Technical Committee on Fire Service Training (FIY-AAA)
NFPA 13E, 1405, 1407, 1408, and 1410 Second Draft Meeting February 5th - 7th, 2019 Orlando, FL
AGENDA
1. Call to Order- Kenneth Richards
2. Introductions and Attendance
3. Review/Accept previous meetings minutes
4. NFPA Update-Ken H.
5. Task group reports, if any
6. Address submitted public comments and develop any second revisions
7. Next Meeting
8. Old Business/New Business
9. Adjourn Meeting
NFPA 13E, 1405, 1407, 1408, and 1410 Second Draft Meeting Agenda
Address List No Phone 01/17/2019 Ed Conlin Fire Service Training FIY-AAA
Kenneth W. Richards, Jr. E 1/10/2002 Colin Samuel Aguilar L 08/17/2017 Chair FIY-AAA Principal FIY-AAA Old Mystic Fire Department Jacksonville Fire & Rescue Reliance Fire Company No. 1 1103 Hamlet Court 295 Cow Hill Road Neptune Beach, FL 32266 Mystic, CT 06355 International Association of Fire Fighters Alternate: Jonathan Carroll
Wesley E. Barbour SE 3/1/2011 David M. Britton E 10/23/2013 Principal FIY-AAA Principal FIY-AAA CrossBar International LLC Hilton Head Island Fire & Rescue 1911 11th Street, Suite 301 50 Fernbank Avenue Boulder, CO 80302-5123 Bluffton, SC 29910
W. Edward Buchanan, Jr. E 10/27/2005 James R. Cannell L 10/29/2012 Principal FIY-AAA Principal FIY-AAA Hanover Fire EMS Department Columbus Ohio Division of Fire Hanover Courthouse 5812 Plantation Road 13326 Hanover Courthouse Road Sunbury, OH 43074-9412 PO Box 470 Columbus Firefighters Union Hanover, VA 23069 Alternate: Chris H. Hubbard
Derrick S. Clouston E 08/09/2012 Rick Egelin M 3/4/2009 Principal FIY-AAA Principal FIY-AAA North Carolina Department of Insurance Fireblast Global Office of the State Fire Marshal 545 Monica Circle 1202 Mail Service Center Corona, CA 92880-5447 Raleigh, NC 27699-1202 Alternate: Jonathan J. Hanson Alternate: Brian A. Wade
Mike Gagliano E 07/29/2013 William E. Glover M 4/28/2000 Principal FIY-AAA Principal FIY-AAA Seattle Fire Department High Temperature Linings (HTL) 18508 75th Avenue NW PO Box 1240 Stanwood, WA 98292 White Stone, VA 22578
Forest Herndon, Jr. SE 04/05/2016 James Keiken U 11/30/2016 Principal FIY-AAA Principal FIY-AAA Maritime Emergency Response Educators LLC Illinois Fire Service Institute 137 Somerset Drive 11 Gerty Drive Willingboro, NJ 08046 Champaign, IL 61820 Alternate: Roger Lunt
Roger M. LeBoeuf SE 7/20/2000 Gordon L. Lohmeyer U 03/05/2012 Principal FIY-AAA Principal FIY-AAA Elliott, LeBoeuf & McElwain Texas A&M Engineering Extension Service 8001 Forbes Place, Suite 201 200 Technology Way Springfield, VA 22151 College Station, TX 77845-3424 Alternate: Jeremy D. Jones Alternate: Howard Meek
1 Address List No Phone 01/17/2019 Ed Conlin Fire Service Training FIY-AAA
Daniel Madrzykowski RT 7/23/2008 F. Patrick Marlatt E 1/10/2008 Principal FIY-AAA Principal FIY-AAA UL Firefighter Safety Research Institute Maryland Fire and Rescue Institute 6200 Dobbin Lane University of Maryland Gaithersburg, MD 20882 4500 Campus Dr. Building 199 Alternate: Keith Myers Stakes College Park, MD 20742-6811
Douglas J. Mitchell, Jr. U 8/9/2011 Jeffrey J. Morrissette M 10/28/2014 Principal FIY-AAA Principal FIY-AAA Fire Department City of New York State of Connecticut 12 Jackson Lane Commission on Fire Prevention & Control Campbell Hall, NY 10916-3212 Connecticut Fire Academy Fire Department City of New York 34 Perimeter Road Windsor Locks, CT 06096-1069 International Fire Service Training Association Alternate: Michael A. Wieder
Kevin Munson, Jr. U 08/05/2009 Brent Norwine U 3/1/2011 Principal FIY-AAA Principal FIY-AAA East Hartford Fire Department CAL-FIRE/Riverside County Fire Department 45 Forest Lane 46990 Jackson Street Canton, CT 06019 Indio, CA 92201-6042 Alternate: Roland Fredrickson
William E. Peterson SE 1/1/1977 Ryan N. Pietzsch I 04/08/2015 Principal FIY-AAA Principal FIY-AAA 2601 Swoop Circle Volunteer Firemen's Insurance Services, Inc. Kissimmee, FL 34741 183 Leader Heights Road International Fire Marshals Association York, PA 17405 Alternate: Steve Brisebois Alternate: William F. Jenaway
Robert E. Raheb SE 8/9/2011 Daniel N. Rossos E 04/05/2001 Principal FIY-AAA Principal FIY-AAA FAAC, Inc. Oregon Department of Public Safety Standards & Training 59 Meadow Ponds Circle 40640 SE George Road Miller Place, NY 11764-3804 Estacada, OR 97023-8731
Mark A. Rutherford U 08/09/2012 Daniel D. Shaw U 10/28/2008 Principal FIY-AAA Principal FIY-AAA Gastonia Fire Department Fairfax County Fire and Rescue Department 260 North Myrtle School Road 6 Forest Drive Gastonia, NC 28052-1258 Catonsville, MD 21228
Robert Upson M 04/04/2017 Steven H. Weinstein M 07/29/2013 Principal FIY-AAA Principal FIY-AAA National Fire Sprinkler Association Honeywell Safety Products 514 Progress Drive, Suite A 3001 South Susan Street Linthicum Heights, MD 21090 Santa Ana, CA 92704-6434 National Fire Sprinkler Association Alternate: Terin Hopkins
2 Address List No Phone 01/17/2019 Ed Conlin Fire Service Training FIY-AAA
Steven J. Williamson M 4/1/1995 Corey Wilson E 03/05/2012 Principal FIY-AAA Principal FIY-AAA KFT Fire Trainer, LLC Portland Fire & Rescue 17 Philips Parkway 3296 Nomie Way Montvale, NJ 07645-1810 West Linn, OR 97068 Alternate: Obed Rios
Frank Jansen M 08/17/2015 Denis G. Onieal SE 1/15/2004 Voting Alternate FIY-AAA Voting Alternate FIY-AAA Haagen Fire Training Products/Bullex US Department of Homeland Security Indstrieweg 5 US Fire Administration Baarle Nassau 16825 South Seton Avenue Noord Brabant, 5111ND The Netherlands Emmitsburg, MD 21727
Steve Brisebois SE 12/08/2015 Jonathan Carroll L 08/17/2017 Alternate FIY-AAA Alternate FIY-AAA Flash Formation Cleveland Fire Department 16615 Rue Jade 370 Keystone Drive Mirabel, QC J7N 0J7 Canada Cleveland, TN 37312 International Fire Marshals Association International Association of Fire Fighters Principal: William E. Peterson Principal: Colin Samuel Aguilar
Roland Fredrickson U 10/29/2012 Jonathan J. Hanson M 08/11/2014 Alternate FIY-AAA Alternate FIY-AAA City of Corona Fire Department Fireblast Global 735 Public Safety Way 45 Elm Street Corona, CA 92880-2005 New Providence, NJ 07974 Principal: Brent Norwine Principal: Rick Egelin
Terin Hopkins M 12/07/2018 Chris H. Hubbard U 08/09/2012 Alternate FIY-AAA Alternate FIY-AAA National Fire Sprinkler Association (NFSA) Hanover Fire EMS Department 514 Progress Drive, Suite A 13326 Hanover Courthouse Road Linthicum Heights, MD 21090 PO Box 470 Principal: Robert Upson Hanover, VA 23069 Principal: W. Edward Buchanan, Jr.
William F. Jenaway I 11/2/2006 Jeremy D. Jones SE 10/29/2012 Alternate FIY-AAA Alternate FIY-AAA Volunteer Firemen’s Insurance Services, Inc. Elliott, Leboeuf & McElwain 102 Hunters Run Road 424 Manor Street King of Prussia, PA 19406 Ephrata, PA 17522 Principal: Ryan N. Pietzsch Principal: Roger M. LeBoeuf
Roger Lunt U 04/08/2015 Howard Meek U 08/11/2014 Alternate FIY-AAA Alternate FIY-AAA University of Illinois Fire Service Institute Texas A&M Engineering Extension Service 11 Gerty Drive 200 Technology Way Champaign, IL 61820-7404 College Station, TX 77845-3424 Principal: James Keiken Principal: Gordon L. Lohmeyer
3 Address List No Phone 01/17/2019 Ed Conlin Fire Service Training FIY-AAA
Obed Rios M 08/17/2015 Keith Myers Stakes RT 8/17/2015 Alternate FIY-AAA Alternate FIY-AAA KFT Fire Trainer, LLC Underwriters Laboratories 17 Philips Parkway 6200 Old Dobbin Lane, Suite 150 Montvale, NJ 07645 Columbia, MD 21045 Principal: Steven J. Williamson Principal: Daniel Madrzykowski
Brian A. Wade E 08/17/2018 Michael A. Wieder M 10/4/2001 Alternate FIY-AAA Alternate FIY-AAA North Carolina State Fire Marshal’s Office Fire Protection Publications 1202 Mail Service Center Oklahoma State University Raleigh, NC 27699-1202 930 North Willis Street Principal: Derrick S. Clouston Stillwater, OK 74078-8045 International Fire Service Training Association Principal: Jeffrey J. Morrissette Voting Alt. to IFSTA Rep.
Ed Conlin 12/13/2018 Robert Fash 10/24/2016 Staff Liaison FIY-AAA Co-Staff Liaison FIY-AAA National Fire Protection Association National Fire Protection Association One Batterymarch Park One Batterymarch Park Quincy, MA 02169-7471 Quincy, MA 02169-7471
4 Technical Committee on Fire Service Training
NFPA 13E, 1405, 1407, 1408 and 1410
First Draft Meeting Minutes
March 20, 2018
Embassy Suites Hotel, Kansas City, MO
The meeting was called to order by Chair Richards at 8:00am Central time.
Introductions of attendees:
Principal Members:
1. Kenneth Richards; Old Mystic (CT) Fire Department (Chair) 2. Derrick Clouston; North Carolina Department of Insurance 3. William Glover; High Temperature Linings 4. James Keiken; Illinois Fire Service Institute 5. Roger LeBoeuf; Ellition, LeBoeuf & McElwain 6. Gordon Lohmeyer; Texas A&M Engineering Extension Service 7. Daniel Madrzykowski; UL Firefighter Safety Research Institute 8. Douglas Mitchell; Fire Department City of New York 9. Jeffery Morrissette; Connecticut Fire Academy 10. Brent Norwine; CAL-FIRE/Riverside County Fire Department 11. William Peterson; International Fire Marshal’s Association 12. Robert Raheb; FAAC, Inc 13. Daniel Rossos; Oregon Department of Public Safety 14. Daniel Shaw, Fairfax County (MD) Fire and Rescue 15. Robert Upson; National Fire Sprinkler Association 16. Steven Williamson; KFT Fire Trainer, LLC 17. Corey Wilson; Portland (OR) Fire & Rescue
Voting Alternate:
18. Chris Hubbard; Hanover (VA) Fire EMS Department
Alternates:
19. Steve Brisebois; Flash Formation 20. Jonathan Carroll; Cleveland (TN) Fire Department 21. Roland Frederickson, City of Corona (CA) Fire Department 22. Howard Meek; Texas A&M Engineering Extension Service
NFPA Staff Liaisons: Robert Fash, NFPA Jeremy Souza, NFPA
Members Not Present:
Colin Aguilar; Jacksonville (FL) Fire Department Wesley Barbour; CrossBar International LLC David Britton; Hilton Head (SC) Fire and Rescue W. Edward Buchanan; Hanover (VA) Fire EMS Department James Cannell; Columbus (OH) Division of Fire Rick Egelin; Fireblast Global Mike Gagliano; Seattle (WA) Fire Department Forest Herndon; Maritime Emergency Response Educators F. Patrick Marlatt; Maryland Fire and Rescue Institute Kevin Munson; West Hartford (CT) Fire Department Ryan Pietzsch; Volunteer Firemen’s Insurance Services, Inc. Mark Rutherford; Gastonia (NC) Fire Department Gary Simpson; E.D. Bullard Company Steven Weinstein; Honeywell Safety Products Frank Jansen; Haagen Fire Training Products Denis Onieal, US Department of Homeland Security Jonathan Hanson; Fireblast Global William Jenaway, Volunteer Firemen’s Insurance Services, Inc. Jeremy Jones; Elliott, LeBoeuf & McElwain Roger Lunt; University of Illinois Fire Service Institute Obed Rios; KFT Fire Trainer, LLC Tony Robinson; North Carolina Department of Insurance Keith Myers Stakes; Underwriters Laboratories Michael Wieder; Fire Protection Publications
Chair Richards made opening remarks including various updates on Committee members.
The phone connection with Global Meetings was unavailable due to problems with the hotel telephone line.
The minutes of the previous meeting of February 25-27, 2014 were reviewed and approved with one abstention (Jeffery Morrissette).
The NFPA staff liaison report was presented by Jeremy Souza.
Roger LeBeouf presented on progress made on NFPA 1402 and coordination between it and NFPA 1403. A request for new documents for technical rescue training and hazardous materials training may also be forthcoming.
Dan Rossos presented on challenges encountered with a NITMAM to NFPA 1981 and its impact to Assistance to Firefighters Grant (AFG) funding, as well as correlating between various NFPA documents. Chair Richards discussed the recent addition of Live Fire Instructor and Live Fire Instructor In Charge to NFPA 1041.
A recess was called by Chair Richards at 9:40.
The meeting was reconvened at 10:08 by Chair Richards.
Public inputs for NFPA 13E were reviewed and resolved.
The committee recessed at 11:50am for lunch.
The meeting reconvened at 1:10pm to continue reviewing public inputs for NFPA 13E.
The review of Public Inputs was completed at 2:15pm.
A recess was called by the Chair at 2:30pm.
The meeting reconvened at 2:40pm. Task groups were reviewed and reassigned as:
NFPA 13E, Recommended Practice for Fire Department Operations in Properties Protected by Sprinkler and Standpipe Systems Fall 2019 cycle – PI closed January 4, 2018 NFPA 1404, Standard for Fire Service Bob Upson, Leader Respiratory Protection Training Dan Madrzykowski Fall 2021 cycle - PI closes January 9, 2020 Pat Marlatt Dan Rossos, Leader Dan Rossos Eddie Buchanan Corey Wilson Jim Keiken Kevin Munson NFPA 1401, Recommended Practice for Fire Brent Norwine Service Training Reports and Records Steve Weinstein Fall 2021 cycle - PI closes January 9, 2020 Corey Wilson Derrick Clouston, Leader Jim Keiken NFPA 1405, Guide for Land-Based Fire Fighters Jeffrey Morrissette Who Respond to Marine Vessel Fires Fall 2019 cycle – PI closed January 4, 2018 NFPA 1403, Standard on Live Fire Corey Wilson, Leader Training Evolutions Rick Egelin Annual 2022 cycle – PI closes June 30, 2020 Bill Glover Eddie Buchanan, Leader Forest Herndon Rick Egelin Roger LeBoeuf Bill Glover Gordon Lohmeyer Roger LeBoeuf Pat Marlatt Dan Madrzykowski Dan Rossos Pat Marlatt Doug Mitchell NFPA 1407, Standard for Training Fire Service Brent Norwine Rapid Intervention Crews Bill Peterson Fall 2019 cycle – PI closed January 4, 2018 Dan Rossos Eddie Buchanan, Leader Dan Shaw Colin Aguilar Jonathan Carroll Doug Mitchell Howard Meek Brent Norwine Doug Mitchell Rob Raheb Kevin Munson Dan Rossos Dan Shaw Dan Shaw Cory Wilson Cory Wilson Brian Wade NFPA 1451, Standard for a Fire Service Vehicle Operations Training Program NFPA 1408, Standard for Training Fire Service Fall 2021 cycle - PI closes January 9, 2020 Personnel in the Operation, Care, Use and Bill Peterson, Leader Maintenance of Thermal Imagers Pat Marlatt Fall 2019 cycle – PI closed January 4, 2018 Kevin Munson Brett Norwine, Leader Ryan Pietzsch Eddie Buchanan Rob Raheb Derrick Clouston Steve Williamson Roland Fredrickson Chris Hubbard Communication Training Dan Madrzykowski Corey Wilson, Leader Doug Mitchell Derrick Clouston Kevin Munson Chris Hubbard Dan Shaw Steve Weinstein
NFPA 1410, Standard on Training for Initial 1041 Live Fire Training Instructor Qualification Emergency Scene Operations Derrick Clouston, Chair, Fall 2019 cycle – PI closed January 4, 2018 Chris Hubbard Ed Buchanan, Leader Pat Marlatt James Cannell Jeff Morrisette Dan Madrzykowski
The Chair recessed the meeting at 2:48pm until March 21, 2018 at 8:30am Central. The committee broke out into task groups to work on first draft material for the respective documents.
The meeting was reconvened by Chair Richards at 8:30am Central on March 21, 2018. After brief remarks, the meeting was recessed for task groups to meet to continue work on first draft material for their respective documents.
The Chair reconvened the meeting at 10:00am Central for task groups to report back with first draft inputs. Task group reports were heard and acted upon from the 13E, 1405, 1407, 1408, and 1410 task groups.
The 1408 task group, along with Bob Upson, was assigned by the Chair to examine the needs, and a potential roadmap, for instructor requirements for Thermal Imaging training.
The reports of the Task Groups were completed at 11:32pm.
No unfinished/old business was brought to the floor.
No new business was brought to the floor. The next meeting, if needed, will be in the months prior to May, 2019. The committee will examine Northbrook, Illinois as a potential meeting location.
The meeting was adjourned at 11:53am.
Respectfully submitted;
Jeremy Souza NFPA Staff Liaison https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-o...
Dates for TC Process Stage Process Step Dates for TC with CC Public Input Closing Date* 1/04/2018 1/04/2018 Final Date for TC First Draft Meeting 6/14/2018 3/15/2018 Posting of First Draft and TC Ballot 8/02/2018 4/26/2018 Final date for Receipt of TC First Draft ballot 8/23/2018 5/17/2018 Final date for Receipt of TC First Draft ballot ‐ recirc 8/30/2018 5/24/2018 Public Input Posting of First Draft for CC Meeting 5/31/2018 Stage (First Draft) Final date for CC First Draft Meeting 7/12/2018 Posting of First Draft and CC Ballot 8/02/2018 Final date for Receipt of CC First Draft ballot 8/23/2018 Final date for Receipt of CC First Draft ballot ‐ recirc 8/30/2018 Post First Draft Report for Public Comment 9/06/2018 9/06/2018
Public Comment Closing Date* 11/15/2018 11/15/2018 Notice Published on Consent Standards (Standards that received no Comments) Note: Date varies and determined via TC ballot. Appeal Closing Date for Consent Standards (Standards that received no Comments) Final date for TC Second Draft Meeting 5/16/2019 2/07/2019 Posting of Second Draft and TC Ballot 6/27/2019 3/21/2019
Comment Stage Final date for Receipt of TC Second Draft ballot 7/18/2019 4/11/2019 (Second Draft) Final date for receipt of TC Second Draft ballot ‐ recirc 7/25/2019 4/18/2019 Posting of Second Draft for CC Meeting 4/25/2019 Final date for CC Second Draft Meeting 6/06/2019 Posting of Second Draft for CC Ballot 6/27/2019 Final date for Receipt of CC Second Draft ballot 7/18/2019 Final date for Receipt of CC Second Draft ballot ‐ recirc 7/25/2019 Post Second Draft Report for NITMAM Review 8/01/2019 8/01/2019
Notice of Intent to Make a Motion (NITMAM) Closing Date 8/29/2019 8/29/2019 Tech Session Posting of Certified Amending Motions (CAMs) and Consent Standards 10/10/2019 10/10/2019 Preparation (& Issuance) Appeal Closing Date for Consent Standards 10/25/2019 10/25/2019 SC Issuance Date for Consent Standards 11/04/2019 11/04/2019
Tech Session Association Meeting for Standards with CAMs 6/17/2020 6/17/2020
Appeals and Appeal Closing Date for Standards with CAMs 7/08/2020 7/08/2020 Issuance SC Issuance Date for Standards with CAMs 8/14/2020 8/14/2020
TC = Technical Committee or Panel As of 2/3/2017 CC = Correlating Committee
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Public Comment No. 5-NFPA 13E-2018 [ Section No. 4.2 ]
4.2* Inspection and Pre-Incident Planning.
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4.2.1 Fire personnel should thoroughly understand the following about properties protected by automatic sprinklers and standpipe systems: (1) The construction, contents, and layout of the buildings, the nature of the occupancies protected by automatic sprinklers or standpipes, the extent of this protection, and the type of fire protection systems. (2) The water supply to the fire protection systems, including the source and type of supply, the flow and pressure normally available, and the anticipated duration of the available supply. (3) * The location of all sprinkler or standpipe control valves, the area controlled by each valve, and the consequence of shutting off each valve. (4) The location of fire department connections to fire protection systems, the specific area each connection serves, and the water supply, hose, and pumper layout that will be used to feed the fire department connections. (See Figure 4.2.1.) (5) The location of water supplies for handlines that can be used without jeopardizing the water supply to the operating sprinklers. (6) An alternative means for supplying water to the system in case of damage to the fire department connection. (7) The location of spare or replacement sprinklers. (8) The location of water flow indicators and annunciator panels associated with the fire protection systems. (9) Keyholder information for contact in case of emergency. Arrangements should be made with the property owners for entering the building as quickly as possible following activation of sprinkler systems when the building is unattended in order to avoid using forcible entry equipment and the resulting damage. (10) The company assigned responsibility for charging the fire department connection. (11) Fire department personnel should periodically verify that fire department connection inlet caps or plugs and inlet swivel(s) are operational and free from debris. (12) Standpipe hose threads should be checked for compatibility with fire department threads. Figure 4.2.1 Fire Department Connection to Automatic Sprinkler Systems.
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4.2.2 Periodic Inspection of Fire Department Connections. The company that is assigned primary responsibility for charging the sprinkler connection during pre- incident planning or annual inspections should do the following: (1) Hook up to the fire department connection to verify hose thread compatibility. (2) Verify that fire department connection inlet caps of plugs and inlet swivel(s) are operational. (3) Verify that the fire department connection inlet is free from debris. 4.2.3 Standpipe Systems. 4.2.3.1 Where the fire department is required to supply hose outlets several hundred feet (meters) from the fire department connection, plans should be made in advance to provide the required pressure and fire flow based on the size of hose, the length of pipe, the maximum height of standpipe outlets, and the number of streams to be supplied. 4.2.3.2 Pre-incident planning should include identification of pressure-regulation devices installed within the system. For those standpipe systems with devices that regulate the pressure available to the hose lines attached to the system, fire personnel should be aware of the devices and their placement on standpipe systems and know how to adjust them so that they work properly with the hose lines and nozzles that can be attached to them. Pressure-regulation device settings should be compatible with the hose and nozzles used by the local fire department. 4.2.3.3* Standpipe hose outlets should be checked annually by opening and closing the valves. 4.2.3.4* Pressure-Regulating Devices Used in Automatic Standpipe Systems. Fire department personnel should be thoroughly familiar with the design and function of the various types of pressure-regulating devices used in automatic standpipe systems in their jurisdictions. 4.2.4 Fire Pumps Fire personnel should be aware to the presence of any fire pumps that may be supporting the sprinkler, standpipe, and/or fire service mains. Pre-incident planning should be performed that identifies: (1) The size of the fire pump. (2) Fuel source and estimated duration of operation. (3) Water source and estimated duration of operation. (4) Amount of pressure being delivered. (5) Systems served by the pump. (6) Limitations the pump. 4.2.4.1 Supply Pressure When a fire pump's normal operating pressure is more than 150 PSI, a permanent sign, approved by the AHJ, should be located at the fire department connection that identifies the minimum pressure setting that should be used to support the system(s).
