Remembering the Sacrafice: Capt. Broxterman and FF Schira
On Friday, April 4, 2008 at 06:13:02 hours, what began as a routine response for Colerain Township Fire and EMS Engine 102 to investigate a fire alarm activation at 5708 Squirrels nest Lane, Colerain Township, Ohio resulted in the deaths of Colerain Township Captain Robin Broxterman and Firefighter Brian Schira.
Upon their arrival at the scene of the two-story wood framed, residential building working fire conditions existed in the basement. The initial attack team consisted of Broxterman, Schira, and one other firefighter. The team advanced a 1¾-inch attack hose line through the interior of the building for fire control.
Even though, they were provided with some of the most technologically advanced protective clothing for structural firefighting and self-contained breathing apparatus, it appeared that Broxterman and Schira were overwhelmed by severe fire conditions in the basement.
During their attempt to evacuate the building, the main-level family room flooring system in which the two were traveling on collapsed into the basement trapping the firefighters. Eleven minutes elapsed from time of arrival to the catastrophic chain of events.
This is one of those distinctive reports that has influential and critical operational, training and preparedness elements embedded throughout the report.
It’s apparent there continues to be common threads shared by this event from 2008 and other events and incidents in the past five years where a single of multiple firefighters have lost their lives due to similarities in the apparent and common cause deficiencies and short comings identified.
All company and command officers should read and comprehend the lessons learned. Then, take these new found insights and see what the gaps are at the personal level (yours or those you supervise) as well as the shift, group, station, battalion, division or department as a whole.
If there are gaps, then identify a way to implement timely changes as necessary so there are No History Repeating (HRE) events.
The importance of Reading the Building, taking the time to complete the three sixty and being combat ready and “expecting fire”.
Remember their sacrifice, so we can learn.
Past Post on CommandSafety.com with Report Narrative and Incident DetailsHERE
The following factors were believed to have directly contributed to the deaths of Captain Broxterman and Firefighter Schira:
A delayed arrival at the incident scene that allowed the fire to progress significantly;
A failure to adhere to fundamental firefighting practices; and
A failure to abide by fundamental firefighter self-rescue and survival concepts
Although the aforementioned factors were believed to have directly contributed to their deaths, they might have been prevented if:
Some personnel had not been complacent or apathetic in their initial approach to this incident;
Some personnel were in a proper state of mind that made them more observant of their surroundings and indicators;
The initial responding units were provided with all pertinent information in a
timely manner relative to the incident;
Personnel assigned to Engine 102 possessed a comprehensive knowledge of their first-due response area;
A 360-degree size-up of the building accompanied by a risk – benefit analysis
was conducted by the company officer prior to initiating interior fire suppression operations;
Comprehensive standard operating guidelines specifically related to structural
firefighting existed within the department;
The communications system users (on-scene firefighters and those monitoring the incident) weren’t all vying for limited radio air time;
The communications equipment and accessories utilized were more appropriate for the firefighting environment;
Certain tactical-level decisions and actions were based on the specific conditions;
Personnel had initiated fundamental measures to engage in if they were to become disoriented or trapped inside a burning building; and
Issued personal protective equipment was utilized in the correct manner.
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
Operations at 30 Dowling Circle 01.19.2011 Box 11-09
Mark Gray Falkenhan had dedicated his life to serving others. He perished in the line of duty on January 19, 2011 while performing search and rescue operations at a multi-alarm apartment fire in Hillendale, Baltimore County (Maryland). He was 43 years old.
On Wednesday, January 19, 2011, a fire occurred in an apartment building located in the Hillendale section of Baltimore County, Maryland. This fire resulted in the line of duty death (LODD) of volunteer firefighter Mark G. Falkenhan, who was operating as the acting lieutenant on Squad 303 . Upon their arrival, FF Falkenhan and a second firefighter from Squad 303 deployed to the upper floors of the apartment building to conduct search and rescue operations. Other fire department units were already involved with both firefighting operations and effecting rescues of trapped civilians.
During these operations, FF Falkenhan and his partner became trapped in a third floor apartment by rapidly spreading fire and smoke conditions. The second firefighter was able to self-egress the building by diving headfirst down a ladder on the front (address side) of the building. FF Falkenhan declared a “MAYDAY” and implemented “MAYDAY” procedures, but was unable to escape or be rescued.
FF Falkenhan was located and removed via a balcony on the third floor in the rear of the building. Resuscitative efforts began immediately upon removal from the balcony, and continued en route to the hospital. FF Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
The Baltimore County (MD) Fire Department published the Line of Duty Death Investgation Report of the 30 Dowling Circle Fire recently. The report was written by a Line of Duty Death Investigation Team comprised of departmental members, including representatives of the local firefighters’ union and the Baltimore County Volunteer Firemen’s Association.
Baltimore County (MD) Fire Department web site HERE
The following is and executive narrative of the final report (PDF) on the apartment fire where Volunteer Firefighter Mark Falkenhan sustained fatal injuries. The entire report can be downloaded HERE .
