland. At 1254 hours, dispatch reported a natural gas leak inside a business at a strip mall. Five minutes later, the initial responding crew and the incident commander (IC) arrived on scene to find a gas company employee looking for an underground gas leak. Approximately 6 minutes later, a natural gas leak was found near the exterior rear corner of the structure. After 23 minutes on scene, approximately 45 civilians were evacuated from 7 occupied businesses.

A captain exited the rear door of the business that had called in the natural gas leak and noticed fire along the roof line. Crews in the front and rear of the structure had begun to pull hoselines as another captain was looking out the rear doorway of a middle unoccupied business and noticed the electric meter located on the exterior wall on fire. Anticipating an explosion, he tried to leap out the rear doorway. At the same time, a fire fighter had entered the front door of the unoccupied business, noticed the heavy smell of natural gas, and felt air rush by as the structure exploded. Debris and fire blew out the front, rear, and roof of the structure. The captain who tried to leap out the rear doorway was blown into the rear parking lot and the fire fighter who had entered the front of the structure was blown out the front door and covered with debris. Numerous other fire fighters, primarily near the front of the structure were blown off their feet and hit with debris.

An uninjured captain issued a Mayday, followed by the IC ordering evacuation tones and a personnel accountability report. Crews began to look for the captain who was blown out the rear doorway. He had walked around the side to the front of the structure, and radioed his location to command. Fire fighters began moving injured personnel to ambulances staged in the front parking lot. Eight fire fighters and a gas company employee were transported to local hospitals. The injuries ranged from third degree burns to an ankle sprain.

Key contributing factors identified in this investigation included: insufficient execution of the fire department’s updated standard operating guidelines (SOGs) on incidents involving flammable gas, e.g., apparatus and fire fighters operating in a flammable area (hot zone); the accumulation of natural gas in the structure’s void spaces; unmitigated ignition source; insufficient combustible gas monitoring equipment usage and training; and, ineffective ventilation techniques.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should

  • ensure that standard operating guidelines for natural gas leaks are understood and followed
  • contact utility companies (natural gas and electric) immediately to cut external supply/power to structures when gas leaks are suspected
  • ensure gas monitoring equipment is adequately maintained and fire fighters are routinely trained on proper use
  • ensure ventilation techniques are conducted after ignition sources are mitigated
  • ensure that rapid intervention teams are staged at the onset of an incident
  • ensure that collapse/explosion control zones are established when dealing with a potential explosion hazard

Although there is no evidence that the following recommendations would have prevented these injuries, they are being provided as a reminder of good safety practices.

  • provide manual personal alert safety system (PASS) or tracking devices to locate potentially missing fire fighters when SCBA are not utilized
  • ensure standard operating guidelines for communications are understood by dispatch
  • ensure adequate staffing for emergency medical services and rapid intervention teams (RITs)
  • ensure training is evaluated for rank and skill levels across the combination department personnel

Contributing Incident Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that ultimately led to the injuries of eight fire fighters:

  • Insufficient execution of the fire department’s updated standard operating guideline on incidents involving flammable gas, e.g., apparatus and fire fighters operating in a flammable area (hot zone).
  • The accumulation of natural gas in the structure’s void spaces.
  • An unmitigated ignition source.
  • Insufficient combustible gas monitoring equipment usage and training
  • Ineffective ventilation techniques.

Building Knowledge=Fire Fighter Safety

When was the last time you and your company took a good look around some of your commercial shopping centers, strip centers, malls and business retail complexes? There is a wealth of mission critical information to be gained by conducting a basis walk through and looking at some key construction, configuration, layout and access and utilities features.

Take note of the structural systems that comprise the roof assemblies and the wall and supporting interface. Identify the basic volume of the commercial spaces paying close attention to the common tenant storage, storerooms, access and transfer loading dock and delivery areas.  Focus and take note of the fire loading and its expected degree of fire behavior and intensity. Check out the condition and operability of the fixed suppression systems and the integrity of fire barriers and separations.

There’s so much “free” data and information to be gained by going “shopping”; all of which will transcend and can be retrieved at such time a response materializes at that location in the future. If you can, capture the pertinent information into your pre-fire planning data base and make sure you discuss and share your observations, postulated strategies and tactics around the kitchen table or as a table top exercise or better yet in the form of an on-site drill or multi-company training exercise.