Statement of Problem and Substantiation for Public Comment
I was not able to locate any information in this standard that addresses operations involving fire pumps. Fire pumps are an important component to a fire protection system and changes the way we fight fire in a sprinklered building. Furthermore, it can be dangerous for firefighters when they are unaware of the existence of fire pump. Here are some examples: Example 1 - A firefighter connects a 1 3/4" hoseline to standpipe on a fire. He knows the FDC has not be supplied yet, so he is expecting to receive around 50 PSI from his smooth bore nozzle. However, when he opens it up, he receives 160 PSI. At this pressure, a firefighter can become injured very easily if they are not prepared for it. Example 2 - The FDC at a structure fire is remote from the building and the next in engine company is told to supply it. The pump operator hooks up his supply lines and begins to pump the FDC at 150 PSI. He then works on establishing his water supply, knowing that his tank water will not last long. However, when he returns to his pump panel, he notes that the water level has not moved. What he is unaware of is that the building has a fire pump supplying 170 PSI to the system already. Since the fire pump's pressure is higher than what he is trying to
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provide, the one way check valve will remain closed and not allow the fire engine's water past it. This situation can overheat the engine's pump if the pump operator is not aware of the situation. Example 3 - A fire department is battling a fire in an industrial building. They know that the building has a fire pump and assume that it is supplied by the municipal water system. What they are unaware of is the fire pump does nothing more than draft water from an underground tank that was installed, because the municipal system could not supply the needed fire flow for the building. After sometime, the tank runs empty and the fire pump shuts down, cutting their water flow in 1/2. Related Item • pi
Submitter Information Verification
Submitter Full Name: Ryan Wyse Organization: Hebron Fire Department Street Address: City: State: Zip: Submittal Date: Thu Nov 08 08:42:21 EST 2018 Committee: FIY-AAA
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Public Comment No. 3-NFPA 13E-2018 [ Section No. 5.1.4 ]
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5.1.4* When arriving at a property protected by an automatic sprinkler system, fire companies should take prompt action to supply the system. [See Figure 5.1.4(a) and Figure 5.1.4(b).] A minimum of one sprinkler supply line should be connected to the fire department connection and should be supplemented according to fire conditions. The supply line should be pumped and the line charged to a pressure of 150 psi (10.3 bar) unless the system is posted for a different pressure. Additional hose lines should be stretched to the fire area as directed by the incident commander in charge. [See Figure 5.1.4(c).] Figure 5.1.4(a) Public Water Supply to the Sprinkler System.
Figure 5.1.4(b) Water Supply to the Fire Department Connection.
Figure 5.1.4(c) Pumper Supply Options That Should Be Considered.
Statement of Problem and Substantiation for Public Comment
In response to the TC's reply for PC 12-NFPA 13E-2017 "The Technical Committee considers a yard hydrant
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differently than a private hydrant. Where as a yard hydrant by definition is not rated to supply a fire department pumper, private hydrants can.", please consider the following information:
A yard hydrant is nothing more than a garden hose connection ran remotely. It is almost impossible to connect a fire hose to a yard hydrant. Telling a firefighter not to connect to a yard hydrant is like telling them not to connect to a garden hose spigot (Please see attachments). The fact is that it has become common for firefighters to mistakenly refer to a private fire hydrant as a yard hydrant and it is causing a large amount of confusion. Neither NFPA 13 or 24 provide a definition for a yard hydrant. Though there is a definition for such in this standard, diagrams and wording lead people to believe the standard is referring to private fire hydrants, not true yard hydrants. If the TC is considering the yard hydrant differently than a private hydrant, why do the diagrams show it connected to the fire service main? Only private hydrants are permitted to be connected to this main. Yard hydrants must be connected to the domestic water system.
The reference to yard hydrants needs to be removed completely. Instead, firefighters need to be instructed that they should use caution when using a private hydrant to supply the FDC and should use NFPA 1620 as a guide to develop pre-incident plans that identify the design and capabilities of the water distribution system for a structure.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 12-NFPA 13E-2017 [Section No. 4.2.1] Response Related Item • 12-NFPA 13E-2017
Submitter Information Verification
Submitter Full Name: Ryan Wyse Organization: Hebron Fire Department Street Address: City: State: Zip: Submittal Date: Thu Jul 19 14:53:20 EDT 2018 Committee: FIY-AAA
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Public Comment No. 10-NFPA 1405-2018 [ New Section after 3.3 ]
TITLE OF NEW CONTENT Located between 3.3.99 and 3.3.100
Vessel Response Plan (VRP): Onboard any tank vessel utilizing the navigable waters of the United States will be a plan for dealing with pollution, fire and salvage emergencies. These plans must be able to be activated anywhere the vessel operates in the United States and will utilize Amercian responders, divers, salvors and contract fire fighters who have been properly certified and credentialed by the USCG. The VRP is activated by the vessel crew and is carried out by a local qualified individual (QI) who is able to spend money and allocate resources on behalf of the vessel. The QI will represent the vessel as the responsible party within an Incident Command Post or Unified Command Post.
Statement of Problem and Substantiation for Public Comment
This is an update by USCG regulation promlugated in 2016 as a requirement for all vessels. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Affiliation: USCG Sector Delaware Bay Street Address: City: State: Zip: Submittal Date: Wed Nov 14 14:50:56 EST 2018 Committee: FIY-AAA
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Public Comment No. 11-NFPA 1405-2018 [ Section No. 3.3.65 ]
3.3.65 MSO. Marine safety officer. Omit this. Marine Safety Offices (MSO's) no longer exist.
Statement of Problem and Substantiation for Public Comment
The definition was incorrectly labled "Marine Safety Officers". I think the original statement was to mean Marine Safety Office. Regardless MSO's have been superceded by USCG Sectors since 2006. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Affiliation: USCG Sector Delaware Bay Street Address: City: State: Zip: Submittal Date: Wed Nov 14 14:53:30 EST 2018 Committee: FIY-AAA
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Public Comment No. 25-NFPA 1405-2018 [ New Section after 5.5 ]
5.5.12 Water Mist Systems Water mist systems are a micro-droplet sprinkler heads that use fresh water typically used to fight fires in and around sensitive electrical systems such as generators. This system uses fresh water taken from the vessel's potable water system onboard the vessel using no outside inputs and are generally operated remotely from engineering, the bridge, or from the steering gear room where the actual system is located. The water mist systems can be used at any time and are not a hazard to personnel operating in and around them when they are activated. These systems cut down on potential electrical system damage allowing critical vessel power to be restored with little or no flooding potential.
Statement of Problem and Substantiation for Public Comment
This is a new type of technical system that has been added to vessels since 2008. They are approved by IMO and USCG. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Affiliation: USCG Sector Delaware Bay Street Address: City: State: Zip: Submittal Date: Wed Nov 14 16:22:23 EST 2018 Committee: FIY-AAA
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Public Comment No. 26-NFPA 1405-2018 [ Section No. 5.5.7.1 ]
5.5.7.1 Life Hazard. Although CO2 is a mildly toxic gas, it is extremely hazardous to humans when present in concentrations sufficient to extinguish shipboard fires (upwards of 30 percent by volume, in many cases). Also, visibility usually is obscured during discharge of CO2. For these reasons, entry into spaces where CO2 has been discharged never should be attempted without self-contained breathing apparatus (SCBA). As an increased safety factor modern US and foreign vessels have been adding an olfactory warning indicator to shipboard CO2 systems. As older CO2 systems are taken out and replaced these olfactory warning systems will be installed. The olfactory warning typically will smell like winter-green mint or a similar strong mint odor. Should you smell a heavy mint odor in a machinary space, paint locker, CO2 storage area or other CO2 protected space this could be an indication that a CO2 system has been activated or is leaking due to fire damage of ship systems.
Statement of Problem and Substantiation for Public Comment
IMO (International Maritime Organization) has approved safety measures for fixed CO2 systems. Intergen is a brand of CO2 that features these warning properties that are being phased in over time to older vessels. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Affiliation: USCG Sector Delaware Bay Street Address: City: State: Zip: Submittal Date: Wed Nov 14 16:30:28 EST 2018 Committee: FIY-AAA
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Public Comment No. 12-NFPA 1405-2018 [ Section No. 7.7.2 ]
7.7.2 Another service some of these companies provide is fire-fighting support. Many, but not all, tugs are equipped with fire pumps or monitors, or both, to provide a water stream from the waterside. The type of equipment that a company operates and its fire-fighting capability usually are can be found in the USCG Fire-Fighting Contingency Plan. Section 8000 of the Area Contingency Plan located at the nearest USCG Sector, Sector Field Office or Marine Safety Detachment. Additional assistance with vessel support information may be obtained by a qualified Duty Marine Inspector who can be contacted through the nearest USCG Command Center (Commcen).
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Affiliation: USCG Sector Delaware Bay Street Address: City: State: Zip: Submittal Date: Wed Nov 14 14:55:49 EST 2018 Committee: FIY-AAA
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Public Comment No. 13-NFPA 1405-2018 [ Section No. 7.20 ]
7.20 Foreign Consulates and Language Schools and Cell Phone Translation Applications . Most vessels entering U.S. ports carry foreign crews that speak many different languages. If In the unlikely event that the vessel's English-speaking senior officers are injured and translators are needed, foreign consulates and language schools in the area are good sources of translators. A list of translators usually can be found in the USCG Fire-Fighting Contingency Plan Additionally there are numerous free or minimal cost translation applications that can be utilized on cell phones and tablets that allow rapid communication in both verbal and written modes .
Statement of Problem and Substantiation for Public Comment
The USCG does not maintain lists of tranlators or translator services any longer. The prevalence of english speaking crew on foreign vessels is less of a problem than in the past as new IMO standards have increased the requirement for crew to speak and understand english. Additionally the modern software applications for cell phones are becoming more reliable/easy to use and most importantly free. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:23:59 EST 2018 Committee: FIY-AAA
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Public Comment No. 14-NFPA 1405-2018 [ Section No. 12.16 ]
12.16* Gas Tanker Fires Ship Fires . Gas tankers referred to in this section are vessels that are Ships or barges are tankers that are specifically designed to transport flammable gas in bulk liquid form at very low temperature. Nonflammable and essentially nonflammable liquefied gases transported in bulk, such as anhydrous ammonia [ignition temperature, 1204°F (651°C)], can be controlled by methods similar to those used for unignited releases. The two most common liquefied flammable gases are LNG and LP-Gas. LNG is mostly methane, liquefies at −260°F (−162°C), and is reduced in volume 600 times during the gas-to-liquid change. LP-Gas is primarily propane or butane, liquefies at −44°F (−42°C), and is reduced in volume 270 times when liquefied. In addition to gas ships that carry LNG/LPG as cargo there are also vessels presently using LNG/LPG as fuel for propulsion. These vessels will have some of the specialized fire fighting equipment listed below but will carry far less quantity of flammable materials. 12.16.1 Although many of the physical characteristics of LNG and LP-Gas differ substantially, fire-fighting strategies and tactics are similar. Both gases are nontoxic but are asphyxiants. They are often stored similarly aboard vessels in large, insulated, spherical containers (usually five spheres per vessel). The spheres or tanks usually are segmented tanks that are specially made of thermally pressure resistant materials. Older LNG vessels were reconizable by having hemispherical tanks on the main deck. The majority of gas ships and barges look much like standard oil tankers with insulated tanks individually isolated within the hull by a secondary barrier designed to contain low-volume leakage from the tank temporarily or by a primary barrier. To cool these gasses to a proper temperature for shipping and safe storage huge quantities of refrigerants and refrigeration equipment are kept onboad presenting a secondary chemical hazard to personnel on these vessels. 12.16.2 These enclosed spaces, like others that exist aboard the vessel, provide an environment that could promote explosion or fire hazards, or both, from either gas. If escaping into open air, however, both gases are subject to fire, but, generally, only LP-Gas is subject to explosion. An open-air LP-Gas explosion usually necessitates a large liquid-phase release and also depends upon environmental factors such as wind conditions, humidity, terrain, and ignition sources. 12.16.3 Ships that carry LNG or LP-Gas usually have water spray systems throughout critical cargo areas on deck. Vessels that use LNG/LPG will have a water spray system in the vicinity of the fueling station and bunker stations on a much smaller scale. Although the water spray normally is not used to extinguish the fire directly, it can prove effective in the following: (1) Dissipating unignited flammable vapors (2) Protecting metal surfaces subject to brittleness and fracture from cryogenic liquids (3) Confining a fire to a limited area (4) Protecting exposures from radiant heat 12.16.4 Most ships also are fitted with sufficient dry chemical units to extinguish a cargo fire on board. Such units include large fixed systems with fixed monitors, smaller skid-type stations, and semiportable wheeled tanks. Generally, crew members are specifically trained to combat liquefied flammable gas fires.
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12.16.5 Ports that regularly handle these gases in bulk are controlled by the USCG COTP LNG/LP-Gas Vessel Management Plan and the LNG/LP-Gas Emergency Contingency Plan will have Vessel Response Plans that are specific to the safe response for LNG/LPG. Facilities that handle LPG/LNG will have a Facility Response Plan as well as an enhanced Emergency Response Plan specific to assisting emergency response personnel . These plans usually separate gas vessel incidents into two separate categories: those incidents that occur while the vessel is in transit to the facility, and those that occur while the vessel is moored at the facility. Generally, regardless of the nature of the emergency, the plans require that the response always be the same and that the worst situation be anticipated. Various factors, including resource response time and high hazard potential, dictate this approach. The following general guidelines apply to most liquefied flammable gas vessel fires, whether they occur on ships or barges: (1) All personnel should remain upwind of the release. (2) High-velocity fog should be used on the vapor of unignited releases. This procedure assists in the dispersion of gas vapors. High-velocity fog can be employed to direct vapors away from an ignition source or toward a more windy area. CAUTION: High-velocity fog should never be applied to the liquid. It merely accelerates the formation of vapor. (3) In the event of ignition, water should be used to cool down surrounding tanks, piping, equipment, and structures. It also should be used to cool down the tank involved in the fire. Water spray should be used to protect personnel involved in shutting down the source or protecting exposures. (4) Normally, gas fires should not be extinguished unless the source can be shut off. A controlled burn generally is preferable to an uncontrolled, unignited leak. Factors for consideration include failure of structural metal from extreme cold (unignited) or extreme heat (ignited). (5) If it is necessary and practical to move the vessel away from the facility, a delay of at least 30 minutes should be expected, depending on the type of hose connection(s) to the shoreside facility.
Statement of Problem and Substantiation for Public Comment
There have been industry changes in "jargon" that Gas Tankers are no longer a typical naming convention. This was primarily to keep the term from getting mixed up with highway trucks during reports at pier facilities. Additonally there have been changes with plan names and procedures implemented in 2016.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 15-NFPA 1405-2018 [Section No. 12.16 [Excluding any Sub- Sections]] Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:28:16 EST 2018 Committee: FIY-AAA
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Public Comment No. 15-NFPA 1405-2018 [ Section No. 12.16 [Excluding any Sub-
Sections] ]
Gas ships (which by classification are tankers but to clarify potential confusion with highway tankers/barges are traditionally called gas ships) referred to in this section are vessels that are specifically designed to transport flammable gas in bulk liquid form at very low temperature. Nonflammable and essentially nonflammable liquefied gases transported in bulk, such as anhydrous ammonia [ignition temperature, 1204°F (651°C)], can be controlled by methods similar to those used for unignited releases. The two most common liquefied flammable gases are LNG and LP-Gas. LNG is mostly methane, liquefies at −260°F (−162°C), and is reduced in volume 600 times during the gas-to-liquid change. LP-Gas is primarily propane or butane, liquefies at −44°F (−42°C), and is reduced in volume 270 times when liquefied. A subset of vessels are known as LNG/LPG Powered ships. These are vessels that have their primary propulsion fueled by flammable gasses in lieu of traditional fuels like diesel and heavy fuel oils. The volume of flammable gasses on an LPG/LNG powered vessel are drastically less than on cargo vessels. On both types there will be similar fire fighting arrangements specifically designed to extinguish LP/LNG fires.
Statement of Problem and Substantiation for Public Comment
Technology and ship design changes have ocurred.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 14-NFPA 1405-2018 [Section No. 12.16] Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:42:34 EST 2018 Committee: FIY-AAA
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Public Comment No. 27-NFPA 1405-2018 [ Section No. 14.1.2 ]
14.1.2 Policy. The Coast Guard has traditionally provided fire-fighting equipment and training to protect its vessels and property. Captains of the Port (COTPs) are also called upon to provide assistance at major fires on board other vessels and waterfront facilities. [NOTE: COTPs are Coast Guard Officers, authorized by Congress [14 U.S.C. 634(a)] to be designated by the Commandant of the Coast Guard, to facilitate execution of Coast Guard duties prescribed by law.] Although the Coast Guard clearly has an interest in fighting fires involving vessels or waterfront facilities, local authorities are principally responsible for maintaining necessary fire-fighting capabilities in U.S. ports and harbors. The Coast Guard renders assistance as available, based on the level of training and adequacy of equipment (i.e., Coast Guard personnel and equipment). The Commandant intends to maintain this traditional “assistance as available” posture without conveying the impression that the Coast Guard is prepared to relieve local fire departments of their responsibilities. Paramount in preparing for vessel or waterfront fires is the need to integrate Coast Guard planning and training efforts with those of other responsible agencies, particularly local fire departments and port authorities. COTPs shall work closely with municipal fire departments, vessel and facility owners and operators, mutual aid groups, and other interested organizations. The COTP may facilitate the creation of Memorandums of Agreement/Understanding (MOU/MOA) which would be similar to mutual aid agreements among municipalities and fire departments. The COTP shall develop a fire-fighting contingency plan which addresses fire-fighting in each port within the COTP zone. This plan should will be organized in a format similar to the federal local pollution plan included in the Area Contingency Plan as required by the National Oil and Hazardous Substances Pollution Contingency Plan (NCP) (40 CFR 300.43). [U.S. Coast Guard Marine Safety Manual, Vol. 6, Chap. 8]
Statement of Problem and Substantiation for Public Comment
This was a minor clarification with the Area Contingency Plan as well as a minor change to clarify USCG position in the coordination role. Related Item • pi
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 16:41:10 EST 2018 Committee: FIY-AAA
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Public Comment No. 16-NFPA 1405-2018 [ Section No. 14.3 ]
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14.3 Personnel 3 Personnel .
Coast Guard personnel who can be helpful to local fire-fighting agencies include the following:
Marine inspectors
National strike teams
Coast Guard reserve fire and safety technicians (FS Marine Safety Specialist Response (MSSR )
Marine fire-fighting coordinators
The COTP or COTP representative
14.3.1 1
Marine inspectors are assigned to the inspection department of an MSO who a USCG Sector, Sector Field Office or Marine Safety Detachment who are familiar with construction, equipment, and operating procedures for various types of vessels.
14.3.2 2
The National Strike Force is composed of the Pacific Area Strike Team and the , Atlantic Area Strike Team (which includes the Gulf of Mexico) and Gulf Strike Team . These teams have expertise in oil and hazardous substance removal and in vessel damage control.
14.3.3 The FS is 3
The is a Coast Guard reservist who is a specialist fully qualified in the fields of marine fire protection, prevention, and fire suppression; hazardous material storage and transfer; and pollution incident monitoring, supervision, and investigation.
14.3.4 4
The marine fire-fighting coordinator, usually a Coast Guard FS MSSR , provides the COTP with expertise and advice during a fire-fighting situation. This individual , due to the requirements of this Coast Guard Reserve rating, is usually a local civilian fire fighter will likely be in charge of the implementation and updating of Salvage and Marine Fire Fighting portion of the Area Contingency Plan (ACP). The MSSR will be part of the Operations or Planning Section within the Incident Command System who will be the primary tactical operational coordination between the COTP, the local fire department and the Qualified Individual (QI) who will act as the vessel representative during emergencies in United States jurisdiction .
14.3.5 5
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The COTP is the Coast Guard officer responsible for administering and enforcing the Port Safety and Security Program, Marine Environmental Response Program, and Waterways Management Program within the boundaries of a specific COTP zone. The COTP has the authority (based on the Ports and Waterways Safety Act, 33 USC 1221) to order a vessel to operate or anchor in a specific manner, in the interest of safety, due to a temporary hazardous circumstance or the condition of the vessel itself.
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 17-NFPA 1405-2018 [Section No. 14.3 [Excluding any Sub-Sections]] Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:44:03 EST 2018 Committee: FIY-AAA
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Public Comment No. 17-NFPA 1405-2018 [ Section No. 14.3 [Excluding any Sub-
Sections] ]
Coast Guard personnel who can be helpful to local fire-fighting agencies include the following: (1) Marine inspectors
National strike teams Coast Guard reserve fire and safety technicians (FS) (2) USCG National Strike Force
(3) Coast Guard Marine Safety Specialist Response (MSSR)
(4) Marine fire-fighting coordinators
(5) The COTP or COTP representative
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 16-NFPA 1405-2018 [Section No. 14.3] Related Item • pi
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:45:27 EST 2018 Committee: FIY-AAA
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Public Comment No. 18-NFPA 1405-2018 [ Section No. 14.3.1 ]
14.3.1 Marine inspectors are assigned to the inspection department of an MSO a USCG Sector, Sector Field Office or Marine Safety Detachment who are familiar with construction, equipment, and operating procedures for various types of vessels.
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:47:18 EST 2018 Committee: FIY-AAA
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Public Comment No. 19-NFPA 1405-2018 [ Section No. 14.3.2 ]
14.3.2 The National Strike Force is composed of the Pacific Area Strike Team and the , Atlantic Area Strike Team (which includes the Gulf of Mexico) and Gulf Strike Team . These teams have expertise in oil and hazardous substance removal and in vessel damage control.
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:48:06 EST 2018 Committee: FIY-AAA
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Public Comment No. 20-NFPA 1405-2018 [ Section No. 14.3.3 ]
14.3.3 The FS Marine Safety Specialist Response (MSSR) is a Coast Guard reservist Active Duty or Reserve Chief Warrant Officer (CWO) who is a marine safety specialist fully qualified in the fields of marine fire protection, prevention, and fire suppression; incident management; vessel salvage; hazardous material storage and transfer; and pollution incident monitoring, supervision, and investigation. If a local/regional Coast Guard Sector, Sector Field Office, or Marine Safety Detachment does not have an MSSR, a qualified USCG Marine Inspector can be utilized to assist with marine fire/salvage emergencies. Both the MSSR and Qualified Marine Inspector can be reached 24 hours a day by contacting the local USCG Command Center (Commcen).
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005. The FS position no longer exisits in the USCG. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:49:44 EST 2018 Committee: FIY-AAA
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Public Comment No. 21-NFPA 1405-2018 [ Section No. 14.3.4 ]
14.3.4 The marine fire-fighting coordinator, usually a Coast Guard FS MSSR , provides the COTP with expertise and advice during a fire-fighting situation. This individual , due to the requirements of this Coast Guard Reserve rating, is usually a local civilian fire fighter will likely be in charge of the implementation and updating of Salvage and Marine Fire Fighting (SMFF) portion of the Area Contingency Plan (ACP). The MSSR will be part of the Operations or Planning Section within the Incident Command System who will be the primary tactical operational coordination between the COTP, the local fire department and the Qualified Individual (QI) who will act as the vessel representative during emergencies in United States jurisdiction .
Statement of Problem and Substantiation for Public Comment
This was a basic clarification on roles and responsibilities with proper plan nomenclature added. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:52:24 EST 2018 Committee: FIY-AAA
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Public Comment No. 22-NFPA 1405-2018 [ Section No. 14.3.5 ]
14.3.5 The COTP is the Coast Guard officer responsible for administering and enforcing the Port Safety and Security Program, Marine Environmental Response Program, and Waterways Management Program within the boundaries of a specific COTP zone. The COTP has the authority (based on the Ports and Waterways Safety Act, 33 USC 1221) to order a vessel to operate or anchor in a specific manner, in the interest of safety, due to a temporary hazardous circumstance or the condition of the vessel itself. The COTP can also issue an Admin Order to vessels to compell them to fully activate their Vessel Response Plans (Non-Tank Vessel Response Plans) in a more timely manner in the event of a vessel fire.
