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The Waldbaum Fire Collapse FDNY 1978 Remembrance

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The Waldbaum’s Supermarket Fire and Collapse FDNY 1978  

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.  

  

Thirty-four firefighters, one emergency medical technician and one Emergency Services police officer were injured in the fire and the tragedy is remembered as one of the worst disasters in the New York City Fire Department’s 143-year history.  

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 

The fire started at 8:40 am in Waldbaum’s supermarket located at 2892  Avenue Y and Ocean Avenue in the Sheepshead Bay section of Brooklyn. Nearly 23 electricians, plumbers and contractors were renovating the building when the fire was discovered in mezzanine area. Box 3300 was transmitted at 08:39 hours and the All hands transmitted at 08:49 and subsequently a 2nd alarm at 09:02 hrs. Shortly after 09:20 with 20 firefighters operating on the bowstring truss roof a crackling sound was heard and the center portion of the roof fell into the smoke and flames. Some of the firefighters were seen running toward the edge of the roof; some made it, others nearby fell into the gaping hole. The third alarm was transmitted at 09:18 3rd alarm and subsequently escalated to a Fifth alarm assignment during the rescue and recovery operations.  

Roof Operations prior to collapse

 

Laborers and firefighters managed to pull out some who were near walls, some crawled out. Several holes were made into the wall to pull out injured survivors and victims.  

The Building  

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.  

Waldbaum Supermarket FDNY Box 3300 1978

 

The heavy timber bowstring arch roof consisted of seven (7) truss units constructed of 4-5 bundled 3 inch x 12 inch attached assemblies.  Two factors contributed to the collapse of the bowstring arch truss system; double roof (rain roof) alterations with concealed spaces and the extent and severity of the fire within the concealed spaces affecting the assembly’s structural stability. The presence of the double concealed ceiling systems; the truss system supported an ornamental tin ceiling and 18 inches below that concealed space a convential suspended acoustic ceiling tile panel system was present. Reports indicated the tin ceiling was attached directly to the bottom cord of the truss system. The failure of  operating companies and command personnel to recognize the signs of an unchecked concealed fire that was propagating at a rapid pace impinging upon critical structural assembly points was a significant contributing factor in the incident outcome. 

Typical Heavy Timber Bowstring Arch Truss Configuration

 

This roof collapsed 32 minutes after the initial units arrived. The immediate collapse occurred approximately 85 feet inward from the Alpha side (Ocean Avenue) and approximately 50 feet from the Bravo side (Avenue Y). The immediate failure and loss of structural stability and collapse of truss unit #5 was followed with the subsequent collapse of truss units #6 and #4 that were interdependent on the roof rafter and purlin system to maintain thier structural stability and vertical orientation. This type of interdependent structural system of structural trusses, rafters and roof deck (membrane) result in large area collapses since the primary truss will usually cause the adjacent two truss systems (on either side of the primary compromised truss) to fail by pulling downward.  

The effects of direct flame impingement on the truss assessmblies, thier connection points of bearing at the outter masonry walls, coupled with the tactical trench cut that had been comopleted by the operating ladder companies resulted in 4,000 sf section of roof to collapse in the truss #5, 6 and 4 bay areas. Rapid and progressing fire travel within the concealed spaces and the degradation of the roof assembly and structural support system, failure to recognize the inherent opertaional risks associated with roof and interior operations on heavy timber truss roof systems and the failure to correlate continued interior suppression operations with simultaneous roof ventilation operations with no significant change in operational progress or mitigation contributed to the tragic outcome of the incident.  

A short ten years would pass and the lessons from the Waldbaum Fire would soon be forgotten when on July 2, 1988 operations in a Type III building consisting of an auto dealership would lead to the deaths of five (5) Firefighters in Hackensack, New Jersey when operations were being conducted in the truss loft storage area when an 80 foot heavy timber truss collapsed trapping the firefighters. The Hackensack Ford Fire occured less than four weeks short of the tenth anniversary of the Waldbaum Fire right across the Hudson River. More on the Hackensack Ford Fire HERE.  

 
 
 
 
 

Bravo Side View

 

Additional References :http://stevespak.com/waldbaums.html  

Fire Investigation: An Analysis of the Waldbaum Fire, Brooklyn, New York, August 3, 1978. Quintiere, J. G. NISTIR 6030; June 1997 http://www.nfpa.org/itemDetail.asp?categoryID=442&itemID;=18676&  

NFPA Fire Command Magazine, Brooklyn Roof Collapse Claims six Lives. Demers, David P.; December 1978  

Waldbaum Fire Facebook page, HERE with numerous photos and recollections honoring those that lost their lives and those that operated at FDNY Brooklyn Box 3300.
   

Rescue efforts on the Bravo Side

 

  

2892 Ocean Avenue Today

 

The lessons learned in the years following the Walbaum’s fire in 1978 and the subsequent Hackensack Ford Fire, NJ in 1988 focused on understanding building construction systems, occupancies and structural assemblies, in both of these cases the timber bowstring truss systems. Over the years the foundation of knowledge necessary to build competencies and knowledgeable firefighters, fire officers and commanders cognizant in the science and technology of building construction has waned and at time has been less than an area of focus.  

Take the time to learn about the FDNY Walbaum’s fire, its history repeating significance as a major fire service LODD event, the lessons learned from the Hackensack Ford Fire (July 2, 1988) and other related case studies that can be found on the NIOSH, USFA and NFPA web sites.  

Look at your buildings within your response areas and jurisdiction. Understand how they’re built and more importantly how they are affected by the exposure and impingement of fire and its byproducts. Understand key building performance indicators and appropriate strategic and tactical actions based upon building profiles, occupancies, fire loading, construction features and fire service resources. Take the time to honor the brave brother firefighters from FDNY who made the supreme sacrifice thirty two years ago, and gave a legacy to learn from in this and in future fire service generations.  

It’s time to think; BUILDING KNOWLEDGE = FIREFIGHTER SAFETY  

Memorial

 

Premiering “What’s on YOUR Radar Screen”? on Fire Fighter Netcast.com

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Taking it to the Streets

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Premiering “What’s on YOUR Radar Screen”?

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What’s On Your Radar Screen?

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BuildingsonFire 2010; Building Construction, Command Risk Management and Operational Safety

Major Influencing Fire Service Reports, Issues or Focus that should be on Your Radar Screen

The following list is but a modest cross section of pertinent information or focus areas today’s Firefighter, Company or Command Officer MUST be knowledgeable in, have insights and proficiency based technical skills to function with a level of competencies demanded in  today’s  fire service.

If these are not on your radar screen or you haven’t got a blip of a clue what they’re about; then you are derelict and not doing your job- and the end result could be a less than desirable outcome on the fireground; it’s that simple, it’s that direct.

Have you read these reports, understand the issues & influences, increased your knowledge, skills and abilities in any gap areas or taken the time to research the cutting edge issues affecting today’s fire service?

The City of Charleston Sofa Super Store LODD-Routley Fire Report

Read the report; understand the incident, the building performance, the fire behavior and the operation process deployed. Gain the insights from the overall apparent and contributing causes identified and presented and assess how these relate to your fire service perspective and department’s culture and performance today.

  • City of Charleston Post Incident Assessment and Review Team Phase I Report, HERE
  • Routley Final Phase II Report HERE
  • NIOSH Investigative Report, HERE
  • NIOSH REPORT SUMMARY
  • NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should:
  • develop, implement and enforce written standard operating procedures (SOPs) for an occupational safety and health program in accordance with NFPA 1500
  • develop, implement, and enforce a written Incident Management System to be followed at all emergency incident operations
  • develop, implement, and enforce written SOPs that identify incident management training standards and requirements for members expected to serve in command roles
  • ensure that the Incident Commander is clearly identified as the only individual with overall authority and responsibility for management of all activities at an incident
  • ensure that the Incident Commander conducts an initial size-up and risk assessment of the incident scene before beginning interior fire fighting operations
  • train fire fighters to communicate interior conditions to the Incident Commander as soon as possible and to provide regular updates
  • ensure that the Incident Commander establishes a stationary command post, maintains the role of director of fireground operations, and does not become involved in fire-fighting efforts
  • ensure the early implementation of division / group command into the Incident Command System
  • ensure that the Incident Commander continuously evaluates the risk versus gain when determining whether the fire suppression operation will be offensive or defensive
  • ensure that the Incident Commander maintains close accountability for all personnel operating on the fireground
  • ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed at each structure fire
  • ensure that crew integrity is maintained during fire suppression operations
  • ensure that a rapid intervention crew (RIC) / rapid intervention team (RIT) is established and available to immediately respond to emergency rescue incidents
  • ensure that adequate numbers of staff are available to immediately respond to emergency incidents
  • ensure that ventilation to release heat and smoke is closely coordinated with interior fire suppression operations
  • conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics
  • consider establishing and enforcing standardized resource deployment approaches and utilize dispatch entities to move resources to fill service gaps
  • develop and coordinate pre-incident planning protocols with mutual aid departments
  • ensure that any offensive attack is conducted using adequate fire streams based on characteristics of the structure and fuel load present
  • ensure that an adequate water supply is established and maintained
  • consider using exit locators such as high intensity floodlights or flashing strobe lights to guide lost or disoriented fire fighters to the exit
  • ensure that Mayday transmissions are received and prioritized by the Incident Commander
  • train fire fighters on actions to take if they become trapped or disoriented inside a burning structure
  • ensure that all fire fighters and line officers receive fundamental and annual refresher training according to NFPA 1001 and NFPA 1021
  • implement joint training on response protocols with mutual aid departments
  • ensure apparatus operators are properly trained and familiar with their apparatus
  • protect stretched hose lines from vehicular traffic and work with law enforcement or other appropriate agencies to provide traffic control
  • ensure that fire fighters wear a full array of turnout clothing and personal protective equipment appropriate for the assigned task while participating in fire suppression and overhaul activities
  • ensure that fire fighters are trained in air management techniques to ensure they receive the maximum benefit from their self-contained breathing apparatus (SCBA)
  • develop, implement and enforce written SOPS to ensure that SCBA cylinders are fully charged and ready for use
  • use thermal imaging cameras (TICs) during the initial size-up and search phases of a fire
  • develop, implement and enforce written SOPs and provide fire fighters with training on the hazards of truss construction
  • establish a system to facilitate the reporting of unsafe conditions or code violations to the appropriate authorities
  • ensure that fire fighters and emergency responders are provided with effective incident rehabilitation
  • provide fire fighters with station / work uniforms (e.g., pants and shirts) that are compliant with NFPA 1975 and ensure the use and proper care of these garments.