The Baltimore Sun newspaper published an editorial about the death of Firefighter Falkenhan that is required reading; HERE . An excerpt from the editorial reads as follows:
FF Mark Falkenhan
The word “hero” gets used too often to describe the most pedestrian of admirable behaviors, from the star quarterback who marches his team for a winning score to the kid who finds a missing wallet and turns it in. But exceptional bravery, special ability, exceptional deeds and noble qualities — those are what define an authentic hero, and Mr. Falkenhan lacked for none of them.
It was not by accidental circumstance or naiveté that he ended up on the third story of that Hillendale apartment complex in the midst of a fire, searching for missing residents. He knew the risks as well as anyone could. But his selfless desire to help others drove him forward into the flames.
That’s what made him exceptional. That’s why his legacy is important. That’s why the community is in his debt.
Incident Executive Summary
On Wednesday, January 19, 2011, a fire occurred in an apartment building located in the Hillendale section of Baltimore County, Maryland. This fire resulted in the line of duty death (LODD) of volunteer firefighter Mark G. Falkenhan, who was operating as the acting lieutenant on Squad 303 (for purposes of this report, Mark will be referred to as FF Falkenhan). Upon their arrival, FF Falkenhan and a second firefighter (FF # 2) from Squad 303 deployed to the upper floors of the apartment building to conduct search and rescue operations. Other fire department units were already involved with both firefighting operations and effecting rescues of trapped civilians.
During these operations, FF Falkenhan and FF # 2 became trapped in a third floor apartment by rapidly spreading fire and smoke conditions. FF # 2 was able to self-egress the building by diving headfirst down a ladder on the front (address side) of the building. FF Falkenhan declared a “MAYDAY” and implemented “MAYDAY” procedures, but was unable to escape or be rescued. FF Falkenhan was located and removed via a balcony on the third floor in the rear of the building. Resuscitative efforts began immediately upon removal from the balcony, and continued en route to the hospital. FF Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
Baltimore County Fire Department Standard Operating Procedures, Personnel #16, requires a team to be formed, a detailed investigation to be conducted and a report produced for any incident involving a line of duty life threatening injury or death. The team’s objective is to thoroughly analyze and document all the events leading to the injury or death and to make recommendations aimed at preventing similar occurrences in the future. At a minimum, a Division Chief, the Department’s Health and Safety Officer, a member from the Fire Investigation Division, an IAFF Local 1311 union representative, and the Baltimore County Volunteer Firemen’s Association Vice President of Operations (when a volunteer member is involved) is required (see Acknowledgements section for actual team make-up).
The investigating team examined any and all data available, including independent analysis of the self contained breathing apparatus (SCBA), turnout gear and autopsy report. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) produced a fire model to assist with evaluating fire behavior. Multiple site inspections were conducted. Extensive interviews were conducted by the team which also attended those conducted by investigators from the National Institute for Occupational Safety and Health (NIOSH). Photographic and audio transcripts were also thoroughly analyzed. A comprehensive timeline of events was developed. All information used to make decisions regarding recommendations was corroborated by at least two sources.
In fairness to those units involved in this incident, the investigating team had the advantage of examining this incident over the period of several months. Furthermore, given the size and nature of the event, and the fact that arriving crews were met with serious fire conditions and several residents trapped and in immediate danger, all personnel should be commended for their efforts for performing several rescues which prevented an even greater tragedy.
The team did not identify a particular primary reason for FF Falkenhan’s death.
What were identified were many secondary issues involving but not limited to crew integrity, incident command, strategy and tactics, and communications.
These issues are identified and discussed, and recommendations are made in appropriate sections of the report, as well as in a consolidated format in the Report Appendix.
Some of the issues identified in this report may require some type of change to current practices, policies, procedures or equipment. Most, however, do not. Specifically, the analysis and recommendations regarding Incident Command and Strategy and Tactics show that if current policies and procedures are adhered to, the opportunity for catastrophic problems may be reduced.
Mark Falkenhan was a well-respected and experienced firefighter.
He died performing his duties during a very complex incident with severe fire conditions and unique fire behavior coupled with the immediate need to perform multiple rescues of victims in imminent danger.
It would be easy if one particular failure of the system could be identified as the cause of this tragedy.
We could fix it and move on. Unfortunately it is not that simple.
No incident is “routine”. Mark’s death and this report reinforce that fact.
Incident Summary
On Wednesday, January 19, 2011 at 1816 hours, a call was received at the Baltimore County 911 Center from a female occupant at 30 Dowling Circle in the Hillendale section of Baltimore County. The caller stated that her stove was on fire and the fire was spreading to the surrounding cabinets. Fire box 11-09 was dispatched by Baltimore County Fire Dispatch (Dispatch) at 1818 hours consisting of four engine companies, two truck companies, a floodlight unit, and a battalion chief. All units responded on Talkgroup 1-2.
The location, approximately one mile from the first dispatched engine company, is a three story garden-type apartment complex, with brick construction and a composite shingle, truss supported roof. The fire building contained a total of six apartments divided by a common enclosed stairway in the center with one apartment on the left and one to the right of the stairs.