Statement of Problem and Substantiation for Public Comment
This was a minor clarification of nomenclature changes to line up with current terminology. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 15:56:29 EST 2018 Committee: FIY-AAA
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Public Comment No. 23-NFPA 1405-2018 [ Section No. 14.4 ]
14.4 Equipment and Supplies. The Coast Guard does not stock large quantities of fire-fighting supplies at either its offices or on board its vessels. It relies upon local agencies and vendors for this support. Coast Guard vessels that have fire- fighting support capability that might be available to fire response agencies are variously sized utility boats with outboard motors, the 32 ft (9.7 m) ports and waterways boat (PWB), the 41 ft (12.5 m) patrol boat (UTB), and the 44 ft (13.4 m) motor life boat (MLB). will primarily act in a supporting search and rescue role with the ability to lend direct tactical assistance with water operations. Some larger Coast Guard vessels have fire hoses and stations and the ability to remain on station for long periods of time but few USCG boats (vessels under 65 feet) have retained fire monitors and the ability to directly attack vessel fires that do not ocur on USCG platforms. USCG vessels have the ability to perform safety zone enforcement and personnel recovery from the water during a marine fire.
Statement of Problem and Substantiation for Public Comment
None of the vessels described in 14.4 are in service any longer. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 16:02:04 EST 2018 Committee: FIY-AAA
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Public Comment No. 24-NFPA 1405-2018 [ Section No. 14.10 ]
14.10 Marine Safety Office USCG Sector . Most Coast Guard captains of the port (COTP) are located within a field organization called the MSO. Sector. Sectors are a "one stop shop" for the many missions that are conducted in a geographic region. In smaller areas typically on the inland rivers and Great Lakes there may also be smaller USCG units that are Sector equivelants such as Marine Safety Field Offices (MSFO) and Marine Safety Detachments (MSD). To locate your nearest USCG Sector or equivelant office on the internet you can go to: homeport.uscg.mil and select the port directory. The commanding officers of the MSO are Sectors are the COTP and the officer in charge of marine inspections (OCMI). The chief of the Port Operations Department at the MSO is the Marine Safety Specialist Response (MSSR) at the Sector can be the local Coast Guard liaison for port fire-fighting efforts and contingency planning.
Additional Proposed Changes
File Name Description Approved 500px-USCG_Sector_Map.jpg United States Map of US Coast Guard Areas, Districts and Sectors
Statement of Problem and Substantiation for Public Comment
The USCG has had a major organizational change and my comments reflect those changes since 2005. The graphic should be helpful in assisting with knowing which USCG Sectors are responsible for each jurisdiction. The homport website was added as that is the USCG port safety and security outward facing public access website. Related Item • PI
Submitter Information Verification
Submitter Full Name: Todd Wardwell Organization: USCG Street Address: City: State: Zip: Submittal Date: Wed Nov 14 16:09:21 EST 2018 Committee: FIY-AAA
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Public Comment No. 1-NFPA 1408-2018 [ New Section after 7.1.1 ]
TITLE OF NEW CONTENT Additional information on the Limitations of Spot Temperture Measurements and change to TI Basic Mode Spot Temperature measurements have been removed from the TI Basic Mode in NFPA 1801, these measurements will still be available in the TI Plus mode, which in 1801 requires TIC specific additional training.
Additional Proposed Changes
File Name Description Approved 1408-1_NIOSH_4_Houston_FF_LODD_Report_201316.pdf 1408-1_Niosh_Appendix_Five_-_Thermal_Imagers_for_Investigation_F2013-16.pdf 1408-1_NIOSH_Hartford_FF_LODD_Report_201419.pdf 1408-1_NIOSH_Ohio_FF_LODD_Report_201519.pdf
Statement of Problem and Substantiation for Public Comment
The following well describes the problem with spot temperature measurement;
NIOSH Report # F2013-16 Appendix Five Use and Operations of Thermal Imagers The Temperature Measurement Feature on Fire Service Thermal Imagers should not be used for interior structural firefighting. USE OF THIS FEATURE MAY CAUSE ERRORS IN JUDGEMENT WHICH MAY RESULT IN SERIOUS INJURY OR DEATH. Fire service thermal imagers may be equipped with a temperature measurement feature. Utilizing either a bar indicator or digital readout or both this feature displays the approximate surface temperature of a targeted surface. The temperature measurement feature is a non-contact solid surface temperature measurement device that is not accurate. Different materials or the same materials with different composition, surface textures, color and polish will not register temperature readings in the same way resulting in variations in the temperature readings. Several factors including but not limited to: • how much heat; • the material being measured and its ability to absorb or reflect heat (emissivity) • the objects temperature; • the distance from the object being measured as well as; • the angle at which the object is being viewed and also; • the cleanliness of the lens as a result of steam or smoke; • the object does not fully fill the center target area then a false reading may be obtained Users must be aware and understand that the temperature measurement feature in a thermal imager will NOT provide atmospheric or air temperature readings. Additionally the thermal imaging camera cannot see through walls. When attempting to view a source of heat behind a wall or above a ceiling the heat source will not be evident if it does not heat the wall itself. Consideration must also be given to the thickness of the wall or ceiling as well as any additional layers of materials that may exist and further insulate or mask the true magnitude of the heat source. All of these factors may individually or collectively greatly affect the accuracy of the temperature measurement feature during interior structural firefighting situations. Because interior structural firefighting is a rapidly changing dynamic environment with many unknown and uncontrolled variables the temperature measurement feature on thermal imagers should not be utilized or relied upon by fire fighters to make tactical interior structural firefighting decisions.
Also refer to NIOSH Firefighter Fatality Investigation LODD reports; 201316, 201419 and 201519. Related Item
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• 7.1.2 & A.7.1.1
Submitter Information Verification
Submitter Full Name: Bruce Varner Organization: BHVarner & Associates Street Address: City: State: Zip: Submittal Date: Fri Oct 19 17:40:19 EDT 2018 Committee: FIY-AAA
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July 15, 2015
4 Career Fire Fighters Killed and 16 Fire Fighters Injured at Commercial Structure Fire - Texas
E xecutive Summary On May 31, 2013, a 35 year-old career captain, a 41 year-old career engineer operator, a 29 year-old career fire fighter, and a 24 year-old career fire fighter were killed when the roof of a restaurant collapsed on them during fire-fighting operations. The captain was assigned to Engine 51 (E51). The engineer/operator was assigned to Ladder 51, but was detailed to E51 and assigned to the left jumpseat (E51B). The two fire fighters were assigned to Engine 68 (E68). Upon arrival, the captain of E51 (E51A) radioed his size-up stating they had a working fire in the restaurant with heavy smoke showing plus a temperature reading from his thermal imager. E51 made an offensive attack from Side Alpha with a 2½ inch pre-connect hoseline in the restaurant. District Chief 68 (D68) arrived on scene and established “Command”. He ordered E51 out of the building because the engine operator of E51 (E51D) advised that E51 was down to a quarter An aerial view of the structure with the restaurant tank of water. Engine 68 had arrived on located on the front left, (Side Alpha/Bravo), motel scene and had laid two 4-inch supply entrance in the middle (Side Alpha), and a sports bar on lines from E51 to a hydrant east of the the right (Side Alpha/Delta). fire building on the feeder road. Once (Photo courtesy of the fire department) E51 had an established water supply, E51’s crew re-entered the building. Engine 68 (E68) was ordered to back-up E51 on the 2½ inch hoseline. Engine 82 (E82) (4th due engine company) was pulling a 1¾ inch hoseline to the front doorway that E51 had entered, when the collapse occurred. The roof collapsed 12 minutes after E51 had arrived on-scene and 15 minutes and 29 seconds after the initial dispatch. The fire fighter from E51 (E51C) was at the front doorway and was pushed out of the building by the collapse. The captain from E82 called a “Mayday” and Rapid Intervention Team (RIT) operations were initiated by Engine 60. During the RIT operations, a secondary wall collapse occurred injuring several members of the rescue group. Due to the tremendous efforts of the Rescue Group, a successful RIT operation was
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conducted. The captain of E68 was located and removed from the structure by the Rescue Group and transported to a local hospital. The engineer operator from E51 (E51B) was removed from the structure by the Rescue Group and later died at a local hospital. A search continued for the captain of E51 and the two fire fighters from E68. Approximately 2 hours after the collapse, the body of the captain from E51 was located on top of the restaurant roof debris. The two fire fighters from E68 (E68B and E68C) were discovered underneath the restaurant roof debris. The officer and two fire fighters were pronounced dead at the scene.
Contributing Factors Fire burning unreported for 3 hours Delayed notification of the fire department Building construction Wind impacted fire Scene size-up Personnel accountability Fireground communications Lack of fire sprinkler system
Key Recommendations Based upon fire department procedures, the strategy and tactics for an occupancy should be defined by the organization for fire-fighting operations. The Incident Commander should ensure that the strategy and tactics match the conditions encountered during initial operations and throughout the incident Fire departments should review and update standard operating procedures on wind-driven fires which are incorporated into fireground tactics Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (U.L.) into operational procedures by developing standard operating procedures, conducting live fire training, and revising fireground tactics
The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program” which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with State or Federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not name the victim, the fire department or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit. For further information, visit the program Web site at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
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July 15, 2015
4 Career Fire Fighters Killed and 16 Fire Fighters Injured at Commercial Structure Fire - Texas
I ntroduction On May 31, 2013, a 35 year-old career captain, a 41 year-old career engineer operator, a 29 year-old career fire fighter, and a 24 year-old career fire fighter died when the roof of a restaurant collapsed during fire-fighting operations. The captain and engineer operator were assigned to Engine 51 (E51). The two fire fighters were assigned to Engine 68 (E68). On June 3, 2013, the United States Fire Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On June 10 - 17, 2013, an investigator, two general engineers, and occupational safety and health specialist from the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) traveled to Texas to investigate this incident.
The NIOSH investigators met with the Fire Chief, Executive Assistant Chief, and the executive staff of the fire department; the Fire Marshal and his staff; the SCBA Maintenance and Repair staff; the International Association of Fire Fighters local union; the department’s training academy staff; physicians with the county medical examiner’s office; representatives from the city’s Building Officials Office; investigators from the Texas State Fire Marshal’s Office; investigators from the Bureau of Alcohol, Tobacco, Firearms, and Explosives; and the city’s 911 communication and dispatch center. The investigators reviewed the fire department’s standard operating procedures, training records from the department and the State of Texas, dispatch and tactical channel printouts, plus audio radio transmissions. The NIOSH investigators visited and photographed the fire scene. During the investigation, witness statements were reviewed and interviews were conducted with the fire fighters, fire officers, District Chiefs and the Deputy Chief that served as the Incident Commander during this incident. The NIOSH investigators inspected and photographed the personal protective clothing (turnout gear) and SCBA of the fire fighters, which was under control of the department’s Arson Bureau.
On June 29 – July 2, 2013, a NIOSH investigator and a NIOSH occupational safety and health specialist returned to Texas to complete the interviews with fire fighters and fire officers involved in this incident.
Fire Department The career fire department involved in this incident serves a city with a population of 2,151,475 which is the fourth largest city and the third largest fire department in the United States. The fire department is rated by the Insurance Services Office (ISO) as a Class I fire department and is an Internationally Accredited department through the Commission on Fire Accreditation International (CFAI).
The urban population is 4,944,332 residents and the metropolitan population is 6,177,035 residents. The city has a total area of 656.3 square miles which is comprised of 634.0 square miles of land and 22.3 square miles of water. The fire department provides aircraft rescue fire-fighting (ARFF) for two
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large commercial airports. The fire department provides automatic aid with one career fire department and one volunteer fire department which are located in entities within the municipality. The fire department is part of a regional mutual aid pact which covers transportation emergencies in the greater metropolitan area.
The fire department employs 3,907 personnel, of which 3,789 are uniformed members. The daily minimum staffing for the Emergency Response Division is 832 personnel. The Emergency Response Division operates on 24/72 work schedule which equates to a 46.7 work-week including a 24-hour debit day which is worked approximately once every 36 days.
The Emergency Response Division is divided into two divisions – north and south. A deputy chief staffs each division on each shift. The South Division (Shift Commander 37) has 13 districts or battalions (District 21, 28, 59, 68, 78, 83, 20, 26, 46, 70, 71, 11 (Rescue), and 22 (Haz Mat). The North Division (Shift Commander 15) has 11 districts or battalions (4, 5, 6, 8, 19, 30 (Safety), 34, 45, 64, 102, and ARFF). District 54, provides aircraft rescue fire-fighting (ARFF) and emergency medical services at two of the city’s airports, which are located in the north and south areas of the city. District 54 and is under the direction of the Aircraft Rescue Coordinator who oversees four stations - 54, 92 and 99 at the airport located in the north section of the city and Station 81 at the airport located in the south section of the city. District 22 is the department’s hazardous materials unit staffed at Fire Station 22. District 11 is the department’s rescue district which has rescue companies: Rescue 10, Heavy Rescue 11, and Rescue 42. District 30 is staffed with the department’s Shift Safety Officers. They are located at Stations 24, 30, and 57.
The fire department operates a fire administration office, a fire marshal’s office, fire training academy, arson division, logistics center, fire apparatus maintenance shop, and fire operations division.
The Emergency Response Division directs all fire suppression, special operations and emergency medical services. These units are housed in 92 fire stations and staff the following resources: 87 engine companies; 37 ladder or truck companies (including 5 tower ladders); 56 basic life support (BLS) ambulances which are staffed with one EMT/B fire fighter and one EMT/B engineer operator per unit; 34 medic units (advanced life support) (ALS) with one fire fighter paramedic and one engineer operator paramedic; and 11 squads (non-transport ALS units) staffed with one fire fighter paramedic and one engineer operator paramedic. Additional units on duty include three rescue companies including one heavy rescue and 3 safety officers.
The fire department utilizes the following designations for riding assignments on fire apparatus: Officer is “A”; right jumpseat is “B”; left jumpseat is “C”; and the engineer operator is “D”.
The minimum staffing for each engine company, ladder company, and rescue company is an officer (senior captain or captain), engineer operator, and two fire fighters. Each district is staffed with a district chief and an incident command technician.
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The rescue companies (Rescue 10, Heavy Rescue 11, and Rescue 42) provide technical rescue services such as structural collapse, high and low angle rescue, trench rescue, and confined space rescue. The hazardous materials team consists of 10 members (two captains, three engineer operators, and five fire fighters) per shift operating response vehicles – HM22 Unit 1, HM22 Unit 2, and Foam Engine 22. The hazardous materials team is under the direction of a district chief (District 22) and assisted by a senior captain.
In calendar year 2013 (January 1 – December 31) the fire department responded to 299,107 incidents (257,107 - EMS and 42,064 – Fire). The average response time for EMS incidents was 5.8 minutes and the average response time for a fire incident was 5.6 minutes.
The Prevention Bureau is managed by an Assistant Chief and consists of 127 fire inspectors (1 Assistant Fire Marshal, 7 Chief Inspectors, 16 Senior Inspectors, and 103 inspectors) and 7 civilian positions. The members of the Fire Marshal’s Office are certified to NFPA 1031, Standard for Professional Qualifications for Fire Inspector and Plan Examiner 1 through the local community college. Each inspector must receive 20 hours of continuing education units (CEU) annually.
The Prevention Bureau consists of the following divisions and teams: Schools Division including Home Day Care facilities (Inspections) High-Rise Team (Inspections) Plans Review Division o Fire Alarm System; o Sprinkler Systems through the Building Officials Office Liaison to the city’s Building Officials Office o New construction o Sprinkler Systems; Electrical; Plumbing; Building Construction Special Operations Team o Providing fire and EMS for festivals and special events Weekend and Night Inspections o 24-hour coverage o Occupancy Load o Complaints
The Public Education Division of the Prevention Bureau conducts life safety training in: Schools High-Rise occupancies
The Fire and Arson Investigation Bureau is a law enforcement agency under the Prevention Division. The Arson Bureau responds in the event of incendiary fires, multiple alarm fires, fire deaths, bombings, and criminal or terrorist activity associated with fires. In many cases, investigators work with federal, state, and local agencies, such as the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF), Federal Bureau of Investigation (FBI), and the city’s police department. Other operations within the Fire and Arson Bureau are crime lab, polygraphs, forensics, and the region’s
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Arson Task Force.
Other Divisions within the department include: Planning/Administration, which includes: Office of Emergency Communication (Fire), Human Resources, Information Technology Liaison, and Planning. Finance, which includes: Finance, Budget, Procurement, Fixed Assets, Internal Audit, Grant Accounting, Warehouse Operations and the Selection, Care, and Maintenance of SCBA.
The rank structure in the fire department is fire fighter, engineer operator, captain, senior captain, district chief, deputy chief, assistant chief, executive assistant chief, and fire chief.
Training and Experience The fire department involved in this incident requires potential candidates for employment as a fire fighter to have a high school diploma or GED and 60 hours of college credit, or two years of military service with an honorable discharge.
Once selected as a candidate, the fire fighter trainee begins a 15-month probation period with the fire department. As a fire fighter trainee, the initial step is to attend the 9-month Recruit Training Program at the department’s fire academy. The training consists of Texas Commission of Fire Protection Basic Fire Suppression Curriculum. The Texas basic curriculum includes 468 hours of training. The curriculum covers all of the National Fire Protection Association's (NFPA) qualifications for: NFPA 1001, Standard on Fire Fighter Professional Qualifications, Fire Fighter I, Fire Fighter II, Hazardous Materials-Awareness, and Hazardous Materials-Operations.2 The trainee meets the requirements of NIMS 100 – Introduction to ICS; NIMS 200 – Basic ICS; IS 700A – The National Incident Management System, An Introduction; and IS 800B - The National Response Framework, An Introduction. In addition to the fire fighter training, the fire fighter trainees receive Emergency Medical Technician Basic (EMT/B) certification.
Upon completion of recruit school, the fire fighter trainee becomes a probationary fire fighter and is assigned within the Emergency Response Division as follows: Phase 1: 2 months with an engine company Phase 2: 2 months with a truck company Phase 3: 2 months with EMS Upon completion of probation, the probationary fire fighter is promoted to the rank of fire fighter.
The department requires that all Emergency Response Division fire fighters receive two hours of continuing education unit (CEU) training, one hour of risk management training, and 24 hours of in- service training per month. The fire department utilizes District Training Officers to assist with this in-service training as well as assuring that probationary fire fighters are obtaining the proper training during their six-month period in the Emergency Response Division. The Texas State Fire Commission requires 20 hours of CEUs per year and the Insurance Services Office requires 8 hours of CEUs plus 8 multi-company drills per year.
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The department conducts live fire training twice a year at the department’s fire academy. The live fire training is compliant with NFPA 1403, Standard on Live Fire Training.3 Each live fire training evolution utilizes four engine companies, two ladder companies, one medic unit, and one district chief. The department provides a certification program for all emergency operators (EO), which is a tested position. The fire academy provides the training for the 56-hour certification program, which complies with NFPA 1002, Standard for Apparatus Driver/Operator Professional Qualifications.4 The department pays for the state certification process through the Texas State Fire Commission.
The fire department provides an officer development program for members which is part of the department’s career path plus the opportunity to acquire a college degree. This process uses curriculum from the National Fire Academy; local community colleges; various colleges and universities; and continuing education programs.
The captain of E51 (E51A) was hired by the department on April 24, 2003. He successfully completed recruit school at the department’s Recruit Training Program and was certified as a fire fighter and EMT/B as of November 9, 2002. He was promoted to engineer operator on April 27, 2007 and promoted to captain on May 8, 2011. Other training courses and certifications included: radio communications, incident management system, apparatus familiarization, crew resource management, pump operations, infection control, ropes and knots, master streams, water supply, area familiarization, diversity awareness, overhaul, building construction, stokes basket operations, patient assessment, water rescue, AED protocol, hydraulics, PPE inspection and care, forcible entry, NIMS 100 – Introduction to ICS, NIMS 200 - Basic ICS, NIMS 700 – An Introduction to NIMS, 800 and 800A – The National Response Framework, An Introduction, review of departmental Orders and Bulletins, fire fighter safety, aerial operations, fire fighter survival, mass casualty incidents, fire protection systems, strategy and tactics, situational awareness, master streams, physical fitness, ground ladders, live fire training – multi-company drills, customer service, portable radio training, BLS continuing education, Grace Accountability System, Officer Development Program for Newly Promoted Captains (80 hours), and rapid intervention team (RIT). In April of 2013, the captain was awarded the Unit Meritorious medal for saving a female victim who had been trapped in an apartment fire.
The engineer operator from Ladder 51, was hired by the department on August 6, 2001. He successfully completed recruit school at the department’s Recruit Training Program and was certified as a fire fighter and EMT/B as of August 6, 2001. He was promoted to engineer operator on December 29, 2007. Other training courses and certifications included: area familiarization, hydraulics, ground ladders, building construction, water supply, high-rise fire-fighting operations, customer service, personnel accountability system, pump operations, fire protection systems, aerial operations, gasoline emergencies, hoseline operations, overhaul, vehicle fires, water rescue, tunnel rescue, review of departmental Orders and Bulletins, vehicle extrication, ventilation, high angle rescue, weapons of mass destruction (WMD), NIMS 700 – An Introduction to NIMS, quarterly operational risk management training, hose testing, master stream operations, live fire multi-company drills, physical fitness, rapid intervention team (RIT), physical fitness, propane and natural gas emergencies, fire fighter survival training, radio communications, portable radios, inspection and care of PPE, radio communications, wind driven fires, apparatus familiarization, and the Grace Accountability System.
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The fire fighter from Engine 68 (E68C) was hired by the department on June 29, 2010. He successfully completed recruit school at the department’s Recruit Training Program and was certified as a fire fighter and EMT/B as of June 29, 2011. Other training courses and certifications included: radio communications, area familiarization, turnout gear care and use, ground ladders, driving safety, apparatus familiarization, water supply, hoseline operations, the Grace Accountability System, water rescue, thermal imaging camera, incident scene rehabilitation, foam operations, live fire multi- company drills, review of departmental Orders and Bulletins, “Mayday” and RIT operations, post incident analysis, building construction, physical fitness, hydraulics, driver/operator course (80 hours), fire protection systems, personnel accountability system, master streams, forcible entry, fire cause and determination, stokes basket operations, high-rise fire-fighting, wind-driven fires, portable radios, truck company operations.
The fire fighter from Engine 68 (E68B) was hired on January 7, 2013. After graduating in April 2013, she was assigned to Fire Station 68 as a Probationary Fire Fighter. Other training courses and certifications included: area familiarization, turnout gear care and use, apparatus familiarization, hydraulics, physical fitness, and water supply.
Equipment and Personnel The Office of Emergency Communications (OEC) is the city’s communication center whose primary duties are to receive calls for fire, EMS, and law enforcement assistance. OEC immediately dispatches the appropriate personnel and equipment to the incident and record pertinent incident information. From the fire and EMS perspective, OEC is staffed by uniformed fire department members. OEC dispatches the following assignments to a reported or confirmed fire: Residential Structure Fire (Heavy Box): o 3 Engines o 2 Ladders o 1 Ambulance o 1 Medic Unit o 2 District Chiefs
Commercial Structure Fire (Heavy Box): o 4 Engines o 2 Ladders o 1 Medic Unit o 1 Safety Officer o 2 District Chiefs
High-Rise Structure Fire (Heavy Box): o 6 Engines o 4 Ladders o 1 Rescue Company o 1 Medic Unit o 2 Safety Officers
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o 4 District Chiefs
Vehicle Fire, Brush Fire, or Still Alarm o 1 Engine or, o 1 Engine and 1 Ladder
1-11 (Working Fire Dispatch) o 1 Engine o 1 Ladder o 1 Rescue Company o 1 District Chief
2-11 (2nd Alarm) o 4 Engines o 2 Ladders o 1 Heavy Rescue o 1 Medic Unit o 1 Safety Officer o 1 Air Cascade Unit o 1 “Rehab” Unit o 2 District Chiefs o 1 Deputy Chief (Shift Supervisor) o 1 EMS Supervisor o 1 Command Van
The department typically employs fast attack offensive operations at structure fires. Generally, fast attack or offensive operations at this department involve the first due engine company attacking the fire with a hoseline charged with water from the engine’s booster tank while water supply is being established from a hydrant. The first due engine company searches for possible victims in the immediate area. The first due ladder company initiates ventilation procedures. The second due engine company pulls a second hoseline to back up the first due engine company. The second due ladder company assists the first-in engine company with search and rescue operations. The third due engine company is assigned as the rapid intervention team (RIT). Other arriving units are assigned to assist with establishing water supply, back-up the initial engine company, search and rescue, RIT operations, assist with accountability and other duties as designated by the incident commander.
