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Cortland Incident -SART-Report Final CORTLAND INCIDENT Multi - Agency Serious Accident Review Team S.A.R.T. Investigation Report Fresno Fire Department March 29, 2015 1310 E. Cortland Fresno, CA CA - FRN – 5017063 Multi – Agency Serious Accident Investigation Team Cortland Fire Final Report Fresno Fire Department March 29, 2015 CA – FRN – 5017063 Multi-Agency SART Members Tim Adams, Battalion Chief, Anaheim Fire and Rescue Butch Agosta, Captain, Kern County Fire Department Vince Bergland, Battalion Chief, CAL FIRE Fresno / Kings Unit Greg Casentini, Battalion Chief, Sacramento Metropolitan Fire District Brad Driscoll, Captain, Local 753 Representative Alan Ernst, Operations Division Chief, Modesto Fire Department Mike Kraus, Fire Chief, Retired, Modesto Fire Department Don Stukey, Battalion Chief, Retired, Los Angeles Fire Department Accident Review Technical Consultants NIOSH: National Personal Protective Technology Laboratory (NPPTL) Evaluation and Testing Branch / Policy and Standards Development Branch Morgantown Testing Team Initial Accident Investigation Team Captain Brad Driscoll, Fresno Fire Department Captain Brian Price, Fresno Fire Department Captain John Pepper, Fresno Fire Department Captain John Creasy, Fresno Fire Department Documentation Dumont Printing 2ÊUÊSERIOUS ACCIDENT INVESTIGATION REPORT Table of Contents Forward...................................................................................7 Acknowledgement of Fire Chiefs...............................................................11 Overview of Fresno Fire Department ...........................................................15 Executive Summary.........................................................................19 Site Information ...........................................................................25 Incident Overview .........................................................................31 Incident Timeline ..........................................................................43 Causal, Contributory, Non-Related Factors ......................................................49 Findings and Recommendations s#ULTUREAND3AFETY....................................................................53 s#OMMANDAND#ONTROL................................................................61 s4RAINING............................................................................71 s0ERSONAL0ROTECTIVE%QUIPMENT00% .....................................................94 s#OMMUNICATIONS....................................................................107 s-EDIA0)/ .......................................................................117 s-EDICAL ...........................................................................119 s)NVESTIGATION .......................................................................122 Serious Accident Review Team Process .........................................................125 Signatory Page............................................................................133 Appendices s!PPENDIX! ........................................................................137 s!PPENDIX" . .138 s!PPENDIX# ........................................................................144 s!PPENDIX$........................................................................203 s!PPENDIX% ........................................................................213 s!PPENDIX& ........................................................................214 s!PPENDIX'........................................................................240 s!PPENDIX(........................................................................264 s!PPENDIX).........................................................................266 s!PPENDIX*.........................................................................268 - ,"1-Ê /Ê 6 -//" Ê, *",/ÊUÊ3 4ÊUÊSERIOUS ACCIDENT INVESTIGATION REPORT FORWARD FORWARD The Cortland Incident Serious Accident Review Team (SART) would like to acknowledge the hard work and professionalism of the following entities: The preliminary accident investigation team: The initial actions on the Cortland Incident were conducted in a clear and systematic manner. This team produced a comprehensive factual document that was well organized and set the tone for the external SART to review and evaluate. Their tireless efforts were very apparent and displayed the passion and professionalism of the Fresno Fire Department. Fresno Fire Chief: In the aftermath of the accident, the Fire Chief had the courage and the wisdom to establish an outside SART to ensure a full, impartial investigation was conducted. She made it clear to the Team that we had the authority to investigate as thoroughly as necessary in order to identify any and all associated factors, with the full understanding