Alpha, Bravo, Charlie, and Delta will be used to designate the clockwise geographic locations of the structure, beginning with Alpha on the address side of the building . Entry is gained through the front split-level stairwell by a common entrance door with individual doors leading to each apartment. Each apartment consists of two bedrooms, a kitchen, bathroom, and a living/dining area. There are sliding doors leading to either a wood joist deck/balcony on the second and third floor apartments, or a concrete patio on the first floor apartments. Utilities consist of gas service to the furnace and hot water heaters located in a utility closet in each apartment, with electric service to the remainder of the appliances, including the stove. Interior walls of the apartments are drywall over wood stud construction.
Floor coverings consist of carpeting over tile and concrete on the terrace/first floor. The second and third floor coverings consist of carpeting covering hardwood floors with a plywood subfloor. Interior doors are hollow wood construction. The door to the common hallway is of solid wood construction. The sliding doors to the deck/patio area are glass.
Building Construction
The development and construction of the Towson Crossing Apartments began in the early 1980’s. The buildings are rated in the existing building code for occupancy as Residential 2 (R2). The building code would describe the construction type as Type III. This construction type includes those buildings where the exterior walls are of non-combustible materials and the interior building elements are of any material permitted by the building code.
Building Construction and Features
The subject apartment building, 30 Dowling Circle, is a three story, middle of the group, apartment building constructed on a reinforced concrete slab. The Alpha and Charlie exterior walls are wood framed construction with brick veneer attached by brick ties. The Bravo and Delta exterior walls are block masonry construction and separate adjoining apartment buildings. The interior partition walls consist of wooden 2″x4″ wall studs covered with sheetrock. Paper faced insulation is found between the exterior walls, ceilings and party-walls that separate the apartments.
The apartment building contains six individual apartment units, which are approximately 1000 square feet in size per apartment unit. Two separate units are located on each floor and consist of two bedrooms, a living area, a dining area, a kitchen, and a bathroom. A utility closet is located in each of the living areas. The closet is located along the Alpha wall, and contains the water heater and furnace.
The building is not equipped with an automatic fire suppression system. Smoke detectors were noted; however, it is unknown if they were operational at the time of the fire. A fire extinguisher was noted on the landing between the second and third floor levels of the building.
Topography
From side Alpha the building has two and a half stories above grade while side Charlie is three stories above grade.
The first floor of the building is approximately five feet below ground level with a 20 foot set back from the apartment building parking lot. Side Charlie of the building is at ground level but slopes upward approximately 8 feet with a set-back of 110 feet from the rear alley.
Roof
The roof is constructed of a lightweight truss assembly consisting of 2″x6″ stringers connected by gusset plates. The truss assembly is covered with 5/8 inch plywood and asphalt shingles.
Floor and Ceiling
The floor assembly consists of 2×10 inch floor joists covered by plywood, wooden tongue and groove planking and finished with carpet. The joists run from Alpha to Charlie and are supported by the interior bearing walls. The kitchen floors in all of the units are covered with vinyl tile.
The ceilings throughout the building are sheetrock nailed to the floor joists of the apartment above with the exception of the third level in which the sheetrock is nailed to the roof joists.
Balconies
The balconies are located on side Charlie of the building. The balconies located on levels two and three consist of 5/4″ deck boards over 2″x10″ wooden joists. The joists are cantilevered off of the floor/ceiling assemblies of levels one and two. The first floor balconies are made of concrete and are at ground level. All balconies are accessible through a single pane sliding glass door located in each apartment.
Incident Overview
The first arriving engine, E-11, was staffed with a Captain, Lieutenant, Driver/Operator, and a Firefighter. Upon arrival at 1820 hours, the Captain gave a brief initial report describing a three story garden apartment with smoke showing from side Alpha: “The Captain of E-11 will have Command and we are initiating an aggressive interior attack with a 1 ¾” hand line”. Command also instructed the second due engine to bring him a supply line from the hydrant.
A female resident (victim # 1) appeared in a third floor apartment window, Alpha/Bravo side (Apt. B-1), yelled for assistance, and threatened to jump. Smoke or fire was visible from any of the third floor windows. At 1823 hours, Command advised Dispatch that he had a rescue and that he was establishing Limited Command. Fire Dispatch was in the process of upgrading the response profile to an apartment fire with rescue when the responding Battalion Chief requested that the fire box be upgraded to a fire rescue box. While the Firefighter and Lieutenant prepared for entry into the building, the Captain and Driver/Operator extended a ladder to the 3rd floor apartment window and rescued the resident. The first attempt by the Firefighter and Lieutenant to make entry into the side Alpha entrance was unsuccessful due to the extreme heat and smoke conditions.
Initial Arrival Conditions
The second due engine, E-10, arrived at 1823 with staffing of a Captain, Lieutenant, Driver/Operator, and a Firefighter. At 1823, E-10’s crew brought a 4″ supply line to E-11 from the hydrant at Deanwood Rd. and Dowling Circle and assisted the first-in crew with fire attack.