Additionally, federal and state occupational safety and health administrations should:

  • consider developing additional regulations to improve the safety of fire fighters, including adopting National Fire Protection Association (NFPA) consensus standards.

Additionally, manufacturers, equipment designers, and researchers should:

  • continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communication in conjunction with properly worn SCBA
  • conduct research into refining existing and developing new technology to track the movement of fire fighters inside structures.

Additionally, code setting organizations and municipalities should:

  • require the use of sprinkler systems in commercial structures, especially ones having high fuel loads and other unique life-safety hazards, and establish retroactive requirements for the installation of fire sprinkler systems when additions to commercial buildings increase the fire and life safety hazards
  • require the use of automatic ventilation systems in large commercial structures, especially ones having high fuel loads and other unique life-safety hazards.

Additionally, municipalities and local authorities having jurisdiction should:

  • coordinate the collection of building information and the sharing of information between building authorities and fire departments
  • consider establishing one central dispatch center to coordinate and communicate activities involving units from multiple jurisdictions
  • ensure that fire departments responding to mutual aid incidents are equipped with mobile and portable communications equipment that are capable of handling the volume of radio traffic and allow communications among all responding companies within their jurisdiction.

Everyone Goes Home Campaign

  • Everyone Goes Home® is a national program by the National Fallen Firefighters Foundation to prevent line-of-duty deaths and injuries. In March 2004, a Firefighter Life Safety Summit was held to address the need for change within the fire service. At this summit, the 16 Firefighter Life Safety Initiatives were created and a program was born to ensure that Everyone Goes Home®.
  • Recognizing the need to do more to prevent line-of-duty deaths and injuries, the National Fallen Firefighters Foundation has launched a national initiative to bring prevention to the forefront.
  • In March 2004, the Firefighter Life Safety Summit was held in Tampa, Florida to address the need for change within the fire and emergency services. Through this meeting, 16 Life Safety Initiatives were produced to ensure that Everyone Goes Home®.
  • The first major action was to sponsor a national gathering of fire and emergency services leaders. The National Fallen Firefighters Foundation will play a major role in helping the U.S. Fire Administration meet its stated goal to reduce the number of preventable firefighter fatalities. The Foundation sees fire service adoption of the summit’s initiatives as a vital step in meeting this goal.
  • The Courage to Be Safe® On-Line Program , HERE
  • Media CenterUsing variations of the Courage to Be Safe ®…So Everyone Goes Home® field program, along with material from the Firefighter Life Safety Initiatives Resource Kit we will develop and deploy a new online learning segment each month. These online learning segments will allow you to expand upon your personal and professional development when you want and how you want. Watch them by yourself or integrate them into your organizational training programs. Remember, that safety results from constant training and putting those skills to work everyday, on every call – SO EVERYONE GOES HOME. HERE
  • The Firefighter Life Safety Initiatives Advocates Program will play a key role in helping to bring about awareness of the Initiatives and act as a conduit for resources to enable departments to implement and advocate them. HERE
  • The 16 Fire Fighter Life Safety Initiatives
    1. Define and advocate the need for a cultural change within the fire service relating to safety; incorporating leadership, management, supervision, accountability and personal responsibility.
    2. Enhance the personal and organizational accountability for health and safety throughout the fire service.
    3. Focus greater attention on the integration of risk management with incident management at all levels, including strategic, tactical, and planning responsibilities.
    4. All firefighters must be empowered to stop unsafe practices.
    5. Develop and implement national standards for training, qualifications, and certification (including regular recertification) that are equally applicable to all firefighters based on the duties they are expected to perform.
    6. Develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform.
    7. Create a national research agenda and data collection system that relates to the initiatives.
    8. Utilize available technology wherever it can produce higher levels of health and safety.
    9. Thoroughly investigate all firefighter fatalities, injuries, and near misses.
    10. Grant programs should support the implementation of safe practices and/or mandate safe practices as an eligibility requirement.
    11. National standards for emergency response policies and procedures should be developed and championed.
    12. National protocols for response to violent incidents should be developed and championed.
    13. Firefighters and their families must have access to counseling and psychological support.
    14. Public education must receive more resources and be championed as a critical fire and life safety program.
    15. Advocacy must be strengthened for the enforcement of codes and the installation of home fire sprinklers.
    16. Safety must be a primary consideration in the design of apparatus and equipment.

NIST Wind Driven Fire Study

  • Smoke and heat spreading through the corridors and the stairs of a building during a fire can limit building occupants’ ability to escape and can limit fire fighters’ ability to rescue them.  Changes in the building’s ventilation or presence of an external wind can increase the energy release of the fire.  This can also increase the spread of fire gases through the building.  In some cases, such as the Cook County Administration Building fire in October 2003, the fire gas flow, into the corridors and the stairway prevented fire fighters from suppressing the fire from inside the structure.  This fire resulted in 6 building occupant fatalities and fire fighter injuries in the stairway.  The Fire Department of New York City has experienced many wind driven fire incidents which have resulted in fire fighter fatalities and injuries, as have a number of other incidents nationally that have resulted in increased research into this operational and tactical challenge.
  • What tactics or tools are appropriate for use with a wind driven fire and how should the tactics or tools be implemented?  Positive Pressure Ventilation (PPV) is being used by fire departments on smaller structures, such as single family homes, to control the fire flow by introducing pressure from the front door and venting the house through a strategic exit opening.  If done correctly, this tactic can remove significant amounts of heat and smoke from the structure, thus improving the fire fighters’ working environment and improving the chances of survival for the building occupants.  NIST has completed several studies which have a two fold impact: 1) providing guidance on the safe use of PPV and 2) characterizing and validating the modeling of PPV with a computational fluid dynamics (CFD) computer model, so that the model can be used as a training tool for the fire service.
  • This project extends previous work for ventilation under wind driven conditions.  There are many questions regarding wind driven fires.  For example can these PPV fans be used successfully under wind driven fire conditions in large structures?  Large structures, such as high rise buildings, provide additional challenges to fire fighter and building occupant safety: increased travel distance (exposure time), more complicated egress path, and potentially larger fires.  In 2002 there were 7,300 reported fires in high rise structures.
  • Other tactics incorporating devices, such as wind control devices (WCD) to control the ventilation conditions or the use of a “high rise” nozzle from the floor below the fire floor have been tried by the fire service under “real fire” conditions with varying levels of success.
  • A comprehensive free DVD set from the NIST includes a presentation video that explains PPV, examines the results of NIST’s PPV research, and closes with a focus on the use of PPV tactics in high-rise buildings.  All of the NIST PPV reports referenced in the presentation are included on Disc 1 of the set.  All of the videos from the high-rise fire experiments are also provided with a user-friendly, graphic menu that can be used on a PC or a DVD player.  NIST, with support from USFA, DHS, and fire departments across the country, has taken engineering principles and applied them to fire service PPV tactics in order to improve fire fighter safety
  • NIST References HERE and HERE

NIST Fire Fighting Tactics Under Wind Driven Conditions: Laboratory Experiments

  • A series of experiments was conducted in our Large Fire Laboratory to examine the impact of wind control curtains and externally applied hose streams on a wind driven fire.  The results from these experiments will allow us to better understand the fire dynamics within a structure and provide guidance as to the important measurements needed in the future experiments in a high-rise on Governor’s Island in New York City.
  • Fire Fighting Tactics Under Wind Driven Conditions Report, HERE
  • Reference Data HERE