Be prepared for the unexpected and always use extreme caution and heightened situational awareness and fluid risk assessment and reconnaissance processing to stay atop of any undefined and evolving incident. Do not allow the potential lack of severity; of what may have all the indications of an unremarkable/uneventful and common call run such as a gas odor investigation or a natural gas leak cause your companies to have less than a high level of alert, focus and attentive accretions through all phases and deployments of the incident. Don’t become complacent.

In addition, take a look at some information relate to another tragic incident response to a reported gas leak that occurred in December, 1983 that lead to five fire fighter LODD’s in Buffalo, New York. HERE

Archived Report From STATter911, from May, 2009 HERE and recent 2010 update HERE with fireground Audio

Prince George’s County (MD) Fire Press Release from May 7, 2009, HERE

Slide Show from WUSA9.com HERE 

BING mapping Images, HERE

NIOSH Compilation of Line-of-Duty Injury and Death Investigation Reports and Publications CD

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3-18-2010 5-26-09 PMIf you’re looking for a great resource check this out at NIOSH’s Fire Fighter Fatality Investigation Program and Prevention Program. HERE.

NIOSH is offering a Compilation of Line-of-Duty Injury and Death Investigation Reports and Publications CD. This CD-ROM contains a compilation of all NIOSH fire fighter fatality and injury investigation reports completed through August 2009. Since 1998 NIOSH has investigated over 420 incidents involving fire fighter line-of-duty deaths and injuries. This CD-ROM also contains 21 NIOSH publications and 1 Safety Advisory covering a number of topics specific to fire fighter safety and health.

CD ROMs of this publication can be downloaded directly from the web site and a copy created using CD authoring software.

Fire Fighter Fatality Investigation and Prevention Program web site HERE

Maintaining Situational Awareness

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00-EOY-ss-buildingcollapseMaintaining focused situational awareness while recognizing and processing a wide latitude of incoming information and observations at complex and multiple alarm incidents is a significant challenge to even the most experienced of incident command teams. However, things can go wrong and they can go wrong in a rapidly escalating manner with little time to recover. A prominent double LODD incident from six years ago provides poignant lessons learned as does another history repeating event (HRE) from 1972.

The Ebenezer Baptist Church fire in Pittsburg, PA (2004) and the Hotel Vendome Fire in Boston, MA (1972) have a number of commonalities related to extended multi-alarm operations, building compromise and collapse and multiple line-of-duty deaths of operating fire service personnel. Although building type, construction features and systems are unique for each incident as are the circumstances that lead to the events, there are mission critical lessons to be reexamined or newly introduced if you’re not familiar with either event. This is especially true when we talk about operational challenges and adverse conditions that result in firefighter injuries and fatalities during overhaul and take-up phases of an incident.

Remember Situation Awareness, [SA], is the perception of environmental elements within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. It is also a field of study concerned with perception of the environment critical to decision-makers in complex, dynamic situations and incidents.

Both the 2006 and 2007 Firefighter Near-Miss Reporting System Annual Reports identified a lack of situational awareness as the highest contributing factor to near misses reported. Situation Awareness (SA) involves being aware of what is happening around you at an incident to understand how information, events, and your own actions will impact operational goals and incident objectives, both now and in the near future. Lacking SA or having inadequate SA has been identified as one of the primary factors in accidents attributed to human error (Hartel, Smith, & Prince, 1991) (Nullmeyer, Stella, Montijo, & Harden, 2005). Situation Awareness becomes especially important in work related domains where the information flow can be quite high and poor decisions can lead to serious consequences.

To the Incident commander, Fire Officer or firefighter, knowing what’s going on around you, and understanding the consequences is mission critical to incident stabilization and mitigation and profoundly crucial in terms of personnel safety. The integration of Situational Awareness and Dynamic Risk Assessment is a mission critical element in strategic incident command management and company level tactical operations as we go forward into the next decade. We’ll expand on some posting in the near future and address Dynamic Risk Assessment in the context of building and occupancy profiling and operations. Additionally, maintaining a heightened sense of risk and safety integrity when operating within non-combat fire suppression modes or phases also requires due diligence, focused and fluid situational awareness coupled with concise monitoring of building conditions, indicators (both evident and projected) and taking conservative actions and postures to ensure personnel are not placed in high risk, no value positions that have a high potential for error likely outcomes.

Check out the detailed posting at our sister site TheCompanyOfficer.com for insights into both the Ebenezer Baptist Church fire in Pittsburg, PA (2004) and the Hotel Vendome Fire in Boston, MA (1972) HERE. Think about the questioned posed related to complex multi-company operations, command safety and operational integrity of compromised buildings and structural systems. Remember; Building Knowledge=Firefighter Safety.