The Captain from E-10 conferred with Command and was instructed to advance a second 1 ¾” hand line.
The window to the first floor right apartment (Apt. T-2) was removed, and the second 1 ¾” line was advanced to the building by the crew of E-10.
Fire attack was initiated through the removed window. At 1827, Command requested a second alarm.
At this time, heat and smoke conditions just inside the front door improved enough to allow the Firefighter and Lieutenant from E-11 to make entry through the front door and into the stairwell. There they encountered heavy, thick black
smoke and high heat conditions coming up the stairs from the terrace level apartment. The Lieutenant reported that the doorway to the first floor apartment was orange with fire and he had to fight his way through heavy heat and smoke conditions to attack the fire in the first floor right apartment (Apt. T-2). Entry was made approximately 3 feet into the doorway when the Firefighter’s low air alarm began to sound, and he exited the building. A member from E-10’s crew replaced the Firefighter from E-11 on the hose line.
At the same time, the Captain from E-11 proceeded to the rear of the structure to complete his initial 360 degree size up. He noted that there was fire emanating from the open sliding doors on the first floor Charlie/Delta apartment (Apt. T-2), extending to the balcony above. E-1, staffed by a Captain, Driver/Operator, and two Firefighters arrived and completed the hookup of the supply line that had been laid to the hydrant by E-10. The rest of Engine 1’s crew grabbed tools and an extension ladder and reported to the Charlie side of the building.
Personnel stated that at this point fire conditions seemed to improve, suggesting that crews were making progress extinguishing the fire. (The first arriving attack crew reported that they were able to see apparatus lights through the sliding doors on Charlie side, which indicated to them that smoke and fire conditions were improving.)
Truck 1, a tiller unit staffed by a Lieutenant, two Driver/Operators, and a Firefighter, arrived on side Alpha and immediately began search and rescue operations. Windows on the second floor Alpha/Delta side apartment (Apt. A-2) were vented and ladders were thrown to gain access. T-8 arrived at the alley on side Charlie. E-1 extended a ground ladder to the third floor balcony on the Charlie/Bravo side of the structure (Apt. B-1), and made access to the apartment to search for additional victims.
They noted fire venting from the first floor Charlie/Delta apartment (Apt. T-2) out of the sliding glass doors progressing upwards towards the balcony on the second floor. Upon entering the apartment, they conducted a primary search and noted minimal heat with light smoke conditions.
The crew accessed the hallway via the apartment entry door and noticed an increase in the temperature and the amount of smoke.
They immediately closed the door and exited the apartment via the ground ladder.
Upon exiting the apartment, E-1’s crew observed E-292 on the scene with a hand line extending into the apartment of origin, (first floor, Charlie/Delta side, Apt. T-2). The officer on E-1 noted white smoke coming from the unit.
Having already laid a supply line from the intersection of the alley and Deanwood Road, E-292’s crew extended a 1 ¾” hand line into the apartment of origin. Moderate fire conditions with zero visibility were encountered, and they reported feeling a great deal of heat on their knees as they crawled through the apartment.
The Lieutenant and the Firefighter from Truck-1 entered Apartment A-2 via a second floor bedroom window (Alpha/Delta side) and began a search for additional victims. As they traversed the living room area they found an unconscious male resident (victim #2). At 1836 hours, the Lieutenant notified Command via an urgent transmission that a victim had been located and they needed assistance with evacuation. The Lieutenant and Firefighter noted a small fire in the rear corner near the victim as they exited the room. The crew returned to the bedroom from which they had entered and closed the door behind them. Victim #2 was then evacuated from the apartment via a ground ladder through the bedroom window, and transferred to EMS personnel on side Alpha.
Preflashover conditions Alpha Side 18:37 hours
At 1831 hours, Squad 303, a unit staffed by a Driver/Operator, Firefighter Falkenhan (acting Officer in Charge), and 3 other Firefighters had arrived at the Alpha side of the building. Firefighter Falkenhan and two crew members grabbed their tools and immediately entered the building. One Firefighter (Firefighter #1) proceeded to the terrace floor apartment to assist crews with fire attack. Firefighter Falkenhan and the other Firefighter (Firefighter #2) proceeded to the second floor
Bravo side apartment (Apt. A-1) to search for additional victims. They forced the door to the second floor apartment and conducted their search. Finding no one, they reported to Command that they had encountered high heat in the apartment and at 1838 hours, inquired as to which apartment victim #2 had been found. Firefighter Falkenhan advised Command that he and his fellow Firefighter were proceeding to the third floor to continue their search.
At 1840 hours, Battalion Chief 11 (BC-11) arrived on the scene, performed a face-to-face pass on with the Captain on Engine 11, and assumed Command. BC-11 initially observed limited smoke conditions, indicating to him that crews had made progress in extinguishing the fire.
