A View from the Street; Remembrance and Paying Respect
A brief trip on Friday took me to the City of Buffalo, New York. Following business, I made my way to 1815 Genesee Street. As the morning sun began to burn off the light layer of fog, I came upon my destination which at first glance is an empty lot sided by a convenience store (bodega) on one side and a side street on the other.
Further observations would reveal a new American flag affixed to the street sign.
A decorative metal plate fastened to a light pole and a small flower arrangement toppled over in the center of the grassy lot.
At 03:51 hours, on August 24, 2009 Buffalo (NY) FD companies responded to a structure fire at this address. As the fire escalated to three alarms, the subsequent partial floor collapse would claim the lives of Lt. Charles “Chip” McCarthy and FF Jonathan Croom. Attached is a previous posting and link on CommandSafety.com with links to the FD and NIOSH reports and incident insights.
NIOSH Report: Career Lieutenant Dies Following Floor Collapse into Basement Fire and a Career Fire Fighter Dies Attempting to Rescue the Career Lieutenant – New York (REPORT HERE)
Much is being written, debated and argued in our profession related to the job, firefighting, operations, safety, tradition and tactics; what we should or should not be doing.
Standing solemnly on this hallowed ground this morning, I prayed and paid tribute to two brother firefighters who represented everything the American Fire Service epitomizes and the sacrifices made for the citizens we protect each and every day.
Look and Study the photo; think about the fact that a building once stood there, that a fire occurred, a Fire Department responded, Companies and Firefighters engaged and went to work the job.
Two brothers paid the ultimate sacrifice based upon their oaths, obligations and responsibilities as firefighters.
1815 Genesee Street Photo by CJ Naum
The panoramic view from the street depicts an empty lot. To the public, it’s a non-descriptive part of the neighborhood and urban landscape and city fabric. To us, it is much more.
That vacant property and it’s represented history from 2009 should give pause and reflection to our job as firefighters, our responsibilities, our duty, our tradition and the continued need for operational excellence, personal competencies and skill development and the strive to be adaptive to the continued challenges the evolving Fireground and buildings presents today and tomorrow.
It’s understanding our buildings, their inherent predictability of performance, occupancy risk and today’s extreme fire behavior that we are leaning so much more about.
My view from the street on Friday, at this address reaffirmed who I am, what I do and why I continue to give back to this; the greatest profession-the Fire Service.
What about you?
Foremost- remembering Lt. McCarthy and Firefighter Croom, and the many other firefighters who over the years and decades have paid the sacrifice. Honor, Duty, Courage and Fortitude.
Courtesy of Buildingsonfire.com
Building Knowledge=Firefighter Safety
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The Waldbaum’s Supermarket Fire and Collapse FDNY 1978 Thirty Five Years ago: The Waldbaum Super market fire, Brooklyn, New York occurred on August 2, 1978. Six firefighters died in the line of duty when the roof of a burning Brooklyn supermarket collapsed, plunging 12 firefighters into the flames. The fire began in a hallway near the compressor room as crews were renovating the store, and quickly escalated to a fourth-alarm. Less than an hour after the fire was first reported, nearly 20 firefighters were on the roof when the central portion gave way.
The FDNY members killed in the Waldbaum’s fire included: • Lt. James E. Cutillo, Battalion 33 • Firefighter Charles S. Bouton, Ladder Company 156 • Firefighter Harold F. Hastings, Battalion 42 • Firefighter James P. McManus, Ladder Company 153 • Firefighter William O’Connor, Ladder Company 156 • Firefighter George S. Rice, Ladder Company 153
Comprehensive incident insights, photos and building construction diagrams on past post here on CommandSafety.com
The approximately 120 ft. x 120 ft. primary building was originally built in 1952 as a supermarket and at the time of the fire was undergoing extensive renovations and was open and operating. Constructed with exterior masonry bearing walls of with timber roof trusses with a 100-foot clear span, supported on pilaster columns embedded in the exterior walls, it was classical Type III construction. The truss system supported an ornamental tin ceiling and 18 inches below that concealed space a conventional suspended acoustic ceiling tile panel system was present. Reports indicated the tin ceiling was attached directly to the bottom cord of the truss system. A two story mezzanine and machine room was located at the north wall of the original building. Access through the truss loft area was accessible through man-doors at the plane of each truss.
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Fire in Syracuse: Four firefighters LODD: The 701 University Avenue Fire April 9, 1978
April 9th marks the 35th anniversary of the 701 University Ave. fire that claimed the lives of four Syracuse (NY) firefighters in 1978 while conducting search & rescue and suppression operations at an apartment building on the Syracuse University Campus, in Syracuse, New York.
The fire began when one of the tenants lit a candle in a styrofoam wig stand and left it unattended. At 00:46 hours on Sunday April 9, 1978, an alarm of fire was transmitted for a reported building fire at 701 University Avenue on the campus of Syracuse University.
The Victorian style house was a three story building constructed of wood balloon framing and was built circa 1898. The house had been converted into ten (10) apartments that were occupied by SU students. The gross area of each of the three floors was approx. 1,750 sq. ft., with a predominate rectangular footprint shape measuring 69 ft. x 35 ft. The third floor apartments only had access via a stairway in the rear, down a long narrow corridor that measured only 33 inches wide.
Post Fire View of Building from Bravo Side. Photo CJ Naum, 1978
The building had inherent vertical and horizontal concealed spaces indicative of balloon frame style construction along with additional concealed spaces in the third floor ceiling area. A partial automatic sprinkler system had been installed in the building in order to comply with a 1952 State of New York law. This system provided protection to the basement, means of egress, a storage area and a portion of the concealed space above the third floor.
The fire originated in a second floor apartment, and then spread into the combustible concealed space above the third floor ceiling. Approximately sixteen minutes into fireground operations the first indications of firefighting personnel being in distress were received. The first call to the Alarm center was made at 0045:17 hrs., with the first-due engine arriving at 0048:05 and first water applied at 0051 (est).
The four SFD fire fighters, Frank Porpiglio Jr., Stanley Duda, Michael Petragnani, and Robert Schuler, who were assigned to the Squad and Rescue Companies, entered the house to conduct a primary search of the premises for SU students thought to be trapped in the house.
While operating on the third floor inside, a scalding steam caused by triggered sprinklers prevented the four firefighters from escaping, and they eventually depleted their air supply and suffocated to death. The firefighters were operating with full PPE that was complaint at that time ( 1978) and were utilizing state-of-the art SCBA in the form of the new 4.5 SCBA systems. All the tenants had escaped safely before the fire fighters had entered the house. The fire was subsequently investigated by the National Fire Protection Association (NFPA) at the request of the City of Syracuse and NFPA Report No. LS-3 was published.
Syracuse Post Standard Front Page April 10, 1978
Killed in the Line of Duty on April 9th, 1978:
Syracuse (NY) Fire Department
FF Michael Petragnani, Age 27. ~ Rescue Company – appointed 8/20/1973
FF Frank Porpiglio Jr., Age 24. ~ Squad Company – appointed 8/20/1973
FF Robert Shuler, Age 31. ~ Squad Company – appointed 1/24/1973
FF Stanley Duda, Age 34. ~ Squad Company – appointed 1/24/1973
Remembrance, Honor, Courage and Sacrifice
Post Fire View, East Adams Street and University Ave. Photo: CJ Naum, 1978
Martin J. Whitman School of Management stands today at the corner, Photo CJ Naum, 2013
Memorial Plaque placed in 2005 in the Martin J. Whitman School of Management located on the site of 1978 fire. Photo: CJ NAum, 2013
Remembering the Sacrafice: Capt. Broxterman and FF Schira
On Friday, April 4, 2008 at 06:13:02 hours, what began as a routine response for Colerain Township Fire and EMS Engine 102 to investigate a fire alarm activation at 5708 Squirrels nest Lane, Colerain Township, Ohio resulted in the deaths of Colerain Township Captain Robin Broxterman and Firefighter Brian Schira.
Upon their arrival at the scene of the two-story wood framed, residential building working fire conditions existed in the basement. The initial attack team consisted of Broxterman, Schira, and one other firefighter. The team advanced a 1¾-inch attack hose line through the interior of the building for fire control.
Even though, they were provided with some of the most technologically advanced protective clothing for structural firefighting and self-contained breathing apparatus, it appeared that Broxterman and Schira were overwhelmed by severe fire conditions in the basement.
During their attempt to evacuate the building, the main-level family room flooring system in which the two were traveling on collapsed into the basement trapping the firefighters. Eleven minutes elapsed from time of arrival to the catastrophic chain of events.
This is one of those distinctive reports that has influential and critical operational, training and preparedness elements embedded throughout the report.
It’s apparent there continues to be common threads shared by this event from 2008 and other events and incidents in the past five years where a single of multiple firefighters have lost their lives due to similarities in the apparent and common cause deficiencies and short comings identified.
All company and command officers should read and comprehend the lessons learned. Then, take these new found insights and see what the gaps are at the personal level (yours or those you supervise) as well as the shift, group, station, battalion, division or department as a whole.
If there are gaps, then identify a way to implement timely changes as necessary so there are No History Repeating (HRE) events.
The importance of Reading the Building, taking the time to complete the three sixty and being combat ready and “expecting fire”.
Remember their sacrifice, so we can learn.
Past Post on CommandSafety.com with Report Narrative and Incident DetailsHERE
The following factors were believed to have directly contributed to the deaths of Captain Broxterman and Firefighter Schira:
A delayed arrival at the incident scene that allowed the fire to progress significantly;
A failure to adhere to fundamental firefighting practices; and
A failure to abide by fundamental firefighter self-rescue and survival concepts
Although the aforementioned factors were believed to have directly contributed to their deaths, they might have been prevented if:
Some personnel had not been complacent or apathetic in their initial approach to this incident;
Some personnel were in a proper state of mind that made them more observant of their surroundings and indicators;
The initial responding units were provided with all pertinent information in a
timely manner relative to the incident;
Personnel assigned to Engine 102 possessed a comprehensive knowledge of their first-due response area;
A 360-degree size-up of the building accompanied by a risk – benefit analysis
was conducted by the company officer prior to initiating interior fire suppression operations;
Comprehensive standard operating guidelines specifically related to structural
firefighting existed within the department;
The communications system users (on-scene firefighters and those monitoring the incident) weren’t all vying for limited radio air time;
The communications equipment and accessories utilized were more appropriate for the firefighting environment;
Certain tactical-level decisions and actions were based on the specific conditions;
Personnel had initiated fundamental measures to engage in if they were to become disoriented or trapped inside a burning building; and
Issued personal protective equipment was utilized in the correct manner.
Colerain Township Department of Fire and Emergency Medical Services, Web Site HERE
Investigation Analysis of the Squirrels nest Lane Firefighter Line of Duty Deaths April, 2010 Full Report HERE
NIOSH Fire Fighter Fatality Investigation Report F2008-09| CDC/NIOSH July, 2009, Report HERE
Was working on an LODD report and came across a past notable incident that occurred over 32 years ago, that should be recognized, for many of you that may not of heard or read about it previous to this.
Here’s an intro and a link to the LAFD January 28, 1981 incident;
On January 28, 1981, at 3:33 a.m, a full alarm assignment was dispatched to Cugees Restaurant,5300 Lankershim Boulevard, in the North Hollywood area.
Firefighters found heavy smoke with some fire showing in the interior of the restaurant.
Because a back draft explosion was a distinct possibility and because the smoke had to be cleared in order to begin a meaningful fire attack, ventilation procedures were begun on the roof.
Four members of Truck 60 were cutting a hole near the center of the roof when, without warning, it began to sink beneath their feet. One firefighter described the sensation as similar to standing on the deck of a rapidly listing ship. As the roof sank, it fell at a steep angle, slowly and agonizingly pulling Apparatus Operator Thomas G. Taylor to his death.
In Memory of Apparatus Operator Thomas G. Taylor Truck Company 60 B Platoon
Appointed July 22, 1973
Died January 28, 1981
Died of burns in roof collapse at arson fire.
5300 Lankershim Boulevard
March 10, 1941: The Strand Theater Fire turned from a routine fire into one of the worst tragedies in Brockton and Massachusetts history when the west section of the roof collapsed, killing 13 firefighters and injuring 20 firefighters.
Check out the comprehensive past post fromCommandSafety.com from 2011
On December 3, 1999, a five-alarm fire at the Worcester Cold Storage & Warehouse Co. building claimed the lives of six brave firefighters who responded to the call. These six heros, The Worcester 6, sacrificed their lives to try and rescue two individuals who were believed to be trapped inside the inferno. May the Worcester 6 always be remembered; “Fallen Heroes Never Forgotten.”
The 1942 Luongo’s Restaurant Fire and Collapse in East Boston; Six Boston Firefighter Line of Duty Deaths
Boston Fire Department Box 6153 Five Alarm November 15,1942
Boston Fire Department Box 6153 Five Alarm November 15,1942
A multiple alarm fire and collapse 70 years ago resulting in six Boston Firefighter LODDs was overshadowed by the Coconut Grove Fire which occurred 13 days later. Here’ the story and legacy.
The 1942 Luongo’s Restaurant Fire and Collapse in East Boston; Six Boston Firefighter Line of Duty Deaths
During the early morning hours of Sunday November 15, 1942, a still alarm followed by box alarm 6153 was received for a fire at 4-6 Henry Street located in the Old Armory Building at Maverick Square in East Boston (MA). The address was for a report of fire in the Luongo’s Restaurant. A fire broke out in the rear of Luongo’s Restaurant on the first floor at about 2:26 a.m. The Boston Fire- District #1 report stated the fire originated in the rear kitchen ceiling.
November 16, 1942 New York Times:
The following is a description of the fire from the November 16, 1942 New York Times: “The fire, starting from a fireless cooker in the cafe on the ground floor at Henry Street and Maverick Square, suddenly swept through the building.
The firemen who were killed had just entered a restaurant on the second floor with a line of hose. As the flames ate through the cross timbers the wall collapsed with a roar, burying two men on the stairs and crushing the three others manning the hose. That part of the wall which fell outward felled about forty firemen standing on the Henry Street side of the building beside the new $20,000 ladder truck, which was buried under the wreckage. At the same, a hot air explosion blew a half dozen firemen across Henry Street.”
The Luongo’s Restaurant was housed in what was called the Armory Building a five and one half story Type III Building of ordinary construction (Brick and joist) consisting of masonry bearing walls with approximate dimensions of 35 feet width x 60 feet depth x 65 foot height. The ensuing fire would spread to the exposure building at 10 Henry Street a three story 20 ft. X 40 ft. x 40 ft type III (brick and joist) structure.
Courtesy of the Boston Public Library, Leslie Jones Collection.