that the process may be disruptive to the organization and uncomfortable for her. She, along with the SART, recognized the opportunity as well as the obligation to affect positive change within the Fresno Fire Department, and the American Fire Service. The Rescue Efforts at the Cortland Incident: It was apparent that several on scene members performed above and beyond in applying their skills during the extraction and rescue of the fire captain. It was the aggressive and immediate actions of the firefighters whom RECOGNIZEDANDENGAGEDINTHERECOVERYEFFORTSTHATALLOWEDAQUICKEXTRACTIONANDRAPIDTREATMENTOFTHElRE captain. The result was an effective rescue and the prevention of a Line-of-Duty-Death. The external Cortland SART honors your courage and effort with pride and appreciation. - ,"1-Ê /Ê 6 -//" Ê, *",/ÊUÊ7 8ÊUÊSERIOUS ACCIDENT INVESTIGATION REPORT ACKNOWLEDGEMENT OF FIRE CHIEFS ACKNOWLEDGEMENT OF FIRE CHIEFS Fresno Fire Department would like to thank and acknowledge the following Fire Chiefs for providing members of their fire departments to assist with the SART process for the Cortland Incident. Randy Bruegman Fire Chief Anaheim Fire & Rescue 201 South Anaheim Blvd. Anaheim, CA 92805 Mark A. Johnson Unit Chief CAL FIRE - Fresno/Kings Unit Fresno County Fire Protection District Brian S. Marshall Fire Chief & Director of Emergency Services Kern County Fire Department Bakersfield, CA 93308 Sean Slamon Fire Chief Modesto Fire Department 600 11th St. Modesto, CA 95354 Mark Wells Fire Chief Sacramento Metropolitan Fire District 10545 Armstrong Ave. Ste 200 Mather, CA 95655 - ,"1-Ê /Ê 6 -//" Ê, *",/ÊUÊ11 12ÊUÊSERIOUS ACCIDENT INVESTIGATION REPORT OVERVIEW OF FRESNO FIRE DEPARTMENT OVERVIEW OF FRESNO FIRE DEPARTMENT Overview The Fresno Fire Department (FFD) was established in 1877 and is one of the oldest fire departments in the United States. FFD provides fire prevention, suppression and investigation services, airport fire and rescue, urban search and rescue, response to medical emergencies (EMS), and response to hazardous materials incidents. The &&$SERVICEAREACONSISTSOFSQUAREMILESANDISCOMPRISEDOFTHE#ITYOF&RESNO ANDINCLUDESEXTRA TERRITORIAL services via contracts to provide services to two fire districts (Fig Garden Fire Protection District (FGFPD) and North Central Fire Protection District (NCFPD)), Fresno Yosemite International Airport, and surrounding areas THROUGHMUTUALAIDANDAUTOMATICAIDREQUESTS4HEREGIONSERVEDBY&&$INCLUDINGTHETWOCONTRACTDISTRICTS CONSISTSOFSQUAREMILESWITHINTHE#ITYOF&RESNO SQUAREMILESIN&IG'ARDEN&IRE0ROTECTION$ISTRICT SQUAREMILESIN.ORTH#ENTRAL&IRE0ROTECTION$ISTRICT ANDSQUAREMILESINTHE&RESNO#OUNTYCONTRACTAREA The Department’s service area includes a population of approximately 525,000 residents and encompasses college / university campuses, an international airport, farm land, and rural communities. FFD also occasionally provides services outside of its boundaries through several mutual aid agreements with other surrounding fire districts, including the City of Clovis, and honors the automatic aid agreement between Fresno County FPD and NCFPD. FFD responds to wildland fires and gets reimbursed from the State for strike team assignments and incidents outside its jurisdiction. Staffing Fresno Fire Department’s 24 stations are divided into three battalions—two within the City and one that covers NCFPD. The Department has 313 authorized sworn safety positions, with 293 filled. Additionally, there are 15 sworn non-safety authorized positions, with 14 filled. Daily FFD sworn firefighter staffing within the City of Fresno and the FGFPD (an island in the middle of the City) consists of 73 members. The FFD staffing for the NCFPD is ANADDITIONALMEMBERS FORATOTALOF&&$MEMBERSONDUTYEACHDAY COVERINGSQUAREMILES3PECIALIZED teams within FFD include Urban Search and Rescue (USAR), Aircraft Rescue and Fire Fighting (ARFF), Hazardous Materials Response Team (HMRT), and a Communication Team. The FFD USAR Team provides special rescue operations for the City of Fresno and within Region 5 of the California Emergency Management Agency (CalEMA). Certified as a Type-1 Heavy Rescue and Type-1 Water / Flood rescue resource, the District’s USAR team members hold the following certifications: Rescue Systems 1, Rescue Systems 2, Low Angle Rescue, Confined Space Operations, Trench Rescue, Swiftwater Rescue Unit-1, Swiftwater Rescue Advanced, Swiftwater Rescue Boat Operator, Basic SCUBA, Public Safety SCUBA, and Supplied Air Diving Operations. Nineteen members of FFD hold Fire Control 5 certifications and comprise the District’s ARFF team, which is located at the Department’s Station No. 24. The ARFF Team provides services for airport emergency response, hazardous materials incidents, first responder calls, and all structure fires within the Fresno Yosemite
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