Timeline This timeline is provided to set out, to the extent possible, the sequence of events according to recorded radio transmissions. Times are approximate and were obtained from review of the dispatch records, witness interviews, and other available information. Times have been rounded to the nearest minute. NIOSH investigators have attempted to include all radio transmissions. This timeline is not intended, nor should it be used, as a formal record of events.
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The following timeline is a summary of events that occurred as the incident evolved from 1207 hours to 1645 hours on May 31, 2013. Not all incident events are included in this timeline. This timeline also lists the changing fire behavior indicators and conditions reported, as well as fire department response and fireground operations. All times are approximate and rounded to the closest minute.
Incident and Fireground Communications Time Response & Fireground Operations OEC dispatched District 68, District 28, 1207 Hours Engine 51, Engine 68, Engine 60, Engine 82, Ladder 68, Ladder 69, Safety 57, and Medic 10 for a restaurant fire. D68 requested a Tac Channel; OEC 1209 Hours assigned Tac Channel SW11. 1210 Hours Engine 51 reported “heavy smoke showing” on Tac Channel 11; District 68 acknowledged that Engine 51 had heavy smoke showing; D68 requested a 1-11 (working fire dispatch) for the incident at the “Freeway”; “This is due to the heavy smoke showing from the structure.” District 68 requested traffic control for 1211 Hours the city street next to freeway; OEC acknowledged the request for traffic control. Engine 51 arrived on scene and stated, “We got a one story restaurant; we got heavy smoke showing from the attic of the restaurant; we’ll be going in making an offensive attack; we’ll be pulling a 2½-inch attack line”.
OEC dispatched a 1-11 for a different working fire; District 68 acknowledged the 1-11. 1212 Hours District 68 on scene; “District 68 is assuming “Command””.
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Incident and Fireground Communications Time Response & Fireground Operations 1213 Hours Engine 51 to 2nd due engine company OEC advised District 68 that the (Engine 68); “We need you to lay us a line”. previous 1-11 was for an incident with Engine 68 on scene; “We are looking for a District 78 and District 83; Stand-by for hydrant.” your 1-11. OEC dispatched the 1-11 for the restaurant fire; “District 21, Engine 48, Ladder 33 and Heavy Rescue 11 respond on the 1-11”. 1214 Hours “Engine 68 has found a hydrant and will be laying into the 1st due engine (E51).” District 28 on scene; “Command” assigned District 28 as Alpha Division; Ladder 68 on scene; “Command” called OEC to advise the 1215 Hours Engine 51 to “Command”, “We have an accountability system is in place and 184oF reading the door – thermal imager operational. reading.”
OEC advised Ladder 51 was added to 1216 Hours Engine 60 staged. the incident and was responding. “Command” called OEC and requested 1218 Hours Engine 82 on scene. a 2-11 for this incident. OEC Engine 51D called Engine 51A and advised acknowledged the request. him that Engine 51 was down to a quarter tank of water; “Command” advised Engine 51A to back the line out of the building until a water supply has been established. Engine 51A acknowledged; Engine 51 reported out of the building.
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Incident and Fireground Communications Time Response & Fireground Operations OEC dispatched the 2-11. Units 1219 Hours “Command” advised L68, “Get to the roof dispatched on the 2-11 were: District 59, and cut a hole in the roof between the main District 5, Engine 28, Engine 2, Engine fire building and the motel”. Ladder 68A 16, Engine 59, Ladder 21, Mutual Aid acknowledged the order regarding cutting a Ladder 1, Rescue 42, and Safety 30. hole in the roof between the main fire building and the motel. 1220 Hours Engine 51 was backing out of the structure. “Command” sent Engine 82 to assist Engine 51. Engine 51D advised “Command” that Engine 51 had an established water supply. E51 went back inside the restaurant. “Command” assigned E68 to “Fire Attack” with Engine 51 and Engine 82. “Command” confirmed with Engine 60A that Engine 60 had been assigned as RIT; Engine 60A acknowledged that Engine 60 had established RIT. 1221 Hours Ladder 69 and Engine 48 are on location. 1222 Hours “Command” called Alpha Division and advised him that he had Engine 51, Engine 68, and Engine 82 assigned to Alpha Division. “Command” called OEC. “We have a 1223 Hours Engine 82 “A” called a “Mayday”; “We “Mayday” at our location; give me a 3- have roof collapse, “Mayday”, roof 11.” collapse, Engine 51 is inside.” OEC confirmed the 3-11. “Command” deployed Engine 60 (RIT).
OEC dispatched units for the 3-11 (3rd Alarm). Units dispatched were District 8, District 46, Engine 33, Engine 38, Engine 49, Engine 5, Ladder 28, and Ladder 16.
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Incident and Fireground Communications Time Response & Fireground Operations 1225 Hours Alpha Division called “Command” and advised that E60 (RIT) was going in the front door. E48 was assigned the secondary RIT. 1227 Hours Rescue 10 (R10) arrived on scene. Rescue 10 assigned to RIT with Alpha Division, E60, and E48. 1228 Hours Ladder 51 arrived on scene. L51 ordered to report to Alpha Division. 1230 Hours Safety 57 (SF57) arrived on scene; SF57 advised “Command” that the light and power company needed to respond for utility control. SF57 asked “Command” to consider another Tac Channel for the “Mayday” operations. “Command” contacted OEC regarding 1231 Hours Rescue 11 (R11) arrived on scene. the use of another Tac Channel. OEC “Command” ordered R11 to assist R10 with replied that Tac Channel 12 can be used the “Mayday”. for the fireground operations. The “Mayday” operations will stay on Tac Channel 11.
OEC dispatched the 4th Alarm (4-11) for the restaurant fire: District 6, District 4, Engine 73, Engine 7, Engine 508, Engine 8, Ladder 59, and Ladder 38. 1235 Hours “Command” ordered all companies not involved with the “Mayday” to switch to Tac Channel 12. 1237 Hours District 21B (Staff Assistant) “to all 3-11 (ROAD companies and 4-11 companies, switch over to Tac Channel 12; stage on the feeder (road), stage on the feeder (road).”
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Incident and Fireground Communications Time Response & Fireground Operations 1239 Hours Rescue 10A reported to Alpha Division, “We got two accounted for. They are pinned right here by this window sill. We need to get somebody on the edge to start cutting this roof away from them.” 1244 Hours L69 advised they are able to cut through the roof to access one of the trapped fire fighters. 1247 Hours “Command” is transferred to District 21(D21); D68 is assigned to manage the Rescue Group 1252 Hours Alpha Division advised “Command” that one missing fire fighter (E68A) has been removed from the building. “Command” requested a 5th Alarm for 1259 Hours Shift Commander 37 (South Division) this incident. assumed “Command”. D21 assigned as “Operations”. E508A advises “Command” that E508 has located a missing fire fighter (E51B). “Command” requested a 5th Alarm. 1301 Hours OEC dispatches the 5th Alarm (5-11) for the restaurant fire: District 19, District 26, Engine 37, Engine 47, Engine 62, Engine 80, Ladder 7, and Ladder 55. 1303 Hours Alpha Division called “Command” to advised that the front facade on Alpha Division collapsed; Fire fighters picked up the wall to remove the injured fire fighters who are treated by EMS. 1304 Hours Alpha Division advised “Command”, “RIT removed another missing fire fighter (E51B) from the interior.” The Incident Action Plan is changed by “Command” from “Rescue” to “Recovery”.
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Incident and Fireground Communications Time Response & Fireground Operations 1309 Hours Rescue Group Supervisor (D68) contacted Alpha Division regarding a PAR for E68 and E51. 1407 Hours “Command” advised “Operations” that a request for heavy equipment has been made. 1420 Hours The Rescue Group Supervisor advised “Operations” that one of the missing fire fighters had been located (E51A). 1432 Hours The Rescue Group located the two other missing fire fighters (E68B and E68C). 1438 Hours The Rescue Group and the arson investigators prepared to remove E51A from the building. 1501 Hours The Rescue Group removed E51A to Ambulance 83. 1537 Hours The Rescue Group Supervisor called “Operations” and advised that the other two missing fire fighters (E68B and E68C) were being prepared for removal. 1554 Hours Ladder 7 assisted with preparing the fire fighters from L68 for recovery. The crew from L68 removed the two missing fire fighters (E68B and E68C) from the structure to awaiting ambulances.
1605 Hours The Rescue Group Supervisor advised “Command” that the recovery process was completed. “Command” to OEC, “7-1 the incident 1645 Hours (declared under control) involving the restaurant fire. Holding all companies.”
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Building Construction and History Fire officers and fire fighters must recognize and comprehend the significance that building construction including renovation and modifications, have on the risk assessment portion of their initial size-up and deployment tactics. Many experienced fire officers and fire fighters may have found themselves in the same position as these fire officers and fire fighters when building compromise and collapse occurred in the early phases of fire suppression operations. A thorough understanding of building construction and the effects of fire dynamics within a renovated building is necessary for the officers to correctly complete an initial size-up, assess building integrity and formulate applicable strategies.
It is easy to just say a defensive strategy should be employed in a fire that cannot be controlled with an offensive attack. This incident had considerations unknown to the responding fire officers and fire fighters that caused a collapse of the structure. The following information on the particular construction and alterations made will give both experienced and developing fire officers and fire fighters a better understanding of considerations for risk assessment and the predictability of performance in similar buildings in their locality.
The structures on the property were constructed in 1966 and were built under adopted building codes that were in effect at the time. The structures on the property consisted of a motel, restaurant, and a sports bar consisting of more than 26,000 square feet. The restaurant and sports bar were one-story structures attached to a two-story facility which housed the lobby, offices, banquet rooms, and meeting rooms for the motel. The property had seven stand-alone buildings that were two-story structures containing motel guest rooms. These buildings were not attached to the main fire building. (See Diagram 1.)
According to records from the city’s Building Inspections Office, the structure was built on a concrete slab with no basement or sub-levels. The building classification was based on its usage and determined to be an “A-2 Assembly occupancy intended for food and drink”. The structure was considered to be a Type V – Wood Frame building in accordance with NFPA 220, Standard on Types of Building Construction.5 When this facility was constructed in 1966, the building code did not require the installation of a sprinkler system.
The restaurant, banquet facilities, and motel lobby area had undergone several renovations. Available information on these renovations was limited in the documentation provided by the city’s Building Inspections Office. The dates, permits, and modifications that were obtained indicate the following renovations were made as follows: 1995: Commercial electrical work; Re-roof and sheetrock repairs: permit issued but no inspections made of this work; 1996: A new front canopy (remodel flat roof canopy to tower roof canopy design– no plans
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Diagram 1. The site plan for the motel, restaurant, and bar. The area of
origin was determined to be in the attic/crawlspace above the kitchen.
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were approved and no permit was issued); 1998: A fire occurred on the premises but there was no available information; Restaurant sold and name change occurred; 2004: Occupancy sold to current owner; No major renovations per the department’s Arson Bureau;
The city’s Building Inspection Office routinely conducts inspections of commercial occupancies to enforce the municipal electrical, mechanical, plumbing, and construction codes. The fire department’s Fire Marshal’s Office conducts fire inspections of commercial occupancies using the 2006 edition of the International Code Council (ICC) Fire Code.6
According to the department’s Assistant Chief of the Fire Marshal’s Office, the restaurant, hotel, and sports bar were on a 3-year inspection cycle. The last inspection occurred in 2012 and the occupancy was fully compliant with the fire code requirements. Fire department records showed that a fire occurred in the restaurant kitchen in November 2012. The range hood system in the kitchen contained and extinguished the fire. The incident was reported as a “fire out” and Engine 51 was the only fire department resource dispatched. The Fire Marshal’s Office was notified as was the city’s health department to inspect the kitchen. This was to insure the necessary repairs were made and the necessary cleanup was completed before the facility could re-open. The last Alarm Permit was issued by the Fire Marshal’s Office on April 07, 2013.
Construction and Materials Note: The description of the building construction and collapse scenario was provided to NIOSH FFFIPP investigators by Christopher J. Naum. This material is based upon information obtained by NIOSH FFFIPP investigators during this investigation and from publicly available sources.
Building alterations over the period of 1966-2013 varied distinctly with different building materials, structural components and roof lines added to the original building footprint. Various additions were added or areas expanded based on the varying gable roofs observed from aerial views of the building. The presence of infill flat roofs appeared to have been integrated with existing building compartments and roof lines. Large and small area gable-style roofs were common with engineered wood trussed systems (engineered structural systems) being incorporated along with flat roofs constructed on both wood and non-combustible materials, load bearing walls, steel beams and columns and masonry, wood frame and veneer construction features.
The primary roof support systems for the gable roofs were metal-plate-connected (MPC) wood truss systems of varying spans, and roof pitch, except for the restaurant roof that is suggested to have been constructed utilizing a lap-nailed wood truss system. A lap-nailed wood truss system utilizes nails (versus MPC) as the mechanical fastener to secure the truss components together in an assembly to provide structural support as a configured truss component. Another predominate architectural feature was the incorporation of extruded concrete interlocking roof tiles as a roof covering on the main building fronting on Side Alpha. Note: According to the report issued by an independent structural engineering firm hired by the city, the additional weight added by the cement clay tiles did create an
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eccentric/dead load. The remaining buildings incorporated asphalt roofing shingles as the roof covering. All of the roof assemblies appear to have incorporated wood sheathing and underlayment. (See Diagram 2.)
Restaurant Roof Design The restaurant facility located at the east side of the main entrance (lobby building) with its main entrance on Division Alpha, had a gable-style roof assembly constructed of an engineered wood truss components incorporating a lap-nailed truss configuration. This type of truss configuration is not commonly found or referenced in fire service case studies or incidents. Unlike other conventional engineered gable truss systems that utilize sized wood components that are fastened and secured utilizing a metal-plate-connected (MPC) that result in an engineered truss, the lap-nailed wood truss system utilizes nails (versus MPC) as the mechanical fastener to secure the truss components together in an assembly to provide structural support as a configured truss component. The truss webs and cords are configured in their defined orientation and angles and fastened utilizing a defined quality and sized metal nail fasteners and connected on the vertical face of the corresponding truss component.
Diagram 2. The truss roof design of the small Banquet Room and the Kitchen. (Diagram courtesy of the fire department)
Diagram Courtesy of Buildingsonfire.com Page 17
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Early in the 1960s, the development of wood roof trusses for residential type construction and applications provided alternatives for contractors and designers. Using the strength of the triangle—the simplest geometric shape—designers were able to come up with space frames made of smaller, light weight framing members, which could span greater distances and could support ceiling finishes. When wood roof trusses were first built, wood plates (gussets) and nails held the joints of the truss together. Soon, these joints became metal plates with nails and finally, stamped metal plates and metal plate connectors to connect the truss components together.7
Adequate connection of the framing members and structural systems is a critical design and construction consideration. Regardless of the type of structure or type of material, structures and components are only as strong as their connections, and structural systems can behave as a unit only with proper interconnection of the components and assemblies.8, 9
The city hired an independent structural engineering firm to determine if the roof structure collapsed due to being overloaded or collapsed due to the fire. The conclusion from the independent structural engineering firm was the roof collapsed due to the fire and not due to insufficient structural capacity of the roof truss. This determination was made based on the observance of post-fire structural framing components (e.g. lumber, supports, connections, etc.) as well as additional internal and external construction material that was salvaged from the site.
Note: The large number of individual roof systems comprised of flat and gable pitch roofs represent the ongoing process of renovations, alterations and expansions that the property and buildings shared over its 45 year history. The gable roofs were constructed of truss assemblies, with large clear spans in the main building. These incorporated a number of different vintage style metal plate connectors (MPC) for the fastening method on truss webs and chords. This was in contrast to the lap-nailed truss assembly found in the roof assembly of the restaurant occupancy.
The restaurant’s perimeter wall (resulting secondary collapse) is visible with the underside of the roof decking and the remnants of roof truss bottom cords. The edge of the roofing tiles can be seen along upper lateral roof edge. (See Photo 1.)
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Photo 1. View of Division Alpha Perimeter Wall & Lean-To Roof Collapse (Fire Department Photo/ Diagram Courtesy of Buildingsonfire.com)
[1] Roof Sheathing-underside [2] Edge of Roof Truss Bottom Cords (24 inch on-center) [3] Edge of Roofing Tiles [4] Charring from flame impingement [5] Restaurant Perimeter wall [6] Secondary Collapse Management Zone (SCMZ)
Concrete Tile Roofing System An extruded concrete interlocking roof tile system was installed over the existing roofing surface and deck that comprised the restaurant roof. This was a similar tile system that was installed on both the large entry portico and the main entrance/lobby gable roof. The extruded concrete roof tiles are interlocking elements having the dimensions and configurations shown in the accompanying table and figures. Accessory tile units are available for ridge, hip and gable areas. The regular-weight tiles are composed of Portland cement and selected sand aggregates. The mix proportions are accurately maintained to ensure tile production in accordance with the specifications. Anchor lugs, located on the
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underside of the tiles overlap wood battens fastened to the roof deck or surface for anchorage in the plane of the roof. Holes are provided in each tile for fastening where required by the installation.
Interlocking ribs are provided on the longitudinal edges of the tiles to restrict lateral movement and provide a water stop. In addition, transverse bars are provided on the underside to serve as weather checks. Mineral coloring oxides are either applied to the exposed surface in a cementitious material or mixed integrally with the tile mix to produce a through-colored product. Concrete interlocking roof tile profiles and details are provided based on technical literature. 10, 11, 12 (See Photo 2 and Diagram 3.)
Photo 2. Concrete Roofing Tiles - Post Fire (NIOSH Photograph)
Due to the absence of historical construction records and specifications, the roofing tile was identified based on the roofing tile manufacturer imprint. This is typically found on the underside of each tile unit. A likely tile unit style was identified, which is consistent with the figures developed and specifications.
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Diagram 3. The concrete roofing tile details which were on Side Alpha of the Small Banquet Room. (Photo: NIOSH/ Diagrams Courtesy of Buildingsonfire.com)
It is highly probable the exiting extruded concrete interlocking roof tiles present on the roof assembly consisted of Roma Style, regular-weight tiles. The individual tile units measured 16.5-inches in length x 13-inches in width x 2-inches in height. The single unit installed weight was 9.3 pounds per square foot (psf.).10
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This weight is in slight contrast to the weight identified in the independent structural engineering firm’s report that indicated a weight of 10.8 psf. For the purpose of this report, calculations and discussions related to roof tile weights area based on 10.8 psf.
The use of extruded concrete interlocking roof tiles is a common architectural treatment and is ubiquitous to a number of geographical areas in the United States. These roof tiles can be found anywhere in the regional and local level due to the component’s popularity and consumer demands. It could be expected to be found on residential, commercial, and retails occupancies.
The presence of extruded concrete roof tiles presents significant increased dead loading to a roof diagram and structural system. This places additional dynamics to the roof system based on day to day performance that can also be affected by age, time, exposure, and ambient temperature gradients within the truss loft compartment-attic area. Research has shown that extended duration of time (years), duration of load for longtime truss performance, and the effects of elevated temperatures within the truss loft space suggest quantifiable structural wood member strength loss. This includes for both tension and compression that affect overall system performance in both pre-incident and during fireground operations for projected or actual fire exposures .13, 14, 15
Based on initial engineering reviews, and subsequent analysis the following insights are provided on the exiting restaurant roof; Plywood Roof Deck 1.00 lbs. psf. Existing Shingles 2.70 lbs. psf. Asphalt Felt Rolls 0.40 lbs. psf. Wood Shiplap 2.30 lbs. psf. Concrete Roof Tiles 10.80 lbs. psf. Total 17.20 lbs. psf.
Roof System with Extruded Concrete Tiles at 17.20 lbs. psf. @1280 SF = 22,016 lbs. load Roof System with Shingles only (No Tiles) at 4.10 lbs. psf. @1280 SF = 5,248 lbs. load (Adding roofing tiles increases roof load by 13.1 lbs. psf. resulting in a 76.2% increase)
Collapse Predictions: A roof and structural support system when insulted by heat and fire impingement, exposure and wood consumption will degrade and have overall structural integrity and load-carrying capacity weakened in a relative time frame under different load factors. Given relatively similar variables such as roof foot print, volume, structural support and fire intensity: The heavier the load; the higher probability for a decreased time-to-collapse window during the conduct of fireground operations. A lighter roof system (total pounds per square foot) with a clear span will likely fail in a compromising fashion resulting in a probable isolated compromise (sagging or bending) collapse configuration. (Based on integrity of the bottom chord and degree of web weakening) A roof system with a significant overall load (total pounds per square foot) with a clear span will likely fail in a catastrophic collapse configuration in a shorter time span.
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Small foot print (square foot), open span roofs comprised of a variation of structural systems: conventional, engineered and materials: wood, non-combustible, steel etc., have typically failed in catastrophic manner due to the loss of structural resiliency, redundancy, load carrying and transfer capacity and loss of diagram or deck integrity. 16, 17, 18, 19
Fire Performance Characteristics of Wood and Fire Impingement Wood will burn when exposed to heat and air. Thermal degradation of wood occurs in stages. The degradation process and the exact products of thermal degradation depend upon the rate of heating as well as the temperatures. This concept has direct relevancy to the sequence of events at the complex and the suggested impact on the roof compromise and collapse. The sequence of events for wood combustion is as follows: The wood, responding to heating, decomposes or pyrolyzes into volatiles and char. Char is the dominant product at internal temperatures less than 572°F (300°C), whereas volatiles become much more pronounced above 572°F. The volatiles, some of which are flammable, can be ignited if the volatile–air mixture is of the right composition in a temperature range of about 752°F to 932°CF (400°C to 500°C) within the mixture. This gas-phase combustion appears as flames. With air ventilation, the char oxidation becomes significant around 392°CF (200°C) with two peaks in intensity reported at 680°F and 968°F (360°C and 520°C). This char oxidation is seen as glowing or smoldering combustion until only ash residue remains. This solid-phase combustion will not proceed if flaming combustion prevents a supply of fresh air to the char surfaces.
Several characteristics are used to quantify this burning behavior of wood, including ignition from heat sources, growing rate of heat release leading to room flashover, flame spread in heated environments, smoke and toxic gases, flashover, and charring rates in a contained room. 8, 13, 20, 21, 22 Ignition of wood takes place when wood is subject to sufficient heat and within compartment atmospheres that have sufficient oxygen. Ignition can be of two types: piloted or unpiloted. Piloted ignition occurs in the presence of an ignition source (such as a spark or a flame). Unpiloted ignition is ignition that occurs where no pilot source is available. The wood surface is ignited by the flow of energy or heat flux from a fire or other heated objects. This flow of energy or heat flux can have both convective and radiative components. The surface temperature of wood materials has been measured somewhere between 572°F and 752°F (300°C to 400°C) prior to piloted ignition.
Surface temperature at ignition is an elusive quantity that is experimentally difficult to obtain. From such tests, values of ignition temperature, critical ignition flux (heat flux below which ignition would not occur), and thermo-physical properties have been derived using a transient heat conduction theory. These properties are material dependent; they depend heavily on density of the material and moisture content. A range of wood products tested have ignition surface temperatures of 572°F and 752°F (300°C to 400°C) and a critical ignition flux of between 10 and 13 kW/m2 in the cone calorimeter. The ignition surface temperature is lower for low density woods.
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The Southern Yellow Pine wood used in the truss assembly has a 130 - 195 Flame Spread Index (FSI) in accordance with Underwriters Laboratories (UL) and a Char Contraction Factor of 0.60 (wood exposed to ASTM E119 exposure) and an average mass loss rate (g m2 s 1) of 3.8 and 8.6 for exposure to a constant heat flux of 18 kW m2 and 55 kW m2 respectively. This is based on an initial moisture content of 8-9%. The “Char Contraction Factor” is the thickness of the char layer at end of fire exposure divided by the original thickness of charred wood layer (char depth).23
Heat Release Rate (HRR) is the rate at which fire releases energy - this is known as power. HRR is measured in units of Watts (W), which is an International System unit equal to one Joule per second. Depending on the size of the fire, HRR is measured in Kilowatts (equal to 1,000 Watts) or Megawatts (equal 1,000,000 Watts). Heat Flux is the rate of heat energy transferred per surface unit area - kW/m2: 2.5 kW/ m2: Typical firefighter exposure 3-5 kW/ m2: Pain to skin within seconds 20 kW/ m2: Threshold flux to floor at flashover 84 kW/ m2: Thermal Protective Performance (TPP) Test (NFPA 1971) 60 - 200 kW/m2: Flames over surface
Select wood construction systems and members have long been recognized for their ability to maintain structural integrity while exposed to fire. This is attributed to the charring effect of wood. As wood members are exposed to fire, an insulating layer is formed that protects the core of the section. Fire exposure and resistance are defined in both ASTM E119 and internationally in ISO 834.20 The concept of wood charring, fire resistance and building integrity are rooted in heavy timber, mill and semi-mill construction.24
The importance of understanding the principle of charring, the potential for reduction in a wood material’s cross section, considerations for fire impingement, exposure, fire duration, intensity and the material compositions, characteristics, age, physical properties and the construction system(s) utilized are important fireground factors. These factors must be understood, recognized and considered during fire operations in buildings with heritage, legacy, conventional, or engineered structural system or wood frame components.