Risk versus Gain: Operations in Vacant or Abandoned Structures

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DFD102406138Risk versus Gain: Operations in Vacant or Abandoned Structures

Fire Fighter LODD after Being Trapped in a Roof Collapse During Overhaul of a Vacant/Abandoned Building. NIOSH recently published a report on a 2008 LODD that occurred in a vacant/ abandoned building. NIOSH Report F2008-0037. The full report is available HERE. Let’s look at some insights and overviews of that report.

Report Summary

On November 15, 2008, a 38-year-old male fire fighter  died after being crushed by a roof collapse in a vacant/abandoned building. Fire fighters initially used a defensive fire attack to extinguish much of the fire showing from the second-floor windows on arrival. After the initial knockdown, fire crews entered the second floor to perform overhaul operations. During overhaul, the roof collapsed with several fire fighters still inside, on the second floor. The victim and two other fire fighters were trapped under a section of the roof. Crews were able to rescue two fire fighters (who self-extricated), but could not immediately find the victim. After cutting through roofing materials, the victim was located by fire fighters, unconscious and unresponsive.

He was removed from the structure and transported to a local hospital where he was pronounced dead. Key contributing factors identified in this investigation include: dilapidated building conditions, incendiary fire originating in the unprotected structural roof members, inadequate risk-versus-gain analysis prior to committing to interior operations involving a vacant/abandoned structure, inadequate accountability system, lack of a safety officer, an inadequate maintenance program for self-contained breathing apparatus (SCBA) and a poorly maintained and likely inoperable personal alert safety systems (PASS), ineffective strategies for the prevention of and the remediation of vacant/abandoned structures and arson prevention.

Inherent Construction Issues

This incident occurred in a vacant unsecured residential structure which had experienced a previous fire approximately one year prior to this incident. During interviews with NIOSH investigators, fire fighters reported large amounts of fire showing from all windows on the second floor on arrival. Fire fighters also reported that the roof had burned through on the Side B/C and one fire fighter reported he could see the sky while ascending the interior stairs to perform overhaul. It is not known if the roof conditions were communicated to the incident commander before fire fighters were assigned to operate on the roof. The fire fighters were unaware of the conditions such as the exposed roof assembly, possible removal of rafter connectors (collar beams), and the use of a flammable liquid in the structural members of the roof and second floor attic area. The roof assembly (being unprotected) was directly involved as part of the fuel in this fire.

The large dormer on the A-side presents an identifiable inherent risk factor (due to the potential for structural compromise or failure) when found on 1.5 story bungalow style residential structure due to the integral manner in which the dormer structure, i.e., roof rafters, dormer framing and roofing boards along with the functionality of the ridge beam must function in order to retain structural integrity under fire conditions. The dormer may be actually supported at the upper end directly onto the roofing boards, which in turn are supported by the perpendicular roof rafters. This creates a potential area for pronounced degradation when exposed to direct or indirect flame impingement creating an area prone to early structural compromise and eventual failure.

Although the initial defensive strategy in fighting the fire was successful in knocking down the fire, the incident commander may have benefited from a continuous risk-versus-gain analysis before allowing crews to operate on interior during overhaul. The first arriving officer reported that he performed a walk around prior to allowing crews to enter the structure and the building appeared intact, but he would not have known of the alterations to the interior roof system and the removal of critical structural members. Interior condition and roof condition reports might have revealed the burned-through area of the roof, and tactics could have been altered to keep fire fighters off the roof and out of the structure.

Report Recommendations included;

  • Ensure that the incident commander conducts a risk-versus-gain analysis prior to committing to interior operations in vacant/abandoned structures and continues the assessment throughout the operations
  • Ensure SOPs are developed for fighting fires in vacant/abandoned buildings
  • Ensure that the incident commander maintains close accountability for all personnel operating on the fireground
  • Ensure that a separate incident safety officer, independent from the incident commander, is appointed at each structure fire
  • Ensure that a respiratory protection program is in place to provide for the selection, care, maintenance, and use of respiratory protection equipment, including PASS devices.

Additionally, municipalities and local authorities having jurisdiction should:

  • Develop strategies for the prevention of and the remediation of vacant/abandoned structures and for arson prevention.

