December 3, 2009 marks the 10th anniversary of the Worcester Cold Storage Warehouse fire that resulted in the line of duty death of six courages brother firefighters.

The Worcester Six;
Firefighter Paul Brotherton Rescue 1
Firefighter Jeremiah Lucey Rescue 1
Lieutenant Thomas Spencer Ladder 2
Firefighter Timothy Jackson Ladder 2
Firefighter James Lyons Engine 3
Firefighter Joseph McGuirk Engine 3

Overview
On Friday, December 3, 1999, at 1813 hours, the Worcester, Massachusetts Fire Department dis¬patched Box 1438 for 266 Franklin Street, the Worcester Cold Storage and Warehouse Co. A motor¬ist had spotted smoke coming from the roof while driving on an adjacent elevated highway. The original building was constructed in 1906, contained another 43,000 square feet. Both were 6 stories above grade. The building was known to be abandoned for over 10 years. Due to these and other factors, the responding District Chief ordered a second alarm within 4 minutes of the initial dispatch.

The first alarm assignment brought 30 firefighters and officers and 7 pieces of apparatus to the scene. The second provided an additional 12 men and 3 trucks as well as a Deputy Chief. Firefighters encountered a light smoke condition throughout the warehouse, and crews found a large fire in the former office area of the second floor. An aggressive interior attack was started within the second floor and ventilation was conducted on the roof. There were no windows or other openings in the warehousing space above the second floor.

Eleven minutes into the fire, the owner of the abutting Kenmore Diner advised fire operations of two homeless people who might be living in the warehouse. The rescue company, having divided into two crews, started a building search. Some 22 minutes later the rescue crew searching down from the roof became lost in the vast dark spaces of the fifth floor. They were running low on air and called for help. Interior conditions were deteriorating rapidly despite efforts to extinguish the blaze, and visibility was nearly lost on the upper floors.

Investigators have placed these two firefighters over 150 feet from the only available exit.
An extensive search was conducted by Worcester Fire crews through the third and fourth alarms. Suppression efforts continued to be ineffective against huge volumes of petroleum based materials, and ultimately two more crews became disoriented on the upper floors and were unable to escape. When the evacuation order was given one hour and forty-five minutes into the event, five firefighters and one officer were missing. None survived.

A subsequent exterior attack was set up and lasted for over 20 hours utilizing aerial pieces and del¬uge guns from Worcester and neighboring departments. Task force groups from across the State of Massachusetts responded to initial suppression and subsequent recovery efforts. During this time, the four upper floors collapsed onto the second which became known as “the deck”. Over 6 million gallons of water were used during the suppression efforts.

According to NFPA records, this is the first loss of six firefighters in a structure fire where neither building collapse nor an explosion was a contributing factor to the fatalities. (Excerpt from USFA report )

Take a moment to reflect on the events of December 3, 1999 and what they may mean to you. Consider your knowledge and understanding of buildings and structures within your district and surrounding response areas. Remember; “Building Knowledge = Firefighter Safety”. For those of you who do not know about this incident, attached is the USFA Incident Report that provides insights into the event and the lessons learned. Also check out the NIOSH Report and numerous archived articles on the web and within various journals.

Take at look at The Worcester Telegram & Gazette which has an archived webpage; http://www.telegram.com/static/fire/video.html

HERE ARE THE LESSONS LEARNED FROM THE 1999 USFA REPORT

1. Abandoned buildings remain a serious threat to the fire service and a danger to the communities in which they stand.
Fire departments have long recognized the danger of abandoned buildings in their communities, and fires in these structures have to be approached with a certain amount of caution and restraint. If questionable structural integrity, unknown hazardous materials, unusual dangers to firefighters, or other extreme risks exist, the buildings should not be entered. It is paramount that the fire service apply tactical risk assessment in its daily operations.

Because of the building design, the fire’s magnitude and location could not be ascertained from the exterior, and the Incident Commander had to assess the risks of sending in teams to evaluate the fire and sending in firefighters for suppression. Initial interior reports did not indicate a serious threat to personnel, and operations were conducted accordingly. To assist arriving crews, a placard system should be instituted which clearly defines the risks at an abandoned building. Subsequent to the fire, Worcester Fire put such a system in place. The process has an added benefit of placing firefighters and/or inspectors on locations which might be at risk and where prefire planning should be initiated.