Important factors for fire officers and fire fighters. This understanding and correlation is fundamental to the impact of fire to the wood truss loft of the restaurant occupancy of the complex. Given the suggested timeline of events and the prolonged elapsed time from the first notice of a burning odor to the time in which both smoke and flames were self-revealing, it is highly probable a smoldering condition was present within the truss-loft compartment. This condition may have led to the exposed wood truss components (chords and webs) responding to heating, decomposition and pyrolyzes into volatiles and char. Sufficient oxygen is introduced and air ventilation in the compartment space The wood components ultimately ignite and the sustained fire grows in intensity, severity and direct and scale.
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The loss of wood cross-section (mass) continued both in the smoldering phase and fire growth phase leading to the loss of redundancy capabilities of the truss assembly, possible buckling and excessive deflection of truss members. 8, 9, 25 (See Diagrams 4, 5, 6, and 7.) o Soft wood pyrolysis and charring = 1 inch per 40-45 minutes at 1400°F to 1600°F o 1.5 inches per 60 minutes o 0.9 mm per minute Complete loss of wood cross-section due to flame impingement results in structural compromise of the truss component to perform as designed to carry and transfer loads. Uneven deterioration or burn thru of webs (loss of tension and compression) and the possible loss of the bottom chord’s stability would lead to structural compromise. If the roof diaphragm and compromised trusses continue to be affected by degradation, then the significant dead load from the extruded concrete roof tiles would hasten the time to collapse. The potential for monolithic and catastrophic collapse would impact the entire roof. The surface to mass ratio of the exposed wood truss members with the increased surface area results in increased consumption and degradation of the wood, leading to decreased cross sectional dimensions and decreased load-bearing capacity of the structural components. 8, 9, 21 (See Diagram 4.) The configured lap-nailed wood truss system utilizes nails (versus metal plate connected) as the mechanical fastener to secure the truss components together in an assembly to provide structural support as a configured truss component. o There is little accessible research or case studies that provide insights as to performance and structural integrity of lap-nailed wood truss systems that could be correlated to this incident. o The unique truss system coupled with the significant load presented by the tile roof suggests and the mechanics of the roof collapse presents questions that cannot be ascertained with present data or information.
Connections are arguably the most important part of a light-frame wood structure. They hold structural components together and transfer forces from one to another. The response of nail connections under applied loads is normally non-linear and is dependent on various factors such as moisture content, wood species, load direction and fastening geometry and configuration.26
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Diagram 4. Reduction in Wood Component Breadth and Depth over time, (Diagram Courtesy of Buildingsonfire.com) [Adapted from AWC Technical Report #10 (2012)]
Diagram 5. Charring Effect on Wood Component and Cross Section (Diagram Courtesy of Buildingsonfire.com)
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Diagrams 6 and 7. Anatomy of a Truss - Assembly Compromise and Collapse (Diagram Courtesy of Buildingsonfire.com)
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Other Collapse Contributors Age of the roof system and loss of moisture content and susceptibly to heat and ignition sources and lack of resistance and resiliency to impingement and exposure; vulnerability of truss web members to flame spread based on age and FSI of the wood species. The degree of time (years) the roof system has imposed loading with the effects of wood fatigue and resiliency. 9, 21, 23, 26 Based on the postulated mechanism of collapse and the resulting lean-to collapse configuration of the partial roof diaphragm along the Alpha Division (North perimeter wall), the condition of post- fire truss components likely generated uneven burning and increased structural compromise of the truss components occurred along the south perimeter or area of the restaurant roof than did along the north perimeter. This increased level of deterioration and/or loss of web performance or materials (due to fire) would cause the wood truss to fold in on its self-downward, and forward toward the front perimeter wall. This series of structural compromise and failure results in a mechanism of collapse that pulls and deflects the roof diaphragm downward, bucking remaining truss components with momentum that results in a pancake collapse of the southern roof deck from the ridge to the south eave line and a lean-to collapse of the roof deck from the ridge to the north eave line. (See Diagrams 8, 9, 10, and 11.) The effects of fire and the impact on structural stability of wood truss components and collapse timelines has been researched in two distinguished research studies.19, 27, 28 It should be noted both referenced studies involved initial compartment fires below the ceiling membrane.
Additional information on Building Construction related to this incident is provided in Appendix One: Additional Building Information and Appendix Two: Fire Fighter Risk Profile and Insights.
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Diagram 8. Anatomy of the Restaurant Roof Collapse (Diagram Courtesy of Buildingsonfire.com)
Diagram 9. Anatomy of the Restaurant Roof Collapse (Diagram Courtesy of Buildingsonfire.com)
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Diagram 10. Anatomy of the Restaurant Roof Collapse (Diagram Courtesy of Buildingsonfire.com)
Diagram 11. When the collapse of the roof occurred, it formed a void area trapping fire fighters from E51 and E68 (Diagram courtesy of the fire department)
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Secondary Collapse of Perimeter Wall Perimeter wall areas that have wall penetrations in the form of windows, doorways, openings for service equipment such as wall mounted heating, ventilation, and air conditioning (HVAC), or mechanical equipment are highly susceptible to compromise and collapse when structural load transfers occur.
At 1303 hours, during the search and rescue operations for the trapped fire fighters, a secondary collapse occurred on the exterior side of the building on Division Alpha. The resulting collapse of the entire roof deck diaphragm and structural support system plus the dynamic downward and lateral momentum and movement of the roof system resulted in an outward bowing and push-out of the north perimeter wall. The greatest risk of collapse in the immediate area was between the north entrance door and the wall area between the two exiting windows. The decking, north of the ridge centerline, came downward in a more monolithic and intact manner than that of the south roof deck surface. It was reported the entire roof along the centerline of the peak came downward in a monolithic manner, with the resulting impact on the floor in a pre-dominate pancake configured collapse. (See Photo 3.)
The roof deck came to rest in a slight lean-to configuration creating lateral forces acting upon the outer (north) perimeter wall. This degraded the integrity of the gypsum wall board and wood stud frame wall and caused cracking along the outer wall. Since the primary entry point to the interior of the restaurant was located on the Side Alpha, this was the entry point for the initial handline taken in the building.
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Photo 3. Details of the secondary collapse on Side Alpha. (Photo courtesy of the fire department/Analysis Diagram Courtesy of Buildingsonfire.com)
Fire Behavior and Extension The department’s Arson Bureau determined that the fire started three hours prior to the 9-1-1 call at 1205 hours on May 31, 2013. During that time the fire had a chance to spread into the area above the first floor. There was an office and open area on the second floor of the hotel. The open void space was accessible through the 2nd floor office. This area went from Side Bravo to Side Delta or at least to the Sports Bar. The ATF agents interviewed maintenance workers that had performed work and had accessed this area. This open void space provided an avenue for fire spread. (See Photo 4.)
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Photo 4. The arrows indicate the support system for the 2nd floor and void space above the restaurant and lobby area of the motel. (Photo courtesy of the fire department)
Personal Protective Equipment At this incident, each officer and fire fighter were wearing a station/work uniform, turnout pants, turnout coat, hood, helmet, boots and a self-contained breathing apparatus (SCBA) with integrated personal alert safety system (PASS) meeting current NFPA requirements. Each SCBA is equipped with a TPASS, which is a two-way personal alert safety system (PASS) that transmits alarms and receives evacuation signals.
NIOSH investigators inspected and photographed the officer and each fire fighter’s personal protective equipment at the Arson Division office. The SCBA and turnout gear inspected had sustained a variety of thermal damage as the result of the exposure to the fire and damage from the collapse in the
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restaurant. Four SCBA units were shipped to the NIOSH National Personal Protection Technology Laboratory (NPPTL) in Pittsburgh, Pennsylvania for evaluation.
On February 20, 2014, NPPTL personnel in Pittsburgh evaluated the SCBA and the summary evaluation report is included as Appendix Three: Summary of Personal Protective Equipment Evaluation – SCBA.
On January 30, 2014, an independent contractor inspected and evaluated the personal protective equipment (PPE). The independent contractor was retained by the fire department. The summary evaluation report is included as Appendix Four: Summary of Personal Protective Equipment Evaluation – Fire Fighter Protective Ensemble.
The TPASS system was shipped back to the manufacturer for testing and evaluation. Due to a problem with the unit’s battery, no information could be downloaded.
Weather Conditions At 1153 hours, the temperature was 86 degrees Fahrenheit (86o F), the humidity was at 65%, the barometric pressure was 29.92 inches, visibility was 10 miles, the wind was from the South at 13.8 miles per hour, with gusts to 23 miles per hour and there were scattered clouds. There had been no precipitation in the past 24 hours.29
Wind-Driven Fire During this investigation, NIOSH Investigators determined, through interviews and discussion with the chairman and members of the department’s Recovery Committee, that a higher than normal wind speed had occurred on this date. A determination was made that this was a contributing factor to the spread and difficulties faced by the fire department at this fire.
The front of the building (Side Alpha) faced northwest. Engine 51 arrived on scene and entered the restaurant through the front door of the restaurant, which was the northwest side. This entry point would become Division Alpha. It is believed that the wind coming from the southwest at a constant speed of 17+ miles per hour (MPH) and gusting to 23+ MPH clearly affected the tactics that took place at the beginning of the fire. Another theory is that the high-rise structure (commercial hotel) located to the southwest of the fire building also created a wind break. This in turn forced high wind patterns to be channeled around both sides of the structure. The wind then funneled down towards the hotel directly into Division Charlie.
The National Institute of Standards and Technology (NIST) has conducted research and testing on the impact of wind-driven fires and fireground operations. Adjusting fire-fighting tactics to account for wind conditions in structural fire-fighting is critical to enhancing the safety and the effectiveness of fire fighters. Studies have demonstrated that applying water from the exterior, into the upwind side of the structure can have a significant impact on controlling the fire prior to beginning interior operations. It should be made clear that in a wind-driven fire, it is most important to use the wind to your advantage and attack the fire from the upwind side of the structure, especially if the upwind side
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is the burned side. Interior operations needs to be aware of the potential for rapidly changing conditions.30
During the initial attack, and well into the rescue, the direction of these strong winds made Division Charlie the intake side of the structure and placed Division Alpha as the exhaust point. The smoke was blowing across the fireground vertically limiting the visibility of members conducting fire attack, ventilation, and rescue. Crews were faced with extreme heat and smoke conditions that would continue to increase and hamper their efforts. (See Photo 5.)
Photo 5. The smoke conditions encountered by the 1st Alarm companies. This picture is looking north on the feeder road and the freeway. E82 is parked on the shoulder of the freeway and Rescue 10 is on scene. The time is approximately 1224 hours. (Photo courtesy of the fire department)
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4 Fire Fighters Killed and 16 Fire Fighters Injured at Commercial Structure Fire – Texas
Investigation On Friday, May 31, 2013, at 1205 hours, the first 9-1-1 telephone call was made to the city’s Office of Emergency Communications (OEC) (9-1-1 Call Center) reporting a fire in a restaurant. The OEC would receive 16 more calls reporting this structure fire.
At 1207 hours, the Office of Emergency Communications dispatched District 68, District 28, Engine 51, Engine 68, Engine 60, Engine 82, Ladder 68, Ladder 69, Safety 57, and Medic 10 for a report of a restaurant fire. Note: The engineer/operator from Ladder 51 was detailed to Engine 51 and assigned as E51B. Ladder 51 was assigned to a meeting and the engineer/operator switched with a fire fighter on E51. Several companies reported dark gray and brown smoke showing while enroute. At 1210 hours, District 68 requested a 1-11 (working fire dispatch) for the incident due to the heavy smoke showing from the structure. (See Photo 5.)
Engine 51 arrived on scene at 1211 hours and the captain stated, “We got a one story restaurant; we got heavy smoke showing from the attic of the restaurant; we’ll be going in making an offensive attack; we’ll be pulling a 2½-inch attack line.” E51 originally pulled into the parking lot near Side Delta upon arrival. E51was then directed by an employee to move towards the restaurant Side Alpha. The crew from E51 pulled a 2½-inch pre-connect from the rear of E51. The hoseline was charged using water from the E51’s booster tank (750 gallons). D68 ordered Engine 68 to lay dual 4” supply lines from E51 to the hydrant. The hydrant which E68 used was located on the feeder road northwest of the restaurant near a moving and storage facility.
At 1213 hours, District 68 arrived on scene and assumed “Command”. OEC advised “Command” that 1-11 companies would be District 21 (D21), Engine 48 (E48), Ladder 33 (L33) and Heavy Rescue 11 (HR11). At 1214 hours, District 28 (D28) and Ladder 68 (L68) arrived on scene. D28 contacted “Command” about L68 wanting to cut a vent hole on Side Delta of the building. “Command” instructed D28 not to cut a vent hole until the fire was located. “Command” assigned D28 as “Alpha Division”. At 1215 hours, the captain from E51 began to make entry with two fire fighters from E51 with a charged 2½-inch handline. The captain advised “Command” of “a thermal imager reading of 184oF at the door before entering the structure.” At 1216 hours, Ladder 51 (L51) was added to the incident record and responded. “Command” asked Alpha Division if the restaurant was attached to the motel and the response was “Yes”. At 1217 hours, “Command” contacted L68 about cutting a ventilation hole in the roof between the restaurant and the motel. This communication was not acknowledged for almost two minutes.
At 1218 hours, Engine 82 (E82) arrived on scene and requested an assignment. Also, Rescue 10 (R10) was added to the incident record and responded. “Command” ordered Engine 60 to be the rapid intervention team (RIT). E82 again tried to contact “Command” by radio about an assignment. The officer from E82 did a face-to-face with “Command” about an assignment and was told to assist E51 with fire attack. The engineer/operator of E51 (E51D) advised the captain of E51 (E51A) that E51 has less than a quarter tank of water. “Command” ordered E51 to back out of the building until a water supply could be established. Note: During the interview with the fire fighter from E51 (E51C),
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he described conditions inside the building. He stated it was very difficult to move in the banquet room due to the tile floor being wet from condensation and water from the hoseline.
“Command” contacted OEC and requested a 2-11 (2nd Alarm) for this incident. At 1219 hours, OEC dispatched District 59, District 5, Engine 28, Engine 2, Engine 16, Engine 59, Ladder 21, Automatic Aid Ladder 1(a truck company from a municipality located within this city), Rescue 42, Safety 30, Rehab 17, and Shift Commander 37 (South Command). “Command” acknowledged the dispatch of the 2-11. E68 contacted “Command” for an assignment. At 1220 hours, E51A contacted “Command” and advised that E51 would re-enter the building. “Command” acknowledged E51A and advised that E82 would be assisting E51 with fire attack. (See Diagram 12.) E68A attempted to contact “Command” again for an assignment. “Command advised E68A to assist E51 with fire attack and E68A acknowledged the assignment. At 1221 hours “Command” contacted E60 to confirm that E60 had assumed RIT and E60A confirms the assignment. Also, L69 and E48 arrived on scene.
Due to the heavy smoke conditions, “Command” contacted E51A and asked which side of the building they entered. E51A advised “Command” that E51 had entered on Side Alpha. At 1222 hours, “Command” contacted Alpha Division (D28) and advised him to remain on Side Alpha of the building. “Command” asked if he had E51, E82, and E68 operating in Alpha Division? Alpha Division reported back to “Command” that E68, E82, and E51 were in Alpha Division. Alpha Division advised there was heavy fire showing from Side Bravo and entry was made into the building on Side Alpha.
At 1223 hours, E82A reported to “Command” “that a roof collapse had occurred and there was a “Mayday” with E51 inside. E82A repeated “E82 “Mayday” “Mayday””. “Command” immediately requested a 3-11 (3rd Alarm) for the restaurant fire. OEC immediately dispatched: District 8, District 46, Engine 33, Engine 38, Engine 49, Engine 5, Ladder 28, Ladder 16, and EMS11 for the 3-11.
The time from dispatch of this incident until the roof collapsed was 15 minutes and 29 seconds. E51 arrived on scene at 12:11:25 and the roof collapse occurred at 12:23:24, which was 11 minutes and 59 seconds.
At 1224 hours, “Command” radioed for all companies to evacuate the building due to a “Mayday” in progress. OEC also announced the following message, ““Mayday”, a “Mayday” has been called; all units sound your air horns for 30 seconds.” OEC announced, “All units need an immediate PAR, all units need an immediate PAR.” “Command” called E51 and asked if they could provide a location. “Command” assigned E48 to RIT and advised Alpha Division. At 1225 hours, “Command” (District 68) announced, ““Command” to all companies, we’re in Rescue Mode. We have a “Mayday” at our location, RIT companies can you give me any information.” At 1226 hours, Alpha Division reported that “the crews” were just inside the front door and Engine 60 was inside looking for E51 and E82. At 1227 hours, Alpha Division reported that the RIT couldn’t access the area where E51 was thought to be located through the front door. RIT crews tried to gain access through the two front windows. Engine 28 and Rescue 10 arrived on scene. “Command” assigned R10 to Alpha Division to assist
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with RIT operations. The Accountability Officer attempted to contact E51, E60, and E68 by ordering them to “check PAR”.
Diagram 12. The initial fire attack by the crews of Engine 51 and Engine 82. The time is approximately 1215 hours.
At 1228 hours, E82 reported to “Command” that they were out of the building and were not the ones trapped. E82A reported that he didn’t know where E51 was located. After about 45 seconds, E82A then advised “Command” that E51 was located inside the front door of Side Alpha and to the left of the doorway. (See Diagram 13.) At 1229 hours, Alpha Division requested two additional companies to assist with RIT operations. At 1230 hours, Safety 57 (SF57) arrived on scene and requested that “Command” contact the power company to secure the power to the building. “Command” reported, “the “Mayday” would stay on the current channel and the Main Command should go to another channel.” District 68 announced” D68 would stay on Tac Channel 11 with the “Mayday” companies (designated as Rescue Operations Section). Note: The proper ICS term is Rescue Group Supervisor. “Command” called District 21 (D21) and ordered him to go to another Tac Channel and assume “Command” of the fire”. OEC advised “Command” companies should use Tac Channel 12 for the
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incident and the “Mayday” should stay on Tac Channel 11. At 1231 hours, the Rescue Group Supervisor (using the designation “Command”) requested a 4-11 assignment (4th Alarm). OEC dispatched District 6, District 4, Engine 73, Engine 7, Engine 508, Engine 8, Ladder 59, and Ladder 38. Heavy Rescue 11 reported on scene at 1231 hours.
Diagram 13. The location of the officers and fire fighters of Engine 51 and
Engine 68 when the roof collapse occurred in the Small Banquet Room and
Kitchen area at 12:23:24 hours.
At 1232 hours, Engine 48 reported to “Command” that they had a member on their crew collapse due to heat exhaustion. The crew of E48 would get the member out of the structure through the front window. Once E48 had the member outside, the fire fighter was taken to the Medical Group for treatment and transport. E51B’s portable radio keyed up with no transmission. Note: E51B’s portable radio would key up intermittently for the next 32 minutes until he was removed from the structure. The approximately 20 transmissions would last as short as 2 seconds and as long as 66 seconds. The department’s investigation determined the cause of these transmissions was caused by the radio accessory on the SCBA failing due to the radiant heat. The wires would inadvertently touch and key the radio. At 1233 hours, Alpha Division (D28) reported that RIT crews don’t appear to be in the correct location. Crews were going into the building with saws to cut through the roofing material.
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Crews operating inside as Rescue Group were E60, E48, E82, E508, L33, L51, L28, TL69, Rescue 10, Rescue 42, and Heavy Rescue 11. District 68 was the Rescue Group Supervisor. At 1234 hours, L68 reported to “Command” “that the fire is running the roof and the apartment complex is in the process of being evacuated.” Note: L68 is referring to the two-story motel rooms located on Side Charlie of the facility. (See Diagram 1.)
At 1236 hours, the Rescue Group Supervisor (District 68) announced on Tac Channel 11, “Command” to all companies, go to Tac Channel 12, if you are not involved in the “Mayday”. One minute later, “Command” announced that all companies assigned to the 3-11 and 4-11 switch to Tac Channel 12 and stage on the feeder road. At 1238 hours, Alpha Division requested that “Command” assign additional resources to Charlie Division so that an attempt could be made to gain access to the “Mayday” crews from a different location.
At 1239 hours, Rescue 10 contacted Alpha Division with “Emergency Traffic”. R10 located two of the missing fire fighters (E68B and E68C) near the front of the “Small Banquet Room”. R10A detailed the necessary steps that needed to be taken to reach these two fire fighters. Note: At this point in the incident, radio communications were severely hampered due to significant radio traffic which overloaded the radio system. Alpha Division contacted “Command” regarding the use of an aerial ladder above the roof to assist with the rescue of E68A. At 1242 hours, Charlie Division (District 59) attempted to contact “Command” regarding the use of a handline to attack the fire from Side Charlie. This generated a response from the Rescue Group Supervisor and “Command” regarding the effect of the hoseline on the rescue operations. Charlie Division had Ladder 76 trying to get a handline in operation at the Bravo/Charlie corner. Charlie Division requested a ladder company be moved to this area to set-up a ladder pipe.
At 1247 hours, the Rescue Group Supervisor contacted Alpha Division (D28) regarding a possible collapse of the front façade on Side Alpha of the restaurant. Alpha Division replied back that there was a possibility of collapse based upon the cracks in the façade and the front wall being pushed out by the roof collapse. (See Photo 6.) Alpha Division requested that L69 start flowing their ladder pipe in order to keep the fire off the rescue operations. Alpha Division requested another handline be brought to Side Alpha. At 1249 hours, Charlie Division requested an engine company be moved to the Bravo/Charlie side to stop the fire from moving into Charlie Division. The Rescue Group Supervisor advised Charlie Division to standby as the main focus was on the RIT operations. At 1251 hours, the ladder pipe from L69 was opened. The stream struck several fire fighters and officers in the parking lot before the ladder pipe could be directed onto the fire.
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Photo 6. A 20 ft. x 8 ft. foot section (160 SF) of compromised perimeter wall collapse into the immediate area directly in front of the structure. Three members from the Rescue Group became trapped under falling debris that resulted from the secondary collapse. These firefighters were quickly removed by other members in the immediate area and then taken to awaiting EMS crews. The time is approximately 1225 hours. (Photograph courtesy of the fire department)
At 1252 hours, Alpha Division reported to “Command” that one missing fire fighter had been removed from the structure (the captain from E68). At 1259 hours, Engine 508 (E508) reported to “Command” that another fire fighter (E51B) had been located and was in the process of being removed from the structure. Shift Commander 37 (South Division) announced he had assumed “Command” and District 21 was assigned as “Operations.” “Command” requested OEC dispatch a 5-11 (5th Alarm) for this incident. At 1301 hours, OEC dispatched District 19, District 26, Engine 37, Engine 47, Engine 62, Engine 80, Ladder 7 and Ladder 55. All companies assigned to the 5-11 were ordered to switch to Tac Channel 12 and report to Staging. At 1303 hours, the front façade collapsed on Side Alpha trapping several fire fighters and fire officers assigned to the Rescue Group. (See Photo 7.) At 1304 hours, Alpha Division reported to “Command” that a second fire fighter had been removed from the structure (E51B).
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Photo 7. The front façade collapsed at 1303 hours striking fire fighters and officers assigned to the Rescue Group. These members were quickly removed by other fire fighters who picked up the façade and pulled the trapped fire fighters and officers out. (Photo courtesy of the fire department)
At 1304 hours, after E51B was removed from the structure, “Command” made the difficult decision to change the Incident Action Plan from “Rescue” to “Recovery”. (See Diagram 14.) Note: “Command” developed an Incident Organizational Chart - ICS 207 for this incident. The Incident Organization Chart (ICS 207) provides a means of depicting the ICS organization position assignments for the incident and to indicate what ICS organizational elements are currently activated and the names of personnel staffing each element. The size of the organization is dependent on the specifics and magnitude of the incident and is scalable and flexible.