Although there is no evidence that the following recommendations could have prevented this fatality, NIOSH investigators recommend that fire departments:

  • Ensure that an EMS unit is on scene and available for fire fighter emergency care at working structure fires
  • Develop inspection criteria to ensure that all protective ensembles meet the requirements of NFPA 1851, Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting
  • Be aware of programs that provide assistance in obtaining alternative funding, such as grant funding, to replace or purchase fire equipment that can support critical fire department operations.

Vacant or Unoccupied: Tactical Risk and Safety

I’ve commented on this subject a few times. We seem to do a lot of things at times out of common practice and repetition, you know; “We’ve always done it that way….” syndrome. There’s a resonating theme that is making its way around the fire service dealing with going to a defensive tactical posture at vacant or unoccupied structure fires.

This command posture leads to limiting interior operating engagement, while promoting a high degree of risk management. With that being said, there are also plenty of opinions on these types of policies as such, since this type of tactical effort may be contrary to the local “culture and traditions” of the responding agencies and may be a hard pill to swallow, since we’re in the job of “ fighting ALL fires..” Please refresh your memories on a past post on Tactical Entertainment HERE and HERE

Here are some basic definitions to keep us all on the same playing field;

Vacant; refers to a building that is not currently in use, but which could be used in the future. The term “vacant” could apply to a property that is for sale or rent, undergoing renovations, or empty of contents in the period between the departure of one tenant and the arrival of another tenant. A vacant building has inherent property value, even though it does not contain valuable contents or human occupants.

Unoccupied; generally refers to a building that is not occupied by any persons at the time an incident occurs. An unoccupied building could be used by a business that is temporarily closed (i.e. overnight or for a weekend). The term unoccupied could also apply to a building that is routinely or periodically occupied; however the occupants are not present at the time an incident occurs. A residential structure could be temporarily unoccupied because the residents are at work or on vacation. A building that is temporarily unoccupied has inherent property value as well as valuable contents.

Here’s a formulative question;

  • As a responding company, you arrive at the scene of a vacant or unoccupied structure. The building’s construction features and systems have inherent risk associated with the occupancy, (as is the case with nearly all of our structures and occupancies).
  • Your company determines that you’re going to go defensive, even though you probably could make a reasonably safe entry and engage in interior structural fire suppression.
  • Would there be any repercussions in your station, battalion/district/community or organization if you took this tactic?
  • What are YOUR personal thoughts on this form of risk management?

 Some insights, HERE and HERE, HERE, HERE and HERE

Additional Links, HERE, HERE and HERE

The “Routiness” of Success, Or Not..

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BM11

It’s no longer just brute force and sheer physical determination that define structural fire suppression operations. Aggressive firefighting must be redefined and aligned to the built environment and associated with goal oriented tactical operations that are defined by risk assessed and analyzed tasks that are executed under battle plans that promote the best in safety practices and survivability within known hostile structural fire environments, while maintaining the values and traditions that defines the fire service.”- Christopher Naum

The lack of appreciation and the understanding of correlating principles involving fire behavior, fuel and rate of heat release and the growth stages of compartment fires within a structural occupancy are the defining paths from which the fire service must reexamine coordinated suppression operations in order to identify with; the predictability of occupancy performance during fire suppression operations, thus increasing suppression effectiveness and firefighter safety.

Our buildings have changed; the structural systems of support, the degree of Compartmentation, the characteristics of materials and the magnitude of fire loading. The structural anatomy, predictability of building performance under fire conditions, structural integrity and the extreme fire behavior; accelerated growth rate and intensively levels typically encountered in buildings of modern construction during initial and sustained fire suppression have given new meaning to the term combat fire engagement.

 

 It begs to suggest that many of today’s incident commanders, company officers and firefighters lack the clarity of understanding and comprehension that correlate to the inherent characteristics of today’s buildings, construction and occupancies and the need for refined suppression operations within the modern building construction setting.

 

We assume that the routiness or successes of our operations and incident responses equates with predictability and diminished risk to our firefighting personnel. Does your company, your officers, your commanders, your department treat all things as equals when addressing the variables of structural combat fire operations? Is the equation of Occupancy Risk balanced with Occupancy Type? Are inherent structural stability and compromise conditions adequately identified and considered in the evolving progression of an incident action plan? Or do SOP and SOG’s drive the manner in which fire ground strategies and tactics are orchestrated and implemented at the company task level?

 

How does this fit into your “culture, values and philosophy as a firefighter, officer or commander?”