Risks are not limited to the fire service. Homeless people and drug addicts have been known to inhabit such buildings out of necessity. Ordinary citizens can be impacted by increased crime, and these properties can become a very dangerous playground for inquisitive children. Efforts should be made to renovate or demolish such places even if public funding is not required.

2. Firefighters must make a concerted effort to know the buildings in their response districts.
Commercial buildings, by their very nature, pose additional dangers to firefighters, and their familiarity with any given fire building will help to lower these dangers. Company tours are an excellent way to accomplish this goal, and can serve to strengthen the bonds between firefighters and business owners. Such efforts must be conducted with sensitivity, and observed conditions or problems within a business should be conveyed in a helpful rather than confrontational manner.

3. Fire prevention efforts should be maximized in abandoned and temporarily vacated building to avoid fires in the first place.
Even temporarily vacated properties can be at risk if utilities like water for a sprinkler system or electricity for an alarm system are disconnected. Although service cessation often occurs when properties are the subject of financial problems it may also take place at the end of a lease or during the sale or renovation of a commercial building. Every effort should be made to forward change of occupancy or use information to first response stations.

4. Fire departments should continue to grown their file information on buildings in their communities.
Through the use of mobile computer systems, much information can be forwarded to responding companies and Incident Command during an emergency. Data could include floor plans, occupancies, hazardous materials, water supplies, special hazards, and much more. A system of this type would certainly not be limited to abandoned buildings, but it could be invaluable at such a scene since the probability of an owner showing up is unlikely.

Although this is laborious process, it may also be a valid use of on duty personnel who can gather information during regular shift time and either forward it to fire prevention or enter it themselves on provided computer terminals. Data could be gathered during in-service inspections and tours.

5. Delayed reporting allowed the fire growth to exceed the capabilities of aggressive interior attack suppression.
The exact time of ignition remains an unknown, but it has been established that the fire was burning for a minimum of 25 minutes before smoke was observed venting from the roof. It could have been burning for over an hour and a half. The huge volume of air in the warehouse could supports a large fire without any additional air from the outside.

Because flames weren’t visible from the exterior, passers-by did not recognize the presence of the fire, and it wasn’t discovered until smoke vented from the roof. Even that was apparently not enough to motivate the hundred of average citizens driving on I-290 that evening to call 9-1-1.

The trained eyes of public safety professionals were needed to separate this from “the ordinary” and then react appropriately. By this time, however, most of the second floor of B-building was burning, and few barriers were present to prevent further growth.

The initial report from Ladder 1 on the second floor describes a “room full of fire” in B-building beyond the door in the party wall. This location is some 30 feet from the room or origin, so a one room fire had enough time to engulf the entire floor. A sustained flow of 1000 GPM for 20 minutes had virtually no effect on the fire, and conditions deteriorated around attack crews.

6. Combustible interior finishes contributed to the rapid fire spread.
The concept of having 18 inches of combustible materials on the inside of all exterior walls of a building is almost unthinkable to firefighters. The original cork insulation which appears to have been attached with a tar-like substance provided a large volume of fuel, and additional layers of polystyrene and polyurethane with there ferocious burn characteristics gave this fire enormous intensity.

The area of origin was office space converted from a cold storage area. Under its original design and intent, insulation would only have been placed on exterior walls since the third floor was also cooled. Large amounts of insulation were put into place during the transition and would have included heavy insulation above the suspended ceiling on the underside of the third floor deck. An easily applied insulation would have been sprayed-on polyurethane foam which would have adhered to the wood joists and girders. Once the ceiling tiles were in place, it would not be noticed. The southern wall of the office space would have also required substantial insulation to keep out the cold and to retain the forced hot water heat from the radiators.

The fire fed on ordinary combustibles during its initial growth, but once the ceiling tiles were breached, flame contacted combustible wire insulation and ceiling insulation. The stubborn flames observed by fire crews and the smoke conditions described on upper floors are consistent with the sustained burning of petroleum based products including rigid polystyrene, polyurethane, tar, and glass board.