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Diagram 14. The Incident Organization Chart developed by “Command” for the restaurant fire.
At 1309 hours, “Operations” called Alpha Division trying to verify the number of fire fighters involved in the “Mayday”. The Rescue Group Supervisor called Alpha Division and advised that he was still trying to verify the actual number of missing fire fighters. E68 and E51 didn’t answer the PAR.
A personnel accountability report was conducted on all companies operating at the restaurant fire. Due to issues with the radio system, it took the Accountability Officer 44 minutes to complete the PAR. At 1354 hours, the Accountability Officer (Ambulance 28B) tried to contact E68 and advised that E68B was “in alarm”. At 1356 hours, “Command” contacted Alpha Division (#13 - Assistant Chief who had relieved District 29) regarding the operational mode. Alpha Division responded that companies were still operating inside the structure on Side Alpha. (See Diagram 15.)
At 1406 hours, the Rescue Group consisted of Ladder 7, Rescue 10, Rescue 11, Tower Ladder 21, Engine 37 and Engine 49. At 1420 hours, the Rescue Group called “Operations” and advised, “We’ve located E51 Alpha” (the officer from E51). At 1432 hours, the two fire fighters from Engine 68 (E68B and E68C) were located in the Small Banquet Room approximately 10 feet – 15 feet from the captain of E51. The captain of E51 was removed at 1507 hours and the two fire fighters from E68 were removed at 1554 hours.
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Diagram 15. The placement of apparatus and hoselines on Side Alpha and Side Delta. The hotel, banquet rooms, and sports bar are heavily involved with fire. The time is approximately 1400 hours.
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The recovery process was completed at 1605 hours. At 1645 hours, “Command” notified OEC to 7-1 the incident (declared under control).
Rapid Intervention Team (RIT) Operation At 1223 hours, E82 announced a “Mayday” due to a collapse of the roof in the Small Banquet Room and kitchen areas. “Command” immediately deployed Engine 60 as the initial RIT crew and requested a 3-11 (3rd Alarm). Also, “Command” ordered all companies out of the building.
Engine 60 entered the front door of the restaurant and found a fire fighter from Engine 51 (E51”C”). This fire fighter was pushed into the doorway by the collapse. E60 assisted the fire fighter out of the structure and sent him to Alpha Division (District 28). E60 reentered the building and found a void area between the front wall of the building and the roof area. When the roof collapse occurred, the roof came straight down. The remaining part of the roof was resting on the top of the exterior wall.
The RIT process was expanded over the next several minutes to include Engine 82, Engine 48, Engine 508, Tower Ladder 69, Ladder 33, Ladder 51, Rescue 10 and Rescue 11. As these RIT companies were deployed, they found it difficult to access the area of the Small Banquet Room due to getting through the roof material. Fire fighters interviewed during the investigation stated that initially they tried to gain access to the area using axes and halligan tools. Note: The investigation revealed that the roof had 3 layers of roofing material. When re-roofing occurred, instead of removing the existing roof materials, the new roof was placed on top of the existing roof materials. The roofing material consisted of asphalt shingles installed on ½-inch thick plywood roof decking which was nailed to the top chords of the trusses. Clay (cement) tiles were added to the roof on Side Alpha for decorative purposes. RIT companies then attempted to cut access holes through the roofing material with chain saws. Access to the trapped fire fighters was tried through the windows in Side Alpha plus entry from Side Bravo and Side Charlie.
At 1239 hours, R10 “A” notified Alpha Division using “R10 Division Alpha Emergency Traffic” to let him know that they had located two fire fighters in the building. Alpha Division (D28A) then notified “Command” to advise him that two of the “Mayday” fire fighters (E68B and E68C) had been located. E508”A” went into the hole and could see the fire fighter from E51 (E51B) lying on top of the clay (cement) tiles.
The RIT crews were trying to gain access to these two fire fighters. Tower Ladder 69 made an access hole into the collapse area which was barely a 2-foot x 2-foot hole. Rescue 10 entered the area where E68A was located. The captain from R10 tried to gain access to the officer from E68. There was fire around the officer and the RIT crews were trying to get water on the fire. Members from R10 were cutting the roof rafters to gain access to the officer (E68A). Members of R10 deployed a RIT pack to get a fresh air supply for E68A. Members of R10 worked on their hands and knees clearing debris away from the captain on E68 (E68A). They were also trying to get an air supply established using a RIT Pack. The RIT Pack was brought in as close as possible, but it still did not reach the captain of E68, because the hose attached to the RIT pack was not long enough. The team placed an extension on the hose and the engineer/operator from R10 then made the decision to try and get the RIT Pack closer
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to the captain by crawling deeper into the hole. This member did so without the use or protection of his own SCBA and helmet. At that point, the captain on E68 was able to reach out for the regulator and put it on his face. At first, he wasn’t getting any air but the regulator was re-adjusted and then locked into his mask.
With E68A “on-air”, members of R10 used cribbing and air bags to remove him from the debris. At 1252 hours, the Rescue Group removed E68A from the building and placed him in an ambulance for transport to the nearest trauma center.
E508 widened the access hole and then the officer of E508 crawled through the access hole. He located the fire fighter from E51 (E51B). E508A crawled in about 15’ – 20’ to get E51B. The roofing tiles were all around him. E508A started trying to get him out of the building. He was in-line with the front window. The officer from E508 stated he could hear PASS alarms from E51A E68B, and E68C. With the help from E508B, E508C, Safety 30, Ladder 33, and other members of the Rescue Group, E51B was brought out of the building at 1304 hours.
This RIT operation was performed successfully under extremely difficult conditions. Members of the Rescue Group operated in extreme heat and smoke conditions trying to access the trapped fire fighters in a very tight and cramped environment. (See Recommendation #11.)
Fire Origin and Cause Published reports suggest that a burning odor had been detected by workers in the building upwards of three hours prior to the report of the fire at 1205 hours. Restaurant employees noticed a burning smell around 0900 hours and attempted to identify the source with maintenance workers. Nothing could be identified or determined and no call was made for the fire department. As the morning progressed, restaurant employees eventually noticed dark smoke coming from nearby vents, a restaurant worker called 9-1-1 at 1205 hours when visible flames became evident. The fire originated in the attic/crawl space above the kitchen area adjacent to the utility room.
The department’s Arson Bureau, the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF), and the Texas State Fire Marshal’s Office listed the classification of this fire as “undetermined” because investigators were unable to identify the exact cause of the fire. Although the exact cause of the fire was not determined, all agencies involved agreed there was no evidence to indicate the fire was deliberately started.
Contributing Factors Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that ultimately led to the fatalities:
Fire burning unreported for 3 hours
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Delayed notification of the fire department Building construction Wind impacted fire Scene size-up Personnel accountability Fireground communications Lack of fire sprinkler system.
Cause of Death According to the death certificates, the medical examiner listed the cause of death for the captain of E51 due to smoke inhalation; the engineer/operator (E51B) was due to smoke inhalation with thermal injuries; the fire fighter from E68 (E68B) was due to compressional asphyxia, blunt head trauma, and smoke inhalation; and the other fire fighter from E68 (E68C) died due to compressional asphyxia.
Recommendations Recommendation #1: Based upon fire department procedures, the strategy and tactics for an occupancy should be defined by the organization for fire-fighting operations. The Incident Commander should ensure that the strategy and tactics match the conditions encountered during initial operations and throughout the incident.
Discussion: Occupancies define the space inside the class of building. Construction types/classes of construction define how the building is constructed with either combustible or non-combustible materials. Occupancies exist inside the constructed building. SOPs must consider numerous factors that affect fire-fighting operations. This will ensure essential strategic, tactical, and task level functions are performed by the Incident Commander, division/group supervisors, and fire fighters. Additionally, this process compliments the defined knowledge, skills, abilities, competencies, and fireground experience to assist: the Incident Commander to plan and implement an effective strategy and Incident Action Plan; division/group supervisors to formulate and follow tactics; company officers to successfully carry out assigned tasks, and, the individual members to effectively perform their duties.32
At any incident, life safety is always the first priority followed by incident stabilization (second priority), and then property conservation (third priority). The ability to ensure for the safety of fire fighters is a continuous process throughout the incident. A sound risk management plan ensures that the risks are evaluated and matched with the actions and conditions. The following risk management principles shall be utilized by the Incident Commander: activities that present a significant risk to the safety of fire fighters shall be limited to situations that have the potential to save endangered lives; activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of fire fighters, and the actions shall be taken to reduce or avoid these risks;
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no risk to the safety of fire fighters shall be acceptable where there is no possibility to save lives or property.33
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. The priority is to get a fire department unit to the rear of the structure on Side Charlie. However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received. If physical barriers make the 360o size-up impractical for the first arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be delegated to another engine company on the 1st Alarm. Even if a 360o can be conducted, the 2nd due engine company or 3rd engine company and the 2nd due truck company should be assigned to Side Charlie.
A radio report of conditions, including those on Side Charlie, should be transmitted over the assigned tactical channel to the Incident Commander and the dispatch center. The transmission should include the following: Smoke and fire conditions, with an emphasis on identifying the seat of the fire; The initial radio report from the first arriving unit for a structural fire should include the signal for a working fire, the number of stories, type of occupancy and location of fire. This lays the foundation for additional reports and serves as notification to responding units as to the type of SOP to implement. If there were critical building description information through the critical incident dispatch system (CIDS) for the address, then this information would aid in implementing or adjusting SOPs. CIDS could contain information that would necessitate alternative action to fulfill said operational goals. Building features – e.g., number of stories (particularly if there is a difference between Sides Alpha and Charlie; Basement access and type; Any other life or safety hazards.
Any change to operational priorities or responsibilities based on the above size-up shall be clearly communicated to “Command”, all responding units, and the dispatch center via the assigned tactical radio channel.34, 35 “Command is then obligated to re-broadcast and receive acknowledgement from all operating companies.
There are necessary tasks which need to occur at any fire regardless of the occupancy such as initial on scene report upon arrival, initial risk assessment, situational report, water supply, deployment of handlines and back-up handlines, search and rescue, ventilation, rapid intervention crews (IRIC), ground and aerial ladder placement, fire attack and extinguishment, and salvage and overhaul. Over the past few years, fire fighters have adopted an acronym that details the steps to take when confronted with a fire: SLICERS. Size up all scenes; Locate the fire; Identify & control the flow path (if possible); Cool the heated space from a safe location;
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Extinguish the fire; Rescue and Salvage are actions of opportunity that may occur at any time. 35
The “flow path” of a fire is how a fire moves determined by incoming and outgoing vents for air (since air is what lets a fire burn). Identifying and controlling the flow path is about knowing where the air comes from and where it’s headed. The importance of identifying and using flow path information cannot be underestimated. The identification of flow path is an item that should find its way into every after-action review. While trying to locate the fire, cool the heated space from a safe location while ensuring for the safety of the fire fighters is important. Once the fire is under control, the fire can be completely extinguished. The rescue and salvage operations are self-explanatory—if anything can be saved, save it. These two actions are always active, right from sizing up to extinguishing.
Establishing a continuous and uninterrupted water supply is a vital and one of the most critical elements of fireground operations. This must be done before or in conjunction with committing crews to interior operations. To ensure a water supply is secured, many fire departments require, per standard operating procedure (SOP), that the 2nd due engine company and 4th due engine company secure a water supply for the 1st due engine company and 3rd due engine company. 36
Procedures developed for fireground operations should be flexible enough to allow the change due to: Life hazard (must be given first priority); Problems with water supply and water application; Volume and extent of fire, requiring large caliber streams; Location of the fire, inaccessible for hand-line operations; Materials involved in the fire and explosion potential compounding the problem; Exposure problems where further fire spread would be a major concern; Stability of the structure, which would be dependent on the condition of the structural components of the building, the intensity and duration of the fire.33
At this incident, the initial Incident Commander was the captain of E51. His initial scene size-up was “smoke showing, working fire, offensive fire, and we are stretching a 2½-inch handline”. Based upon the time of day and type of occupancy, the captain based his strategy and tactics on the possibility of occupants were still inside the restaurant and kitchen. District 68 then assumed “Command” upon his arrival and maintained the same strategy and tactics.
Based upon the type of occupancy, the department did not pre-plan this building based on the risk assessment. The initial on-scene size-up and evaluation was made as the first alarm companies arrived on scene. The arriving units were able to view Side Delta and Side Alpha. The view of Side Alpha was very limited due to the amount of smoke. It is essential that during the initial stages of an incident, at least one company is designated to Side Charlie of a structure, even if a 360o walk-around is conducted. The first units to be assigned to Side Charlie were during RIT Operations and Charlie Division was established, which was approximately 20 minutes into the incident. This ensures that “Command” has a complete initial assessment of the fireground. “Command” is assured that a continuous risk assessment and situational report is available from Side Charlie.
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Moreover, the Incident Commander must continually match the actions against the conditions based upon continuous reports from all operating companies. This gives the Incident Commander the ability to control the situation by forecasting and staying ahead, rather than the fire dictating the actions taken. Additionally, due to problems with the radio communications, this greatly hindered “Command’s” ability to ensure this occurred.
Recommendation #2: Fire departments should review and update standard operating procedures on wind-driven fires which are incorporated into fireground tactics.
Discussion: Based on the analysis of this fire incident and results from current research and field studies, adjusting fire-fighting tactics to account for wind conditions in structural fire-fighting is critical to enhancing the safety and the effectiveness of fire fighters. Previous studies demonstrated that applying water from the exterior, into the upwind side of the structure can have a significant impact on controlling the fire prior to beginning interior operations.37 It should be made clear that in a wind-driven fire, it is most important to use the wind to your advantage and attack the fire from the upwind side of the structure, especially if the upwind side is the burned side. Crews operating on the interior need to be aware of the potential for rapidly changing conditions.
Fire departments should develop standard operating procedures (SOPs) for incidents with high-wind conditions including defensive attack. It is important that fire officers and fire fighters develop an understanding of how wind conditions influence fire behavior and impact fireground tactics. Wind conditions can have a major influence on structural fire behavior. When wind speeds exceed 10 mph (16 km/hr.) the Incident Commander, division/group supervisors, company officers, and fire fighters should use caution and take wind direction and speed into account when selecting a strategy and developing tactics. The National Institute of Standards and Technology and Underwriter’s Laboratories have determined that wind speeds as low as 10 mph (16 km/hr.) are sufficient to create wind-driven fire conditions if the flow path is uncontrolled.30 NIST, in a recent study on wind-driven fires in structures, has shown that wind speeds as low as 10 mph can turn a routine “room and contents fire” into a floor to ceiling fire storm or “blowtorch effect,” generating untenable conditions for fire fighters, even outside of the room of origin. Temperatures in excess of 600 ºC (1100 ºF) and total heat fluxes in excess of 70 kW/m² were measured at 4 feet above the floor along the flow path between the fire room and the downwind exit vent. These conditions were attained within 30 seconds of the flow path being formed by an open vent on the upwind side of the structure and an open vent on the downwind side of the structure. 30
Fire departments are encouraged to develop and implement a standard operating procedure (SOP) addressing such issues as obtaining the wind speed and direction, considering the possible fuel load associated with a particular occupancy. This information can be used to determine the proper strategy and tactics for wind-driven fireground operations. Further, consideration of ventilation plus predicting and forecasting fire conditions associated with the wind speed based upon risk assessment. Under wind-driven conditions an exterior attack from the upwind side of the fire may be necessary to reduce fire intensity so fire fighters can successfully and safely gain access to the involved compartments. 38
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A fire department should incorporate the following considerations into their training and education component on wind impacted fires: Ensure that an adequate initial size-up and risk assessment of the incident scene is conducted before beginning interior fire-fighting operations; Ensure that fire fighters, company officers, division/group supervisors, and the Incident Commander have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior such as smoke color, velocity, density, visible fire, and heat; Ensure that fire fighters and company officers are trained to recognize the potential impact of windy conditions on fire behavior and implement appropriate tactics to mitigate the potential hazards of wind-driven fire; Ensure the Incident Commander’s strategy considers high wind conditions, if present; Ensure that fire fighters understand the influence of ventilation on fire behavior and effectively apply ventilation and fire control tactics in a coordinated manner; Ensure that fire fighters and officers understand the capabilities and limitations of thermal imager; Ensure a thermal imager is used as part of the size-up process; Ensure that fire fighters are trained to check for fire in overhead voids upon entry and as charged hoselines are advanced; Develop, train and educate, implement, and enforce a comprehensive “Mayday” SOP to insure that fire fighters clearly understand the process and know how to initiate a “Mayday”; Ensure fire fighters are trained in fireground survival procedures; Ensure all fire fighters on the fire ground are equipped with radios capable of communicating with the Incident Commander and the dispatch center.37
At this incident, when the 1st Alarm companies arrived on scene, the smoke was pushing towards the northwest directly across the parking lot of the restaurant. Visibility proved to be very difficult for all companies operating on the scene. The captain of Ladder 51 stated during his interview, L51 went to Side Charlie, opened a door going to the Banquet rooms, and the opening “was sucking air”. Ladder 51 arrived on-scene at 1228 hours and went to Side Bravo and Side Charlie. L51 may have been one of the first companies on Side Charlie.
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. If physical barriers make the 360o size-up impractical for the first arriving officer, the size-up of Side Charlie should be delegated to the 2nd due engine company or 3rd due engine company and the 2nd due truck company. However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received.
The fire department has made numerous changes in standard operating procedures and fireground tactics as it relates to wind-driven fires since the incident on May 31, 2013.
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Recommendation #3: Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (U.L.) into operational procedures by developing standard operating procedures, conducting live fire training, and revising fireground tactics.
Discussion: The National Institute of Standards and Technology (NIST) and Underwriters Laboratories (UL) have conducted a series of live burn experiments designed to replicate conditions in modern homes and residential structures and to validate previous testing done in laboratory settings. The results of these experiments will enable fire fighters to better predict and react to effects of new materials and construction on fire. The fire research experiments were conducted in cooperation with the Fire Department of New York, Chicago Fire Department, Spartanburg SC Fire and Rescue and other agencies. The live burn tests are aimed at quantifying emerging theories about how fires are different today, largely due to new building construction and the composition of home furnishings and products. In the past, these products were mainly composed of natural materials, such as wood and cotton, but now contain large quantities of petroleum-based products and synthetic materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a room once took approximately 20 minutes to “flashover” — igniting all the contents — this can happen with today’s furnishings in as little as four to five minutes.39
In addition, modern living spaces tend to be more open, less compartmentalized and are better insulated than homes built years ago. As a result, interior residential fires can generate oxygen depleted, fuel rich environment within minutes. This fire condition of hot, fuel rich smoke is highly reactive to the introduction of oxygen. Introducing oxygen to this environment by opening a door or venting a window may result in a rapid transition to flashover. These same conditions can occur in commercial structures as seen in the Charleston, SC Sofa Super Store fire.40
The NIST and UL experiments evaluated individual and combinations of methods for strategically ventilating and isolating fires to prevent flashover—or at least delay it. In contrast, kicking a door open or breaking a window without knowledge of conditions inside could create a portal for air that can literally fan the flames by introducing oxygen into an oxygen-limited fire environment.
Traditionally, fire suppression operations were conducted from the interior of the structure as a means to reduce water damage and limit fire damage to structures. These operations must be coordinated with the ventilation operations. Previous research and examinations of line of duty deaths have shown that ventilation events occurring with fire fighters in the structure prior to suppression have led to tragic results. 40. 41, 42 One means of eliminating the possibilities of this occurrence would be a transitional attack, in which water is directed into the structure from the exterior to cool the fire gases and reduce the heat release rate of the fire, prior to the fire fighters entering the building. The major concern with this type of operation is the potential harm that might occur to people trapped in the structure or the amount of water damage to the structure. Therefore, measurements are needed to document the changes of the thermal environment within the structure and the impact on the viability of people, who might be trapped in the structure.39
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Based upon the NIST and UL research, the following fireground operations should be considered for implementation.
Size-Up Size-up must occur at every fire. Consideration must be given to the resources available and situational conditions, such as weather, fire location, size of the fire and building, and the construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical plan for each fire must be developed, communicated and implemented.
Ventilation Fire departments should manage and control the openings to the structure to limit fire growth and spread, and to control the flow path of inlet air and fire gases during tactical operations. All ventilation must be coordinated with suppression activities. Uncontrolled ventilation allows additional oxygen into the structure which may result in a rapid increase in the fire development and increased risk to fire fighters due to increased heat release rates within the flow path.
Fire-fighting Operations Given the fuel rich environment that the fire service operates in today, water should be applied to the fire as soon as possible. In many cases, water application through an exterior opening into a fire compartment may be the best first action, prior to committing firefighting resources to the interior. Fire departments should cool the interior spaces of a fire building with water from the safest location possible, prior to committing personnel into spaces with, or adjacent to, fully developed or smoldering (ventilation limited) fire conditions.
Rapid Intervention Fire department rapid intervention procedures should be updated to provide water on the fire as soon as possible and ventilation openings controlled during fire fighter "Mayday" incidents.39
This information is presented to educate the fire service and to ensure that fire departments consider a change in fireground tactics based upon the current research presented by NIST and UL. Much of this research has been directed toward developing a better understanding of the characteristics of the modern fire. This modern research provides members of the fire service with the information and knowledge needed to modify essential fire-fighting tactics. While fire-fighting will never be without risk, this research represents a vital contribution to overall efforts to reduce risks and to save lives.
Recommendation #4: Fire departments should consider implementing a pre-incident planning program which complies with NFPA 1620, Standard for Pre-Incident Planning.
Discussion: Pre-incident planning is the process of gathering and documenting information that could be critical for making life-saving decisions at an incident such as a structure fire. Pre-fire planning is essential, no matter the size of a fire department. Even the smallest towns contain buildings or sites that require pre-incident plans based upon a community risk assessment. These occupancies can include but are not limited to schools, high-rise occupancies, hospitals, nursing homes, medical clinics,
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hazardous materials manufacturer or shipper, transportation agency (e.g., a railroad), or any other businesses that is deemed by the fire department to be a high-risk occupancy or target hazard. NFPA 1620, Standard for Pre-incident Planning serves as the foundation for this process. The purpose of NFPA 1620 is to develop pre-incident plans to assist responding personnel in effectively managing emergencies for the protection of occupants, responding personnel, property, and the environment.43 Moreover, NFPA 1500, Standard on Fire Department Occupational Safety and Health Program requires fire departments to develop pre-incident plans as determined by the authority having jurisdiction which complies with NFPA 1620, Standard for Pre-incident Planning.44
The pre-incident plan is designed based upon an emergency occurring in the occupancy, which can assist the Incident Commander in developing the strategy and Incident Action Plan.43
A detailed pre-incident plan highlights all aspects of the structure including: A site plan Floor plans Construction type age and condition of the building Ingress and egress Pre-existing structural damage/deterioration Presence of wall anchor plates or stars Engineered load systems/lightweight construction Types of doors and windows Roof construction and covering including HVAC units Renovation/modifications to structure Height of the building Fuel loads Fire protection features such as sprinkler systems, standpipe system, fire alarm system, and hydrant locations Stairwells Utility shut-offs Occupant contact information Any other pertinent information.45
A pre-incident plan identifies deviations from normal operations and can be complex such as a formal notation about a particular problem, to include the storage of flammable liquids, explosive hazards, lack of hydrants, or modifications to structural building components.
Another consideration of the pre-incident planning process is that strategy and tactics which need to be utilized for a target hazard occupancy. Based upon the potential risks encountered at target hazard occupancies, the pre-incident plan should outline the deployment of resources (front-loading the incident), type of strategy to be considered, and how to deploy resources once fire-fighting operations are initiated.
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Another benefit of this program is the ability to provide information to company officers and chief officers responding from other battalions or from different jurisdictions that may not be familiar with a specific occupancy. Moreover, a jurisdiction’s building and permit office or department may have information that the fire department does not have. Information should be routed to the department’s dispatch center to ensure vital information about a structure is available. For example a target hazard is included in the comments of the CAD system dispatch. Information should include the number and type of code violations and whether the building has been abandoned or vacant, or is undergoing extensive renovation. Additionally, the CAD system can provide a real-time view of an occupancy from mapping programs that are available on the internet. 42
Pre-incident information, pre-fire plans and building knowledge are mission critical - at a minimum for the first-due area response. Understanding building construction and related engineering, reading key building indictors and having the skills to apply predictive modeling and projected outcomes is essential. The tactical objectives and incident action plan thus increases exponentially the safety margin to have a successful incident outcome and not unexpected events.