NIST Firefighter Safety and Deployment Study; Report on Residential Fireground Field Experiments

  • The NIST Firefighter Safety and Deployment Study; Titled- Report on Residential Fireground Field Experiments was recently released to the public providing . A copy of the report is attached.
  • Report Abstract:
  • Service expectations placed on the fire service, including Emergency Medical Services (EMS), response to natural disasters, hazardous materials incidents, and acts of terrorism, have steadily increased. However, local decision-makers are challenged to balance these community service expectations with finite resources without a solid technical foundation for evaluating the impact of staffing and deployment decisions on the safety of the public and firefighters. For the first time, this study investigates the effect of varying crew size, first apparatus arrival time, and response time on firefighter safety, overall task completion, and interior residential tenability using realistic residential fires.
  • This study is also unique because of the array of stakeholders and the caliber of technical experts involved. Additionally, the structure used in the field experiments included customized instrumentation; all related industry standards were followed; and robust research methods were used. The results and conclusions will directly inform the NPFA 1710 Technical Committee, who is responsible for developing consensus industry deployment standards.
  • This report presents the results of more than 60 laboratory and residential fireground experiments designed to quantify the effects of various fire department deployment configurations on the most common type of fire—a low hazard residential structure fire. For the fireground experiments, a 2,000 sq ft (186 m2), two-story residential structure was designed and built at the Montgomery County Public Safety Training Academy in Rockville, MD. Fire crews from Montgomery County, MD and Fairfax County.
  • Report results quantify the effectiveness of crew size, first-due engine arrival time, and apparatus arrival stagger on the duration and time to completion of the key 22 fireground tasks and the effect on occupant and firefighter safety.
  • The report is also available for download at the NIST, HERE
  • Synopsis HERE

USFA/NIST Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002

  • Between the years 1979 and 2002 there were over 180 firefighter fatalities due to structural collapse, not including those firefighters lost in 2001 in the collapse of the World Trade Center Towers. Structural collapse is an insidious problem within the fire fighting community. It often occurs without warning and can easily cause multiple fatalities.
  • As part of a larger research program to help reduce firefighter injuries and fatalities the U.S. Fire Administration (USFA) funded the National Institute of Standards and Technology (NIST) to examine records and determine if there were any trends and/or patterns that could be detected in firefighter fatalities due to structural collapse. If so, these trends could be brought immediately to the attention of training officers and incident commanders and investigated further to determine probable causes.
  • Report: Trends in Firefighter Fatalities Due to Structural Collapse1979-2002
  • Report: Early Warning Capabilities for Firefighters:Testing of Collapse Prediction Technologies

UL Fire Academy CBT

  • UL Structural Stability of Engineered Lumber in Fire Conditions
  • Base on the UL research and
  • This two-hour presentation summarizes a research study on the hazards posed to firefighters by the use of lightweight construction and engineered lumber in floor and roof designs. This free on-line computer based presentation will allow fire professionals to better interpret fire hazards and assess risk for life safety of building occupants and firefighters.
  • This online firefighter training course is the result of a research partnership among UL, the Chicago Fire Department, IAFC, and Michigan State University, funded in part by the U.S. Department of Homeland Security. This self-guided course, which focuses on the structural stability of engineered lumber under fire conditions, is targeted toward the 1.1 million fire service personnel in the United States and Canada. The knowledge developed and shared in this course is critically important to firefighter and civilian safety.
  • This two-hour presentation summarizes a research study on the hazards posed to firefighters by the use of lightweight construction and engineered lumber in floor and roof designs. This free on-line computer based presentation will allow fire professionals to better interpret fire hazards and assess risk for life safety of building occupants and firefighters.
  • Program Objectives:
  • Provide brief history of events leading up to DHS Grant tests
  • Identify the fire test hypothesis, parameters, and steps completed in the testing process
  • Compare tests results (legacy vs. modern construction)
  • Communicate learnings from our partners representing the fire service
  • Discuss code recommendations
  • UL University on-line Program HERE

USFA/NIST Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002

  • Between the years 1979 and 2002 there were over 180 firefighter fatalities due to structural collapse, not including those firefighters lost in 2001 in the collapse of the World Trade Center Towers. Structural collapse is an insidious problem within the fire fighting community. It often occurs without warning and can easily cause multiple fatalities.
  • As part of a larger research program to help reduce firefighter injuries and fatalities the U.S. Fire Administration (USFA) funded the National Institute of Standards and Technology (NIST) to examine records and determine if there were any trends and/or patterns that could be detected in firefighter fatalities due to structural collapse. If so, these trends could be brought immediately to the attention of training officers and incident commanders and investigated further to determine probable causes.
  • Report: Trends in Firefighter Fatalities Due to Structural Collapse1979-2002
  • Report: Early Warning Capabilities for Firefighters:Testing of Collapse Prediction Technologies

NIOSH LODD Reports

  • Each year an average of 105 fire fighters die in the line of duty. To address this continuing national occupational fatality problem, NIOSH conducts independent investigations of fire fighter line of duty deaths. The dedicated web page provides access to NIOSH investigation reports and other fire fighter safety resources.
  • NIOSH Web Page HERE
  • Through the Fire Fighter Fatality Investigation and Prevention Program, NIOSH conducts investigations of fire fighter line-of-duty deaths to formulate recommendations for preventing future deaths and injuries. The program does not seek to determine fault or place blame on fire departments or individual fire fighters, but to learn from these tragic events and prevent future similar events.
  • Fire Fighter Fatality Investigation Reports, HERE

NIOSH Alert: Preventing Deaths and Injuries of Fire Fighters using Risk Management Principles at Structure Fires

  • 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.
  • Report HERE

NIOSH Report; Preventing Deaths and Injuries of Fire Fighters Working Above Fire Damaged Floors

  • Fire fighters are at risk of falling through fire-damaged floors. Fire burning underneath floors can significantly degrade the floor system with little indication to fire fighters working above.
  • Floors can fail within minutes of fire exposure, and new construction technology such as engineered wood floor joists may fail sooner than traditional construction methods.
  • NIOSH recommends that fire fighters use extreme caution when entering any structure that may have fire burning beneath the floor.
  • Report HERE

NIOSH ALERT: Preventing Injuries and Deaths of Fire Fighters due to Truss System Failures

  • Fire fighters may be injured and killed when fire-damaged roof and floor truss systems collapse, sometimes without warning.
  • The National Institute for Occupational Safety and Health (NIOSH) requests assistance in preventing injuries and deaths of fire fighters due to roof and floor truss collapse during fire-fighting operations. Roof and floor truss system collapses in buildings that are on fire cannot be predicted and may occur without warning.
  • NIOSH recommends that fire departments review their occupational safety programs and standard operating procedures to ensure they include safe work practices in and around structures that contain trusses. Building owners should follow proper building codes and consider posting building construction information outside a building to advise fire fighters of the conditions they may encounter.
  • ALERT Report HERE

National Near Miss Reporting System (NNMRS) Operating Experience

  • The National Fire Fighter Near-Miss Reporting System is a voluntary, confidential, non-punitive and secure reporting system with the goal of improving fire fighter safety.
  • Submitted reports will be reviewed by fire service professionals. Identifying descriptions are removed to protect your identity. The report is then posted on this web site for other fire fighters to use as a learning tool.
  • National Fire Fighter Near-Miss Reporting System Web Site, HERE
  • Search Reports, HERE
  • Resources, HERE

USFA Incident Reports (Stop History Repeating Events-HRE)

  • USFA provides information resources in many formats, including books, pamphlets and DVD’s, free of charge.
  • The U.S. Fire Administration develops reports on selected major fires throughout the country. The fires usually involve multiple deaths or a large loss of property. But the primary criterion for deciding to do a report is whether it will result in significant “lessons learned.” In some cases these lessons bring to light new knowledge about fire–the effect of building construction or contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough to highlight once again, with yet another fire tragedy report. In some cases, special reports are devel­oped to discuss events, drills, or new technologies which are of interest to the fire service.
  • The reports are sent to fire magazines and are distributed at National and Regional fire meetings. The International Association of Fire Chiefs assists the USFA in disseminating the findings throughout the fire service. On a continuing basis the reports are available on request from the USFA; announce­ments of their availability are published widely in fire journals and newsletters
  • This body of work provides detailed information on the nature of the fire problem for policymakers who must decide on allocations of resources between fire and other pressing problems, and within the fire service to improve codes and code enforcement, training, public fire education, building technology, and other related areas.
  • The Fire Administration, which has no regulatory authority, sends an experienced fire investigator into a community after a major incident only after having conferred with the local fire authorities to insure that the assistance and presence of the USFA would be supportive and would in no way interfere with any review of the incident they are themselves conducting. The intent is not to arrive during the event or even immediately after, but rather after the dust settles, so that a complete and objective review of all the important aspects of the incident can be made
  • Technical Reports and On-line Publications, HERE