18:41 hours
Meanwhile, the Lieutenant and Firefighter from T-8 entered the second floor apartment that S-303 had just searched (Apt. A-1, second floor, Bravo side). They proceeded through the apartment and went across the hallway to Apartment A-2 where Truck-1 had just made their rescue (second floor, Delta side).
The Lieutenant noted smoky conditions, and saw that the sliding doors to the rear of the apartment were open, and saw a small fire in the rear of the apartment to the left of the open doors. On their way back to their point of entry, T-8’s crew discovered an unconscious female victim (victim #3). At 1837 hours, T-8 attempted to reach Command via radio and was covered by inaudible radio traffic. Dispatch was able to receive the radio transmission from T-8, and advised Command that another victim had been located on the second floor.
At this point, the crew from S-303 had completed their search of the third floor Bravo side apartment (Apt. B-1).
Firefighter Falkenhan and Firefighter #2 were able to look out of the sliding doors on side Charlie down to the first floor apartment, Apt. T-2 (Charlie/Delta side) and could see fire.
Smoke conditions on the third floor were light enough to walk upright in a somewhat crouched position.
The crew returned to the hallway, forced open the door to the third floor Charlie/Delta side apartment, Apt. B-2, and made entry.
Firefighter #2 walked down the hallway to the bedroom on the right while Firefighter Falkenhan searched to the left. After checking the bedroom, Firefighter #2 stated that he heard something behind him and turned to see fire in the hallway.
As the crew from S-303 searched the third floor Delta side apartment (Apt. B-2), The Lieutenant and Firefighter from T-8 were attempting to remove victim #3 from the second floor Delta side apartment (Apt. A-2). As they prepared to move their patient, fire conditions changed suddenly.
The Lieutenant from T-8 observed fire, “…rolling over our heads and out of the apartment door.” An immediate increase in heat conditions was noted. Upon exiting the apartment, T-8’s crew described a “tunnel of fire” coming out of the apartment and into the hallway. At 1841 hours, a radio transmission was made by an unknown source that heavy fire was observed in the hallway through a window at the stairwell landing.
At the same time, (1841) one minute after his arrival, Battalion Chief-11 (Command) noted heavy black smoke coming from the building and observed a “flash” through a second floor window. Command immediately ordered an evacuation of the building. Dispatch sounded the evacuation tones over the radio, and repeated the order to evacuate. Engines on the scene sounded their air horns to indicate that the order to evacuate had been given.
Firefighter #2 from S-303 reported hearing the engines on the fire ground sound their air horns, indicating to him that he needed to leave the building. Smoke conditions in the apartment had changed to thick black smoke, and the fire intensified, blocking his means of egress from the bedroom.
Realizing that he needed to get out of the apartment quickly, Firefighter#2 crawled to a window on the Alpha side of the bedroom and signaled Firefighters below with his hand light to move a ladder to the window. Crews immediately moved the ladder, and at 1841, Firefighter#2 dove headfirst out of the window and down the ladder, where he was assisted by crews working on the exterior of the building.
At 1841, Firefighter Falkenhan declared, “Emergency” on his radio, and repeated the same seven seconds later.
Command immediately queried S-303 for his location and the transmission “I’m down to the floor, heavy fire” was heard. At 1842 hours, Dispatch sounded emergency tones and restricted the Talkgroup to communications only between S-303 and Command.
Seconds later Firefighter Falkenhan again keyed up his portable radio and advised “…trapped on the 3rd floor, heavy fire on the Alpha/Bravo.”
Fourteen seconds later he advised “I hear crew members, the third, MAYDAY, MAYDAY, MAYDAY.”
Command notified Dispatch, “We have a MAYDAY” and was interrupted by a transmission from Firefighter Falkenhan, “urgent.”
Command made several attempts to contact Falkenhan to ascertain his location and determine resources needed (Location Unit Name Assignment Resources) for rescue.
Upon hearing the MAYDAY, crews on side Charlie threw multiple ladders to the third floor balcony to assist with rescue.
Heavy heat, smoke, and fire conditions made rescue difficult, but Firefighter Falkenhan was located and removed from the apartment via the balcony to the extended aerial ladder from T-8. He was unconscious and unresponsive at this time. Resuscitative efforts began immediately upon removal from the balcony, and continued enroute to the hospital. Firefighter Falkenhan succumbed to his injuries and was pronounced deceased at the hospital.
Consolidated List of Recommendations
Crew Integrity
1. Company officers shall ensure that crew integrity is maintained at all times by all personnel operating in an IDLH environment. 2. No personnel shall operate in an IDLH environment without a portable radio.
MAYDAY
1. If possible, the firefighter should activate his/her Emergency button on the portable radio. 2. Once personnel have called a MAYDAY and provided the information needed (LUNAR), they will activate their PASS Device manually and intermittently.
Incident Command
1. Tactical Operations Manual 07 allows Incident Commanders the flexibility to adapt to fast-moving and complex incidents. When re-assuming command, the IC must be identified (verbally through Fire Dispatch) to allow units involved and responding to know who is in command.
2. Incident Commanders must understand that an early initial 360° would give the IC the information needed to develop effective strategy and tactics for incident mitigation.