Proper permitting and on going inspections for construction changes within business occupan¬cies can help reduce non-complaint interior finishes.

7. The fire service should initiate life safety activities early on at a fire scene.
The concept of a Rapid Intervention Team was known to the Worcester Fire Department and was being implemented before the Worcester Cold Storage Fire, but it was not put into place until the 5th alarm on December 3rd. Firefighters had entered an unknown structure over one hour before the team was assigned. It is now standard procedure in Worcester to assign a RIT at the onset of each structure fire attack.

The first radio transmission by the Safety Officer was 10 minutes after the RIT was assigned. For control and monitoring of personnel, structural integrity, and other safety concerns, this position should also be filled early on. In an ideal fire scene, the Safety Officer and RIT would be in place before the first firefighters enter the building. Command should strive to have these jobs filled as early as possible even if doing so escalates the event to a higher alarm level to provide sufficient personnel. A system of personnel accountability should be in place. Someone should be tracking who enters the building, the time of entry, and time of exit. Firefighters who are nearing expected times of air exhaustion could then be contacted to ascertain their safety. The establishment of a Safety Officer at the onset of an event can work towards the goal of accountability. The Safety Officer need not be a department officer but could be a chief’s aide or available firefighter familiar with the duties and responsibilities of the assignment.

8. Large buildings such as warehouses and highrise merit unique search techniques and tools.
While the standard air bottle for SCBA has a 30 minute capacity, it might be necessary to have available 60 minute bottles for extended search situations and/ or RIT use. Some fire depart¬ments have obtained 60 minute systems for use in confined space rescues or other unusually long events. The 30 minute system has remained the norm in recent years as the necessity of Rehab time has gained prominence, and it would not be advisable to use longer air supplies on a regular basis.

In high rise incidents, it is common practice to carry in extra SCBA bottles. The same can be done in large space searches. Development of equipment and techniques to change bottles in a hot environment would give extra range to rescuers, and it could prolong their survival should their own rescue be required.

Long lifelines should be maintained for entry crews in these types of structures as well as marking devises for the interior. These devices include luminescent stickers to show direction, labels to signify searched areas, and other commercially available products. Their effectiveness, how¬ever, depends on their use. And the fire service should incorporate these procedures into more common firegrounds, such as single family houses. The time to try out a new technique is not during a major fire scene.

For searches involving extended distances, it might be helpful to position secondary search teams part way into a search area. They can wait in reserve in case they are needed, and they can serve as a rescue team for civilians or firefighters.

Finally, all firefighters who enter a structure must be wearing an SCBA. Worcester Fire has such a policy. Although the facemask and air may not be needed, it must be available. This includes chief officers, aides, and ladder personnel. Even firefighters who are outside structure like apparatus drivers should have SCBA protection available in case of wind shifts or air born particles and debris. With the preponderance of hazardous materials in businesses and residences, SCBA’s use is an essential.

9. Techniques must be improved to better track the movements of firefighters within a structure.
Under current technology limitations, Incident Command is essentially limited voice communication/radio to track the movements of firefighters once they enter a building and disappear from sight. IC normally knows where a crew entered and possibly what their destination is, but without good radio reports, the exact movements and locations of crews are uncertain at best.
Rescue 1’s crew and Engine 3’s Lieutenant both had difficulty communicating their positions which complicated and delayed rescue attempts. Crews continued to search multiple floors in the warehouse because of this uncertainty tying up precious personnel resources and adding more congestion to Stairway 3.

Despite all lost firefighters wearing integral PASS alarms on their SCBA’s, no surviving firefighters recalled hearing them at any time. The building insulation may have absorbed much of their sound, and the ever present background noise of the fire scene itself may have obscured the rest.