Prince William County (VA) Fire Rescue Kyle Wilson LODD Report

  • The Prince William County (VA) Department of Fire and Rescue published a comprehensive line of duty death report for Technician I Kyle R. Wilson on Saturday, January 26, 2008. Technician I Wilson was the first line of duty death in the Department’s 41-year history. The Department is sharing the LODD Investigative Report to honor Kyle, and in an effort to reduce and prevent firefighter line of duty deaths at the local, region, state, and national levels.
  • Technician Kyle Robert Wilson was 24-years old and was born in Olney, Maryland. He grew up in Prince William County and graduated from Hylton High School and George Mason University. He was an avid baseball and softball player. Technician Wilson joined the Prince William County Department of Fire and Rescue on January 23, 2006. Technician Kyle Wilson died in the line of duty on April 16, 2007 while performing search and rescue operations at a house fire on Marsh Overlook Drive, located in the Woodbridge area of Prince William County. On that day, Technician Wilson was part of the firefighter staffing on Tower 512 which responded to the house fire that was dispatched at 0603 hours. The Prince William County area was under a high wind advisory as a nor’eastern storm moved through the area. Sustained winds of 25 mph with gusts up to 48 mph were prevalent in the area at the time of the fire dispatch to Marsh Overlook Drive.
  • Initial arriving units reported heavy fire on the exterior of two sides of the single family house and crews suspected that the occupants were still inside the house sleeping because of the early morning hour. A search of the upstairs bedroom commenced for the possible victims. A rapid and catastrophic change of fire and smoke conditions occurred in the interior of the house within minutes of Tower 512’s crew entering the structure.
  • Technician Wilson became trapped and was unable to locate an immediate exit out of the hostile environment. Mayday radio transmissions were made by crews and by Technician Kyle Wilson of the life-threatening situation. Valiant and repeated rescue attempts to locate and remove Technician Wilson were made by the firefighting crews during extreme fire, heat and smoke conditions. Firefighters were forced from the structure as the house began to collapse on them and intense fire, heat and smoke conditions developed. Technician Wilson succumbed to the fire and the cause of death was reported by the medical examiner to be thermal and inhalation injuries.
  • The Department of Fire and Rescue immediately formed a multi-dimensional investigation team following the incident. The investigation team was comprised of five Department of Fire and Rescue uniform personnel and two external members from area fire departments. For eight months, the team thoroughly examined the events that occurred at the Marsh Overlook fire incident and identify the factors involved with the line of duty death of Technician I Kyle Wilson. The resulting report represents thousands of hours of effort to analyze fire and rescue operations and is a factual representation of the events that occurred. The report also provides a frame work for organizational level improvements.
  • The major factors in the line of duty death of Technician I Wilson were determined to be:
    • The initial arriving fire suppression force size.
    • The size up of fire development and spread.
    • The impact of high winds on fire development and spread.
    • The large structure size and lightweight construction and materials.
    • The rapid intervention and firefighter rescue efforts.
    • The incident control and management.
    • The Marsh Overlook fire incident was an immense fire fueled by extremely flammable building material products and a vicious wind. It was an environment where information gathering and decision making had to be performed in the time measurement of seconds. During the chain of events that occurred and under severe circumstances, fire and rescue personnel performed at exceptional levels.
  • During the repeated attempts to reach and rescue Technician I Wilson, personnel displayed heroic efforts and jeopardized their own safety. The Department will never forget the sacrifice that Technician Wilson made in an attempt to ensure others were safe. By sharing the knowledge gained from this very tragic and painful incident, the Department will ensure his sacrifice was not in vain and hope that other fire and rescue departments can avoid another similar occurrence.
  • Resources and Report

Loudoun County (VA) Fire Rescue  Significant Near Miss Event Report

  • On May 25, 2008, fire and rescue personnel from Loudoun County responded to a structure fire at 43238 Meadowood Court in Leesburg, Virginia. During the course of the incident, seven responders were injured. Of those injured, four firefighters received significant burn injuries, two firefighters sustained orthopedic injuries, and one EMS provider was treated for minor respiratory distress. To date, five of the injured personnel have returned to duty. Two firefighters continue to recover from their injuries, including one who was severely burned.
  • Given the severity of the injuries and magnitude of the event, an independent Investigative Team was assembled to review the incident. The Team was comprised of four Loudoun County personnel, three external members from area fire departments, and two resource/support personnel. The Team was tasked with reviewing “the events leading up to the incident, the incident operation(s), the firefighter MAYDAY(s), and incident mitigation.”
  • For three months, the Team thoroughly examined the events surrounding the Meadowood Court fire incident and identified the factors associated with the injury of personnel.
  • The Report contains the results of the Investigative Team’s comprehensive review and analysis.
  • Fact Sheet, HERE
  • SIGNIFICANT INJURY INVESTIGATIVE REPORT 43238 MEADOWOOD COURT MAY 25, 2008 Report HERE

Worcester (MA) Fire Cold Storage Fire LODD Report; Abandoned Cold Storage Warehouse Multi-Firefighter Fatality Fire 1999, Worcester, Massachusetts

  • A technical review of the 1999 Worcester, MA fire that claimed six firefighters concludes that abandoned buildings are a serious threat to firefighters and fire departments must make a concerted effort to use technology to maintain data on buildings in their response districts.
  • 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.
  • Eleven minutes into the fire, the owner of the abutting Kenmore Diner advised fire operations of two homeless people who might be living in the warehouse. The rescue company, having divided into two crews, started a building search. Some 22 minutes later the rescue crew searching down from the roof became lost in the vast dark spaces of the fifth floor. They were running low on air and called for help. Interior conditions were deteriorating rapidly despite efforts to extinguish the blaze, and visibility was nearly lost on the upper floors. Investigators have placed these two firefighters over 150 feet from the only available exit.
  • An extensive search was conducted by Worcester Fire crews through the third and fourth alarms. Suppression efforts continued to be ineffective against huge volumes of petroleum based materials, and ultimately two more crews became disoriented on the upper floors and were unable to escape. When the evacuation order was given one hour and forty-five minutes into the event, five firefighters and one officer were missing. None survived.
  • A subsequent exterior attack was set up and lasted for over 20 hours utilizing aerial pieces and del­uge guns from Worcester and neighboring departments. Task force groups from across the State of Massachusetts responded to initial suppression and subsequent recovery efforts. During this time, the four upper floors collapsed onto the second which became known as “the deck”. Over 6 million gallons of water were used during the suppression efforts. According to NFPA records, this is the first loss of six firefighters in a structure fire where neither building collapse nor an explosion was a contributing factor to the fatalities.
  • USFA Report HERE

Colerain Township (OH) Fire and EMS Department Final Report Investigation Analysis of the Squirrels Nest Lane Firefighter Line of Duty Deaths

  • The Colerain Township (OH) Fire and EMS Department under the leadership of Director and Chief G. Bruce Smith recently released its final report Investigation Analysis of the Squirrels nest Lane Firefighter Line of Duty Deaths related to the April 4, 2008 Double Line of Duty Death of a Captain and Firefighter.  This investigative analysis and report, although specific to the events and conditions encountered during the conduct of operation at the residential occupancy at 5708 Squirrels nest Lane has pertinent and relevant insights, recommendations and factors that all Fire Service personnel, regardless of rank should read.
  • Incident Overview, HERE
  • NIOSH Report, HERE
  • Investigative Report, HERE

Field Trips

  • Take a good look at the structures, occupancies and  buildings in you first, second and third due areas, look around your community and jurisdiction as well as your mutual aid and greater alarm response box areas.
  • Have you stopped for a minute today and taken a good look around? Whether you’re sitting in the front seat at the stop light of an intersection or as you’re peering out the side cab window coming back from an alarm or while running errands in your POV; have you taken a good look around? As the Springsteen song goes; “this is your town”.
  • There’s a lot that can be gleaned from your surroundings on any given day. We sometimes take for granted the subtle changes that are happening all around us as we take care of business on our rounds, runs and calls. We tend to focus in on the immediacy of the events that are happening in front of us that demand our attention but fail to take a look around to pick up on information, data and insights that can help us on that next run or down the road in the future.
  • Take a look at the construction that might be going up in your areas. I’m certain you’re paying close attention to what’s happening in your first-due, but what about that third-due area, that neighboring jurisdiction or the mutual-aid area that you occasionally run in to? When you’re on that next EMS run or an investigation of an odor or alarm bells service call, take a few extra minutes to walk through the occupancy. Conduct your own mini company level pre-plan.
  • Look at the layout, features, access and construction features. If you have a chance, verify the structural support systems employed by the building for the floor and roof systems. If you have time, take the company on a quick site visit to that building that’s under construction or the renovations that are again underway in that commercial or business occupancy around the corner from quarters.
  • These continuing challenging economic times places a great deal of influence on what’s being built, how it might be constructed, the manner in which a building may be operational one day, vacant the other and under renovation the next. Sometimes these transformations occur literally overnight.
  • Take a good look around, this is your town…your district, your response area. Know your buildings, understand their performance profiles, and assess the predictability of performance. Remember; Building Knowledge = Firefighter Safety.