3. Additional arriving units must give the IC an updated report on fire conditions when noticeably different than those announced in the Brief Initial Report.
4. Arriving units should prompt the IC to assign them supervision of a division when conditions warrant such action.
5. The IC must ensure that all division and group supervisors are properly deployed and verbalize same on the radio for Dispatch and units involved on the incident.
6. Reinforce the importance of the ICS and its functional components for all officers.
7. Ensure a manageable span-of-control is maintained throughout the incident.
8. Evaluate the efficiency of command and control as incidents escalate.
9. A Rapid Intervention Team is a vitally important part of the ICS and its assignment should not be overlooked.
Strategy and Tactics
1. Use caution when passing a hydrant that is in your direction of travel and close to the fire building in an attempt to get a closer one.
2. Consider having the initial backup line proceeding into the same point of entry as the initial crew operating in the IDLH environment. Doing this allows for the line to also aid in protecting the common stairwell (i.e. fire extension/protection for egress). Deploy a third line if needed into another point of access.
3. Consider dialing nozzles up to higher gallons per minute for large structures such as apartment buildings.
4. Consider utilizing a 2-1/2″ attack line for fire attack.
5. The current SOP should be modified to state that when the initial Incident Commander feels that the incident has stabilized to a point where there is no longer a need for him/her to be directly involved with incident operations, a notification through Dispatch shall be made to inform crews on and en route to the scene.
6. The Department should develop training to ensure that Incident Commanders relay changes in modes of operations.
7. Consider attacking fires from other sides of the structure that are on grade.
8. Consider the use of “door control” for protection during search and rescue and exposure protection
9. When deviations to initial orders are made, they must be communicated to Command.
10. IC should consider setting up a division supervisor with the first arriving officer to balance his/her span-of-control early into the incident.
11. Command should initiate group and division supervisors early into an incident and use them to reduce his/her span-of-control. Communicate Conditions, Actions, Needs (CAN) reports early and often.
12. When units are the initial crews deployed to a geographic location, consideration should be given to “prompt” Command to make them a division supervisor (in the absence of direction from Command).
13. Units should request resources, or supply their own as necessary to support the operations that they are undertaking.
14. When given a division assignment, “step back” to take in the overall picture and communicate progress reports to Command.
15. Be clear and concise when setting up division assignments.
16. Utilize the division supervisors for incident operations once assigned.
17. Training on effective use of interior doors to control fire spread should be promoted throughout the department.
18. Consider removing common stairwell windows earlier in fire ground operations when appropriate.
19. While performing operations above the fire, notify Command of changing conditions and immediately request resources to support your function.
20. Set up a command post as early as possible to aid in deploying and accounting for resources as they arrive on the fire ground.
21. Notify Command when entering an IDLH.
22. Request resources to support functions.
23. Set up divisions and groups early to aid in managing the strategic priorities.
24. Be clear in communicating strategy and tactics to companies involved in operations.
25. Command should make it a priority to deploy attack lines on all floors to support the operations of crews working in the area.
Communications
1. A rubberized cover for the radio speaker microphone should be tested by communications and field personnel. This device will cover the push-to-talk (PTT) button and will increase the pressure required for activation. If proved effective, this cover will decrease the likelihood of an accidental activation of the PTT button during vigorous fire ground activity.
2. Continuing study should occur to evaluate methods to control inadvertent radio interference from all units (on the scene, responding, or monitoring) during incident operations. Review PTT logs to identify sources of communications interference.
3. As a result of the investigation, PTT log files will now be saved for 25 days.
4. Fire Communications and field personnel will develop and distribute a mandatory training program outlining proper radio procedures including the importance of radio discipline, MAYDAY procedures, and the procedure for establishing a Command restricted talk group during critical operations.
5. All personnel engaged in operations in an environment immediately dangerous to life and health shall carry a portable radio.
6. The aforementioned mandatory training program shall stress the importance of giving regular updates to Command regarding the extent and location of the fire and other pertinent information.
Here are five (5) NIOSH Firefighter LODD Event report summaries for incidents that occurred in the March 4th through the 8th time frame in the years 1998, 2001, 2002, 2008.
Take the time to look over the event summaries, discuss and comment on the factors that lead to the events and the recommendations formulated from the subsequent investigations.
Take the opportunity to identify the common themes and apparent causes that were identified and discuss with your company, team or station, relevant considerations that may have a direct or indirect relationship to your organization, past incident calls or district risk profile.
What are your capabilities?
What are your gaps?
How can you prevent a similar situation from occurring?
Promote questions and dialog related to operational issues such as these;
Coordinated multi-company operations; how “coordinated” is your incident scene?
Do rapidly changing incident conditions get identified promptly and communicated to Command in rapid succession for actions?
How effective is the base line knowledge and skill set of company and command officers in “reading the building”?
What is the adequacy of your training for conducting operations above the fire floor?
When was the last time you “tested” the effectiveness of your RIT/FAST Team? Can they truly perform under the most demanding of incident conditions?