Fire and Collapse
Upon arrival of the first alarm companies, the fire initially was commanded by Fire Captain Amsler, Ladder Co. 2. District Chief Crowley rapidly assumed command upon his arrival and directed initial fire suppression activities of the companies to interior operations and quickly ordered a second alarm at 03:04hours.
Command was subsequently transferred to Deputy Chief Louis Stickel who ordered a third alarm struck due to fire extension twenty minutes later.
Suppression, ventilation and rescue operations were conducted with the fire under control when at 04:15 hours with without warning, it was reported the 3rd, 4th and 5th floors began to collapse with the brick masonry wall on the Henry Street side collapsing outward into the street. Ladder Company 8, a new 125 ft. aerial ladder, the largest in the United States at the time was buried in the timber and brick rubble and collapse pile. It was reported that as many of 43 firefighters in the street were injured as a result of the collapse.
Search, Rescue and Recovery Efforts
The arrival of Chief of Department Samuel Pope ordered fourth and fifth alarms. This brought Engine Companies 40, 9, 5, 11, 50, 8, 32, 6, 39, 3, 33, 12, 13, 38, 21, 35, 37, 20, 16, 10, 42, 51, 19; Ladder Companies 2, 31, 21, 8 and 3.
First Alarm: 02:27 hrs.
Second Alarm: 03:05 hrs.
Third Alarm: 03:24 hrs.
Fourth Alarm: 04:20 hrs.
Fifth Alarm: 04:35 hrs.
With both extensive interior and exterior collapse conditions with numerous trapped and injured firefighters, rescue efforts and medical assistance was being rendered by all fire service, military, hospital and civilian resources. Local Coast Guardsman were deployed to support the massive search and rescue efforts.
Rescue and Recovery
Six Boston Firefighters were killed in the line of duty as a result of the collapse, all of whom were conducting operations and working on the second floor with hose lines.
Supreme Sacrifice in the Line of Duty:
Hoseman John F. Foley, Engine Company 3
57 years of age | 30 year veteran
Hoseman Edward F. Macomber, Engine Company 12
47 years of age | 24 year veteran
Hoseman Peter F. McMorrow, Engine Company 50
45 years of age | 19 year veteran
Hoseman Francis J. Degan, Engine Company 3
24 years of age | 15 month veteran
Ladderman Daniel E. McGuire, Ladder Company 2
44 years of age | 19 year veteran
Hoseman Malachi F. Reddington, Engine Company 33
48 years of age | 19 year veteran
The Department’s 125 foot “jinx” aerial ladder, reported to be the largest in the nation at that time, was standing beside the falling wall on Henry Street. It was buried in the wreckage. The ladder was originally purchased by the City of Somerville. They found upon delivery that it was too big for their firehouse. Boston bought it. The truck had a series of problems. (additional Story on the 1941 American La France 125′ metal aerial By William Noonan,HERE) Apparatus Info – See Bostonfirehistory.org HERE
Boston Ladder 8 1941 ALF 125 ft. Aerail Ladder Shop#207. Photo Courtesy BostonFireHistory.org
There was some speculation that due to the long ladder and wide bed, the large ladder might have caused the wall collapse. This theory was later ruled out. In fact, some of the firefighters who were on the ladder at the time of the collapse, credit the ladder bed with saving their lives. When the granite and debris began falling, they lay down in the bed and the rubble slid down over them to the street.
Many felt that this was the end to the ladder. But, it was repaired and returned to service in South Boston as Ladder 19. Tragedy would continue to haunt this piece of apparatus. On December 3, 1947, Ladder 19 was out of service conducting tests on its brakes when it overturned and rolled. Provisional Firefighter Joseph B. Sullivan, on the job for less than six months, was killed. The Department took the truck out of service and scrapped
As with many of these incidents, the men involved came from different backgrounds and circumstances that put them on that second floor that fateful night.
Edward Macomber was the father of eight children and considered to be one of the best firefighters in the department according to his superior officers. He was a member of the department for 28 years, and had been injured while on duty more than seven times.
Francis Degan, at age 24 was one of the youngest members of the Boston Fire Department at the time. He had been on the job only 19 months prior to November 15th. His officers thought that the young fireman was well on his way to becoming an officer. Young Degan took great pride in being a firefighter and realized his life’s ambition when he was appointed to the department to follow in the footsteps of his father, who was attached to Ladder Company 1.
John Foley, a hoseman on Engine Company 3, had been a member of the department for more than 30 years. He was planning to retire in a short time. In a tragic case of irony , Firefighter Foley should have been on a day off at the time of the fire, but had changed his schedule in order to get some time off later.
World War 1 veteran Pete McMorrow was a bachelor member of Engine Company 50 and was loved by many of the school children of Charlestown. He had served in the Navy in the first war and was telling his closest pals that he might just be going back to serve again. At age 46, he had carried the colors of the Boston Fireman’s Post #94, American Legion, through downtown Boston. While trapped in the debris for eleven hours, McMorrow’s fellow company members crawled into the space where he lay to tell him to hang on and they’d get him out soon. Throughout the early morning and into the next day the rescue efforts continued. However, when they were finally able to get to McMorrow, it was too late.
This fire and the subsequent six firefighter line of duty deaths were overshadowed by the Cocoanut Grove Fire which occurred only 13 days later on November 28, 1942.
Memorial, Dedication, and Reception
On Thursday November 15, 2012 the East Boston Neighborhood Health Center and theBoston Fire Department will be conducting aMemorial, Dedication, and Reception in Recognition of the 70th Anniversary of the Luongo Fire at Maverick Square, East Boston.
The event is scheduled from 12:00 pm to 2:00 pm at 20 Maverick Square, Boston, MA.
Video: Former Boston Fire Commissioner Paul Christian shares the story of the little-known Luongo fire as well as that of the 8-alarm Thanksgiving Day Fire of 1889. November has been a tragic month in Boston’s fire history. On November 15, 1942, a fire started in the back room of the Luongo Restaurant.
Collapse Scene from Maverick Square
Boston Fire Department 125 ft. Aerial Ladder on Henry Street Side
Fire Department Journal Luongo Restaurant Fire, HERE
Aerial Image of current property block in East Boston (MA). Bing Maps Image
Historical Note: Three and a half story high, with granite faced and brick exterior walls, the interior wooden joisted building at the corner of Henry Street and Maverick Square in 1942 was one of the oldest buildings in East Boston. It was typical of mid 19th century Boston commercial construction. In accounts of the fire it is frequently referred to as “Old Armory Hall”. “Armory Hall” is the name by which it was known in the early years of the 20th century. That building however never was actually an armory as such. There once was an armory in East Boston. It was located at the corner of Maverick and Bremen Streets in a wooden building that preceded the still standing brick Overseers of the Public Welfare Building. The building in which the “Luongo Fire” occurred was built sometime before 1858. It was known originally as “Ritchie Hall” likely from the name of its owner.
Armory Hall Building is to the left of Photo – Circa 1910
Operations at 30 Dowling Circle 01.19.2011 Box 11-09
Mark Gray Falkenhan had dedicated his life to serving others. He perished in the line of duty on January 19, 2011 while performing search and rescue operations at a multi-alarm apartment fire in Hillendale, Baltimore County (Maryland). He was 43 years old.
On Wednesday, January 19, 2011, a fire occurred in an apartment building located in the Hillendale section of Baltimore County, Maryland. This fire resulted in the line of duty death (LODD) of volunteer firefighter Mark G. Falkenhan, who was operating as the acting lieutenant on Squad 303 . Upon their arrival, FF Falkenhan and a second firefighter from Squad 303 deployed to the upper floors of the apartment building to conduct search and rescue operations. Other fire department units were already involved with both firefighting operations and effecting rescues of trapped civilians.
During these operations, FF Falkenhan and his partner became trapped in a third floor apartment by rapidly spreading fire and smoke conditions. The second firefighter was able to self-egress the building by diving headfirst down a ladder on the front (address side) of the building. FF Falkenhan declared a “MAYDAY” and implemented “MAYDAY” procedures, but was unable to escape or be rescued.
FF Falkenhan was located and removed via a balcony on the third floor in the rear of the building. Resuscitative efforts began immediately upon removal from the balcony, and continued en route to the hospital. FF Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
The Baltimore County (MD) Fire Department published the Line of Duty Death Investgation Report of the 30 Dowling Circle Fire recently. The report was written by a Line of Duty Death Investigation Team comprised of departmental members, including representatives of the local firefighters’ union and the Baltimore County Volunteer Firemen’s Association.
Baltimore County (MD) Fire Department web site HERE
The following is and executive narrative of the final report (PDF) on the apartment fire where Volunteer Firefighter Mark Falkenhan sustained fatal injuries. The entire report can be downloaded HERE .
The Baltimore Sun newspaper published an editorial about the death of Firefighter Falkenhan that is required reading; HERE . An excerpt from the editorial reads as follows:
FF Mark Falkenhan
The word “hero” gets used too often to describe the most pedestrian of admirable behaviors, from the star quarterback who marches his team for a winning score to the kid who finds a missing wallet and turns it in. But exceptional bravery, special ability, exceptional deeds and noble qualities — those are what define an authentic hero, and Mr. Falkenhan lacked for none of them.
It was not by accidental circumstance or naiveté that he ended up on the third story of that Hillendale apartment complex in the midst of a fire, searching for missing residents. He knew the risks as well as anyone could. But his selfless desire to help others drove him forward into the flames.
That’s what made him exceptional. That’s why his legacy is important. That’s why the community is in his debt.
Incident Executive Summary
On Wednesday, January 19, 2011, a fire occurred in an apartment building located in the Hillendale section of Baltimore County, Maryland. This fire resulted in the line of duty death (LODD) of volunteer firefighter Mark G. Falkenhan, who was operating as the acting lieutenant on Squad 303 (for purposes of this report, Mark will be referred to as FF Falkenhan). Upon their arrival, FF Falkenhan and a second firefighter (FF # 2) from Squad 303 deployed to the upper floors of the apartment building to conduct search and rescue operations. Other fire department units were already involved with both firefighting operations and effecting rescues of trapped civilians.
During these operations, FF Falkenhan and FF # 2 became trapped in a third floor apartment by rapidly spreading fire and smoke conditions. FF # 2 was able to self-egress the building by diving headfirst down a ladder on the front (address side) of the building. FF Falkenhan declared a “MAYDAY” and implemented “MAYDAY” procedures, but was unable to escape or be rescued. FF Falkenhan was located and removed via a balcony on the third floor in the rear of the building. Resuscitative efforts began immediately upon removal from the balcony, and continued en route to the hospital. FF Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
Baltimore County Fire Department Standard Operating Procedures, Personnel #16, requires a team to be formed, a detailed investigation to be conducted and a report produced for any incident involving a line of duty life threatening injury or death. The team’s objective is to thoroughly analyze and document all the events leading to the injury or death and to make recommendations aimed at preventing similar occurrences in the future. At a minimum, a Division Chief, the Department’s Health and Safety Officer, a member from the Fire Investigation Division, an IAFF Local 1311 union representative, and the Baltimore County Volunteer Firemen’s Association Vice President of Operations (when a volunteer member is involved) is required (see Acknowledgements section for actual team make-up).
The investigating team examined any and all data available, including independent analysis of the self contained breathing apparatus (SCBA), turnout gear and autopsy report. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) produced a fire model to assist with evaluating fire behavior. Multiple site inspections were conducted. Extensive interviews were conducted by the team which also attended those conducted by investigators from the National Institute for Occupational Safety and Health (NIOSH). Photographic and audio transcripts were also thoroughly analyzed. A comprehensive timeline of events was developed. All information used to make decisions regarding recommendations was corroborated by at least two sources.
In fairness to those units involved in this incident, the investigating team had the advantage of examining this incident over the period of several months. Furthermore, given the size and nature of the event, and the fact that arriving crews were met with serious fire conditions and several residents trapped and in immediate danger, all personnel should be commended for their efforts for performing several rescues which prevented an even greater tragedy.
The team did not identify a particular primary reason for FF Falkenhan’s death.
What were identified were many secondary issues involving but not limited to crew integrity, incident command, strategy and tactics, and communications.
These issues are identified and discussed, and recommendations are made in appropriate sections of the report, as well as in a consolidated format in the Report Appendix.
Some of the issues identified in this report may require some type of change to current practices, policies, procedures or equipment. Most, however, do not. Specifically, the analysis and recommendations regarding Incident Command and Strategy and Tactics show that if current policies and procedures are adhered to, the opportunity for catastrophic problems may be reduced.
Mark Falkenhan was a well-respected and experienced firefighter.
He died performing his duties during a very complex incident with severe fire conditions and unique fire behavior coupled with the immediate need to perform multiple rescues of victims in imminent danger.
It would be easy if one particular failure of the system could be identified as the cause of this tragedy.
We could fix it and move on. Unfortunately it is not that simple.
No incident is “routine”. Mark’s death and this report reinforce that fact.
On Wednesday, January 19, 2011 at 1816 hours, a call was received at the Baltimore County 911 Center from a female occupant at 30 Dowling Circle in the Hillendale section of Baltimore County. The caller stated that her stove was on fire and the fire was spreading to the surrounding cabinets. Fire box 11-09 was dispatched by Baltimore County Fire Dispatch (Dispatch) at 1818 hours consisting of four engine companies, two truck companies, a floodlight unit, and a battalion chief. All units responded on Talkgroup 1-2.
The location, approximately one mile from the first dispatched engine company, is a three story garden-type apartment complex, with brick construction and a composite shingle, truss supported roof. The fire building contained a total of six apartments divided by a common enclosed stairway in the center with one apartment on the left and one to the right of the stairs.
Alpha, Bravo, Charlie, and Delta will be used to designate the clockwise geographic locations of the structure, beginning with Alpha on the address side of the building . Entry is gained through the front split-level stairwell by a common entrance door with individual doors leading to each apartment. Each apartment consists of two bedrooms, a kitchen, bathroom, and a living/dining area. There are sliding doors leading to either a wood joist deck/balcony on the second and third floor apartments, or a concrete patio on the first floor apartments. Utilities consist of gas service to the furnace and hot water heaters located in a utility closet in each apartment, with electric service to the remainder of the appliances, including the stove. Interior walls of the apartments are drywall over wood stud construction.
Floor coverings consist of carpeting over tile and concrete on the terrace/first floor. The second and third floor coverings consist of carpeting covering hardwood floors with a plywood subfloor. Interior doors are hollow wood construction. The door to the common hallway is of solid wood construction. The sliding doors to the deck/patio area are glass.
The development and construction of the Towson Crossing Apartments began in the early 1980’s. The buildings are rated in the existing building code for occupancy as Residential 2 (R2). The building code would describe the construction type as Type III. This construction type includes those buildings where the exterior walls are of non-combustible materials and the interior building elements are of any material permitted by the building code.