Building Construction

I continue to suggest that it’s no longer just brute force and sheer physical determination that define structural fire suppression operations, although any seasoned firefighter and company officer knows that at times; it is what gets the job done under the most arduous and demanding of circumstances. However, from a methodical and disciplined perspective, 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.

We can still meet the demands of the job, as firefighters; but do it with Tactical Patience and not at the expense of Command Compression and Tactical Entertainment or worst Operational Recklessness.

The traditional attitudes and beliefs of equating aggressive firefighting operations in all occupancy types coupled with the correlating, established and pragmatic operational strategies and tactics must be adjusted and modified to include intelligent risk assessment, calculated risk analysis, safety and survivability profiling, and strategic operational and tactical value. 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. As a result, risk management must become fluid and integrated with intelligent tactical deployments and operations recognizing the risk problematically and not fatalistically, resulting in safety conscious strategies and tactics. We need to think about the Predicative Strategic Process, refined Tactical Deployment Models integrating intelligent Structural Anatomy and Predictive Occupancy Profiling.

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 adjusted and enhanced to address these new rules of structural fire engagement. There is a profound need to gain 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. Its all about the new formula….Bk=F2S.

Additionally, think about the following

  • Don’t Treat Your Buildings and Occupancies the Same anymore
  • Increase Situational Awareness
  • Increase Your Competencies
  • Know Your Buildings
  • Be aware of Command Compression
  • Implement Tactical Patience
  • Tactical Entertainment
  • Building Knowledge = Firefighter Safety
  • Fire Behavior & Fire Dynamics
  • Situational Awareness
  • Naturalistic Decision Making

More on these and some additional key reports on a future post…..

Eleven Minutes to Mayday; What You Need to Know

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The Colerain Township (OH) Fire and EMS Department under the leadership of Director and Chief G. Bruce Smith recently released its final report Investigation Analysis of the Squirrels nest Lane Firefighter Line of Duty Deaths related to the April 4, 2008 Double Line of Duty Death of a Captain and Firefighter.  This investigative analysis and report, although specific to the events and conditions encountered during the conduct of operation at the residential occupancy at 5708 Squirrels nest Lane has pertinent and relevant insights, recommendations and factors that all Fire Service personnel, regardless of rank should read.

This is one of those distinctive reports that has influential and critical operational, training and preparedness elements embedded throughout the report. Following my review of the report, having previously read the preliminary report findings, it is apparent there continues to be common threads shared by this and other events and incidents 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.

I have provided a comprehensive synopsis of the report for your review. Take the time to read the entire report, make the time to improve where you need to.  

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.

The investigation of this incident provided a number of findings and recommendations that should be considered by Colerain’s fire department, as well as other fire department organizations. The examination encompassed issues that related to building construction, firefighting tactics, command and control, situational awareness, communications, training, firefighting equipment and the individual responsibility of firefighters of the Colerain Township Department of Fire and Emergency Medical Services (Colerain Fire & EMS). In addition, a segment of the examination included a review of the individual and group affects following such an event, and the measures initiated that attempted to ensure individual, family and organizational wellness.

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.

 Incident Reported

On Friday, April 4, 2008, at 06:11:23, the Hamilton County Communications Center (HCCC) received notification of an automatic alarm activation (smoke detector and carbon monoxide) at 5708 Squirrels nest Lane (LN).

  • An automatic fire alarm response complement of two engine companies (Engines 102 & 109), one ladder company (Ladder 25), and the Battalion Chief (District 25) were dispatched to investigate at 06:13:02.
  • At 06:13:43, a second notification was received from the female homeowner reporting a fire in the basement of the building.
  • At 06:20:43, a third notification by means of a cellular phone from the female homeowner to HCCC routed through the City of Cincinnati’s Fire and Police Communications Center was received.
  • At 06:22:41, the initial response complement was then upgraded to a building fire, also known as a structure fire response complement to include one additional engine company (Engine 25), one rescue company (Rescue 26), and one basic life support transport unit (Squad 25).

Property and Building Description: The building at 5708 Squirrels nest LN was a single-family residence that set back approximately 450-feet from the street at the end of a private driveway on a heavily wooded lot.

  • The building was two-stories in height, approximately 45-feet wide by 30-feet deep with a finished below-grade (basement) living space and attached two-car garage.
  • For simplicity, the report refers to the living space under the main-level of the building as a basement.
  • From the front (side Alpha), the building was two-stories above grade. The vertical distance between floors was approximately eight-feet. The exterior main entrance was located in the front middle of the building approximately one-foot above grade level.
  • Additional entrances to the first-floor living space were by means of a rear entry door from an upper-level deck area and through the garage area.
  • The interior stairway to the basement was located approximately 15-feet from the front main entry door towards the rear of the building. There were no exposed buildings on the adjacent sides of the fire building.

The building was located approximately 450-feet from the curb and a driveway leading to the front entrance. The nearest fire hydrant was located approximately 500- feet from the front entrance. To provide for uniform identification of locations and operationalforces at the incident scene, the scene was divided geographically into smaller parts, which were designated as sectors. Specific areas of the incident scene were designated as follows:

  • The side of the building that bears the postal address of the location was designated as Side Alpha or front by the Incident Commander;
  • The property sloped downward towards the rear (side Charlie) of the building with an approximate 13-foot elevation difference from side Alpha to Charlie. The
  • Charlie side of the building was three-stories above the rear grade level with the building’s basement floor approximately five-feet above grade level. The exterior entrance to the building’s’ basement area, also known as a walk-out was by means of a stairway that led to a wooden deck on the Charlie side adjacent to the Delta side. A second stairway led to an upper level deck that served the main level of the building.

 

Initial Fire Attack Operation: Upon arrival at the incident address, Engine 102 (E102), assigned four personnel (one captain, one fire apparatus operator [FAO], and two firefighters) entered and proceeded down the driveway deploying a five-inch supply hose line.

  • With their apparatus positioned in front of the building Captain (Capt.) Broxterman radioed, “Moderate smoke showing. E102 will be Squirrelsnest Command.” at 06:24:01.
  • Verification was made by the E102’s FAO through face-to-face communication with the male homeowner that all occupants were out of the building, which was then relayed to Capt. Broxterman.

District 25 (D25) arrived at the scene at 06:26:35 and assumed Command from Capt. Broxterman. Capt. Broxterman, Firefighter (Ffr.) Schira and E102’s Ffr. #2 advanced a 1¾-inch pre-connected hose line through the front main entrance. The fire was determined to be located in the basement of the building.

  • At 06:27:52, Capt. Broxterman radioed, “E102 making entry into the basement, heavy smoke”.
  • At 06:30:35, E109′s captain radioed, “Command from E109, contact 102,have them pull out of the first floor, redeploy to the back. It’s easy access. Conditions are changing at the front door.”
  • At 06:34:48, Engine 25 (E25), the designated Rapid Assistance Team, had just completed their 360-degree size-up around the building, and encountered E102’s Ffr. #2 in front of the building, whom reported that he had lost contact with his crew.
  • During the time period between 06:29:24 and 06:34:48, the investigation committee believed that one or more catastrophic events occurred including a failure of the main-level flooring system near the Beta – Charlie corner of the building.

 Rescue and Recovery Operations

  • At 06:35:34, the Incident Commander (IC) identified a potential Mayday operation, which indicates a life threatening situation to a firefighter.  
  • RAT25 was deployed at 06:36:48. The actual Mayday operation was initiated by the IC at 06:37:41 followed by a request at 06:37:53 to the HCCC for a second alarm complement of firefighting resources.  
  • At 06:42:01, RAT25 entered the basement from the rear of the building. At 07:00:27, E26’s personnel entered through the front main entrance of the building and into the basement by means of the interior stairway.  
  • Both missing firefighters were located in the basement near the Charlie side wall adjacent to the Beta side following a floor collapse. Capt. Broxterman and Ffr. Schira were obviously deceased as a result of their injuries. 

Fire Origin and Cause: Information from the property owners was that the female had smelled an odor in the house. She told her husband, who went to investigate. Neither of them observed any smoke or flames at that time. The husband went to the basement, and located a fire near a cedar wood lined closet used to cultivate orchids in the unfinished utility room. He attempted to extinguish the fire with portable fire extinguishers and pans of water. As the fire alarm activated, the husband had his wife call 9-1-1 to report the fire. The state of Ohio Fire Marshal’s Office Fire and Explosion Investigation Bureau ruled the fire to be accidental in nature. The fire was determined to have originated in the unfinished utility room of the basement level in or near the cedar closet. This area was directly below the family room on the first floor. The probable ignition source for this fire was determined to be at and about a plastic air circulation fan and the associated electrical wiring.

