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 4^th, 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

• WLTW.com Previous Stories:
• November 18, 2009: Firefighter’s Parents File Wrongful Death Suit
• August 8, 2009: Report On Fatal Colerain Twp. Fire Released
• April 3, 2009: Service Planned For Anniversary Of Firefighter’s Death
• July 11, 2008: Report On Fire That Killed Firefighters Released
• June 28, 2008: Firefighters Hold Benefit For Fallen Friends
• June 12, 2008: Owner Of Home Where 2 Firefighters Died Sentenced On Pot Charges
• May 21, 2008: Firefighter Recalls Fiancee Killed In Colerain Twp. Fire
• May 13, 2008: Burned Home’s Owner Pleads No Contest To Drug Charge
• May 6, 2008: Tri-State Residents Reach Out To Families Of Fallen Firefighters
• April 20, 2008: Deaths Of Firefighters Lead To New Proposed Regulations
• April 18, 2008: Fatal Fire Home’s Owner Indicted On Drug Charge
• April 14, 2008: Prosecutor: Homeowners Won’t Be Charged In Firefighters’ Deaths
• April 11, 2008: Coroner: Fire, Smoke, Heated Air Killed Firefighters
• April 11, 2008: Firefighters Make Emotional Return To Work
• April 10, 2008: Fallen Firefighters Memorialized By Comrades, Family
• April 9, 2008: Sources: Marijuana Growing Operation Found In Burned Home
• April 9, 2008: Firefighters At Visitation For Fallen Comrades Called To Fight Fire
• April 9, 2008: Thousands Attend Colerain Firefighters’ Visitation
• April 8, 2008: Firefighters Pour In, Pay Tribute To Two Of Their Own
• April 8, 2008: Sources: ‘Hidden’ Marijuana Grow Room Found At Fatal Fire Scene
• April 8, 2008: Officials Adjust Fallen Firefighters’ Funeral Procession Plans
• April 8, 2008: Candlelight Vigil Held For Fallen Firefighters
• April 7, 2008: Sources: Plant Containers, Grow Room Found In Burned Home
• April 7, 2008: Blaze That Killed Firefighters Ruled Accidental
• April 7, 2008: Families Of Firefighters Thank Community For Support
• April 7, 2008: Candlelight Vigil Planned For Two Fallen Firefighters