Building Construction and Features
The subject apartment building, 30 Dowling Circle, is a three story, middle of the group, apartment building constructed on a reinforced concrete slab. The Alpha and Charlie exterior walls are wood framed construction with brick veneer attached by brick ties. The Bravo and Delta exterior walls are block masonry construction and separate adjoining apartment buildings. The interior partition walls consist of wooden 2″x4″ wall studs covered with sheetrock. Paper faced insulation is found between the exterior walls, ceilings and party-walls that separate the apartments.
The apartment building contains six individual apartment units, which are approximately 1000 square feet in size per apartment unit. Two separate units are located on each floor and consist of two bedrooms, a living area, a dining area, a kitchen, and a bathroom. A utility closet is located in each of the living areas. The closet is located along the Alpha wall, and contains the water heater and furnace.
The building is not equipped with an automatic fire suppression system. Smoke detectors were noted; however, it is unknown if they were operational at the time of the fire. A fire extinguisher was noted on the landing between the second and third floor levels of the building.
From side Alpha the building has two and a half stories above grade while side Charlie is three stories above grade.
The first floor of the building is approximately five feet below ground level with a 20 foot set back from the apartment building parking lot. Side Charlie of the building is at ground level but slopes upward approximately 8 feet with a set-back of 110 feet from the rear alley.
The roof is constructed of a lightweight truss assembly consisting of 2″x6″ stringers connected by gusset plates. The truss assembly is covered with 5/8 inch plywood and asphalt shingles.
Floor and Ceiling
The floor assembly consists of 2×10 inch floor joists covered by plywood, wooden tongue and groove planking and finished with carpet. The joists run from Alpha to Charlie and are supported by the interior bearing walls. The kitchen floors in all of the units are covered with vinyl tile.
The ceilings throughout the building are sheetrock nailed to the floor joists of the apartment above with the exception of the third level in which the sheetrock is nailed to the roof joists.
The balconies are located on side Charlie of the building. The balconies located on levels two and three consist of 5/4″ deck boards over 2″x10″ wooden joists. The joists are cantilevered off of the floor/ceiling assemblies of levels one and two. The first floor balconies are made of concrete and are at ground level. All balconies are accessible through a single pane sliding glass door located in each apartment.
The first arriving engine, E-11, was staffed with a Captain, Lieutenant, Driver/Operator, and a Firefighter. Upon arrival at 1820 hours, the Captain gave a brief initial report describing a three story garden apartment with smoke showing from side Alpha: “The Captain of E-11 will have Command and we are initiating an aggressive interior attack with a 1 ¾” hand line”. Command also instructed the second due engine to bring him a supply line from the hydrant.
A female resident (victim # 1) appeared in a third floor apartment window, Alpha/Bravo side (Apt. B-1), yelled for assistance, and threatened to jump. Smoke or fire was visible from any of the third floor windows. At 1823 hours, Command advised Dispatch that he had a rescue and that he was establishing Limited Command. Fire Dispatch was in the process of upgrading the response profile to an apartment fire with rescue when the responding Battalion Chief requested that the fire box be upgraded to a fire rescue box. While the Firefighter and Lieutenant prepared for entry into the building, the Captain and Driver/Operator extended a ladder to the 3rd floor apartment window and rescued the resident. The first attempt by the Firefighter and Lieutenant to make entry into the side Alpha entrance was unsuccessful due to the extreme heat and smoke conditions.
Initial Arrival Conditions
The second due engine, E-10, arrived at 1823 with staffing of a Captain, Lieutenant, Driver/Operator, and a Firefighter. At 1823, E-10’s crew brought a 4″ supply line to E-11 from the hydrant at Deanwood Rd. and Dowling Circle and assisted the first-in crew with fire attack.
The Captain from E-10 conferred with Command and was instructed to advance a second 1 ¾” hand line.
The window to the first floor right apartment (Apt. T-2) was removed, and the second 1 ¾” line was advanced to the building by the crew of E-10.
Fire attack was initiated through the removed window. At 1827, Command requested a second alarm.
At this time, heat and smoke conditions just inside the front door improved enough to allow the Firefighter and Lieutenant from E-11 to make entry through the front door and into the stairwell. There they encountered heavy, thick black
smoke and high heat conditions coming up the stairs from the terrace level apartment. The Lieutenant reported that the doorway to the first floor apartment was orange with fire and he had to fight his way through heavy heat and smoke conditions to attack the fire in the first floor right apartment (Apt. T-2). Entry was made approximately 3 feet into the doorway when the Firefighter’s low air alarm began to sound, and he exited the building. A member from E-10’s crew replaced the Firefighter from E-11 on the hose line.
At the same time, the Captain from E-11 proceeded to the rear of the structure to complete his initial 360 degree size up. He noted that there was fire emanating from the open sliding doors on the first floor Charlie/Delta apartment (Apt. T-2), extending to the balcony above. E-1, staffed by a Captain, Driver/Operator, and two Firefighters arrived and completed the hookup of the supply line that had been laid to the hydrant by E-10. The rest of Engine 1’s crew grabbed tools and an extension ladder and reported to the Charlie side of the building.
Personnel stated that at this point fire conditions seemed to improve, suggesting that crews were making progress extinguishing the fire. (The first arriving attack crew reported that they were able to see apparatus lights through the sliding doors on Charlie side, which indicated to them that smoke and fire conditions were improving.)
Truck 1, a tiller unit staffed by a Lieutenant, two Driver/Operators, and a Firefighter, arrived on side Alpha and immediately began search and rescue operations. Windows on the second floor Alpha/Delta side apartment (Apt. A-2) were vented and ladders were thrown to gain access. T-8 arrived at the alley on side Charlie. E-1 extended a ground ladder to the third floor balcony on the Charlie/Bravo side of the structure (Apt. B-1), and made access to the apartment to search for additional victims.
They noted fire venting from the first floor Charlie/Delta apartment (Apt. T-2) out of the sliding glass doors progressing upwards towards the balcony on the second floor. Upon entering the apartment, they conducted a primary search and noted minimal heat with light smoke conditions.
The crew accessed the hallway via the apartment entry door and noticed an increase in the temperature and the amount of smoke.
They immediately closed the door and exited the apartment via the ground ladder.
Upon exiting the apartment, E-1’s crew observed E-292 on the scene with a hand line extending into the apartment of origin, (first floor, Charlie/Delta side, Apt. T-2). The officer on E-1 noted white smoke coming from the unit.
Having already laid a supply line from the intersection of the alley and Deanwood Road, E-292’s crew extended a 1 ¾” hand line into the apartment of origin. Moderate fire conditions with zero visibility were encountered, and they reported feeling a great deal of heat on their knees as they crawled through the apartment.
The Lieutenant and the Firefighter from Truck-1 entered Apartment A-2 via a second floor bedroom window (Alpha/Delta side) and began a search for additional victims. As they traversed the living room area they found an unconscious male resident (victim #2). At 1836 hours, the Lieutenant notified Command via an urgent transmission that a victim had been located and they needed assistance with evacuation. The Lieutenant and Firefighter noted a small fire in the rear corner near the victim as they exited the room. The crew returned to the bedroom from which they had entered and closed the door behind them. Victim #2 was then evacuated from the apartment via a ground ladder through the bedroom window, and transferred to EMS personnel on side Alpha.
Preflashover conditions Alpha Side 18:37 hours
At 1831 hours, Squad 303, a unit staffed by a Driver/Operator, Firefighter Falkenhan (acting Officer in Charge), and 3 other Firefighters had arrived at the Alpha side of the building. Firefighter Falkenhan and two crew members grabbed their tools and immediately entered the building. One Firefighter (Firefighter #1) proceeded to the terrace floor apartment to assist crews with fire attack. Firefighter Falkenhan and the other Firefighter (Firefighter #2) proceeded to the second floor
Bravo side apartment (Apt. A-1) to search for additional victims. They forced the door to the second floor apartment and conducted their search. Finding no one, they reported to Command that they had encountered high heat in the apartment and at 1838 hours, inquired as to which apartment victim #2 had been found. Firefighter Falkenhan advised Command that he and his fellow Firefighter were proceeding to the third floor to continue their search.
At 1840 hours, Battalion Chief 11 (BC-11) arrived on the scene, performed a face-to-face pass on with the Captain on Engine 11, and assumed Command. BC-11 initially observed limited smoke conditions, indicating to him that crews had made progress in extinguishing the fire.
Meanwhile, the Lieutenant and Firefighter from T-8 entered the second floor apartment that S-303 had just searched (Apt. A-1, second floor, Bravo side). They proceeded through the apartment and went across the hallway to Apartment A-2 where Truck-1 had just made their rescue (second floor, Delta side).
The Lieutenant noted smoky conditions, and saw that the sliding doors to the rear of the apartment were open, and saw a small fire in the rear of the apartment to the left of the open doors. On their way back to their point of entry, T-8’s crew discovered an unconscious female victim (victim #3). At 1837 hours, T-8 attempted to reach Command via radio and was covered by inaudible radio traffic. Dispatch was able to receive the radio transmission from T-8, and advised Command that another victim had been located on the second floor.
At this point, the crew from S-303 had completed their search of the third floor Bravo side apartment (Apt. B-1).
Firefighter Falkenhan and Firefighter #2 were able to look out of the sliding doors on side Charlie down to the first floor apartment, Apt. T-2 (Charlie/Delta side) and could see fire.
Smoke conditions on the third floor were light enough to walk upright in a somewhat crouched position.
The crew returned to the hallway, forced open the door to the third floor Charlie/Delta side apartment, Apt. B-2, and made entry.
Firefighter #2 walked down the hallway to the bedroom on the right while Firefighter Falkenhan searched to the left. After checking the bedroom, Firefighter #2 stated that he heard something behind him and turned to see fire in the hallway.
As the crew from S-303 searched the third floor Delta side apartment (Apt. B-2), The Lieutenant and Firefighter from T-8 were attempting to remove victim #3 from the second floor Delta side apartment (Apt. A-2). As they prepared to move their patient, fire conditions changed suddenly.
The Lieutenant from T-8 observed fire, “…rolling over our heads and out of the apartment door.” An immediate increase in heat conditions was noted. Upon exiting the apartment, T-8’s crew described a “tunnel of fire” coming out of the apartment and into the hallway. At 1841 hours, a radio transmission was made by an unknown source that heavy fire was observed in the hallway through a window at the stairwell landing.
At the same time, (1841) one minute after his arrival, Battalion Chief-11 (Command) noted heavy black smoke coming from the building and observed a “flash” through a second floor window. Command immediately ordered an evacuation of the building. Dispatch sounded the evacuation tones over the radio, and repeated the order to evacuate. Engines on the scene sounded their air horns to indicate that the order to evacuate had been given.
Firefighter #2 from S-303 reported hearing the engines on the fire ground sound their air horns, indicating to him that he needed to leave the building. Smoke conditions in the apartment had changed to thick black smoke, and the fire intensified, blocking his means of egress from the bedroom.
Realizing that he needed to get out of the apartment quickly, Firefighter#2 crawled to a window on the Alpha side of the bedroom and signaled Firefighters below with his hand light to move a ladder to the window. Crews immediately moved the ladder, and at 1841, Firefighter#2 dove headfirst out of the window and down the ladder, where he was assisted by crews working on the exterior of the building.
At 1841, Firefighter Falkenhan declared, “Emergency” on his radio, and repeated the same seven seconds later.
Command immediately queried S-303 for his location and the transmission “I’m down to the floor, heavy fire” was heard. At 1842 hours, Dispatch sounded emergency tones and restricted the Talkgroup to communications only between S-303 and Command.
Seconds later Firefighter Falkenhan again keyed up his portable radio and advised “…trapped on the 3rd floor, heavy fire on the Alpha/Bravo.”
Fourteen seconds later he advised “I hear crew members, the third, MAYDAY, MAYDAY, MAYDAY.”
Command notified Dispatch, “We have a MAYDAY” and was interrupted by a transmission from Firefighter Falkenhan, “urgent.”
Command made several attempts to contact Falkenhan to ascertain his location and determine resources needed (Location Unit Name Assignment Resources) for rescue.
Upon hearing the MAYDAY, crews on side Charlie threw multiple ladders to the third floor balcony to assist with rescue.
Heavy heat, smoke, and fire conditions made rescue difficult, but Firefighter Falkenhan was located and removed from the apartment via the balcony to the extended aerial ladder from T-8. He was unconscious and unresponsive at this time. Resuscitative efforts began immediately upon removal from the balcony, and continued enroute to the hospital. Firefighter Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
Consolidated List of Recommendations
1. Company officers shall ensure that crew integrity is maintained at all times by all personnel operating in an IDLH environment. 2. No personnel shall operate in an IDLH environment without a portable radio.
1. If possible, the firefighter should activate his/her Emergency button on the portable radio. 2. Once personnel have called a MAYDAY and provided the information needed (LUNAR), they will activate their PASS Device manually and intermittently.
1. Tactical Operations Manual 07 allows Incident Commanders the flexibility to adapt to fast-moving and complex incidents. When re-assuming command, the IC must be identified (verbally through Fire Dispatch) to allow units involved and responding to know who is in command.
2. Incident Commanders must understand that an early initial 360° would give the IC the information needed to develop effective strategy and tactics for incident mitigation.
3. Additional arriving units must give the IC an updated report on fire conditions when noticeably different than those announced in the Brief Initial Report.
4. Arriving units should prompt the IC to assign them supervision of a division when conditions warrant such action.
5. The IC must ensure that all division and group supervisors are properly deployed and verbalize same on the radio for Dispatch and units involved on the incident.
6. Reinforce the importance of the ICS and its functional components for all officers.
7. Ensure a manageable span-of-control is maintained throughout the incident.
8. Evaluate the efficiency of command and control as incidents escalate.
9. A Rapid Intervention Team is a vitally important part of the ICS and its assignment should not be overlooked.
Strategy and Tactics
1. Use caution when passing a hydrant that is in your direction of travel and close to the fire building in an attempt to get a closer one.
2. Consider having the initial backup line proceeding into the same point of entry as the initial crew operating in the IDLH environment. Doing this allows for the line to also aid in protecting the common stairwell (i.e. fire extension/protection for egress). Deploy a third line if needed into another point of access.
3. Consider dialing nozzles up to higher gallons per minute for large structures such as apartment buildings.
4. Consider utilizing a 2-1/2″ attack line for fire attack.
5. The current SOP should be modified to state that when the initial Incident Commander feels that the incident has stabilized to a point where there is no longer a need for him/her to be directly involved with incident operations, a notification through Dispatch shall be made to inform crews on and en route to the scene.
6. The Department should develop training to ensure that Incident Commanders relay changes in modes of operations.
7. Consider attacking fires from other sides of the structure that are on grade.
8. Consider the use of “door control” for protection during search and rescue and exposure protection
9. When deviations to initial orders are made, they must be communicated to Command.
10. IC should consider setting up a division supervisor with the first arriving officer to balance his/her span-of-control early into the incident.