Cause of Deaths

Capt. Broxterman was a 37-year old employee of the Colerain Fire & EMS with approximately 17-years of certified firefighting experience. Capt. Broxterman became trapped in the basement area for a prolonged amount of time following the sudden floor collapse. Capt. Broxterman was found positioned face down over top of Ffr. Schira. The majority of her protective clothing ensemble and equipment were heavily damaged as a result of exposure to heat and direct flame impingement. She was pronounced deceased following her removal from the building. Her body was transported to the Hamilton County Coroner’s Office for autopsy. The Coroner’s report cited the manner of death as “accidental” and the cause of death as “burns and inhalation of smoke and superheated and noxious gases.” Capt. Broxterman sustained burns to 100% of her body surface, which ranged from first to fourth degree in severity as described in the coroner’s autopsy report. Postmortem carboxyhemoglobin (COHb), which is a measure of carbon monoxide exposure, was measured at 22% saturation and soot was observed in portions of her upper and lower respiratory system.

  • Based on the injuries sustained and the damage to Capt. Broxterman’s protective clothing ensemble and equipment, it is likely that she was exposed to a rapid intensification of heat and flames in the building’s basement that overwhelmed her protective ensemble and equipment, exposing her body and respiratory system to intense heat and toxic products of combustion.

 Ffr. Schira was a 29-year old employee of Colerain Fire & EMS with approximately 3½-years of certified firefighting experience. He also became trapped in the basement area for a prolonged amount of time following the sudden floor collapse. Ffr. Schira was found positioned on his right side and back, face-up beneath Capt. Broxterman. The majority of his protective clothing ensemble and equipment was heavily damaged as a result of exposure to heat and direct flame impingement. Ffr. Schira was pronounced deceased following his removal from the building. His body was transported to the Hamilton County Coroner’s Office for autopsy. The Coroner’s report cited the manner of death as “accidental” and the cause of death as “burns and inhalation of smoke and superheated and noxious gases”. Ffr. Schira sustained burns to 100% of his body surface, which ranged from first to fourth degree in severity as described in the coroner’s autopsy report. Postmortem COhb was measured at 8% saturation and soot was observed in portions of his upper and lower respiratory system.

  • Based on the injuries sustained and the damage to Ffr. Schira’s protective equipment, it is likely that that he was exposed to a rapid intensification of heat and flames in the building’s basement that overwhelmed his protective ensemble and equipment, exposing his body and respiratory system to intense heat and toxic products of combustion.

Select Findings and Recommendations

Findings, Discussions and Recommendations

FINDING #3.1: The area of fire origin had no finished ceiling, which exposed the floor joists and the underside of the floor decking to direct fire impingement causing rapid deterioration and failure of the flooring system directly underneath the main-level family room.

During this incident, based on communications transcripts (telephone and radio) it’s probable that the fire had advanced from its incipient stage to a free burning stage in approximately 18 to 20-minutes by the time Capt. Broxterman radioed that they were making entry into the basement.

  • As stated in the Incident Overview section, during the time period between 06:29:24 and 06:34:48, it is believed that one or more catastrophic events occurred within the building, which included a failure of the flooring system near the Beta-Charlie corner of the building’s first floor.

It has been widely believed in the firefighting profession that traditional sawn lumber is far superior to some of the more innovative lightweight construction components (e.g., wood I-joist) in use today. With dimensional lumber, two-inch by eight-inch and larger, there is a greater surface to mass ratio to resist the damaging effects of fire and the structural components will maintain their integrity for a longer period of time. While this has traditionally been accurate, this incident clearly shows that this may not always be the case. Heavy charring was evident to structural members in the fire area of origin. Notice the burn damage shows how the wooden floor joists had been burned to and away from the band joist. A band joist is a vertical member that forms the perimeter of a floor system in which the floor joists tie in to. Also known as the rim joist. Early platform framed homes very likely used solid, dimensional lumber and plywood, which provided a reasonable surface to mass ratio. But the later the home was built, the less mass even dimensional lumber has due to the reduction in the actual thickness of solid dimensional lumber provided by the lumber industry through the mid-1900’s. As the years go by, building materials will likely keep getting lighter and lighter and introduce more resins and other chemicals.

 Laboratory tests that exposed structural wood components to the American Society for Testing and Materials (ASTM) E119 Assembly Test indicated that a traditional two-inch by ten-inch structural member failed in 12-minutes and six-seconds. ASTM E119 test is the standard test method for evaluating building and construction materials exposed to fire. Unlike the standardized ASTM test fires, it is widely recognized that real building fires are highly variable in their size, rate of growth and intensity. Responding firefighters are unlikely to know when a given fire started, how hot it had been prior to arrival, how long it had been at any given temperature, the design capacity and actual loads on the floors over the fire or the amount of actual damage that the fire may have done to the joists. All of these factors make it impossible to predict the remaining capacity of a floor by even the most knowledgeable, professional fire experts.

RECOMMENDATION #3.1a: Fire departments should ensure that firefighters and incident commanders are aware that unprotected floor and ceiling joist systems, no matter the type, may fail at a faster rate when exposed to direct fire impingement.

Unfinished basement ceilings and other areas that have exposed joists or trusses jeopardize flooring and roof systems unnecessarily during a fire, causing premature failure. Often, a weakened floor and ceiling joist system can be difficult to detect from above as the floor surface above may still appear intact. Firefighters operating on floors above fire-damaged joist systems may fall through a weakened area and become trapped in a fire below. IC’s and firefighters must be aware that these systems can fail rapidly and without warning, and plan interior operations accordingly.

Firefighters must also be aware that while floor sag may be a widely accepted warning of an impending structural failure, floor sag is not always present or visible prior to a catastrophic collapse in a fire, regardless of the joist type, due to floor coverings, the fire’s intensity, the combination of joist spans and loads present, the location of serious structural fire damage or simply because it is too dark and smoky to see a sag in the floor. This is true for all types of structural joists, including materials such as sawn lumber, wood I-joists, and open web wood trusses and noncombustible members such as lightweight steel joists. The floor covering in this area was carpeting that transitioned to ceramic tile. When unprotected, any traditional or lightweight residential floor or ceiling assembly material, either combustible or noncombustible, may fail within several minutes of the fire’s ignition. It makes sense, therefore, that when there is a serious fire beneath a floor, there is no predictable safe amount of time that anyone can remain on that floor. Any floor system protected or not, can fail unpredictably when exposed to a substantial fire beneath.

FINDING # 4.2: E102′s officer failed to properly analyze the scene by not performing a 360-degree scene size-up to determine an overall strategy, and implement safe and effective firefighting tactics.

After the apparatus was positioned in front of the building, E102’s FAO was ordered by Capt. Broxterman to, “Ask the homeowner where the fire [location] was”, which was indicated to be in the basement by the male homeowner. As this was taking place, Capt. Broxterman continued donning her protective clothing ensemble (coat, helmet and self-contained breathing apparatus). Although E102′s officer provided a brief radio report of conditions observed upon arrival, she did not properly evaluate the scene so as to develop a basic strategy for implementation of safe and effective firefighting tactics. Had the officer visually evaluated the Charlie side of the building, the advanced fire conditions may have been noted, and that the lower level fire area was accessible by means of an exterior entry door for a more direct fire attack from the interior unburned side.

This means that firefighters enter a building and position the attack hose line between the fire and the uninvolved portions of the building. This direction of fire attack is preferred because it is likely to contain the fire, protect occupants, and push heat and gases out of the building if ventilation has been performed. On the other hand, danger increases significantly when attacking from the unburned side and is not always practical based on fire location, intensity, and building construction.

It cannot be conclusively known as to why Capt. Broxterman and Ffr. Schira proceeded into the area of the building that eventually collapsed resulting in their deaths. The investigation committee has concluded that the most probable explanation is that E102′s three-person interior team was successful in advancing their uncharged attack hose line into the basement recreation room area; reaching a point approximately 10 to15-feet from the bottom of the basement stairway as shown in the Incident Overview chapter. Once the team reached this area, it was realized they did not have sufficient hose line to continue advancing towards the seat of the fire. The team’s third member (Ffr. #2) reversed his travel and made his way back to the exterior of the building to advance additional hose line. As the team of two waited for additional hose line to be stretched and the hose line to be charged by the pump operator, the interior conditions rapidly deteriorated to a stage that it became untenable for them to hold their position.

The team evacuated back-up the stairway without following the hose line, which by all indications was tight up against the stairway wall and tightly wrapped around the stairway door entry. Once at the top of the stairway, one of the two deceased, if not both were likely in some form of distress; became disoriented and proceeded into the family room in a direction opposite the route of travel from which they entered the building. As the two moved across the family room floor, the flooring system collapsed into the utility room area of the basement. When the third team member re-entered the building, he was unable to locate the other two members.