At this incident, there was no information available for first due or first alarm companies due to the fact this occupancy was not considered a high-risk occupancy. As part of the department’s recovery process, they have developed a program which will provide the ability for electronic storage and retrieval of building assessments for suppression personnel plus offering real-time information. The pre-incident plans (Tactical Evaluation and Assessment Plans (TEAPS)) that are on file in the department are being entered into this system. Future plans include entering information that is shared by other city departments and regional agencies.
Recommendation #5: Fire departments should consider implementing a critical building information system which is available to responding units to enhance situational awareness.
Discussion: Coupled with the Pre-Incident Planning program, the critical incident dispatch system (CIDS) program provides critical building information which may not be readily apparent to responding companies upon arrival. This program also provides accurate and consistent information for required radio progress reports and indicates where standard operating procedure variations would be necessary due to previously known features found at this location.
The process starts with input from the company officers who must consider all buildings in their first- due area as potential CIDS buildings. In considering a building, the company officer must look for conditions that would not be immediately apparent to arriving companies assigned to the initial alarm assignment. Additionally, there are key building factors which should automatically be included in CIDS. Examples could be bowstring truss, major alterations have occurred, or if a pre-incident plan exists for the building. Other examples that should be included or considered for inclusion in the CIDS program are: Hazardous chemicals, liquids and substances. This information should always indicate floor and location of these hazards;
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High voltage equipment including transformers containing PCBs and always indicate floor and location of such equipment; Interconnected odd or unusually shaped buildings and indicate which floors are interconnected. Buildings with structural hazards or heavy fire loading; Renovated buildings with hidden voids, or duplex apartments. Indicate which floors give access to duplex apartments; Truss buildings (describe type of truss); Metal bar joist and other lightweight construction materials; Q-deck roofs or floors, steel plated buildings; Handicapped, bedridden, or incapacitated individuals. Where possible, specify the location; Schools with handicapped students; Special extinguishing systems, and the location of related controls; Siamese locations, if not in a normal location or readily visible; The location of OS&Y (outside screw and yoke) valves or alarm panels, if not located in an easily found location; Sub-cellar levels and access locations; Location of guard dogs; Telephone numbers of knowledgeable persons, such as the owner, building engineer or superintendent; Vacant buildings. 46
This list is not intended to be all-inclusive. Company officers should be encouraged to include other items if they feel that the condition or hazard should be identified.46
Fire departments can utilize a variety of methods to ensure critical building information is available during response to an incident. Mobile data terminals or mobile computer terminals, hand-held computers or tablets, information from station response printers, or printed pre-incident plans can provide location specific data triggered by place, address, and/or name. This information can be a valuable tool for the fire officers and command officers, especially when the jurisdiction has a large number of defined target hazard occupancies. This information assists the Incident Commander in implementing the strategy and Incident Action Plan for a defined building.47
As part of the department’s recovery process, the organization has developed a program which will provide the ability for electronic storage and retrieval of building assessments for district chiefs and company officers as well as offer real-time information. The department is entering pre-incident plans (Tactical Evaluation and Assessment Plans (TEAPS)) into this system. Future use will include information that is shared by other city departments and regional agencies.
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Recommendation #6: Fire departments should ensure that the radio communication system is capable of providing adequate coverage based upon the demands of an incident which complies with NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety.
Discussion: Effective fireground radio communication is an important tool to ensure fireground command and control as well as helping to enhance fire fighter safety and health. The radio system must be dependable, consistent, and functional to ensure that effective communications are maintained especially during emergency incidents. Fire departments should have a “Communications” standard operating procedure (SOP) which outlines the communication procedures for fireground operations. Fire departments should ensure that the Communications Division and Communication Center is part of this process. Another important aspect of this process is an effective education and training program for all members of the department.
Radio frequency usually refers to the radio frequency of the assigned channel. A radio channel is defined as the width of the channel depending on the type of transmissions and the tolerance for the frequency of emission. A radio channel is normally allocated for radio transmission in a specified type of service or by a specified transmitter. Fire department should ensure that an adequate number of radio channels are available. Multiple radio channels are necessary at large-scale or complex incidents such as a commercial structure fire, mass-casualty incident, hazardous materials incident, or special operations incident.48, 49
Fire departments should preplan for not only large-scale or complex incidents, but also for the ability to handle daily operations. Standard operating procedures, radio equipment (e.g. mobile radios, portable radios, mobile data terminals, laptop computers), other hardware (e.g. CAD system), and dispatch and communications protocols should be in place to ensure that these additional channels are available when needed.48
Every fire fighter and company officer should take responsibility to ensure radios are properly used. Ensuring appropriate radio use involves both taking personal responsibility (to have your portable radio, having the portable radio turned on, and on the correct channel). A company officer’s responsibility is to ensure that all members of the crew comply with these requirements. Portable radios should be designed and positioned to allow a fire fighter to monitor and transmit a clear message.50, 51
A fire department should provide the necessary number of radio channels relating to complex or large scale incidents needing multiple tactical channels. NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety states in Paragraph 6.1.4, “the communications system shall provide reserve capacity for complex or multiple incidents.” This would require fire departments to preplan radio channel usage for all incident levels based upon the needs of an emergency incident including large-scale or complex incidents.48
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When a fire department responds to an incident, the Incident Commander should forecast for the incident to determine if there is potential for being a complex or long term operations that may require additional resources including demands on the communications system. As incidents increase in size, the communication system has to keep up with the demands of the incident. The Incident Commander must be able to communicate with company officers and division/group supervisors.49 Before communications become an issue, the Incident Commander must consider options for alleviating excessive radio traffic. Several options are: assigning non-fireground resources (e.g. Staging, “Rehab”) to a separate tactical channel or talk-group channel; designate a “Command Channel” which is a radio channel designated by the fire department to provide for communications between the Incident Commander and the division/group supervisors or branch directors during an emergency incident;48 for incidents involving large geographical areas, designate tactical channel or talk-group for each division.
In this incident, the Emergency Communications Center had switched to a digital radio system a approximately one month earlier. This fire was the first significant incident at which the fire department operated with this new system. As noted in the report, radio communication issues were quickly identified as an issue. Since this incident, the department has addressed many of the radio issues through changes in hardware, re-programming, training, and standard operating procedures. This is an on-going process for the department.
Recommendation #7: Fire Departments should review standard operating procedures regarding the use and operations of the thermal imagers.
Discussion: Another valuable tool that enhances situational awareness is the thermal imager. The thermal imager provides a technology with potential to enhance fire fighter safety and improve the ability to perform tasks such as size-up, search and rescue, fire attack, and ventilation. Thermal imagers should be used in a timely manner. Fire fighters should be properly trained in the use of a thermal imager and be aware of their limitations.52, 53
The application of thermal imaging on the fire ground may help fire departments accomplish their primary mission, which is saving lives. This mission can be accomplished in many ways. First and foremost, in near zero visibility conditions, primary searches may be completed quickly and with an added degree of safety. The use of thermal imaging technology may also be invaluable when fire fighters are confronted with larger floor areas or unusual floor plans.52 Searching for trapped civilians is part of a fire department’s primary mission. Thermal imagers may provide a method for fire fighters to track and locate other fire fighters in very limited visibility conditions. This process can enhance fire fighter accountability before an issue arises.52
While the use of a thermal imager is important, research by Underwriters Laboratories has shown that there are significant limitations in the ability of these devices to detect temperature differences behind structural materials, such as the exterior finish of a building or outside compartment linings (i.e., walls,
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ceilings, and floors).53 The most common misconception about temperature measurement is that it estimates air temperatures. Thermal imagers do not read air temperatures; they read surface temperatures. Thermal imagers operate solely based on differences in surface temperatures. Although occasionally a thermal imager may show superheated or cryogenic gases, in general, thermal imagers do not "see" or measure gases. Fire fighters should not be lulled into a mistaken sense of security because the temperature measurement on the thermal imager seems relatively low or has not reached its scale maximum.54
At a structure fire, the thermal imager may help identify the location of the fire or the extent of fire involvement prior to fire fighters being deployed into a structure. Knowing the location of the fire may help fire fighters determine the best approach to the fire. The thermal imager may provide additional information for a crew(s) making the fire attack that they would not previously have had due to poor visibility and building construction. Using this information, fire fighters may be able to locate the fire more quickly and may also ensure that the water application is effective. From a ventilation perspective, fire fighters can use the thermal imager to identify areas of heat accumulation, possible ventilation points, and significant building construction features. This helps ensure proper and effective ventilation that successfully removes smoke and heat from a building.52, 55
Per department protocol, the first arriving officer provides a temperature reading as they enter the structure as part of the initial size-up. Most thermal imagers only read surface temperature. Therefore a thermal imager can only estimate the air temperature and products of combustion. The thermal imager does not provide an accurate assessment of the total room temperature. In all reality, the temperature readings and color variations of a thermal imager provides are best suited to establish differences of an area being entered, rather than the true atmospheric temperature. 52, 55
The intent of this recommendation and the appendix material is to ensure that the fire service clearly understands the concept, use, and limitations of thermal imagers. This does not reflect on the operations of the fire department in this investigation.
The fire department did utilize thermal imagers in a positive manner. The first-in officer (E51A) provided a thermal imager reading per department guidelines; A thermal imager was used to locate the heat source by the crew making entry (E51A) while advancing a 2 ½-inch handline and pulling ceiling as they made forward progress; The officer on E82 used a thermal imager as a tool to size-up the exterior and relayed that information to Division A (D28) The officer on E60 used the thermal imager as a tool to size-up the exterior as part of the Rescue Group (RIT).
Additional information is provided in Appendix Five: Use and Operations of Thermal Imagers
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Recommendation #8: Fire Departments should ensure that the Incident Commander incorporates “Command Safety” into the incident management system.
Discussion: The purpose of “Command Safety” is to provide the Incident Commander with the necessary resources on how to use, follow, and incorporate safety into the incident management system at all incidents. “Command Safety” is used as part of the eight functions of command developed by (Retired) Fire Chief Alan V. Brunacini. “Command Safety” defines how the Incident Commander must use the regular, everyday command functions to complete the strategic level safety responsibilities during incident operations. Using the command functions creates an effective and close connection between the safety officer and the Incident Command. The eight functions of command are: Assumption/confirmation/positioning Situation evaluation which includes risk management Communications Deployment Strategy/incident action planning Organization Review/revision Transfer/continuation/termination.33, 56
A major objective of the incident management system is to create, support, and integrate an Incident Commander who will direct the geographical and functional needs of the entire incident on the strategic, tactical, and task level. Issues develop for the Incident Commander when these three standard levels are not in place, operating, and are effectively connected. One of the most important components is to ensure the Incident Commander operates on the strategic level from the very beginning of the incident and stays on the strategic level as long as fire fighters are operating in an immediately dangerous to life and health (IDLH) environment. 33, 56
The Incident Commander uses the incident management system as the basic foundation for managing the strategic level safety function. “Command Safety” ensures the highest level of safety for fire department members operating at emergency incidents. The Incident Commander completes the operational and safety responsibility to the fire fighters by performing the eight command functions. These functions serve as a very practical performance foundation for how the Incident Commander completes their responsibility as the strategic level incident manager and the overall incident safety manager.48
At this incident, there were several “Command Safety” issues which are being addressed by the fire department as part of their recovery process. These issues included fireground communications, personnel accountability, use of a tactical worksheet (which compliments personnel accountability and crew integrity), and a continuous scene size-up and evaluation.
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Recommendation #9: Fire Departments should provide a checklist for the Incident Commander regarding procedures in the event of “Mayday”.
Discussion: When a “Mayday” is transmitted for whatever reason, the Incident Commander has a very narrow window of opportunity to locate the lost, trapped, or injured member(s). The Incident Commander must restructure the strategy and Incident Action Plan (tactics) to include a priority rescue.48
Some departments have adopted the term “LUNAR” – location, unit assigned, name, assistance needed, and resources needed - to gain additional information in identifying a fire fighter who is in trouble and in needs assistance. The Incident Commander, division/group supervisors, company officers, and fire fighters need to understand the seriousness of the situation. It is important to have the available resources on scene and to have a plan established prior to the “Mayday”.48. 56
A checklist is provided in Appendix Six: Incident Commander’s Tactical Worksheet for “Mayday” which can assist the Incident Commander to ensure the necessary steps are taken to clear the “Mayday” as quickly and safely possible. This checklist serves as a guide and can be tailored to any fire department’s “Mayday” procedures. The intent of the checklist is to provide the Incident Commander with the essential actions to be taken in the event of “Mayday”. This format allows the Incident Commander to follow a structured worksheet. This process is too important to operate from memory and risk missing a vital step that could jeopardize the outcome of the rescue of a fire fighter who is missing, trapped, or injured.
At this incident, when the “Mayday” occurred, the Incident Commander quickly called for additional resources and conducted a personnel accountability report to determine if any companies were lost or missing. Due to the influx of resources, the Incident Commander was quickly overwhelmed mostly due to the issues dealing with radio communications. The intent of this “Mayday” worksheet, like the tactical worksheet, is to assist the Incident Commander during a very difficult and stressful time on the fireground.
Recommendation #10: Fire departments should review standard operating procedures used to account for all fire fighters and first responders assigned to an incident.
Discussion: A personnel accountability system is a system that readily identifies both the location and function of all members operating at an incident scene.44, 48 The philosophy of the personnel accountability system starts with the same principles of an incident management system company unity and unity of command. Unity can be fulfilled initially and maintained throughout the incident by documenting the situation status and resource status on a tactical worksheet.
One of the most important functions of “Command Safety” is for the Incident Commander to initiate an accountability system that includes the functional and geographical assignments at the beginning of operations until the termination of the incident. It is very important for the first on-scene officer to
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initiate an accountability system. This initial system allows the passing or transfer of information to the next officer who assumes “Command” upon his/her arrival. 48
A functional personnel accountability system requires the following: Development and implementation of a departmental SOP; Necessary components and hardware; Training and education program including practical applications for all members on the operation of the system; Strict enforcement during emergency incidents.
There are many different methods and tools for resource accountability. Some examples are: Electronic accountability system; Tactical worksheets; Command boards; Apparatus riding lists; Company responding boards; Electronic bar-coding systems; Accountability tags or keys (e.g., PASSPORT System).48
At a large scale incident such as this, the accountability process may have to be assigned to an Accountability Group. Each division and group would be responsible for maintaining the accountability of all members assigned to their division and group. This would be very similar to the accountability process used during high-rise fire-fighting operations. The personnel accountability system should comply with the requirements of NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety. 48
The fire department utilizes both the personal alert safety system (PASS) and a fireground electronic accountability system (EAS). As part of “Resource Status”, the Incident Commander assigns an “Accountability Officer” to maintain an accurate and continuous status of all members operating at the incident. This individual is usually the second Incident Command Technician (ICT) on scene. The first due district chief’s ICT maintains accountability until an “Accountability Officer” is appointed. The “Accountability Officer” is responsible for monitoring the EAS when members are operating in an immediately dangerous to life and health (IDLH) atmosphere.
The “Accountability Officer” is responsible for monitoring the EAS display for the following items: “Mayday” alarm indications, Loss of signal indications, Continual display of all crewmembers from each unit on scene - apparatus on scene (engine, ladder, and rescue) will display four activated riding positions.
The “Accountability Officer” will advise the Incident Commander of any alarms that cannot be cleared or verified.
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These components can be used in conjunction with one another to facilitate the tracking of responders by both location and function. The components of the personnel accountability system should be modular and expand with the size and complexity of the incident.48
At this incident, the electronic accountability system became quickly overwhelmed when the “Mayday” occurred. Due to radio communication issues, the “Accountability Officer” could not contact individual fire fighters whose EAS was in alarm. As the incident escalated, fire fighters removed their SCBA without turning off the EAS, thus causing the EAS to go into alarm and adding to the confusion.
The department has been implementing several changes in their personnel accountability process. For example, as an incident escalates, the Incident Commander would consider assigning an “Accountability Group” to assist the “Accountability Officer” in maintaining situational awareness and helping to expand this important function at every fire. The electronic accountability system can be used to conduct a personnel accountability report (PAR) which greatly reduces radio traffic. The Incident Commander would announce over the radio that an “Electronic PAR” will be conducted. All members would acknowledge the “Accountability Officer” and then “clear” the signal from their unit.
Recommendation #11: Fire departments should review the standard operating procedure for Rapid Intervention Team (RIT) operations including the RIT bag and air supply to trapped or downed fire fighter(s).
Discussion: During the incident, fire department members performed a successful rescue of the captain of E68 from the restaurant after the roof collapse of the restaurant and small banquet area. Due to the configuration of the RIT Pack, the airline was not long enough to reach the captain. The RIT Pack had to be moved closer to the officer under very difficult conditions. (See Rapid Intervention Team Operations section.)
Many fire departments have a defined response plan for the dispatch of additional companies (engine, truck, squad, and/or rescue company) to respond to an incident and standby as the rapid intervention team. Based upon the complexity, magnitude, configuration of the structure or geographical layout of the incident, the Incident Commander may deploy additional rapid intervention teams by location or function.57
Upon arrival or upon appointment, the RIT officer should confer with the Incident Commander. The RIT officer should establish an area to stage the rapid intervention team and the necessary RIT equipment. The RIT equipment should include: A tool staging tarp; Rescue SCBA (RIT Pack); Forcible entry tools such as a Halligan bar or other pry tool; Thermal imager; Stokes basket; 150’ long rope for search and rescue;
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Wire cutters; Rebar cutter; Life-saving rope/life belt; Elevator keys for buildings with elevators. 58, 69, 60
It is important to stage all necessary RIT equipment in an expedient manner. The RIT officer, accompanied by one member of the RIT, should perform an incident scene survey while the remaining RIT members assemble the RIT equipment. If the size of the structure negates a 360-degree survey of the building, this fact shall be relayed to the Incident Commander as soon as possible. This should be a benchmark for “Command” to designate another RIT in order to effectively cover all sides of the building.
During the survey or a “360” of the structure, the RIT Officer and RIT members will coordinate with the Incident Commander or Operations Section Chief (if established) to formulate rescue plan contingencies and continue to monitor the radio and fire ground conditions. RIT protection is not a passive assignment. This is a process of ongoing information gathering and diligent scene monitoring until the unit is released by the Incident Commander. RIT is a critical component for ensuring fire fighter safety while operating on the fireground. Rapid Intervention Team (RIT) duties should include establishing a means of egress on all sides of a structure.61
Another consideration for “Command” is to request the response of an advanced life support (ALS) engine company or truck company as a component of the RIT Group including a medic unit or ambulance for transportation capabilities. The members of the ALS company are trained to operate in an IDLH, can function as part of the RIT, and provide advanced life support to affected fire fighters.59
In January 2014, the fire department issued a Special Bulletin outlining the necessary changes that need to occur based upon the events of this incident. Some of the changes which have occurred include: New RIT bags or packs were fitted with two air-lines, which can be stored separately and deployed independently or together based upon the needs of the situation. Removing miscellaneous tools from the RIT pack; A new style quick disconnect couplings were added; RIT masks were upgraded by the department’s Mask Service Unit for easier donning with gloved hands; All RIT bags were fitted with one hour air cylinders. (See Photo 8.)
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Photo 8. The RIT Pack that the department has redesigned based upon this incident. (Photo courtesy of the fire department)
The members, assigned to the Rescue Group during this incident, performed extraordinarily under very difficult and dangerous conditions during the rescue of the captain from Engine 68 and the removal of the engineer/operator from Engine 51 (E51B). The changes made by the department for RIT operations will improve an already effective and efficient rapid intervention team process.
Recommendation #12: Fire departments should ensure adequate incident scene rehabilitation is established in accordance with NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises.
Discussion: NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises establishes the minimum criteria for developing and implementing a rehabilitation process for fire department members at incident scene operations and training exercises operating within an incident management system.62 The physical and mental condition of personnel should be monitored to ensure their health does not deteriorate to the point it affects the safety of each fire fighter or endangers the safety and integrity of the operation. An Incident Commander should consider the circumstances of each incident and make suitable provisions for rest and rehabilitation for personnel. This process shall include medical evaluation and treatment, food and fluid replenishment, rest and relief from extreme climatic conditions.
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NFPA 1584 states an Incident Commander should establish rehabilitation operations when emergency operations pose a safety or health risk to fire fighters and other responders. Rehabilitation operations should be provided in accordance with fire department SOPs, NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, and NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety. 44, 48
Incident scene rehabilitation (“Rehab”) is a term often used for the care given to fire fighters and other responders while performing their duties at an emergency scene. The Incident Commander shall consider the circumstances of each incident for the rest and rehabilitation for all personnel operating at the scene. “Rehab” includes medical evaluation, treatment and monitoring, food and fluid replenishment, mental rest, and relief from extreme climatic conditions. 44, 62, 63 When the size of the operation or geographic barriers limit member’s access to the rehabilitation area, the Incident Commander shall establish more than one rehabilitation area. The site shall be a sufficient distance from the effects of the operation where members can safely remove their personal protective equipment and can be afforded physical and mental rest.63 Once “Rehab” area(s) have been established, this information must be communicated over the radio, so all members know the location of “Rehab” or know where to report when assigned to “Rehab”.
Several considerations for rehabilitation sites are as follows: Should be in a location that will provide physical rest by allowing the body to recuperate from the demands and hazards of the emergency or training evolution. Should be far enough away from the scene that personnel may safely remove their turnout gear and SCBA and be afforded physical and mental rest from the stress and pressure of the emergency or training evolution. Provisions should be available to have SCBA cylinders refilled. Should provide suitable protection from the prevailing environmental conditions. During hot weather it should be in a cool, shaded area and during cold weather it should be in a warm, dry area. Should enable personnel to be free of exhaust fumes and noise from apparatus, vehicles, or equipment, including those involved in the rehabilitation group operations. Should be large enough to accommodate multiple crews based on the size of the incident. Should be easily accessible by EMS units. Should allow prompt re-entry back into the emergency operation upon complete recuperation. Crews assigned to rehab will be instructed to turn portable radios off and/or have radio and thermal imager portable batteries recharged or exchanged.63 (See Diagram 16.)
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Diagram 16. An example of how a “Rehab” area can be organized. There are many ways to establish an effective “Rehab” area.
The Rehab Group Supervisor should secure all necessary resources required to adequately staff and supply the rehabilitation area. The supplies should include the following items: Fluids: water, activity beverage, oral electrolyte solutions, and ice; Food: soup, broth, or stew in hot/cold cups; Medical devices: blood pressure cuffs, stethoscopes, oxygen administration devices, cardiac monitors, intravenous solutions, and thermometers; Other: awnings, fans, tarps, fans, heaters, dry clothing, extra equipment, floodlights, blankets and towels, traffic cones, and fire line tape (to identify the entrance and exit of the rehabilitation area); Hygiene facilities to decontaminate all exposed skin surfaces; Restroom facilities. 63
The fire department operates an “informal” Rehab at every incident. As members are relieved from their current assignment and report their assigned apparatus, the informal “Rehab” process starts. The informal “Rehab” includes short breaks (e.g. SCBA cylinder changes, hydration of water, which is carried on every heavy apparatus). A formal “Rehab” is usually established when the “Rehab” vehicle (Rehab 17) is dispatched (e.g. Special Called or on all 2-11 fires).
For this incident, Rehab 17 was dispatched on the 2nd Alarm (2-11) at 1219 hours. However, Rehab 17 was not fully operational at the scene until 1313 hours. Logistical problems were encountered throughout the process which included the distance the Rehab 17 had to travel (response distance); the same traffic conditions that most of the other responding companies were faced with as they traveled to the incident; and radio problems prevented the transmission of when and where Rehab 17 was finally set-up. Additional problems included rotating crews through “Rehab” and making it known that
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“Rehab” was not a choice but an actual assignment. The emotional stress that was faced by the members on scene that day also had a tremendous effect on how members perceived a formal “Rehab”. Many crews wanted to be directly involved in the rescue and/or recovery process. Crews shortened their time in “Rehab” or even deferred this assignment so they could be available to assist on the fireground.