11. Command should initiate group and division supervisors early into an incident and use them to reduce his/her span-of-control. Communicate Conditions, Actions, Needs (CAN) reports early and often.
12. When units are the initial crews deployed to a geographic location, consideration should be given to “prompt” Command to make them a division supervisor (in the absence of direction from Command).
13. Units should request resources, or supply their own as necessary to support the operations that they are undertaking.
14. When given a division assignment, “step back” to take in the overall picture and communicate progress reports to Command.
15. Be clear and concise when setting up division assignments.
16. Utilize the division supervisors for incident operations once assigned.
17. Training on effective use of interior doors to control fire spread should be promoted throughout the department.
18. Consider removing common stairwell windows earlier in fire ground operations when appropriate.
19. While performing operations above the fire, notify Command of changing conditions and immediately request resources to support your function.
20. Set up a command post as early as possible to aid in deploying and accounting for resources as they arrive on the fire ground.
21. Notify Command when entering an IDLH.
22. Request resources to support functions.
23. Set up divisions and groups early to aid in managing the strategic priorities.
24. Be clear in communicating strategy and tactics to companies involved in operations.
25. Command should make it a priority to deploy attack lines on all floors to support the operations of crews working in the area.
1. A rubberized cover for the radio speaker microphone should be tested by communications and field personnel. This device will cover the push-to-talk (PTT) button and will increase the pressure required for activation. If proved effective, this cover will decrease the likelihood of an accidental activation of the PTT button during vigorous fire ground activity.
2. Continuing study should occur to evaluate methods to control inadvertent radio interference from all units (on the scene, responding, or monitoring) during incident operations. Review PTT logs to identify sources of communications interference.
3. As a result of the investigation, PTT log files will now be saved for 25 days.
4. Fire Communications and field personnel will develop and distribute a mandatory training program outlining proper radio procedures including the importance of radio discipline, MAYDAY procedures, and the procedure for establishing a Command restricted talk group during critical operations.
5. All personnel engaged in operations in an environment immediately dangerous to life and health shall carry a portable radio.
6. The aforementioned mandatory training program shall stress the importance of giving regular updates to Command regarding the extent and location of the fire and other pertinent information.
The Chief of the Department directed the Department Safety Officer to conduct a Safety Investigation of this incident. The primary purpose of the investigation was to identify and analyze the contributing factors that led to the incident as well as to create situational awareness to prevent future occurrences. The main objective of the Team’s investigation and subsequent report was to discover the key factor that led to the fatal outcome of two Firefighters. The SFFD report contains the findings and recommendations to help prevent Firefighter injuries or fatalities in the future.
In analyzing and recording these events, the Investigation Team acknowledges and respects that members confronted a challenging situation. On‐scene personnel reacted quickly to the changing conditions at this incident. We request that every person who reads this report show respect, appreciation and consideration for all personnel who responded to this incident.
As is a common industry practice, for this report Lieutenant Vincent Perez was referred to as Victim 1 and Firefighter Paramedic Anthony Valerio was referred to as Victim 2, with the exception of the Rescue Events Section.
Excerpt from Chief of Department’s Letter
“On Thursday, June 2, 2011 at 10:45 a.m., the San Francisco Fire Department responded to Box 8155, at 133 Berkeley Way. What was seemingly a routine working fire in a single family residence quickly transformed into a fierce and unrelenting incident with ultimately tragic results.
When we answered the call to a career in the Fire Service and took our Oath of Allegiance, we were aware of the inherent danger of our occupation. Despite this awareness, we do not expect to encounter a line of duty death of a brother or sister, especially not in our very own Department. The profound loss of Lieutenant Vincent Perez and Firefighter/Paramedic Anthony Valerio has left an indelible impression in our hearts and will forever be remembered in the annals of SFFD history.
Even as we mourned our fallen brothers in the early days after the tragedy, our Department began the painful and difficult, but necessary, steps of a Line of Duty Death investigation. We were resolute in understanding what occurred during those fateful minutes and compelled to uncover any recommendations for improvement that may arise to future operations so that their passing will not have been in vain. For over six months, the Investigative Team worked tirelessly, scrutinizing every piece of evidence in order to produce a comprehensive report.”
Chief of Department
Executive Summary and Report Excerpt
On June 2, 2011 at 10:45 hours, the San Francisco Fire Department was dispatched to a report of a fire in the building at 133 Berkeley Way in the City’s Diamond Heights neighborhood. The first unit arriving on the scene, Engine 26, observed light smoke showing from the garage of the 4 story (2 above grade, 2 below grade) wood framed building, detached on the Bravo side.
Aerial from the Charlie Side
An aggressive interior fire attack was initiated through the front door, which is on a level between the ground level and second floor. After investigating the garage (ground level), Engine 24, the second Engine on the scene, led a small line through the garage to the interior door to back up the first Company. Battalion 9 was assigned Fire Attack by Battalion 6, who had assumed Command. Battalion 9 entered the fire building and, after conferring face to face with Engine 26 on the first floor (ground level), concluded that the fire was below them.
Alpha Side Operations
Battalion 9 exited the building and proceeded to the Bravo side to check for an entrance leading directly to the fire floor. Engine 11 led a large line wye to the driveway with the intention of leading a 1 ¾ inch line through the garage. They were redirected by Battalion 6 to make their lead down the Bravo side of the building to Sublevel 1 (one floor below grade) to assist Battalion 9. The Division Chief, upon arrival, assumed Command. He assigned Battalion 6 to Division 3 (ground floor).
Truck 15 was assigned Roof Division. Truck 11 split their crew, two members to the roof and three members to search and ventilate the top floor of the fire building. The Rescue Squad was ordered to conduct a search. Two members initially attempted to make entry through the garage but, due to extreme heat conditions, redeployed and entered through Sublevel 1 on the Bravo side.
The other two members of the Rescue Squad made entry through the front door, were pushed back by the heat and then made a successful second effort and conducted a search of the top floor.
In the course of fireground operations, members of several Companies came upon the stricken members on the first level and removed them from the building. All possible efforts were employed to revive the members and they were transported to San Francisco General Hospital (SFGH). One member (Victim 1) succumbed to his injuries that day and the second member (Victim 2) succumbed to his injuries two days later. Two other Firefighters were treated at SFGH for various injuries and released that day.
The Medical Examiner determined the cause of death for both members was due to complications from external and internal thermal injuries. Both victims suffered burns to 40% of their body surface. This fire was determined to be accidental by the SFFD Fire Investigative Unit. The fire originated on Sublevel 1, on the West side of the family room, near the large floor to ceiling windows. The ignition was a non‐specific electrical sequence in the electrical wiring or appliance (handheld vacuum cleaner) in this area.
There was a delay in reporting the fire due to the occupants’ attempting to extinguish it on their own. (SFFD Fire Investigation Report 11‐0500532)
The investigation identified that the failing of the window on Sublevel 1, located near the seat of the fire and directly across the stairwell leading to the ground floor, led to the extreme fire behavior which ultimately caused the death of two Firefighters. This fire was in a stage of deprived oxygen when the window failed, causing a rapid extreme high heat event to occur. The extreme heat followed the natural flow path up the interior stairs where Victims 1 and 2 were located.
The Safety Investigation Team found no conclusive evidence that the members were exposed to direct flame impingement during this rapid extreme heat event. However,
Victims 1 and 2 received varying degree of burns up to 40% of their body. The investigation concluded that this was caused by the rapid extreme heat conditions that radiated through their Personal Protective Equipment (PPE) to their bodies. These temperatures exceed the ability for human survival regardless of PPE.
The PPE was inspected and evaluated by NIOSH and the manufacturer. Both reviewing parties concluded that the PPE performed to its specifications and design. The manufacturer concluded that the PPE was exposed to temperatures in the range of 550‐ 700°F. These extreme temperatures were short in duration which caused limited damage to the outer shell of the PPE.
The Safety Investigation Team noticed severe heat damage to the portable radios remote speaker/microphones on Victims 1 and 2 and had the radios tested. The testing indicated that the remote speaker/microphones failed to operate correctly due to heat damage. The Safety Investigation Team was not able to determine, after testing, exactly when the remote speaker/microphones failed. The investigation has shown that multiple attempts were made to contact Engine 26 with no response.
The investigation also found that no radio transmissions of distress were received from Victims 1 or 2. Command and Control of any incident in the San Francisco Fire Department is acquired and maintained through the use of the Incident Command System (ICS).
The Incident Command System provides the tools for clear objectives, a single action plan, clear and acknowledged communications, and accountability for all members assigned to an incident. At this incident, some of the components of Incident Command System that were not followed include:
Single action plan
From these findings, this report makes recommendations for several areas of the Department, including:
The Safety Investigation Team gathered and analyzed many facts and conducted interviews of members directly involved in this incident. The Team identified several factors that occurred that contributed to the deaths at this incident.
These factors include:
Extreme heat conditions accelerated by the failure of a window on the fire floor.
Layout of building
Excessive live fuel load which contributed to the growth of the fire
This incident appeared from the onset to be a routine “room and contents” fire that the SFFD encounters on a regular basis. As the Companies were performing standard fireground operations, the incident rapidly deteriorated due to a hostile fire event. The failure of a window in the fire room allowed fresh oxygen to enter the room, providing a fire that was deprived of one of the key elements of combustion to rapidly intensify.
Due to the growth of the fire, the room flashed, causing extreme and rapid heat conditions which traveled up the interior stairs (the flow path) to the location which our members were operating. Our members were caught in this high heat, causing the injuries that ultimately claimed their lives.
Due to this fire event, other Companies attempting to conduct fireground support operations were prevented from making entry into the structure from street level (through garage) to back up Engine 26. These Companies were forced to regroup and find an alternate point of entry. In the process of doing so, crews made entry from the Bravo side directly into the fire room and extinguished the fire. This allowed members to make entry from above which led to the discovery and rescue of our members.
These events happened in a time frame of less than fourteen minutes.
During the course of this investigation, the Safety Investigation Team recognized that no matter how experienced or properly prepared we are, we must always approach all incidents with the utmost awareness.
This incident showed that a simple failure of a piece of glass/window caused unforeseeable and fatal consequences.
We, as a Department, need to gain further knowledge and understanding of the following:
Having Situational Awareness prior to taking action, this would include the ongoing process when conditions change
How Risk Management must be used when making all decisions
Limitations of the PPE (turnouts, SCBA, and equipment)
Building construction, including layout and how fire/smoke will
move within the structure
Ventilation practices and how they affect fire conditions
Importance of Communications for all members operating on the scene
Companies must use strict discipline when assigned task/locations
The mission of the Fire Department is to protect the lives and property of the people of San Francisco from fires, natural disasters, and hazardous materials incidents; to save lives by providing emergency medical services; to prevent fires through prevention and education programs; and to provide a work environment that values health, wellness and cultural diversity and is free of harassment and discrimination.
Take a moment to look back at an incident: On December 18, 1998, Three FDNY Firefighters died in-the line of duty while conducting suppression and rescue operations at fire on the tenth floor of 10-story high-rise apartment building for the elderly. At 0454 hours Brooklyn transmitted box 4080 for a top floor fire at 17 Vandalia Avenue in the Starrett City development complex. The sprawling complex is located on Brooklyn’s south shore in the Spring Creek section. The 10 story 50 x 200 fireproof building is used as a senior citizen’s residence. Engine 257 and ladder 170, both quartered in Canarsie, were assigned 1st due and arrived within 4 minutes. By that time the fire already could be seen blowing through two windows. Second and 3rd alarms were quickly transmitted.
As the 1st due Ladder Company, L170′s duty is to search the fire floor. Lieutenant Joseph Cavalieri, and fire fighters Christopher Bopp and James Bohan ascended 10 flights of stairs with extinguishers and forcible entry tools. Their mission was to rescue the resident of apartment 10-D who was believed trapped inside.
NIOSH INVESIGATIVE REPORT SUMMARY (F99-01) On December 18, 1998, several fire companies and fire fighters responded at 0454 hours to a reported fire on the tenth floor of a 10-story high-rise apartment building for the elderly. The fire had been burning for 20 to 30 minutes before it was called in because the resident attempted to put the fire out with small pans of water. As the fire fighters approached the building from the rear, an orange glow was observed in the window of Apartment 10D. As the fire fighters were arriving in front of the high-rise, a call was received from Central Dispatch that a female resident in the apartment next door to the fire apartment was trapped in her apartment and needed help. Several fire fighters entered the lobby area, and some took the stairs to the ninth floor, while others took the elevator to the ninth floor. A Lieutenant and two fire fighters on Ladder 170 (the victims), along with the Lieutenant on Engine 290, took the B-stairs from the ninth floor to the tenth floor, and entered the hallway, in search of the fire, while 4 fire fighters on Engine 290 were flaking out the hose line on the ninth floor and in the stairwell between the ninth and tenth floor in preparation for hookup.
During this same time period, other fire fighters had gone to the tenth floor A-stairwell landing to attempt a hose line hookup to the standpipe in the landing. Engine Company 257 fire fighters, who were attempting to make a hook-up on the fire floor landing, experienced trouble with the heat, heavy smoke, and heavy insulation on the standpipe and were forced to abandon this hook-up. The Lieutenant on Engine 290 and the victims, who were on the B-side, were approaching the center smoke doors (see diagram), when the Lieutenant radioed his driver on the outside, and asked, “Where is the fire?”
The driver radioed back, the fire is in the rear, towards exposure 4. The Lieutenant on Engine 290 then left the tenth floor, descended the stairs to the ninth floor and helped his men drag the hose to the A-stairwell, where they met up with fire fighters on Engine 257, who assisted them in stretching their line and hook-up on the ninth floor. The victims proceeded through the center smoke doors in search of the fire. From the information obtained during this investigation, it is believed the victims found the fire apartment, with the door partially opened, allowing smoke and hot gases to enter the hallway. They then opened the door fully, the wind pushed the fire and extreme heat in the apartment into the hallway, and a flashover occurred, exposing the victims to extreme radiant heat that potentially elevated their body core temperature.
The last radio transmission from the victims was a Mayday call. When the victims were found, all were unresponsive, they were treated at the scene and taken to the hospital where they were pronounced dead by the attending physician.
This wind-driven fire event and the lessons-learned contributed directly to the current body of research and new insights on emerging strategies and tactics. The NIOSH Investigative Report HERE. NIST References on Wind Driven Fire Research HERE . FDNewYork.com HERE. New York Times Archived Articles, HERE and HERE. Photos and legacy, HERE
Take the time to remember FDNY Lt. Joseph Cavaleiri, FF Christopher Bopp and Firefighter James Bohan from Ladder 170
Today December 3, 2011 marks the 12th anniversary of the Worcester Cold Storage Warehouse fire that resulted in the line of duty death of six courages brother firefighters.