The inability of Ffr. #2 to locate his team and the loss of radio communications contact with the interior team prompted the IC to declare a Mayday and activation of the RATs. This incident resulted in tragedy primarily due to the concealment of several burned-through floor joists under the carpet covered flooring system, which was nearly impossible to recognize due to heavy smoke conditions inside the burning building.

The following factors are believed to have directly contributed to the deaths that occurred in this incident:

  • The delayed arrival at the incident scene allowed the fire to progress significantly and the hazardous conditions to exponentially increase;
  • The failure to adhere to fundamental firefighting practices (e.g., entry into an enclosed building with obvious working fire conditions without a charged attack hose line)
  • The failure to abide by the fundamental concepts of fire fighter self-rescue and survival (e.g., following of the hose line in the direction of travel back to the building’s entrance or exit).

 Although the aforementioned factors are believed to have directly contributed to the deaths reported here, they might have been prevented if:

  • Some personnel had not been complacent or apathetic in their initial approach to this incident which eventually led to being overwhelmed in their response to their initial findings;
  • Some personnel were in a proper state of mind that made them more observant of their surroundings and indicators, and the potential threats and risks that presented themselves;
  • The initial responding units were provided with all pertinent information in a
  • timely manner relative to the incident, especially critical was the information  given to the emergency communications center from the homeowners reporting an actual fire
  • Personnel assigned to E102 possessed a comprehensive knowledge of their firstdue response area specifically related to road and street locations, and any particular characteristics related to those areas.
  • 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; the risk of an action must be weighed against the probable benefit that may be reasonably and realistically expected.
  • 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. This competition led to missed and distorted messages and less than efficient use of resources, which exacerbated the problems of already taxed communications.
  • 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 as encountered with an emphasis placed on fire ground tactical priorities (i.e., life safety, incident stabilization and property conservation);
  • 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.

In Memory

The Colerain Township (OH) Department of Fire and Emergency Medical Services’s report examined the events of April 4th, 2008 with the benefit of hindsight, while seeking to be independent, impartial, and thorough. From the beginning, Colerain Fire & EMS has been committed to share our findings with others in the hope that it may prevent another such event.

The deaths of Captain Robin M. Broxterman and Firefighter Brian Schira had a profound loss not only to their parents, family and this organization, but also to the larger fire service community. In order to prevent these tragic losses in the future, we must first understand how and why our sister and brother firefighters died. We must learn from their incident and take that knowledge forward. If it was possible, what would these firefighters tell us today that might prevent a similar death of a firefighter in the future? What would they want us as firefighters, company officers and chief officers to know about the circumstances that lead to their deaths and the things we (and they) might have done to alter the most tragic of outcomes?  

From the information that was made available for review, it was evident that these two individuals were well-loved in life, and greatly missed in death. Every line of duty death of a firefighter in the United States is significant. This investigative analysis document is dedicated to Captain Broxterman and Firefighter Schira, their families, friends and the community whose lives were forever changed. In working to improve the health and safety of all United States firefighters, we have much to learn from the supreme sacrifice of these two individuals, who they were in life and in death. We honor their memories.

  

References

  • 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
  • WLTW.com news report Summary HERE

  

 

Shopping Center Explosion: Fluid Risk Assessment

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

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

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

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

 3-18-2010 9-29-48 PM

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

 3-18-2010 9-09-52 PM

Building Knowledge

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

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

NIOSH Report Summary

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

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

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

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

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

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

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

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

Contributing Incident Factors

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

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

Building Knowledge=Fire Fighter Safety

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

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

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

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

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

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

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

Slide Show from WUSA9.com HERE 

BING mapping Images, HERE

The “Routiness” of Success, Or Not..

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BM11

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

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

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

 

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

 

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

 

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

Doctrine of Combat Fire Engagement

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1Considerations for changing fire flow rates, the sizing of hose line and the adequacies for fire flow demand and application rates, staffing needs for safe operations, considerations for defensive positioning and defensive operating postures must be considered, and it warrants repeating again;

Reckless-Aggressive firefighting must be redefined in the built environment and associated with goal oriented tactical operations that are defined by risk assessed and analyzed tasks that are executed under battle plans that promote the best in safety practices and survivability within known hostile structural fire environments- with determined, effective and proactive firefighting; New Terminology and operational perspectivies to meet today’s challenges….Here’s your introduction to the new lexicon;

  • Doctrine of Combat Fire Engagement
    • Predictive Strategic Process
    • Tactical Deployment Model
    • Dynamic Tactical Deployment
    • Performance Indicators and Street Aides
      • Fire Dynamics
      • Resistance
      • Resilience
      • Structural Systems
      • Occupancy Hazard Profiles

The Doctrine of Combat Fire Engagement, coming soon with a new persepctive and outlook on firefighting operations…are you going to be ready?

Executing Effective Tactical Plans

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45418t1When we look at various buildings and occupancies, past operational experiences; those that were successful, and those that were not, give us experiences that define and determine how we access, react and expect similar structures and occupancies to perform at a given alarm in the future. Naturalistic (or recognition-primed) decision-making forms much of this basis. We predicate certain expectations that fire will travel in a defined (predictable) manner that fire will hold within a room and compartment for a predictable given duration of time; that the fire load and related fire flows required will be appropriate for an expected size and severity of fire encountered within a given building, occupancy, structural system; in addition to having an appropriately trained and skilled staff to perform the requisite evolutions.

Executing tactical plans based upon faulted or inaccurate strategic insights and indicators has proven to be a common apparent cause in numerous case studies, after action reports and LODD reports. Our years of predictable fireground experience have ultimately embedded and clouded our ability to predict, assess, plan and implement incident action plans and ultimately deploy our companies-based upon the predictable performance expected of modern construction and especially those with engineered structural systems.

Looking Forward Through the Rear View Mirror

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crystalBall1As the end of the year fast approaches and in turn the end of the decade, it amazes me how “fast” time seems to have passed. Certainly when looking back and reflecting upon the past year or the previous few years, each of us thinks and contemplates upon those events, milestones, anniversaries, highlights as well as those common everyday occurrences that seem to permeate back and forth in our minds and hang at times like the smoke from a smoldering contents fire. When reflecting, there are the good times as well as those that were not so good. There are those events that were life altering and changing that forever formulate a different view upon each of our respective worlds we live and work within. As well as those events that have provided us with the joys and virtue of what we do everyday as firefighters both on and off the job, at the firehouse and at home.

For each or us, the events that form and shape our worlds; our families at home and our families at the fire station and within the fire department or agencies we volunteer or work for, leave indelible marks upon us that at times formulate and transcend us. My good friend Chief Ben Waller reflected upon a number of issues and insights in his recent post that was right on the mark as did my partner Chief Doug Cline in his perspective of 2009 and for 2010. A lot has happened to this our Fire Service during the past ten years and most certainly in the past twelve months that has shaped and forged a new generation of firefighters and tempered the existing veterans. Stop and think about it.

Looking back at 2009 and in the waning decade, the one certainty that we all share is that we have the ability and look forward to a new year, a new decade and to new challenges. Prior to this week, the 2009 Firefighter LODD events that sadly have occurred seemed like it would pause and we’d end the year with no further events. Tragically, in the past few days, five additional line-of-duty deaths have been reported through the USFA. From the events of 9-11, to the seeds that were planted in Tampa and the crusade that was embarked upon to ensure everyone [has] the opportunity to go home, through the tragedy, wake-up call and the lessons-learned from Charleston. A lot has happened, many tears have been shed, alot was learned, with so much more work still remaining.

As of this posting, the United States Fire Service has borne ninety-three (93) LODDs this year. In comparison to previous years, this may finally indicate a turning point in the previous escalating trends in LODD we’ve experienced during the past decade. Take a moment to look through the USFA postings and the narratives of each of the firefighters who made the supreme sacrifice in 2009 and reflect upon the circumstances and events that lead to their respective LODD incident. Take the time to spend an evening reading through some of the recent or past reports published on the NIOSH Fire Fighter Fatality Investigation and Prevention Program web site. Look the History Repeating Events (HRE) and think about what you can do to champion changes in your organization, department or company to eliminate or reduce the likelihood for a similar event from occurring to you or your organization.

The formulative and diligent efforts of the NFFF and the Everyone Goes Home Program and the Sixteen Firefighter Life Safety Initiatives have made their mark in this decade and must continue to be embraced and institutionalized as we move forward to twenty ten. Don’t forget about the inroads made by the National Firefigher Near-Miss Reporting System and the knowledge being gained to reduce HRE. We must look at and examine the successes and the failures of our methodologies, processes, culture and perspectives and continue to seek behaviors and practices that make our job safer. When we focus our attention on Building Construction, Command Risk Management and Firefighter Safety and the essence of combat structural fires; Structural firefighting is what it’s all about, is it not? The fundamental nature and reason we have such veneration for firefighting and the fire service and all it entails, has a lot to do with going into burning buildings and fighting fire. But firefighting has its adverse consequences, with all too familiar costs, in the form of injuries, debilitating accidents and line of duty deaths. As a firefighter; to say that we love firefighting would be an understatement, BUT one issue that we need to address is the fact that there are many individual firefighters, companies and organizations that employ fireground operational practices that promote the “enjoyment and entertainment” of working a good job within the occupancy compartment of a structural fire in the building environment.