When was the last time you trained or drilled on Fire Behavior or on Building Construction?
Are you training on calling the mayday and personal survival techniques?
Have you implemented and trained on procedures for rapid and efficient transition in operational modes on the fireground?
Do you implement a 360 when applicable?
Down load the complete NIOSH Reports and expand on the lessons learners and their applicably to your organization and capabilities.
Manlius, New Yrok
Floor Collapse and Fire Conditions: On March 7, 2002, a 28-year-old male volunteer fire fighter and a 41-year-old male career fire fighter died after becoming trapped in the basement. One firefighter manned the nozzle while second firefighter provided backup on the handline as they entered the house. After entering the structure, the floor collapsed, trapping both victims in the basement.
A career fire fighter captain joining the fire fighters near the time of the collapse was injured trying to rescue one of the fire fighters. Crew members responded immediately and attempted to rescue the victims; however, the heat and flames overcame both victims and eliminated any rescue efforts from the garage entrance.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should;
Ensure that the Incident Commander is clearly identified as the only individual responsible for the overall coordination and direction of all activities at an incident
Ensure that the Incident Commander conveys strategic decisions to all suppression crews on the fireground and continually reevaluates the fire condition
Ensure that Incident Command conducts an initial size-up of the incident before initiating fire fighting efforts and continually evaluates the risk versus gain during operations at an incident
Ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts
Ensure that fire fighters report conditions and hazards encountered to their team leader or Incident Commander
Ensure fire fighters are trained to recognize the danger of operating above a fire
Wall Collapse and Fire Conditions On March 7, 2008, two male career fire fighters, aged 40 and 19 were killed when they were trapped by rapidly deteriorating fire conditions inside a millwork facility in North Carolina. The captain of the hose line crew was also injured, receiving serious burn injuries.
The victims were members of a crew of four fire fighters operating a hose line protecting a firewall in an attempt to contain the fire to the burning office area and keep it from spreading into the production and warehouse areas. The captain attempted to radio for assistance as the conditions deteriorated but fire fighters on the outside did not initially hear his Mayday. Once it was realized that the crew was in trouble, multiple rescue attempts were made into the burning warehouse in an effort to reach the trapped crew as conditions deteriorated further.
Three members of a rapid intervention team (RIT) were hurt rescuing the injured captain. One firefighter was located and removed during the fifth rescue attempt. The second firefighter could not be reached until the fire was brought under control.
The fourth crew member had safely exited the burning warehouse prior to the deteriorating conditions that trapped his fellow crew members. Key contributing factors identified in this investigation include radio communication problems (unintelligible transmissions in and out of the fire structure that may have led to misunderstanding of operational fireground communications), inadequate size up and incomplete pre-plan information, a deep-seated fire burning within the floor of the office area that was able to spread into the production and warehouse facility, the procedures used in which operational modes were repeatedly changed from offensive to defensive, lack of crew integrity at a critical moment in the event, and weather which restricted fireground visibility.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should:
Ensure that detailed pre-incident plan information is collected and available when needed, especially in high risk structures
Limit interior offensive operations in well-involved structures that are not equipped with sprinkler systems and where there are no known civilians in need of rescue
Develop, implement, and enforce clear procedures for operational modes. Changes in modes must be coordinated between the Incident Command, the command staff and fire fighters
Ensure that Rapid Intervention Crews (RIC) / Rapid Intervention Teams (RIT) have at least one charged hose line in place before entering hazardous environments for rescue operations
Ensure that the incident commander establishes the incident command post in an area that provides a good visual view of the fire building and enhances overall fireground communication
Ensure that crew integrity is maintained during fire suppression operations
Encourage local building code authorities to adopt code requirements for automatic protection (sprinkler) systems in buildings with heavy fire loads.
Floor Collapses in Residential Fire - North Carolina
Floor Collapse On March 4, 2002, a 22-year-old male career fire fighter was injured and subsequently died and a 25-year-old male Captain was injured when the floor collapsed while they were fighting a residential fire.
The Captain was transported by ambulance to an area hospital where he was admitted overnight for first- and second-degree burns. The victim was conscious and was transported by medical helicopter to a State medical center where he died 2 days later.
NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should;
Ensure that each Incident Commander conducts a size-up of the incident before initiating fire-fighting efforts, after command is transferred, and continually evaluates the risk versus gain during operations at an incident
Ensure fire fighters are trained to recognize the dangers of searching above a fire
Ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed
Ensure that ventilation is closely coordinated with fire attack
Ensure that a Rapid Intervention Team is established and in position immediately upon arrival
Ensure that adequate numbers of staff are available to operate safely and effectively
Fall Through Floor Fighting a Structure Fire at a Local Residence - Ohio
Floor Collapse On March 8, 2001, a 38-year-old male career fire fighter fell through the floor while fighting a structure fire, and died 12 days later from his injuries. At 1231 hours, Central Dispatch notified the career department of a structure fire with reports of the occupants still inside. The Assistant Chief arrived on the scene along with Engine 70 and assumed Incident Command (IC).