For those of you who remember this event, take the time to reflect and honor the sacrifice made this day; to those of you who have not heard about the fire before- take the time to learn about the incident, the firefighters, the building, the operational factors and challenges, the courage, fortitude and convictions that define the American Fire Service, it’s honor, tradition and brotherhood.
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
On Friday, December 3, 1999, at 1813 hours, the Worcester, Massachusetts Fire Department dispatched Box 1438 for 266 Franklin Street, the Worcester Cold Storage and Warehouse Co. A motorist 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.
From last year’s posting and links here at CommandSafety.com: HERE
The Federal Emergency Management Agency’s (FEMA) United States Fire Administration (USFA) have recently issued a special report examining the characteristics and causes of Large Loss Building Fires (PDF, 834 Kb).
The report, developed by USFA’s National Fire Data Center, is based on 2007 to 2009 data from the National Fire Incident Reporting System (NFIRS).
From 2007 to 2009, an estimated 900 large loss building fires were reported by U.S. fire departments annually.
These fires caused an estimated 35 deaths, 100 injuries, and $2.8 billion dollars in property damage.
In this report, large loss building fires are defined as fires that resulted in a total dollar loss of $1 million or more.
According to the report:
Forty-eight percent of large loss fires occur in residential buildings.
Exposures are the leading cause of large loss building fires at 22 percent, followed by electrical malfunctions (12 percent), other unintentional, careless actions (11 percent), and intentional (9 percent).
A peak in large loss building fires is seen between the hours of 1 a.m. and 4 a.m.
Attics are the primary origin of all large loss building fires, along with cooking areas or kitchens.
Topical reports explore facets of the U.S. fire problem as depicted through data collected in NFIRS. Each topical report briefly addresses the nature of the specific fire or fire-related topic, highlights important findings from the data, and may suggest other resources to consider for further information.
Also included are recent examples of fire incidents that demonstrate some of the issues addressed in the report or that put the report topic in context.
The following are some recent examples of large loss fires reported by the media:
October 2010: A fire in a Franklin, TN, home resulted in $2.5 million worth of damage. The cause of the fire is still unknown, but the fire began in a patio fireplace. The family of four present in the house at the time of the fire was able to escape safely. Four firefighters were injured while fighting the fire; two of them were treated at the scene and two were sent to the hospital for minor injuries.
June 2010: A Palo Alto, CA, two-alarm house fire caused between $1 and $2 million worth of damage. The family of four living in the house was awoken by their son when he heard the smoke alarm. The fire is believed to have been started by an unattended candle or cigarette the son left in a second-story room. The fire was brought under control in about 45 minutes and no deaths or injuries were reported.
June 2010: A fire that started in a Carmel, IN, shopping mall is believed to have been caused by lightning. Investigators have determined that the fire started in a restaurant located at the north end of the mall. There were no deaths or injuries as a result of the fire, but investigators estimate that the fire caused over $5 million worth of damage.
May 2009: A fire that started in a Gallery Furniture storage warehouse located in Houston, TX, resulted in at least $15 million worth of damage. Investigators have determined that the fire was caused by arson. Thirty to 40 employees were present when the fire broke out. The fire was determined to have been started in an area only accessible to employees. There were no injuries or deaths as a result of the fire.
Video Clip recorded live by Fire Department Network News TV (FDNNTV) at the 50th IAFF Fire Fighter Convention in San Diego, CA on August 23, 2010.
The National Institute for Occupational Safety and Health, also known as NIOSH, is a federal agency that is part of the Centers for Disease Control. NIOSH has a mission of generating new knowledge in the occupational safety and health field and to transfer that knowledge into practice for the advancement of workers, including firefighters and emergency responders.
In 1998, the International Association of Fire Fighters (IAFF) requested that Congress fund NIOSH to start a firefighter safety initiative called the NIOSH Fire Fighter Fatality Investigation and Prevention Program. “We investigate fatalities to learn from the mistakes the others made and to try to prevent future fatalities and injuries from occurring in similar events,” stated Project Officer Tim Merinar with the NIOSH Fire Fighter Fatality Investigation and Prevention Program. According to NIOSH, the Fire Fighter Fatality Investigation Program has made over 1,000 recommendations arising from over 300 investigations since its inception in 1998.
Merinar claimed that some do not fully understand who NIOSH is and what their goals are, often being confused with OSHA. However, the National Institute for Occupational Safety and Health is not an enforcement agency, they are a research and education agency. Merinar added, “We’re not looking to find fault or place blame on the fire departments or the individual firefighters in the incidents.”
As soon as possible after an incident, a NIOSH investigator will meet with the fire department. “Oftentimes, we have to explain who we are, why we’re there, what we’re trying to accomplish,” added Merinar. NIOSH investigates as many firefighter fatalities as possible involving structure fires, deaths from cardiovascular disease, as well as deaths during non-fireground incidents.
NIOSH offers many different publications to firefighters, including their newest one about risk management at structure fires. This literature is distributed to the fire service free of charge. Another publication offered to firefighters deals with floor joists and the risk of falling through fire-damaged floors. “They work very well for the construction industry, but when they’re exposed to fire they also fail very rapidly. Which leads to early building collapses,” explained Merinar. “Many firefighters have been injured and killed in these collapses.”
Trends such as this uncovered during their investigations and spread to the fire service, could help prevent future deaths. Another trend found several years ago by NIOSH involved PASS devices not sounding on firefighters who died. According to Merinar, NIOSH worked with the National Fire Protection Association to have the standard changed to make the PASS devices more reliable and more effective for firefighters. Currently, they are working with the NFPA on the thermal degradation characteristics of face piece lenses.
Fire Fighter Fatality Investigation and Prevention Program
For more information on the NIOSH Fire Fighter Fatality Investigation and Prevention Program, incident reports or fire fighter publications, visit www.cdc.gov/niosh/fire/.
Stakeholder Comment on the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program (FFFIPP)-2011
The National Institute for Occupational Safety and Health (NIOSH) is seeking stakeholder input on the progress and future directions of the Fire Fighter Fatality Investigation and Prevention Program (FFFIPP). Since its initiation in 1998, NIOSH has sought public input to help plan and direct the goals and objectives of the FFFIPP. NIOSH received public comments on the FFFIPP in 1998, March 2006, and November 2008. NIOSH is again seeking input on the progress and future directions of the FFFIPP to ensure that the program is meeting the needs and expectations of the U.S. fire service and to identify ways in which the program can improve its impact on the safety and health of fire fighters across the United States. NIOSH will compile and consider all comments received and use them in making decisions on how to proceed with the FFFIPP.
There are several resources that may be useful to individuals and groups who would like to comment on the FFFIPP:
The NIOSH Fire Fighter Fatality Investigation and Prevention Program Progress (FFFIPP) Report and Proposed Future Directions – 2011. This document includes specific topics for stakeholder input.
The Strategic Plan for the NIOSH Fire Fighter Fatality Investigation and Prevention Program that was finalized in 2009 after public input.
The FFFIPP web site that includes an overview of the FFFIPP, fatality investigation reports and other publications.
NIOSH Docket number 063NIOSH Docket number 063-A
Public Comment Period
Written comments on the document will be accepted through July 29, 2011 in accordance with the instructions below. All material submitted to NIOSH should reference Docket Number NIOSH-063-B. All electronic comments should be formatted as Microsoft Word documents and make reference to docket number NIOSH-063-B.
Comments will be accepted until 5:00 p.m. EDT on July 29, 2011
To submit comments, please use one of these options:
Send NIOSH comments using this online form
Send comments by email.
Fax comments to the NIOSH Docket Office: 513-533-8285
Send by Mail to:
NIOSH Mailstop: C-34
Robert A. Taft Lab.
4676 Columbia Parkway
Cincinnati, Ohio 45226
All information received in response to this notice will be available for public examination and copying at the …
NIOSH Docket Office
4676 Columbia Parkway, Room 111
Cincinnati, Ohio 45226.
A complete electronic docket containing all comments submitted will be available on the NIOSH docket home page, and comments will be available in writing by request. NIOSH includes all comments received without change in the docket, including any personal information provided.
Contact persons for technical information
Chief, Fatality Investigations Team
1095 Willowdale Road
Morgantown, WV 26505
Recent NIOSH Fire Fighter Safety Publications
Preventing Deaths and Injuries of Fire Fighters Operating Modified Excess/Surplus Vehicles
DHHS (NIOSH) Publication No. 2011-125
Fire fighters may be at risk for crash-related injuries while operating excess and other surplus vehicles that have been modified for fire service use. Fire departments with limited resources often craft fire apparatus out of excess/surplus military and other vehicles as an affordable alternative to purchasing new or used apparatus. NIOSH urges fire departments to take precautions and actions to minimize the hazards and risks to fire fighters when using modified excess/surplus vehicles.
Evaluation of Chemical and Particle Exposures During Vehicle Fire Suppression Training (2010) (56 pages, 4.85 MB)
Health Hazard Evaluation Report, HETA 2008-0241-3113
In September 2008 and July 2009, NIOSH researchers collected area and personal breathing zone air samples during a Health Hazard Evaluation (HHE) to evaluate firefighters’ exposures to airborne chemicals during vehicle fire suppression training. Several hazardous chemicals were found on the area samples, including respiratory toxicants and potential carcinogens. Of the chemicals measured in the personal breathing zones, levels of formaldehyde, carbon monoxide, and isocyanates were near or above short term exposure limits or ceiling limits. In addition, the number of particles and mass of the particles in the air increased during knockdown and remained elevated throughout the fire overhaul. Based on this evaluation, the levels of gases and particles released during vehicle fires have the potential to cause acute health effects to firefighters who do not wear self-contained breathing apparatus.
NIOSH Alert: Preventing Deaths and Injuries of Fire Fighters using Risk Management Principles at Structure Fires
DHHS (NIOSH) Publication No. 2010-153
Fire fighters are often killed or injured when fighting fires in abandoned, vacant, and unoccupied structures. These structures pose additional and sometimes unique risks due to the potential for fire fighters to encounter unexpected and unsafe building conditions such as dilapidation, decay, damage from previous fires and vandals, and other factors such as uncertain occupancy status. Risk management principles must be applied at all structure fires to ensure the appropriate strategy and tactics are used based on the fireground conditions encountered.
Preventing Exposures to Bloodborne Pathogens among Paramedics
DHHS (NIOSH) Publication No. 2010-139
Patient care puts paramedics at risk of exposure to blood. These exposures carry the risk of infection from bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), which causes AIDS. A national survey of 2,664 paramedics contributed new information about their risk of exposure to blood and identified opportunities to control exposures and prevent infections.
NIOSH Workplace Solutions—Preventing Deaths and Injuries to Fire Fighters During Live-Fire Training in Acquired Structures
DHHS (NIOSH) Publication No. 2005-102
Fire fighters are subjected to many hazards when participating in live-fire training. Training facilities with approved burn buildings should be used for live-fire training whenever possible. However, when acquired structures are used for live-fire training, NIOSH strongly recommends that fire departments follow the national consensus guidelines in NFPA 1403, standard on live-fire training evolutions [NFPA 2002a] to reduce the risk of injury and death. These guidelines are summarized in the recommendations in this document.
The past few decades have seen major advancements in the communication industry. These advancements have improved radio frequency spectrum efficiency, but also have added complexity to the expansion of existing systems and the design of new systems. The U.S. Fire Administration in conjunction with the International Association of Fire Fighters has released the report Voice Radio Communications Guide for the Fire Service 3.85 MB (77 pages) This report is designed to help fire service leaders and members understand new communication and radio system issues in order to remain informed players in the process.
Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio Communication Systems
The National Institute for Occupational Safety and Health (NIOSH) commissioned this study to identify and address specific deficiencies in firefighter radio communications and to identify technologies that may address these deficiencies. Specifically to be addressed were current and emerging technologies that improve, or hold promise to improve, firefighter radio communications and provide firefighter location in structures.
The National Institute of Standards and Technology, Building and Fire Research Laboratory publication “Testing of Portable Radios in a Fire Fighting Environment” 265 KB (24 pages)
focuses on the thermal environment that radios would be expected to withstand while being used in structural fire fighting operations. Current NFPA standards for radios are reviewed and recommendations for establishing performance standards are presented. The need for providing additional protection from the thermal environment is documented.
For those of you that follow or have attended one of my many seminar and lecture program offerings, one program seems very pertinent in both context and content on this, the Sixth Day of Fire/EMS Safety Week 2011 that resonates around the theme and focus of Surviving the Fire Ground – Fire Fighter, Fire Officer and Command Preparedness.
“From Waldbaum’s to Hackensack-Worcester to Charleston; Legacies for Operational Safety”; in most cases, any discussion of these four landmark incidents in the fire service leads directly to a rich discussion and dialog on a myriad of facets, aspects and issues characteristic of the incidents; the time, the place, the circumstances, the names and faces, the deployment, the operations, the challenges and the tragic outcomes.
The legacies of these iconic events as well as so many others of national prominence and impact; and others with lesser national significance, but having far reaching implications, impacts and power on the regional and local levels continue to shine in the remembrance, honor and memory of those impacted by those events and incidents.
I still find it astonishing during my lecture travels around the country lecturing and presenting these programs on building construction and fireground operations, that when those in attendance were posed with a simple question; “What do the Walbaum’s Fire and Hackensack fire share in common?”, the response at times was less than stellar, or at best difficult to solicit let alone convey the commonalities.
The more seasoned and experienced veterans (translation; older firefighters) when present, were able to convey some information on the subject – Some, with a firm and reflected understanding of the question and its ramifications, others not so much. But yet, the true essence of the basic incident particulars and the lessons learned in most cases failed to be fully conveyed. It’s sad to state but; we are not remembering the past!
History Repeating Events-Integrate into your Training
Are the fire service legacies of the past and the lessons learned from those incidents and the sacrifices that were made transcending time? Or are they lost in the immediacy of day to day challenges, issues and operations.
Or are these events, lessons and operations issues dismissed and disregarded as a result of their “time and place” not being relevant to “today’s” operations and modern fire service advancements or lack the relevancy to local organizations, operations, make-up and risks. Is it just a “Big City” issue or is it a failure to comprehend the commonality of the event parameters and distill those lessons learned and operations into the essence that is formulative of all of our organizations and operations?
Surviving the Fire Ground – Fire Fighter, Fire Officer and Command Preparedness, has a multitude of facets, features and functional elements. I spoke of some of these commonalities in a previous post this week on Day Two (HERE).
I’ve spoken on numerous occasions about History Repeating Events (HRE), and the common themes related to fire fighter line-of-duty deaths, close-calls, near-misses, maydays and incident operations that had less than desirable outcomes or performance.