One of the formulative postings I published this past year focused on working that good job for the shear enjoyment of what and who we are; firefighters. It’s worth repeating again, since this is an opportune time to reflect. Today’s incident scene and structural fires are unlike those in past decades and will continue to challenge us operationally when confronted with structural fire engagement and combat operations. Operationally, we need to be doing the right thing, for the right reason in the right place to increase our safety and incident survivability.

We also can share the belief and understanding that we at times may have found ourselves staying too long in the wrong place, operating tactically in an adverse environment with known hazards that do not have value, for nothing other than the enjoyment of nozzle and operating time in the fire. We have a tendency when working a room and contents, compartment fire or a structural fire in the building environment placing operating companies and personnel in high hazard environments- sometimes at the expense of justifying our own entertainment value in working the job, the assignment or in maintaining the interior operational interface. Think about it.

We need to stop “entertaining” ourselves. Don’t mistake determined, effective and proactive firefighting with that of reckless, baseless and risk-preferring and self-indulging firefighting. There is a difference. The job is dangerous, it has risks, we are not invincible, and we can die; at any alarm, in any fire, at anytime for any number of reasons. But it’s tragic when we die for all the wrong reasons. Think about the definitions; think about how they apply to you, your personnel, your company or your operations; past, present or future. More importantly, think about when and where you’ve found yourself doing any one of these; could the outcome have been different?

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

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. As a result, risk management must become fluid and integrate all personnel. We must manage dynamic risks with a balanced approach of effective assessment, analysis and probability within command decision making that results in safety conscious strategies and tactics.

On any given day, at any give alarm, the dynamics around us at times may be in or out of our direct control. We may not be able to see what the cards have in store for us, BUT we must ensure we use every fragment of training, fortitude, knowledge, skills, courage, bravery, insights, luck and sometimes (other divine) intervention to get us through. We must have the fortitude and courage to be both safety conscious and measured in the performance of our sworn duties while maintaining the appropriate balance of risk and bravery.
• 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.

• As a result, risk management must become fluid and integrate all personnel.

• We must manage dynamic risks with a balanced approach of effective assessment, analysis and probability within command decision making that results in safety conscious strategies and tactics.

• The traditional attitudes and beliefs of equating aggressive firefighting operations in all occupancy types coupled with correlating, established and pragmatic operational strategies and tactics MUST not only be questioned, they need to be adjusted and modified.

Risk assessment, risk-benefit analysis, safety and survivability profiling, operational value and firefighter injury and LODD reduction must be further institutionalized to become a recognized part of modern firefighting 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.

Aggressive: Assertive, bold, and energetic, forceful, determined, confident, marked by driving forceful energy or initiative, marked by combative readiness, assured, direct, dominate…

Measured: Calculated; deliberate, careful; restrained, think, considered, confident, alternatives, reasoned actions, in control, self assured, calm…

There is a melting of both pragmatic aggressive firefighting with measured and deliberate tactical approaches. It’s a balance and equilibrium; the question is do you know when to recognize that balance, where it exists and how not to cross that adverse threshold?

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. You need to gain the knowledge and insights and to change and adjust your operating profile in order to safe guard your companies, personnel and team compositions.

Looking Forward through the Rear View Mirror; remember the past, recall those history repeating events that seem to manifest themselves time and time again; are we ever going to learn. I truly believe we are starting to finally “get it”-even if it’s on a smaller incremental scale, it’s a starting point. Remember the lessons from those events that have impacted you, your department, your community and the fire service; from close-calls to near-miss events; from minor or debilitating injuries to the tragedy and sorrow of a LODD event.

As we transition into a new year, and as plans begin to take place that frame and outline the year’s activities, foremost in this planning, preparation, scheduling and outlook should be those activities and commitments that training, education and skill development can be implemented and enhanced. Take the initiative to recognize and identify training and operational gaps and distinguish the risk and options available to lessen or eliminate the risk and reduce the gap deficiencies. Take the time to implement effective, accurate and frequent training and skill development drills, training curriculums and programs. Don’t sacrifice or forego on this mission critical area when so much is at stake in the domain of combat structural fire suppression. Understand the predictability of performance in the buildings and occupancies not only in your jurisdiction, first or second-due areas, but also in those areas that you may be called upon to respond to for greater alarms or mutual aid. Understand the structural anatomy of your community. Remember Building Knowledge = Firefighter Safety. Understand the fomulative issues affecting engineered structural systems (ESS) and the change in operational deployment and tactics on the fire ground. Keep an eye in the rear view mirror; learning from the wisdom and knowledge from where you’ve been, what you’ve done and all your past experiences and practice; but at the same time focusing on the road before you with keen attentiveness on situational awareness, anticipating error-likely conditions and balanced risk assessment and operational management in both your strategic and tactical deployments.

We don’t know what’s in the cards on any given day, but the citizens we protect can rest assured, we will do our jobs as firefighters, to the best of our abilities, because of who we are; today, in 2010 and certainly well into the next decade and beyond. 

Ensure you’re glancing occasionally in your rear view mirror to monitor where you’ve been, while driving your initiatives, programs, processes and actions forward. Above all, maintain the courage to be safe.

Remembering Brackenridge 1991 Floor Collapse and LODD

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12-21-2009 9-53-23 PMRemembering Brackenridge, Pennsylvania December 20, 1991: Four Firefighters Killed, Trapped by Floor Collapse

Four volunteer firefighters died when they were trapped by a partial floor collapse during a structure fire in Brackenridge, Pennsylvania, on the morning of December 20, 1991. All four were members of a mutual aid truck company that had responded to the early morning incident and were assigned to prevent fire extension from the basement to the ground floor of a 2-story building. Although they were wearing full protective clothing and using self-contained breathing apparatus, it appears that they were overwhelmed by the severe fire conditions that erupted when a section of the ground floor collapsed into the basement. The collapse cut off their primary escape path, and the fire burned through their hose line, leaving them without protection from the flames.  

 SUMMARY OF KEY ISSUES

  • Situation: Fire in enclosed room in basement. Unable to locate fire because of smoke. Smoke and heat increasing, but no visible fire.
  • Structure: Appeared to be heavy concrete construction. Actually thin concrete floors supported by unprotected steel.
  • Contents: Furniture refinishing business. Quantities of flammable finishes and solvents in basement.
  • Exits: One entrance/ exit on each level; no alternate exits.
  • Structural Collapse: Floor section collapsed between interior crew and their only exit. Fire overwhelmed crew.
  • Rescue Attempts: Valiant rescue efforts proved unsuccessful. Unsure if missing members fell into basement or were trapped on ground floor.
  • Incident Command: No formal command system or personnel accountability in place. Chief of first-due company in command of incident; Assistant Chiefs assigned to basement and ground floor.
  • Information: No pre-fire plan and no detailed knowledge of occupancy. Clues of structural danger not recognized as fire conditions increased
  • Communications: Radio system inadequate for current needs.
  • Response: Independent volunteer companies. Mutual aid requested on arrival and additional companies called in succession.
  • Weather: Extremely cold night, predawn hours. Problems with frozen hydrants.
  • Water System: Weak supply. Extensive mutual aid and long relays needed to protect exposures.

The analysis of this incident provides several valuable lessons for the fire service. Unfortunately these are all revisited lessons, not new discoveries. These firefighters died in the line of duty, while conducting operations that appeared to be routine, and were unaware of the situation that was developing below them. They died in spite of the fact that they were experienced, they were operating with a standard approach to operational safety, and they were the object of repeated rescue attempts by highly capable comrades.

There are several factors that could have provided warning or changed the outcome of this situation. Like most accidents, this situation was the result of a number of problems that came together under the worst possible circumstances. Firefighting obviously involves inherent dangers that must be accepted by its practitioners. The important messages for the fire service are to identify risk factors in advance of an incident and to develop mechanisms to react appropriately when critical situations present themselves.

This situation bears distinct similarities to other incidents that have claimed the lives of several firefighters in the past. The lessons that must be derived from this incident are not a condemnation of the actions or judgment of anyone who was involved in the situation; they simply identify information that can help to prevent this type of accident from occurring in the future.

USFA Report; HERE

NFPA Summary; HERE

NFPA Report Order; HERE 

Brackenridge Pioneer Hose Co. Memorial, Pennsylvania, HERE

FDNY Brooklyn Box 4080: 17 Vandalia Avenue 12.18.98

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12-18-2009 12-24-25 PMTake 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