The IC immediately called for the second alarm, began conducting the initial size-up of the structure, and confirmed heavy fire in the left front section. At that time, the neighbors approached the IC and informed him that the occupants were trapped inside. The IC ordered the fire fighters on scene to commence search and rescue efforts, and then verified the stability of the structure through radio and face-to-face communications.
Engine 68 arrived on the scene at approximately 1250 hours with an Assistant Chief and the victim. The Assistant Chief provided tactical command of the fire ground, and along with the victim, conducted search and rescue operations. Other crews conducted searches with a thermal imaging camera of the first floor and basement level of the residence with no sign of any occupants. During these searches the stability of the structure was diminishing due to the intense fire that was now venting through the roof.
Fire fighter #3 and the victim were at the front entrance conducting a defensive attack as the third emergency evacuation signal was sounded. The neighbors were still insisting to the IC and fire fighters that the occupants were trapped inside, and one of the occupants was handicapped. The victim and one other fire fighter conducted another search of the structure.
The heat and flames were now extending from the basement level to the first floor when the fire fighter’s low air alarm sounded. The victim and the fire fighter were backing out of the structure when the floor beneath the victim gave way, causing him to fall through the floor and become trapped in the basement.
Attempts were made from the first floor to rescue the victim by utilizing a handline and an attic ladder, but they were unsuccessful due to the intense heat and flames. Two Rapid Intervention Teams (RIT #1 & RIT #2) were deployed simultaneously from separate entrances into the basement to perform a search and rescue operation for the downed fire fighter. The RITs were able to locate and remove the victim on their initial entry. He sustained third degree burns to over half of his body and died 12 days later.
NIOSH investigators concluded that to minimize the risk of similar occurrences, fire departments should;
Ensure that Incident Command continually evaluates the risk versus gain during operations at an incident
Ensure that a separate Incident Safety Officer independent from the Incident Commander is appointed
Ensure that fire fighters are trained in the tactics of defensive search
Ensure that fire fighters performing fire fighting operations under or above trusses are evacuated as soon as it is determined that the trusses are exposed to fire
Ensure consistent use of Personal Alert Safety System (PASS) devices at all incidents and consider providing fire fighters with a PASS integrated into their Self-Contained Breathing Apparatus which provides for automatic operation
Ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions
Roof Collapse and Fire Conditions On March 8, 1998, one male fire fighter, the Captain on Engine 57, died while trying to exit a commercial structure after his egress was cut off by the wooden trussed roof that collapsed. Task Force 66 was the first on scene and reported light smoke showing from a one-story commercial building. A ventilation team from Truck 66 proceeded to the roof of the building and commenced roof ventilation. Forcible entry into the building required about 7 ½ to 9 ½ minutes from arrival on scene to force open the two metal security doors in the front. While fire companies waited for the security doors to be opened, fire conditions changed dramatically on the roof.
Fire was coming from the ventilation holes opened by the ventilation crew. As soon as the security doors were opened, three engine crews (Engine 66, Engine 57, and Engine 46) advanced hand lines through the front door in an attempt to determine the origin of the fire. Approximately 15 feet inside the front door, the fire fighters encountered heavy smoke with near zero visibility conditions. The engine crews advanced their hose lines approximately 30 to 40 feet inside the building.
As conditions continued to deteriorate inside the building, the members from the four engine companies involved in the fire attack began to withdraw. During this time the victim became separated from his crew and remained in the building. The victim was subsequently located by the Rapid Intervention Team and cardiopulmonary resuscitation was performed immediately and en-route to the hospital, where the victim was pronounced dead.
NIOSH investigators conclude that, to prevent similar occurrences, fire departments should:
Ensure that incident command conducts an initial size up of the incident before initiating fire fighting efforts, and continually evaluate the risk versus gain during operation at an incident
Ensure that incident command always maintains close accountability for all personnel at the fire scene
Ensure communications are established between the interior and exterior attack crews, e.g., the ventilation crew and the interior fire attack crew should communicate conditions among themselves and back to incident command
Ensure that Rapid Intervention Teams are in place before conditions become unsafe
Ensure that some type of tone or alert that is recognized by all fire fighters be transmitted immediately when conditions become unsafe for fire fighters
Ensure sufficient personnel are available and properly functioning communications equipment are available to adequately support the volume of radio traffic at multiple-responder fire scenes
Consider placing a bright, narrow-beamed light at the entry portal to a structure to assist lost or disoriented fire fighters in emergency egress.
Stay tuned for upcoming announcements for the March 16th Taking it to the Streets Program on Firefighternetcast.com
Taking it to the Streets on Firefighternetcast.com
Taking it to the StreetsTM
Featuring a two part program on Near Miss Firefighter Reporting with Lt. Steve Mormino, FDNY (ret) and Capt. CJ Haberkorn, Denver (CO) Fire Department and joing us on the second part of the program will be special guest, Captain Michael Long, with a personal Near-Miss Event account you won’t want to miss.
Join in on the live open discussion with fire service personnel from around the country.
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
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