These History Repeating Events and incidents on a wide variation of scale, outcome and operations have common issues, apparent and contributing causes and operational factors that share legacy issues that the fire service at times fails to identify, relate to and implement. In other words, (we) fail a times to learn from the past or we make a deliberate choice to ignore those lessons and the apparent similarities and prevailing fireground indicators due to other internal or external influences, pressures, authority, beliefs, values or viewpoints.
What are we Learning? What are we Applying?
We make choices and we determine our direction, path and destiny. Officers, Commanders, Companies fail to connect with situational factors, parallels and signs that have the full potential to direct the incident towards favorable or disastrous conclusions. The Job isn’t as fatalistic as we sometimes make it out to be.
The prevailing topical areas being addressed this year during Safety week have focused on the mayday component of an incident operation and have included:
Preventing the Mayday: situational awareness, planning, size up, air management, fitness for survival, defensive operations.
Being Ready for the Mayday: personal safety equipment, communications, accountability systems.
Self-Survival Procedures: avoiding panic, mnemonic learning aid “GRAB LIVES”— actions a fire fighter must take to improve survivability, emergency breathing.
Hackensack (NJ) Auto Dealership Fire (1988) HERE and HERE
Worcester (MA) Cold Storage Fire (1999) HERE and HERE
Charleston (SC) Sofa Super Store (2007) HERE and HERE
These have tremendous Legacies for Operational Safety, lessons and a wealth of applications for Safety Week and for training, dialog, discussions, tabletops, skillsets and drill activities throughout the entire year.
Integrate the lessons from these as well as other legacies and HRE into your Surviving the Fire Ground – Fire Fighter, Fire Officer and Command Preparedness; training and deliveries. The reality is, we, the present generation of veteran firefighters and officers have the profound obligation and responsibility to recognize the importance of passing along the lessons of the past as well as integrating and playing forward the lessons of our life’s journey throughout our fire service careers; the events of our day and the profound tough lessons and sacrifices learned the hard way. Understand and embrace the shared responsibilities, accountability and requirements that contribute towards Surviving the Fire Ground.
We sometimes need a receptive, sympathetic and compassionate audience that is willing to listen, hear and comprehend the messages conveyed. There needs to be a high degree of empathy related to these past History Repeating Events, the legacies of national, regional and local level prominence. For each event, each and every line of duty death, close-call, near-miss and mayday event has a message and a Legacy of Operational Safety.
Make the time to research, learn and understand the factors of these events, the lessons and opportunities that are borne from each and how they relate to the theme, message and initiatives that make up Fire/EMS Safety, Health and Survival Week and beyond.
The Strand Theatre was first erected in 1915 on the site of a previous theatre which was destroyed by fire on April 7, 1915. The Strand Theatre opened in March, 1916 on School Street between Main Street and City Hall in Brockton. It replaced another theatre that was destroyed by fire April 7, 1915. With a seating capacity of 1,685, it was the largest playhouse in the City.
When opened, the Strand Theatre was considered a leader in modern fire safety. The stage area included a dry pipe sprinkler system termed “fireproof” and the surface exits were 20% more than state law requirements.
Located on an irregular lot, the Theatre measured 139 feet deep and 60 feet tall. The walls were made of brick and the roof was made up of wood boards on joists supported by unprotected steel trusses. The interior walls were metal lath and plaster as was the ceiling, which was suspended from the trusses. The balcony covered a large area above the auditorium and housed a manager’s office, usher’s room and rest rooms. The area under the auditorium was dead space with the exception of the west end of the basement where finished rooms contained the furnace, ventilation equipment and a janitor’s room. The lobby was an open area with two open stairwells on each end providing access to the balcony. A long corridor connected the Theatre lobby to School Street.
In August, 1937, the Strand Theatre underwent extensive remodeling and improvements under new management. The building remained intact under the new management until the fire occurred in 1941.
March 10, 1941: The Stand Theatre Fire
In the heart of Brockton’s business district, people usually flocked to the downtown area to shop or take in a show in what was a busy part of the city. Sunday, March 9, 1941, like all other Sundays, drew large crowds looking for the entertainment of a movie or vaudeville show. That evening the Strand showed the double feature, “Hoosier School Boy” starring Mickey Rooney, followed by “Secret Evidence,” a crime drama.
Long after the curtain had closed and the crowds had filtered out, a custodian discovered a fire burning in the Theatre basement and instructed his helper to activate the fire alarm box located at Main and High Street. At 12:38 a.m., the fire department received Box 1311 and sent the first alarm apparatus to the scene. A second alarm followed shortly after the first, and finally a general alarm was sounded bringing all of Brockton’s apparatus to the Strand Theatre.
When firefighters first arrived on the scene, the fire did not seem very serious. However, as time progressed, the fire gained headway. This became more apparent to those on the outside of the theatre than crews working inside.
Crews knocked down the fire in the basement with cellar pipes while flames raced through the vertical voids in the walls and ventilation ducts. Firefighters worked feverishly to extinguish hidden fire while crews opened walls and ceilings in the lobby and under the balcony. A number of men moved up to the balcony to attack the fire which had made its way to the auditorium ceiling just below the roof.
The first signs of visible outside fire erupted from the southwest corner of the building as outside crews played a large hose-line on the exposed flames. Firefighters on the balcony continued their efforts to expose the fire within the ceiling as hose streams were directed overhead from the auditorium floor.
Less than one hour later, the Strand Theatre Fire turned from a routine fire into one of the worst tragedies in Brockton and Massachusetts history when the west section of the roof collapsed, killing 13 firefighters and injuring 20 firefighters.
Uninjured firefighters worked tirelessly to save their fellow brothers despite the danger and fear of another collapse. Eventually, fire departments from neighboring towns relieved Brockton firefighters.
No definite cause for the fire was ever discovered. Initial reports of arson proved to be inconclusive. Further investigation revealed that the unprotected steel roof trusses played a major role in the collapse. The heat of the fire within the concealed space between the roof and the auditorium ceiling was believed to have distorted the steel trusses, causing them to buckle and separate with ease. Experts questioned the effectiveness of the construction and design used in the roof assembly. Some reports state that the weight of a previous snowfall may have added to the collapse. However, witness accounts and photographs indicate a minimal amount of snow.
March 10, 1941 Newspaper Headlines
Every year on March 10th a commemorative service is held at Brockton City Hall to honor the 13 Brockton firefighters who made the ultimate sacrifice that winter night:
Captain John F. Carroll –Ladder Company 3
Lieutenant Raymond A. Mitchell–Engine Company 4
Firefighter Roy A. McKeraghan–Squad A
Firefighter Denis P. Murphy–Squad A
Firefighter William J. Murphy–Squad A
Firefighter Daniel C. O’Brien–Squad A
Firefighter George A. Collins–Engine Company 1
Firefighter Frederick F. Kelley–Engine Company 1
Firefighter Martin E. Lipper–Engine Company 1
Firefighter Henry E. Sullivan–Engine Company 1
Firefighter Bartholomew Herlihy–Ladder Company 1
Firefighter Matthew E. McGeary–Ladder Company 3
Firefighter John M. McNeill–Ladder Company 1
From Brockton IAFF Local 144 site, The following information is available:
Chicago: Anatomy of a Building and its Collapse PDF Training Aid
The recent post titled: Chicago: Anatomy of a Building and its Collapse has been receiving a considerable amount of attention as the post makes its way throughout the fire service eMedia sites, links, likes, shares and commentary circles, with over 6,000 views in the past 24 hours on various sites.
It furthers the premise that I have advocated my entire career and that is the fire service continues to recognize the need for increased knowledge, training, insights and skill sets related to building construction and its diametric relationship to firefighter, command risk management and operational safety.
And that we need to learn from each and every incident response,operation and run….Let’s continue to gain learnings and insights from not only this event, but from the vast resources of published LODD investigations, after-action reports, case studies, near-miss events and close-calls; for each has a lesson that we can use on our next call.
In order to provide support for continuing training and insight opportunities, I’ve developed a PDF download of the Chicago: Anatomy of a Building and its Collapse article in its entirety.
A power point program will be forthcoming to accompany both media items.
Thirty years ago on the morning of November 21, 1980, 85 people died and more than 700 were injured as a result of a fire at the MGM Grand Hotel in Las Vegas, Nevada. This was the second largest life-loss hotel fire in United States history. It was determined during the investigation that the fire originated in the wall soffit of the side stand in the Deli, one of five restaurants located on the casino level. The investigators concluded that several factors contributed to the cause of the fire but the primary source of ignition was an electrical ground fault.
Once the fire ignited, it quickly traveled to the ceiling and the giant air-circulation system above the casino. In the casino, flames fed on flammable furnishings, including wall coverings, PVC piping, glue, fixtures, and even the mirrors on the walls, which were made of plastic.
The fire burned undetected for hours until it flashed over just after 7 a.m. and began spreading at a rate of 19 feet (5.8 meters) per second through the casino. As fire companies and firefighters were arriving, according to published reports, an estimated one-million-cubic-foot wall of flames was rushing through the casino, melting slot machines and sending a cyanide-laced cloud of killer smoke pouring upward.
The investigation determined that the rapid fire spread was due to a series of installation and building design flaws. A wire at the point of fire origin that had been improperly grounded could’ve been discovered had the area been inspected. A compressor wasn’t properly installed. A piece of copper wasn’t insulated correctly. A fire alarm never sounded. A stairwell that was a crucial escape route filled with smoke. The laundry chutes failed to seal and defects existed in the heating, ventilation, and air-conditioning systems. All of these factors contributed to the spread of smoke.
Photo: AP/World Wide
This fire provided a wake-up call for the industry to improve fire safety standards in hotels around the country. As a result, hotels today are safer than ever.
About 5,000 people were in the resort when the blaze started to burn in earnest.
Many were trapped in their rooms, in the corridors, and in stairwells, and most of the victims died at the scene or in Las Vegas Valley hospitals.
Another handful of victims succumbed to fire-related injuries within a year.
Fourteen firefighters were hospitalized, most suffering from smoke inhalation.
According to the newspapers reports, NFPA’s Fire Investigation Manager, David Demers, concluded that “with sprinklers, it would have been a one or two sprinkler fire, and we would never have heard about it.”
An employee cutting through the closed Deli on the way to work was the first to see the fire. The worker, not identified by name in the fire investigation report, called security, then tried to put it out. The worker wasn’t trained and the proper equipment wasn’t there, the NFPA investigation said.
A visiting firefighter from Illinois breakfasting in an adjacent coffee shop also tried to help a security guard find an extinguisher to put out the electrical fire, but they couldn’t locate one.
A flame front moved into the casino, where the fire gained speed and strength, fueled by more flammable materials, including the highly flammable adhesive used to attach ceiling tiles.
Again, sprinklers would have put the fire out there.
Without them, within minutes, the fireball tore through the casino, blowing out the doors leading to the valet area.
Soon, killer smoke rose through the 26-floor high-rise tower via ventilation ducts.
While the lack of sprinklers was a major factor contributing to the severity of the MGM fire, it’s not that simple. Blame also has to be given to code violations, design flaws, installation errors, and materials that made the fire worse.
The fire alarms didn’t sound because they were manual and nobody pulled them. However, the disaster might have been worse if the alarms had prompted more people to rush into smoke-filled hallways.
Despite the discovery of 83 building code violations, nobody was ever charged criminally with any wrongdoing
To make matters worse, fire marshals had insisted sprinklers be installed in the casino during the building’s construction in 1972, but the hotel refused to pay for the $192,000 system, and a Clark County building official sided with the resort. Authorities later said the sprinkler system could have prevented the disaster at the hotel, which is now Bally’s Las Vegas Hilton Casino Resort. The fallout was $223 million in legal settlements, in addition to the lives lost.
Construction of the 26-story MGM Grand Hotel and Casino (currently Bally’s) started in 1972 and it opened in December of 1973.
There were 2,078 rooms at the hotel and the total area of the hotel and casino was approximately two million square feet.
Fire sprinkler systems were not installed in the high-rise hotel, the casino (approximately 380 by 1200 feet, or 450,000 square feet), and the restaurant areas.
Only partial fire sprinkler protection was provided for limited areas (arcade, showrooms and convention areas) on the ground level.
Where the sprinklers had been installed, they clearly worked. But sprinklers weren’t anywhere near where the fire broke out behind a wall near a serving station at The Deli that Friday morning about 7:10 a.m.
The Deli had received an exemption for sprinklers because it was supposed to be a 24-hour restaurant. It was assumed someone would always be there to put out a fire.
But then the hours changed and The Deli wasn’t open all the time. It was closed when the fire erupted.
The fire, caused by an electrical ground-fault, smoldered for hours before breaking through the wall.
According to NFPA’s final investigation report , several major factors contributed to the large loss of life in this fire. Among them was the rapid fire and smoke development in the casino in the early stages of the fire due, in part, to the lack of sprinklers and adequate fire barriers.
The fire generated massive amounts of smoke that spread up the hotel’s 23-story high-rise tower through unprotected vertical seismic joints and elevator hoistways and the substandard interior stair enclosures and exit passages.
In addition, the hotel’s heating, ventilating, and air conditioning continued to operate during the fire, pushing smoke throughout the high-rise.
Investigators found no evidence that the hotel had executed an emergency plan or sounded an evacuation alarm signal. Nor was there any evidence of manual fire alarm pull stations in the natural escape path in the casino.
The number and capacity of the exits from the casino were deficient, and the travel distances from certain areas of the casino to the exits were too long.
Finally, there was no automatic means of recalling the elevators to the main floor during the fire to prevent people from boarding them. Ten of the MGM Grand victims were found in the hotel’s elevators.
As a result of this fire, NFPA Life Safety Code® requirements for stairwell re-entry onto building floors if the exit stair enclosure becomes untenable were changed to include three options.
Stairwell doors must now remain unlocked on the inside of the stairwell so that people can get from the stairwell back to guest room floor.
Or they may be locked, but they must automatically unlock when the building’s fire alarm system activates.
Or hotels may use selected re-entry, in which there may be no more than four intervening floors between unlocked doors and signs must be provided to direct occupants to the floors with unlocked doors
Graphic by Mike Johnson.
On the night of February 10, 1981, just 90 days after the devastating MGM Grand fire, an arson fire started at the Las Vegas Hilton, which at the time was being retrofitted with modern fire safety equipment. Firefighters, using the knowledge they had learned from the MGM fire, used local television networks to notify people to stay in their rooms and not go out to the halls and stairwells. Because of the lessons learned, only eight people died in this fire compared with the 84 people who died in the MGM Grand fire
USFA Topical Fire Report Series; Hotel and Motel Fires, HERE
Lessons from the Past: MGM Grand Fire on Firehouse.com, HERE
Las Vegas and Nevada history as told by those who lived it- The MGM Fire 1980. This six part series was broadcast in 2000 and produced by KNPR’s Tim Anderson with support from the Nevada Humanities Committee. HERE
These links from the Las Vegas Review Journal Media covered the 25th Anniversary of the event;
An estimated 3,900 hotel and motel fires are reported to U.S. fire departments each year and cause an estimated 15 deaths, 150 injuries, and $76 million in property loss.