10. Radio channels are often overloaded at multiple alarm fires, and alternatives must be explored.
The 800 Mhz trunked radio system used by the Worcester Fire Department had several major failures during this event. Mechanical failure of individual units occurred when the “emergency alert” button on the hand microphone shorted out on contact with water. Fire Alarm repeatedly ordered individual radio operators to shut down, and this took precious air time during an escalating multiple alarm event. In some cases the microphones were detached in the field at which time they functioned normally. Microphones without the alert button were placed on all radios after the conclusion of this fire. During interior operations, there were 1,000 “push-to-talks” registered for the Operations A talk group, the assigned fireground channel.

Like many progressive fire departments, Worcester has taken steps to insure that all crews enter¬ing a fire building have radio communications. A typical piece of apparatus carries one portable for the officer and one for a second firefighting crew. All members of the Rescue Company carry portables. Having multiple radios is good for safety, but their use requires significant training and discipline. It is all too easy to clog up the air with nonessential transmissions.

In some events it may even be necessary to use more than one radio and frequency to properly manage the incident. This would require someone to assist the Incident Commander and keep communications in order. If nothing else, a fireground frequency must be adopted by Command and all working units. One possible way to limit talk time would be to have a staging officer communicate with, and pass along assignments to incoming companies on a frequency other than those used for dispatch and fireground command. Once an assignment was initiated, the company would switch over to the fire- ground channel.

Departments must also choose their radio equipment carefully. The band used must be the best for the standard physical environment in which operations are conducted. Urban departments working inside cement buildings have requirements that contrast greatly with a rural department operating over long geographical distances. If transmission quality continues to suffer, the use of mobile repeaters or other devices might need to be explored.

11. The use of Thermal Imaging Cameras should be further developed.
The Thermal Imaging Camera has become a useful rescue and investigative tool for the fire ser¬vice over the past six years. Although early models had some operational problems, the latest versions are reliable and offer more options such as transmission capabilities. It is a device that belongs in every fire department, but its high cost has prevented the purchase by many agencies. Sales volume will hopefully bring down the price of this beneficial tool.

The camera used at the Worcester fire failed to operate properly, and the manufacturer attributed the problem to thermal overload. This was an early model, and the rescue crew using it was nearly prevented from entering the warehouse by the high heat. Their attempt to enter was one of the last, and no other crews made significant interior progress.

Under this high heat, the effectiveness of the device is questionable. Thermal imaging devices work well in cooler environments where the body temperature of a victim is higher than the surrounding air or a hot spot within a wall is warmer than the abutting construction. At high heat levels, these cameras will often “white out” because everything in its view is hot enough to affect the imager. If a victim was down in elevated heat, he would absorb the thermal energy of his environment. The turnout gear, for instance, would get hotter and the camera would not be able to differentiate between it and its surrounds. The survivability of a person in high heat for an extended time is negligible.

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

ensure that inspections of vacant buildings and pre-fire planning are conducted which cover all potential hazards, structural building materials (type and age), and renovations that may be encountered during a fire, so that the Incident Commander will have the necessary structural information to make informed decisions and implement an appropriate plan of attack

ensure that the incident command system is fully implemented at the fire scene

ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed when activities, size of fire, or need occurs, such as during multiple alarm fires, or responds automatically to pre-designated fires

ensure that standard operating procedures (SOPs) and equipment are adequate and sufficient to support the volume of radio traffic at multiple-alarm fires

ensure that Incident Command always maintains close accountability for all personnel at the fire scene

use guide ropes/tag lines securely attached to permanent objects at entry portals and place high-intensity floodlights at entry portals to assist lost or disoriented fire fighters in emergency escape

ensure that a Rapid Intervention Team is established and in position upon their arrival at the fire scene

implement an overall health and safety program such as the one recommended in NFPA 1500, Standard on Fire Department Occupational Safety and Health Program

consider using a marking system when conducting searches

identify dangerous vacant buildings by affixing warning placards to entrance doorways or other openings where fire fighters may enter

ensure that officers enforce and fire fighters follow the mandatory mask rule per administrative guidelines established by the department

explore the use of thermal imaging cameras to locate lost or downed fire fighters and civilians in fire environments

In addition,
manufacturers and research organizations should conduct research into refining existing and developing new technology to track the movement of fire fighters on the fireground.

http://www.cdc.gov/niosh/fire/reports/face9947.html

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