Hotel and motel fires are considered part of the residential fire problem. However, they comprise only approximately 1 percent of residential building fires.
Half of hotel and motel fires are small, confined fires.
Cooking is the leading cause of hotel and motel fires (46 percent). Almost all hotel and motel cooking fires are small, confined fires (97 percent).
Eighteen percent of non-confined hotel and motel fires extend beyond the room of origin. The leading causes of these larger fires are electrical malfunctions (24 percent), intentionally set fires (15 percent), and fires caused by open flames (12 percent). In contrast, 42 percent of all non-confined residential building fires extend beyond the room of origin.
While bedrooms are the primary origin of non-confined fires (23 percent), when confined cooking fires are considered, the kitchen or other cooking area is the most prevalent area of fire origin.
Hotel and motel fires are more prevalent in the cooler months due to increases in heating fires and peak in February (9 percent).
Bally's Las Vegas, formerly the MGM Grand Hotel and Casino today
Many U.S. buildings are vulnerable to extreme loads that may cause partial or total collapse. Modern structures have a limited reserve capacity to accommodate abnormal loads. There is no accepted science-base or design practice to maintain overall structural robustness within a multi-hazard context that considers both design loads and abnormal loads. The National Institute of Standards and Technology (NIST) is an agency of the U.S. Commerce Department, has initiated a new project will address the development of procedures and computational methodologies for assessment of overall structural robustness and will provide the measurement science needs for the development of performance-based provisions in U.S. codes and standards for disproportionate collapse resistance that will ensure improved robustness of building structures.
The term “disproportionate collapse” is defined as the spread of an initial local failure from element to element resulting in the collapse of an entire structure or a disproportionately large part of it.
Since the terrorist attacks on the WTC towers and the Pentagon, owners of major U.S. buildings including the federal government (the largest single owner of buildings in the U.S.) have emphasized disproportionate collapse resistance as one of the design requirements (see, e.g., Senate Committee Report 107-57). Currently, GSA, DoD, and DoS require that their buildings be designed and evaluated for disproportionate collapse potential. The NIST WTC Towers Investigation (NIST NCSTAR 1, Recommendation 1) calls for the development of consensus-based codes and standards for disproportionate collapse mitigation, and was reiterated in the investigation of the fire-induced disproportionate collapse of WTC 7 (NIST NCSTAR 1A).
There are no metrics to compare the overall system-level performance of structures, making it impossible to compare and quantify the safety performance of different types of structural systems. There is no accepted science-base or design practice to maintain overall structural robustness within a multi-hazard context that considers both design loads and abnormal loads. Critical measurement science capabilities that are lacking include;
(1) system-level structural models capable of estimating the reserve capacity of building structures and assessing disproportionate collapse resistance,
(2) measures of structural robustness, and
(3) proven and cost-effective methods to mitigate disproportionate collapse.
The behavior of structural systems near their ultimate limit states is not well understood, and simulating this behavior depends on the availability of accurate structural models. Development of accurate models to predict reserve capacity of structural systems and allow the quantification of robustness, in turn, depends on the availability of validated models of members and connections. At the present time, experimental data on the behavior of connections undergoing disproportionate collapse are lacking. In addition, detailed modeling of a complete structural system to failure is often beyond the capability of existing tools. Reduced models of connections that capture the predominant behaviors and failure modes are needed for cost effective assessment of structural robustness and disproportionate collapse potential.
While the measurement science needs identified above have not been solved, organizations in the U.S. such as NIST, ERDC, DTRA, and GSA as well as few universities in Belgium, England, and Japan have conducted limited testing of full and scaled models of steel subassemblies. No concrete subassemblies have been tested anywhere. Over the past few years, organizations such as NIST and a few private sector companies under contract to federal agencies have made some progress in the modeling of subassemblies; both at the detailed and reduced models levels. However, measurement science needs such as metrics for structural system robustness, system-level computational tools, and agreed-upon methods for disproportionate collapse mitigation have not been developed.
This project will provide the measurement science needs for the development of performance-based provisions in U.S. codes and standards for disproportionate collapse resistance that will ensure resilience of building structures and as a result improve life safety and thereby improving the quality of life. Furthermore, the project is part of the “Measurement Science for Structural Performance under Multi-Hazards” program within EL’s strategic goal on “Measurement Science for Disaster Resilient Structures and Communities”. EL is well positioned to address the needs outlined in this project because of its long history in investigating structural failures and the capabilities built over the years in analyzing the failures of complex multi-story structures using state of the art computational tools.
What is the new technical idea? A key focus of the project is to develop system-level performance metrics to quantify the robustness of building structures. Robustness is a key structural property that is related to disproportionate collapse resistance. Both structural redundancy and integrity are key factors that influence the robustness of the structure. These factors must be quantified to express the robustness in a meaningful and measurable manner. The assessment of the degree of structural redundancy for redistribution of loads and structural integrity for system continuity requires simulation of structural behavior under various local failure scenarios. Realistic and efficient simulations require the development and use of advanced and experimentally validated modeling methodologies to examine the structural system performance. Both traditional and new design concepts will be evaluated to determine the relative merits of various structural systems in resisting disproportionate collapse. The project will examine collapse limit states of structural systems to quantify the reserve capacity of various structural systems, through a combination of push-down and push-over analyses. The project will also develop design and retrofit methodologies that take explicit advantage of the synergies associated with mitigating disproportionate collapse under multiple hazards to enhance overall efficiency and cost-effectiveness. The required work depends heavily on the use of advanced and detailed structural models to evaluate the nonlinear behavior of structural systems in post ultimate capacity limit states. With today’s high-performance computational tools, it is feasible to predict structural response due to abnormal dynamic loads. Complementary to the analytical evaluation of structures, the project will review and make use of the knowledge gained from controlled demolition technology. Through decades of experience, the demolition community has developed detailed knowledge about the collapse behavior of structural systems.
The recommendations from a national workshop formed the basis for a coordinated national plan for problem-focused research on mitigation of disproportionate collapse of buildings. The project proposes to develop metrics to quantify the robustness of various structural systems to assess their disproportionate collapse potential. These metrics will be based on experimentally validated computational models of structural systems incorporating the predominant behaviors and failure modes of components and connections. Such models can also be used by design professionals in design for disproportionate collapse resistance. A key component in the development and evaluation of robustness metrics will be a series of push-down and push-over analyses to assess the reserve capacity of a variety of structures with different systems and materials. The project will develop performance objectives, acceptance criteria, and evaluation methods for both new and existing structures, which will be used to develop guidance documents and pre-standards for design and rehabilitation of structures to mitigate disproportionate collapse.
The NIST project will produce the following outcomes:
1. Best Practices Guide for design of new buildings and rehabilitation of existing buildings (Complete).
2. Computational methodologies to evaluate the disproportionate collapse potential of building structures for practicing engineers based on the following work:
(a) testing of full-scale subsystems to validate detailed computer models.
(b) testing of 3-D multi-story frames to validate reduced 3-D computer models.
(a) development of reduced 3-D models of various structural systems.
(b) comparative assessment of reserve capacities of various structural systems.
(c) evaluation of structural systems capable of resisting disproportionate collapse.
3. Guidelines for assessing disproportionate collapse vulnerability, including both rapid and comprehensive evaluation guides.
4. Comprehensive guidelines for design of new buildings to resist disproportionate collapse.
5. Comprehensive guidelines for retrofit of existing buildings to resist disproportionate collapse.
6. Pre-standards for design of new buildings and retrofit of existing buildings to resist disproportionate collapse.
FY 2010 the projects overview:
Development of 3-D structural models of 10-story reinforced concrete shear wall and precast concrete buildings.
Evaluation of reserve capacity and development of structural robustness metrics for various structural systems.
Evaluation and comparison of disproportionate collapse vulnerability of various steel and reinforced concrete structural systems.
Design and testing of precast concrete beam-column assemblies.
Best Practices Guide (NISTIR 7396) adopted by ASCE 7-10 Standard as part of the commentary section on General Structural Integrity.
Developed experimentally validated 3D models of steel frame buildings for assessment of reserve capacity and vulnerability to disproportionate collapse (Journal publication being developed).
Developed experimentally validated 3D models of reinforced concrete frame buildings for assessment of reserve capacity and vulnerability to disproportionate collapse (Journal publication being developed).
Published “Best Practices for Reducing the Potential for Progressive Collapse in Buildings-NISTIR 7396.”
Major factors contributing to a rapid spread of fire at the Sofa Super Store in Charleston, S.C., on June 18, 2007, included large open spaces with furniture providing high fuel loads, the inward rush of air following the breaking of windows and a lack of sprinklers, according to a draft report released for public comment today by the U.S. Commerce Department’s National Institute of Standards and Technology (NIST). The fire trapped and killed nine firefighters, the highest number of firefighter fatalities in a single event since 9/11.
Based on its findings, the NIST technical study team made 11 recommendations for enhancing building, occupant and firefighter safety nationwide. In particular, the team urged state and local communities to adopt and strictly adhere to current national model building and fire safety codes.1 If today’s model codes had been in place and rigorously followed in Charleston in 2007, the study authors said, the conditions that led to the rapid fire spread in the Sofa Super Store probably would have been prevented.
“Furniture stores typically have large amounts of combustible material and represent a significant fire hazard,” said NIST study leader Nelson Bryner. “Model building codes should require both new and existing furniture stores to have automatic sprinklers, especially if those stores include large, open display areas.”
Specifically, the NIST report calls for national model building and fire codes to require sprinklers for all new commercial retail furniture stores regardless of size, and for existing retail furniture stores with any single display area of greater than 190 square meters (2,000 square feet). Other recommendations include adopting model codes that cover high fuel load situations (such as a furniture store), ensuring proper fire inspections and building plan examinations, and encouraging research for a better understanding of fire situations such as venting of smoke from burning buildings and the spread of fire on furniture.
Using a state-of-the-art computer model to simulate the fire, the study team found that the addition of automatic sprinklers inside the loading dock could have significantly slowed the fire (which began just outside the dock area), prevented it from spreading beyond the dock, and eventually, extinguished it completely. The model also showed that sprinklers on the loading dock likely would have maintained what firefighters call tenability conditions, the ability for individuals in a fire event to escape unassisted.
Factors identified as contributing to the fire’s progress include: (1) the high fuel loads—especially furniture—present throughout the building; (2) the lack of sprinklers throughout the Sofa Super Store; (3) the open floor plan of the facility; (4) the hidden build-up of combustible smoke and gases in the area between the drop ceiling and the roof of the main showroom; (5) the non-fire-activated roll-up door that was open between the loading dock and the holding area; (6) the four fire-activated roll-up doors (out of seven) that activated but did not close during the fire; (7) the metal walls in the warehouse and west showroom that allowed heat from the fire to ignite items next to the walls; and (8) the breaking of windows at the front of the store that supplied air to the fire.
NIST’s team of experts traveled to Charleston to gather data within 36 hours of the Sofa Super Store fire. Using these data and other information collected in the following months (such as building design documents, records, plans, video and photographic data, radio transmissions, interviews with emergency responders, and informal discussions with store employees), the NIST study team developed its computer model to simulate and analyze the characteristics of the fire, including fire spread, smoke movement, tenability, and the operation of active and passive fire protection systems.
Based on their model and the data collected, the NIST researchers determined the following sequence of events on June 18, 2007, at the Sofa Super Store:
The fire began in trash outside the loading dock and spread into the enclosed loading dock. The fire spread from the exterior to the interior of the loading dock, which was used for staging furniture for delivery and repair. The fire spread quickly within the loading dock and moved into both the retail showroom and warehouse spaces.
During the early stages of this fire, the fire was unable to access enough air, a state that slowed its growth. However, the lack of sufficient air for complete combustion did result in large volumes of smoke and combustible gases flowing into the space below the roof and above the drop ceiling of the main retail showroom.
The fire spread to the rear of the main showroom through the holding area and ignited additional fuel in the rear of the main showroom, at which time it became more visible to firefighters in the main showroom.
The growth of the fire at the back of the main showroom was still slowed by the lack of air. As the fire burned in the rear of the main showroom, the fire pumped more hot unburned fuel into the smoke layer below the drop ceiling. The lack of air prevented the unburned fuel in the smoke layer from igniting.
When the front windows were broken (approximately 24 minutes after firefighters arrived at the store), additional air flowed in the front windows, along the floor and to the rear of the showroom, and became available to the fire. The additional air allowed the burning rate of the fire to increase rapidly and ignite the layer of unburned fuel below the drop ceiling.
The fire swept from the rear to the front of the main showroom extremely quickly, then into the west and east showrooms, trapping six firefighters in the main showroom and three firefighters in the west showroom.
Furniture and merchandise in the showrooms and warehouse continued to burn for an additional 140 minutes before the fire was extinguished.
NIST welcomes comments on the draft report and its recommendations. To be considered for the final report, comments must be received by noon EST on Dec. 2, 2010. Comments may be submitted via e-mail to firstname.lastname@example.org; fax to (301) 975-4052; or mail to the attention of NIST Technical Study: Sofa Super Store, NIST, 100 Bureau Dr., Stop 8660, Gaithersburg, MD 20899-8660.
Once the final report is published, NIST will work with the appropriate committees of the International Code Council (ICC) on using the study’s recommendations to improve provisions in model building and fire codes. NIST also will work with the major organizations representing state and local governments—including building and fire officials—and firefighters to encourage them to seriously consider its recommendations.
Recommendations from the NIST Study of the Charleston Sofa Super Store Fire
1. High Fuel-Load Mercantile Occupancies: NIST recommends that, at a minimum, all state and local jurisdictions adopt a building and fire code based upon one of the model codes, covering new and existing high fuel-load mercantile occupancies, and update local codes as the model codes are revised.
2. Model Code Adoption and Enforcement: NIST recommends that all state and local jurisdictions implement aggressive and effective fire inspection and enforcement programs that address:
a) all aspects of the building and fire codes;
b) adequate documentation of building permits and alterations;
c) the means of inspecting fire protection systems and detailing record keeping;
d) the frequency and rigor of fire inspections, including follow-up and auditing procedures; and
e) guidelines for remedial requirements when inspections identify deviations from code provisions.
3. Qualified Fire Inspectors and Building Plan Examiners: NIST recommends that all state and local jurisdictions ensure that fire inspectors and building plan examiners are professionally qualified to a national standard such as National Fire Protection Association (NFPA) 1031.
4. Sprinklers: NIST recommends that model codes require sprinkler systems and that state and local authorities adopt and aggressively enforce this provision:
a) for all new commercial retail furniture stores regardless of size; and
b) for existing retail furniture stores with any single display area of greater than 190 square meters (2,000 square feet).
5. Comprehensive Risk Management Plans: NIST recommends that state and local jurisdictions use comprehensive risk management plans to:
a) identify low, medium, and high hazard occupancies;
b) allocate resources according to risk identified; and
c) develop operating procedures that respond to specific risks.
6. Ventilation of Burning Structures: NIST recommends that state and local authorities:
a) develop guidelines as to how and when ventilation should be implemented during a fire; and
b) provide training to fire fighters on different types of ventilation—vertical, horizontal and positive-pressure—and integrate into daily operations on the fire ground.
7. Research on Upholstered Furniture Flame Spread: NIST recommends that research be conducted to better understand ignition and fire spread on upholstered furniture in order to provide the tools needed by design professionals to improve the fire performance of furniture. The specific areas requiring research are:
a) prediction of ignition of natural and synthetic coverings for current furniture, wall, ceiling and floor lining materials, and room furnishings;
b) prediction of fire spread over actual furniture with and without fire barriers, fire retardants and fire resistive materials; and
c) quantification of smoke and toxic gas production in realistic room fires.
8. Research on Improving Fire Barriers: NIST recommends that research be conducted to provide the tools needed by design professionals to improve the performance of compartmentalization. The specific areas requiring research are:
a) prediction of fire spread through walls constructed of wood, metal and gypsum wallboard;
b) prediction of fire spread through doors constructed of glass, wood, and metal;
c) prediction of fire spread through penetrations; and
d) prediction of performance of roll-up fire doors in actual fires and after extended service.
9. Research on Decision Aids for Allocation of Resources: NIST recommends that research be conducted to:
a) refine computer-aided decision tools for determining the costs and benefits of alternative code changes and fire safety technologies; and
b) develop computer models to assist communities in allocating resources (money and staff) to ensure that their response to an emergency with a large number of potential casualties is effective.
10. Research on Ventilation of Burning Structures: NIST recommends that additional research be conducted to:
a) improve characterization of how ventilation affects the growth and spread of fire within structures; and
b) provide the fire service with guidance on when and how to use ventilation to improve the fire environment during fire service operations.
11. Research on Performance Metrics for Fire Protection: NIST recommends that research be conducted to:
a) develop performance and effectiveness metrics for community fire protection;
b) survey effectiveness of existing fire services; and
c) use metrics to optimize development of new technologies.
NIST has more than 40 years of experience conducting building and fire safety studies and researching the aftermath of disasters and failures. By understanding the technical causes for such incidents and making the information available to the public, NIST scientists and engineers strive to improve the safety of buildings, their occupants and emergency responders. NIST’s technical building failure and fire studies do not address fault.
NIOSH released it’s latest Alert on Firefighter Risk Reduction. Fire fighters are often killed or injured when fighting fires in abandoned, vacant, and unoccupied structures. These structures pose additional and sometimes unique risks due to the potential for fire fighters to encounter unexpected and unsafe building conditions such as dilapidation, decay, damage from previous fires and vandals, and other factors such as uncertain occupancy status. Risk management principles must be applied at all structure fires to ensure the appropriate strategy and tactics are used based on the fireground conditions encountered.
Fire fighters should take the following steps to minimize their risk of death and injury while fighting structure fires:
Report conditions and hazards encountered to your officer, incident commander, or incident safety officers
Recognize that maintaining your safety is a shared responsibility
Comply with your department’s standard operating procedures (SOPs) / standard operating guidelines (SOGs) and safety rules.
Be constantly aware of your surroundings and changing conditions.
Fire departments (chief officers, company officers and policy makers) should take the following steps to protect fire fighters:
Develop and enforce risk management plans, policies, and standard operating procedures and guide-lines (SOPs/SOGs) for risk management.
Train incident commanders, incident safety officers, and fire fighters in the fire department risk management plans and SOPs/SOGs for risk management.
Develop and implement fire department policies and SOPs/SOGs for emergency response and fire-fighting activities in and around abandoned, vacant, or unoccupied structures.
A thorough size-up and risk analysis should be performed before conducting operations in any burning structure.
Fire-fighting operations should be limited to defensive (exterior) strategy if the structure is judged to be unsafe and in any situation where the risks to fire fighter safety are excessive.
Offensive (interior attack) operations should only be considered when sufficient resources are on scene to conduct offensive operations with a reasonable degree of safety, including the ability to perform essential support functions (i.e., water supply, ventilation, lighting, utility control, accountability, rapid intervention teams).
Additional size-ups and risk analyses should be performed before changing strategies, including any decision to conduct interior overhaul operations following a defensive fire attack.
Have adequate resources available on scene to per-form rapid intervention team (RIT) duties anytime personnel are operating at any structure fire.
Inspect and preplan buildings within your jurisdiction. Note the type of construction, materials used, presence of trusses and/or lightweight construction in the roof and floor, type of occupancy, fuel load, exit routes, and other distinguishing characteristics.
Enter preplan information into the dispatch computer so that when a fire is reported at a preplanned location, the critical information is provided to all responding units. Adopt and enforce a standard system of marking dangerous abandoned, derelict, and vacant buildings, based on a prefire assessment of their structural conditions and other risk factors, in cooperation with municipal agencies and local authorities such as local housing authorities.
Train fire fighters and officers to recognize the marking system and incorporate the information into their size-up considerations. Additionally, local authorities should ensure programs are in place that provide for the demolition and removal of structures deemed unsafe by code enforcement.
Make sure that the incident commander conducts an initial size-up of critical fireground factors before beginning fire fighting efforts and continuously re-views and reevaluates these factors during all fire-ground operations. A 360-degree size-up should be conducted for all abandoned, vacant, or unoccupied structures.
Ensure those in charge of fire incidents (e.g., incident commanders, chief officers, safety officers) are fully trained to fulfill their responsibilities and obligations in the execution of their duties.
Educate the public on the need to have home fire drills and designated meeting places in the event of an emergency. The location of designated meeting
places should be communicated to the fire department as a way to help confirm and verify building occupancy status.
Incident commanders (IC) and incident safety officers (ISO) should do the following:
The IC should conduct an initial size-up of each incident weighing critical fireground factors (i.e., occupancy status; occupant survivability and rescue potential; vacant building markings or indicators; size, construction and use of the building; age and condition of the building; and the location, size, and extent of the fire in the building) against the department’s risk management profile to determine the initial incident strategy (offensive or defensive). The IC should develop an incident action plan before beginning firefighting efforts and continually review and reevaluate the factors and the risk management plan throughout the operation.
The IC should use appropriate risk management criteria to decide whether an offensive or defensive strategy should be employed to attack a fire. The IC should attempt to determine whether the building is occupied or not. Signs to look for include vehicles in garage, driveway, or parked nearby; people at windows of apartment or office buildings calling for help indicates the possibility of other occupants as well; time of day; type of occupancy; and reports from occupants who have escaped the burning structure. Reports from neighbors and bystanders may also provide valuable information.
The IC should consider the number of fire fighters, the amount and type of apparatus and equipment available, and the stage of the fire when determining the type of fire attack.
Follow departmental policies (risk management plans, SOPs/SOGs) for risk management.
Establish, clearly mark, and monitor an exterior collapse zone at structure fires where there is a risk of collapse.
Use effective and universal evacuation signals when command personnel determine that all fire fighters should be evacuated from a burning building, as well as during the initiation of defensive operations and during overhaul and salvage operations.
As we approach the July 4th holiday period, two significant LODD incidents previously occurred during this time frame that hold a number of lessons learned related to command management, operations, building construction principles and building performance, fire behavior and the ever present dangers of the job. Take the opportunity to learn more about these events, and expand your insights and knowledge base. Those events being the 1988 Hackensack (NJ) Ford Fire which resulted in five (5) LODD and the 2002 Gloucester City (NJ) Fire that resulted in three (3) LODD along with three children.
Take a moment to reflect upon the supreme sacrifice made by these heroic firefighters and the messages that lay within the pages of the incident case studies, reports and summaries. Our sister site TheCompanyOfficer.com has a comprehensive overview of both events with report links and a must see video on the Gloucester City (NJ) 2002 LODD event. For Remembering Hackensack and Gloucester follow the link HERE
Hackensack (NJ) Fire Department • CAPT. RICHARD L. WILLIAMS, Engine Co. No. 304 • LIEUT. RICHARD REINHAGEN, Engine Co. No. 302 • F/F WILLIAM KREJSA, Engine Co. No. 301 • F/F LEONARD RADUMSKI, Engine Co. No. 302 • F/F STEPHEN ENNIS, Rescue Co. No. 308
Gloucester City (NJ) Fire • James Sylvester Fire Chief, Mount Ephraim Fire Department
• John West Deputy Chief, Mount Ephraim Fire Department
• Thomas G. Stewart III Paid Firefighter, Gloucester City Fire Department
Over the next few days, much will be written up reflecting on a number of past historical events that resonate with the rich heritage, honor and tradition that makes this Fire Service what it is. Anniversaries come and go; remembrance, sorrow, grief and respect; the good and the bad all seem to come streaming back-or these emotions and the lessons from these events seem to diminish and fade over even the shortest spans of time that may have passed. Or may have been all but forgotten as a new generation comes through the firehouse doors. Yes it does happen.
We need to learn, remember and implement the lessons from the past, especially when we refer to or are confronted with History Repeating Events (HRE) or similar situational profiles. We must develop an inherent understanding on the Predictability of Performance of our building and occupancies and truly understand and apply effective strategic and tactical plans under combat structural fire engagement. There are legacies for operational safety; do you know what they where, who was affected and what the outcomes where?
We must implement a process of Tactical Patience that correlates to the manner in which our building perform, the dynamics and behavior of fire that affects them and defines our firefighting methodologies when we engage in our missions of operations within the built environment. I’ll post more on Tactical Patience after I roll this emerging concept out at my lecture program presentation at the upcoming Southeastern Association of Fire Chief’s Conference (SEAFC) in Louisville later this month.
The built-environments that form and shape our response districts and communities pose unique challenges to the day-to-day responses of fire departments and their subsequent operations during combat structural fire engagement. With the variety of occupancies and building characteristics present, there are definable degrees of risk potential with recognizable strategic and tactical measures that must be taken. Although each occupancy type presents variables that dictate how a particular incident is handled, most company operations evolve from basic strategic and tactical principles rooted in past performance and operations at similar structures. This basis is based upon Predictability of Performance.
Modern building construction is no longer predicable
Command & company officer technical knowledge may be diminished or deficient
Technological Advancements in construction and materials have exceeded conventional fire suppression practices
Some fire suppression tactics are faulted or inappropriate, requiring innovative models and methods.
Fire Dynamics and Fire Behavior is not considered during fireground size-up and assessment
Risk Management is either not practiced or willfully ignored during most incident operations
Some departments or officers show and indifference to safety and risk management
Command & Company Officer dereliction
Nothing is going to happen to me (us)
STOP THE ENTERTAINMENT
There’s another factor contributing to unsafe practices, one that we rarely talk about. In short, we need to stop “entertaining” ourselves during fire suppression operations and instead focus on comprehending and reacting to evolving risks. Rather than practicing appropriate risk management, it is suggested that some individuals employ adverse behaviors that occur on a tactical level while Incident Commanders and Company Officers believe firefighters are completing their assigned tasks, thus compromising accountability.
These behaviors include; • Tactical amusement: engaging in any practice or tactic during fire suppression, support tasks or operations that places personnel at risk for the sake of entertainment.
• Tactical diversion: diverting from an assignment while engaging in fire suppression, support tasks or operations in such a way that places personnel at risk.
• Tactical circumvention: deliberately “getting around” an assignment or disregarding risk assessment and incident action plans.
Here’s the expanded versions in case this is th first time you’ve seen them;
TACTICAL AMUSEMENT *tak-ti-kəl ə- *myüz-mənt
1: of or relating to structural fireground tactics: as a (1) a means of amusing or entertaining during fire suppression, support tasks or operations that places personnel at risk
2: the condition of being amused while engaging in fire suppression, support tasks or operations that places personnel at risk
3: pleasurable diversion while engaging in fire suppression, support tasks or operations: entertainment; that places personnel at risk
TACTICAL DIVERSION *tak-ti-kəl də- *vər-zhən
1: the reckless act or an instance of diverting from an assignment, task, operation or activity while engaging in fire suppression, support tasks or operation for the sake of amusing or entertainment; that places personnel at risk
2: the reckless act of self determined task operations that diverts or amuses from defined risk assessment and incident action plans; that places personnel at risk
TACTICAL CIRCUMVENTION *tak-ti-kəl sər-kəm- *ven(t)-shən
1: to deliberately manage to get around especially by ingenuity or approach that diverts for the purpose of amusing; assignment, operations or tasks that countermand or disregard defined risk assessment and incident action plans; that places personnel at risk
TACTICAL PATIENCE(NEW) This is a new one that’s called Tactical Patience…I’ll post more on Tactical Patience after I roll this out at the upcoming Southeast Association of Fire Chief’s Conference (SAFC) in Louisville later this month.
If we’re going to reduce firefighter injuries and deaths, we must be doing the right thing, at the right time, for the right reasons, and in the right place. We must stop the entertainment.
The demands and requirements of modern firefighting will continue to require the placement of personnel within situations and buildings that carry risk, uncertainty and inherent danger. Fire suppression tactics must be adjusted for the rapidly changing methods and materials impacting all forms of building construction, occupancies and structures. The need to redefine the art and science of firefighting is nearly upon us. Some things do stand the test of time, others need to adjust, evolve and change. Not for the sake of change only, but for the emerging and evolving buildings, structures and occupancies being built, developed or renovated in our communities. 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 know hostile structural fire environments, while maintaining the values and tradition that defines the fire service.
Without understanding the building-occupancy relationships and integrating; construction, occupancies, fire dynamics and fire behavior, risk, analysis, the art and science of firefighting, safety conscious work environment concepts and effective and well-informed incident command management, company level supervision and task level competencies…You are derelict and negligent and "not "everyone may be going home".
Our current generation of buildings, construction and occupancies are not as predictable as past conventional construction; risk assessment, strategies and tactics must change to address these new rules of structural fire engagement. There is a need to gain the building construction knowledge and insights and to change and adjust operating profiles in order to safe guard companies, personnel and team compositions. It's all about understanding the building-occupancy relationships and the art and science of firefighting, Building Knowledge = Firefighter Safety (Bk=F2S)
The Newest radio show on FireFighter Netcast.com at Blogtalk Radio… Taking it to the Streets with Christopher Naum. On the Air Monthly on Firefighter Netcast.com. A Buildingsonfire.com Series and Firefighter Netcast.com Production. Advancing Firefighter Safety and Operational Integrity for the Fire Service through provocative insights and dynamic discussions dedicated to the Art and Science of Firefighting and the Traditions of the Fire Service.