Recommendation #13: Fire departments should consider upgrading SCBA to the current edition of NFPA 1981, Standard on Open-Circuit SCBA which includes the enhanced heat and flame testing criteria. Discussion: A number of recent NIOSH investigations, including this incident, suggested that the facepiece lens material may have melted before other components of the fire fighter's self-contained breathing apparatus and personal protective equipment ensemble degraded. 32, 64, 65, 66 Additionally, a number of documented near-miss incidents also identify the potential for thermal damage to facepiece lenses is greater than commonly believed.67, 68, 69, 70 SCBA manufactured to the 2007 edition of NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus included a "Heat and Flame Test," which included placing a complete SCBA unit in an oven at 95 degrees C (approximately 203 degrees F) for 15 minutes, followed by exposure to direct flame impingement for 10 seconds. These NFPA certification requirements covering SCBA dictated that facepiece lens materials were evaluated at lower temperatures than electronic and other protective ensemble components.71 The NFPA Respiratory Protective Equipment Technical Committee worked with the United States Fire Administration (USFA), National Institute of Standards and Technology (NIST), and the NFPA Research Foundation to better understand the environments faced by fire fighters. This led the Respiratory Protective Equipment Technical Committee to add more rigorous testing requirements to NFPA 1981, especially requirements that would increase the SCBA’s resistance to thermal degradation.
Two new performance tests were proposed and adopted for the 2013 edition of NFPA1981: A radiant heat panel test A convection heat performance test, in addition to the current heat and flame test in the standard. Additionally, other changes to the 2013 edition of NFPA 1981 include enhanced communications testing and use of the Emergency Breathing Safety System (EBSS).71 Fire departments should consult with their SCBA manufacturer to inquire if upgrade kits are available for their SCBA that would allow them to benefit from improved components that pass the enhanced heat and flame tests. At this incident, although there was no indication of any manufacturer defect with any of the fire fighters’ SCBA, the conditions encountered likely exceeded the thermal performance limitations of the SCBA facepiece lens worn by E51B. E51B had his SCBA facepiece in place and functioning during fire-fighting operations. During the collapse, his facepiece became thermally degraded and exposed him to products of combustion. The medical examiner’s report identified his injuries that were
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consistent with being exposed to the products of combustion. It is likely that the conditions encountered exceeded the capabilities of the SCBA facepiece lens.
Recommendation #14: Fire departments should implement a Restricted Access SOP which provides the mechanism for the chain of custody of personal protective equipment and/or SCBA in the event of a fire fighter fatality or serious injury.
Discussion: When a fire fighter fatality or serious fire fighter injury occurs, a fire department must have procedures in place to ensure that the personal protective equipment (PPE) - (turnout gear) and/or self- contained breathing apparatus (SCBA) is properly isolated. This insures the PPE and/or SCBA is in as close to the same condition as at the time of the incident. Information gathered from this process will assist the investigating officer(s) and investigating agency(s) in cause determination.72
The process entails that a fire department have a waterproof evidence bag which is carried in chiefs’ vehicles such as a battalion chief, district chief, duty chief, and/or the safety officer’s vehicle. The evidence bags should have a seal which requires a signature once items are secured. These bags also contain a chain of custody form that identifies who secured the item(s), the individual who transported the item(s) to the evidence locker, and the date and time the item(s) were entered as evidence. A sample standard operating procedure (SOP) is provided in Appendix Seven: Sample SOP – Restricted Access for PPE/SCBA/Equipment. This SOP which details all necessary actions to take in the event of any PPE (turnout gear) and/or SCBA fails to operate in its designed and prescribed fashion, whether in training or on an emergency incident.72
This is a very important fire fighter safety process which allows a fire department to have an understanding of the performance of the PPE and/or SCBA. Also, this process documents a likely sequence of events of the user. It is so important that the PPE and/or SCBA be collected and secured on the incident scene, which can protect valuable information. Newer SCBA and personal alert safety systems (PASS) contain electronic and pneumatic data which can provide important information about the performance of the equipment and actions of the user.
At this incident, the process of securing the PPE and SCBA from the officer of E68 and the fire fighter from E51was conducted at the scene and at the hospital. The PPE and SCBA from both fire fighters from E68 were removed at the hospital. There was no documentation about the process of who secured each of the fire fighter’s turnout gear and SCBA.
Additionally, Recommendation #15: States and municipalities should consider adopting and enforcing regulations for automatic fire sprinkler protection in renovated structures.
Discussion: This recommendation focuses on fire prevention and minimizing the impact of a fire if one does occur. The National Fire Protection Association (NFPA) Fire Protection Handbook states “Throughout history there have been building regulations for preventing fire and restricting its spread. Over the years these regulations have evolved into the codes and standards developed by committees
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concerned with fire protection. The requirements contained in building codes are generally based upon the known properties of materials, the hazards presented by various occupancies, and the lessons learned from previous experiences, such as fire and natural disasters.”73 Although municipalities have adopted specific codes and standards for the design and construction of buildings, structures erected prior to the enactment of these building codes may not be compliant. Such new and improved codes can improve the safety of existing structures.73 Sprinkler systems are one example of a safety feature that can be retrofitted into older structures. Sprinkler systems can reduce fire fighter and civilian fatalities since such systems can contain and may even extinguish fires prior to the arrival of the fire department.
Fire development beyond the incipient stage presents one of the greatest risks fire fighters are exposed to during fireground operations. This risk exposure to fire fighters can be dramatically reduced when fires are controlled or extinguished by automatic sprinkler systems.
NFPA statistics show that most fires in sprinklered buildings are controlled by the activation of one or two sprinkler heads prior to fire department arrival.74 An automatic fire sprinkler system also reduces the exposure risk to fire fighters during all phases of fireground operation and allows the safe egress of building occupants before the fire department arrives on scene. Finally, by controlling fire development, the risks associated with the potential for structural collapse and during overhaul operations are greatly reduced, if not eliminated.
Fire Department Actions Taken Since the Incident During the course of the investigation, the fire department advised NIOSH FFFIPP investigators that they had implemented a number of changes in department equipment, procedures, and training as the direct result of these fatalities. A description of these efforts can be found in Appendix Eight: Fire Department Update.
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62. NFPA. [2008]: NFPA 1584, Standard on the rehabilitation process for members during emergency operations and training exercises. 2008 ed. Quincy, MA: National Fire Protection Association.
63. USFA [2008]. Emergency incident rehabilitation manual for firefighters and other emergency responders. 2008. Washington, DC: U.S. Department of Homeland Security, U.S. Fire Administration.
64. NIOSH [2007]. Career officer injured during a live fire evolution at a training academy dies two days later—Pennsylvania. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2005-31 [http://www.cdc.gov/niosh/fire/reports/face200531.html].
65. NIOSH [2008]. Career fire fighter dies in wind driven residential structure fire—Virginia. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2007-12 [http://www.cdc.gov/niosh /fire/reports/face200712.html.]
66. NIOSH [2009]. Volunteer fire fighter dies while lost in residential structure fire—Alabama. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2008-34 [http://www.cdc.gov/niosh/ fire/reports/face200834.html].
67. National Fire Fighter Near Miss Reporting System [2006]. Firefighter experiences near miss in flashover trailer training, Report 06-441[http://www.firefighternearmiss.com]. Date Accessed: March 18, 2014.
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68. National Fire Fighter Near Miss Reporting System [2006]. Engine crew surprised by sofa flare up, Report 06-428 [http://www.firefighternearmiss.com]. Date Accessed: March 18, 2014.
69. National Fire Fighter Near Miss Reporting System [2006]. Facepiece damaged during live burn training, Report 07-903 [http://www.firefighternearmiss.com]. Date Accessed: March 18, 2014.
70. National Fire Fighter Near Miss Reporting System [2006]. Problem with CAFS unit identified at live burn, Report 08-044 [http://www.firefighternearmiss.com]. Date Accessed: March 18, 2014.
71. NFPA [2013]. NFPA 1981 Standard on open-circuit self-contained breathing apparatus (SCBA) for emergency services, 2013 edition. Quincy, MA: National Fire Protection Association.
72. VBFD [2011]. Virginia Beach Fire Department Standard Operating Procedure OHS-7.18, Restricted Access Bags for Gear/Equipment. April 20, 2011. Virginia Beach, VA. Virginia Beach Fire Department.
73. NFPA [2008]. Fire Protection Handbook, 20th ed. Quincy, MA: National Fire Protection Association.
74. The Truss Guy [2014]: Roof Truss Designs – What to Know About a Fink Trusses. http://www.thetrussguy.com/fink-truss.html. Date accessed: November 14, 2014.
Investigator Information This incident was investigated by Murrey E. Loflin, Matt Bowyer, Stephen T. Miles, and Paul H. Moore with the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, WV. The report was authored by Murrey E. Loflin. The information provided in the Building Construction and History section was authored by Christopher J. Naum, SFPE (Command Institute). Chief Naum provided information on building construction and materials, complex construction demographics, the restaurant roof design, the concrete tile roofing system, fire performance characteristics of wood and fire impingement, occupancy risk profile, building risk and severity considerations, and assessment matrix. An expert technical review was provided by Mario D. Rueda, Deputy Chief, Bureau of Emergency Services with Los Angeles Fire Department and Dennis L. Rubin, Fire Chief, City of De Pere, WI Fire Department. A technical review was also provided by the National Fire Protection Association, Public Fire Protection Division.
Additional Information Modern Fire Behavior This site is meant to serve as a clearinghouse of news and training information related to Modern Fire Behavior and Modern Building Construction Research, Tactics, and Practices along with actual street experiences. http://modernfirebehavior.com/
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National Institute for Standards and Technology and Underwriters Laboratory These two agencies provide information including training videos showing the findings from NIST and UL research conducted in cooperation with the Fire Department of New York on Governor’s Island in 2012. http://www.firecompanies.com/modernfirebehavior/governorsislandonlinecourse/story.html.
Flashover TV sponsored by FireRescue.com includes a series of training presentations by NIST researcher Dan Madrzykowski. http://flashovertv.firerescue1.com/videos/1875870-nist-and-ul-research-on-fire-dynamic-case-studies- part-4/
Information on completed fire-fighting research studies available at the National institute of Standards and Technology website at http://www.nist.gov/el/fire_research/firetech/index.cfm
The information on completed fire-fighting research studies available at the UL Firefighter Safety Research Institute website at www.ULfirefightersafety.com.
IAFC Rules of Engagement for Firefighter Survival The International Association of Fire Chiefs (IAFC) is committed to reducing fire fighter fatalities and injuries. As part of that effort the nearly 1,000 member Safety, Health and Survival Section of the IAFC has developed DRAFT “Rules of Engagement for Structural Firefighting” to provide guidance to individual fire fighters, and incident commanders, regarding risk and safety issues when operating on the fireground. The intent is to provide a set of “model procedures” for structural fire-fighting to be made available by the IAFC to fire departments as a guide for their own standard operating procedure development. http://www.iafcsafety.org/downloads/Rules_of_Engagement.
IAFF Fire Ground Survival Program The purpose of the International Association of Fire Fighters (IAFF) Fire Ground Survival Program is to ensure that training for “Mayday” prevention and “Mayday” operations are consistent between all fire fighters, company officers and chief officers. Fire fighters must be trained to perform potentially life-saving actions if they become lost, disoriented, injured, low on air or trapped. Funded by the IAFF and assisted by a grant from the U.S. Department of Homeland Security through the Assistance to Firefighters (FIRE Act) grant program, this comprehensive fire ground survival training program applies the lessons learned from fire fighter fatality investigations conducted by the National Institute for Occupational Safety and Health (NIOSH) and has been developed by a committee of subject matter experts from the IAFF, the International Association of Fire Chiefs (IAFC) and NIOSH. http://www.iaff.org/HS/FGS/FGSIndex.htm
NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety (2014 edition) The primary focus of the revision to NFPA 1561 in the 2014 edition is develop requirements directly aimed at reducing and eliminating fireground injuries and fireground deaths of fire department members. The most apparent change addition to this edition has been the document title to include
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“Command Safety” and the creation of a new chapter, Command Safety. This chapter is intended to provide a foundation on how to incorporate the incident management system at all emergency incidents especially Type V and Type IV incidents.
The chapter on “Command Safety” clearly defines the requirements for the Incident Commander to meet including establishing a fixed Command Post, personnel accountability, the use of staff aides, rapid intervention crews, and the appointment of a safety officer and assistant safety officer(s)(as needed) plus the expectations and authority of the safety officer. There are annexes that cover Functional Assignments for High-Rise Building Incidents, Development of Subordinate Officers or Implementing a More Efficient Management System, Incident Management for the Fire Service on Type 5 or Type 4 Incidents, and Structural Fire Fighting — Risk Assessment and Operational Expectation.
NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety (2014 edition) can be purchased from the National Fire Protection Association at http://www.nfpa.org.
Buildingsonfire.com A reference and informational site, with extensive documentation, insights, research and studies dedicated to building construction, engineering, fireground risk management and fire-fighting operations. http://buildingsonfire.com
Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these Web sites.
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Appendix One Additional Building Construction Information
Overall Hotel Complex Construction Demographics (See Photo 9.) Constructed: circa 1966
Photo 9: Aerial View of Building Complex and Exposures (Bing.com Maps/ Analysis Diagram Courtesy of Buildingsonfire.com)
Incident Site, buildings and exposures. [1] Main Entry and Lobby [2] Restaurant – Red Circle [3] Banquet Rooms, [4] Kitchen [5] Lodging Units (typical) [6] Low Rise Hotel
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[7] Motel [8] Commercial Occupancies [9] Multiple Occupancy Apartments [10] Freeway [11] Perimeter fencing
Construction Type: 5B NFPA 220 Type: Type V- Wood Frame 5 Occupancy: R2/ A2 State Class Code: Commercial Land Use: Hotel/ Motel Low Rise 1- 3 Stories Land Area: 149,210 square feet (SF) Building Area: 69,284 SF Building Class: D Total Units: 110 Total Number of Buildings: Eight (8) o Bldg. 1 6,350 SF o Bldg. 2 6,350 SF o Bldg. 3 6,350 SF o Bldg. 4 6,350 SF o Bldg. 5 6,250 SF o Bldg. 6 5,100 SF o Bldg. 7 26,284 SF o Bldg. 8 6,250 SF
Construction System: Floor Area: Primary Building: 26,284 square feet. Perimeter Walls: Wood frame, masonry block, brick masonry veneer and combined stucco finish: Load bearing walls, steel beams and columns and masonry, wood frame and veneer construction features. Roof: Various: gable-style roof with engineered wood trussed systems (engineered structural systems) being incorporated along with flat roofs constructed on both wood and non-combustible materials. Specific construction details not determined. The gable roofs and truss loft attic space appear to have had connectivity due to the fire extension and travel experienced during fire- fighting operations resulting in fire communicating to other building sections and compartments, resulting in a large scale collapse. The presence, absence or integrity of any fire stopping in the truss loft attic space is unknown. Protective Systems: None – No fixed sprinkler system present. Building Additions: Numerous renovations, alterations, roofing systems & additions.
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Restaurant Construction Type: 5B NFPA 220 Type: Type V - Wood Frame 5 Occupancy: R2/A2 Building Area: o Small Banquet Area: approximately 1100 square feet (primary roof collapse zone) o Kitchen Area: approximately 5200 square feet (adjacent to and connected to the Small Banquet Room) Building Class: D Construction System: o Columns: None – 30 feet clear span in restaurant area from north to south (front bearing wall to steel beam - kitchen area) o Floor: Concrete slab on grade. Finish: Carpet, vinyl tile, or exposed concrete Floor Area: Primary building: open floor plan, ~ 1920 square feet (40 ft. x 48 ft.) Perimeter Walls: Wood Frame: 2-inch x 4-inch nominal wood stud construction at 16-inch on center with 5/8 inch gypsum wall board, some masonry block, brick masonry veneer, and combined stucco finish. Roof: Gable-style lap nail wood truss – Modified Fink Design with approximately 20 each (24- inch on center); Note: The Modified Fink Design can usually span up to about 20 feet in length, before additional webbing is required. Top and bottom chords generally are made with 2-inch x4- inch Southern Yellow Pine (SYP) or Spruce (SPF). The most unique aspect with this profile is its "W" web structure.74 (See Diagram 17.) o Truss: Suggested to have been constructed utilizing a lap-nailed wood truss system. A lap- nailed wood truss system utilizes nails (versus MPC) as the mechanical fastener to secure the truss components together in an assembly to provide structural support as a configured truss component. (See Diagram 17.) o Engineered Structural System: Wood (southern yellow pine): 2-inch x 6-inch nominal top chords with 2-inch x 4-inch nominal bottom chord and diagonal web members. 2-inch x 4-inch nominal vertical strut at center line of truss. Mechanically fastened with nails and connected at the ridge with plywood gusset plate. Spaced 24-inches on center. Note: The presence of any bridging could not be determined. o Slope Ratio: 4:12 (18.5 degrees) Rise: approximately 6 feet. Run: approximately 15 feet. o Deck: ½ inch plywood deck sheathing nailed directly to truss cord, two (2) layers asphalt felt underlayment, multiple layers of aged asphalt shingles (nominal size – unknown) o Covering: Extruded concrete interlocking roof tiles with shiplap as a roof covering on the Restaurant roof and on the main building and entry portico fronting Side Alpha. (See Photo 10.) o Total Dead Load Roof Weight: 17.20 pounds per square foot (PSF) equaling 22,016 pounds o Approximate Roof Surface Area: 1280 Square Feet (SF); o Approximate Roof/ Truss Loft Attic Space: 3000 Cubic Feet (CF); o 5/8 inch Gypsum wall board (GWB) ceiling attached to bottom chord of truss with acoustic mineral fiber tile ceiling attached to the GWB;
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o The presence, absence or integrity of any fire stopping in the truss loft attic space: unknown; o Exposed Wood Surface Area of Truss Assembly: > 1700 Square Feet; Protective Systems: None – no fixed sprinkler protection system present; Building Additions: Numerous renovations, alterations, roofing systems and additions. The restaurant has connectivity to the main entry lobby area to the west and the main kitchen to the south. The restaurant appears to have a different construction vintage than the adjacent kitchen area when assessing aerial views of the Side Alpha and Side Bravo areas. The gable roof of the restaurant appears to be nested into the kitchen and front façade while it appears to be contiguous to the end of the main entrance lobby building it adjoins.
Lap Nail Truss Component The wood web and nail configuration are as follows for the lap-nailed truss. (See Diagram 18 and Diagram 19.)
Diagram 17. Lap-Nailed Truss Assembly Configurations (Partial Detail) (Diagram Courtesy of Buildingsonfire.com)
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Photo 10. Bottom Truss Cord and Two-Web (Photo courtesy of the fire department/ Diagram Courtesy of Buildingsonfire.com)
[1] 2 in. x 4 in. Wood Web; [2] 2 in. x 4 in. Wood Web; Note: See loss of remaining web material [3] 2 in. x 4 in. Wood Bottom Chord; [4] 2 in. x 6 in. Wood Top Chord; [5] Circle depicts the typical surface connection point of the truss webs as they are mechanically fastened with nails to the cord, (absent is any MCP, which is typical of most fabricated truss assemblies of that period, and today).
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Diagram 18. Truss Configuration (Diagram Courtesy of Buildingsonfire.com)
Diagram 19. Typical Lap-Nailed Truss (Diagram Courtesy of Buildingsonfire.com) [Adapted from USDA LSU AgCenter Diagram EX5923 circa 1961]
The gable roof profile of the restaurant and the main building can be seen from an aerial view which consists of extruded concrete interlocking roof tiles with shiplap as a roof covering fronting Division Alpha. (See Photo 11).
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Photo 11. Pre-fire Aerial View of Building Complex (North-East Geographical/Division Alpha-Bravo) (Bing.com Maps/ Diagram Courtesy of Buildingsonfire.com)
[1] Restaurant Gable Roof
[2] Kitchen Flat Roof [3] Main Entrance and Lobby Gable Roof [4] Main Portico Canopy Roof [5] Ventilation Fan Housing (assumed) [6] Roof-top mounted Mechanical Units & Ventilator/Fans (type unknown) [7] Extruded Concrete Interlocking Roof Tiles with shiplap as a roof covering [8] Flat Roof Areas [9] Gable Roofs
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The post-fire profile of the complex after the collapse of the roof and walls focusing on Side Alpha and Side Bravo of the structure. (See Photo 12).
Photo 12. Post Fire-Collapse Aerial View of Building Complex (Photo courtesy of the fire department/ Diagram Courtesy of Buildingsonfire.com)
[1] Restaurant Gable Roof - Outline [2] Restaurant Floor Outline [3] Kitchen Area [4] Main Entry and Lobby Gable Roof-Outline [5] Main Portico - Canopy Roof Destroyed [6] Adjacent Rooms [7] Secondary Wall Collapse Zone [8] Interior Pancake Collapse Zone
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Appendix Two Fire Fighter Risk Profile and Insights
Occupancy Risk Profile The complex of buildings that comprised the property at the Southwest Inn (SWI) had common inherent building, construction, design features and characteristics that provided a recognizable predictability of expected building performance. This predictability of building performance have definable degrees of risk potential that once identified and assessed against an evolving fireground scenario can be align with recognized strategic and tactical measures that must be considered and implemented in order to increase the probability of a safe and effective incident stabilization and mitigation.
The significance of the extent and degree of renovations, alterations and modifications over the complex’s forty plus years of use cannot be underscored and contribute highly towards the overall projected probabilities of risk and impacts on fire department operations.
Understanding the building’s anatomy, its current occupancy use and the characteristic of the building’s internal compartments (occupied rooms and space use) are integral to effective and efficient firefighting operations within buildings on fire and are essential for all phases of fire engagement and suppression.26
The challenge for today’s command officer, fire officers, and fire fighters on the modern fireground is to clearly recognize building performance factors and inherent characteristics. These are issues fundamental to the manner in which a building’s anatomy presents itself at an evolving incident. Moreover, to ascertain and distinguish how it will subsequently perform during fire duress and the continuum of elapsed incident time.16, 17
The prevailing building characteristics present, for the restaurant occupancy and the main lobby/entrance buildings and adjacent kitchen areas consisted of; conventional construction features with related performance parameters with an average building age exceeding over 40 years, wood frame construction, some masonry veneer and wood perimeter wall construction, and engineered gabled truss roof assembly construction systems, flat roofs and integrated unprotected steel beam, and column structural support systems integrated into past renovations and additions.
Additional proximal buildings comprised of transient hotel/motel occupancy use. These are not included in this discussion section. Overall building anatomy, operational risk, and probability of performance for operating fire-fighting personnel, and in the management of the incident is normal- marginal. A higher emphasis toward the marginal band primarily due to the inherent wood frame construction, interconnected buildings and roofing systems, large span/open floor areas and the lack of a fixed fire protection system.
The inherent building materials in the form of the light-frame wood structural systems, roofing diaphragms with some structural steel components coupled with a moderate interior fuel load package
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would contribute towards fire growth. This supports the premise of a higher probability of expected fire development in a compartment and rapid fire extension in the event of a fire incident.
The restaurant occupancy and the main lobby/entrance buildings and adjacent kitchen areas were adjoining and contiguous creating interconnectivity of varying volume compartment spaces. The restaurant space was nestled on three sides with the front of the buildings accessing directly to the parking lot. The other three sides connected to the main lobby/entrance building (west), ancillary rooms (east) and kitchen (south). The restaurant structure appears to have been part of the original construction circa 1966, with the ancillary rooms and kitchen areas added at an unknown later time period.
The roof construction configuration when identified on the fireground should be considered an indication that the structural supporting systems in this area may have been radically modified. The roof diaphragm supporting system has been modified revealing the presence of large open span area is probable. Caution must be exercised and considered if fire or fire-indictors are present. Structural stability and integrity must be closely monitored or considered a high risk factor. Overall operations conducted under this area may be consider at-risk deployments that require fluid and concise risk- benefit assessment and close monitoring. This is based on incident priorities, immediate or deferrable operational demands associated with life hazards and fire severity, growth or propagation.
The street view of the restaurant clearly reflects the difference in building anatomy with a predominate gable roof with cement tile roofing treatment. This distinctive feature and the manner in which it is physically situated present operational barriers that could have adverse effects on subsequent incident operations in terms of access, size-up and assessment, smoke tunneling, compartment ventilation, multiple flow paths routes, ventilation-limited or fuel-limited conditions, structural integrity and collapse considerations, tenability and connectivity of spaces and fire dynamics.
Predicting a potential structural collapse is one of the most challenging tasks facing an Incident Commander at a fire scene. Usually the lack of information on the construction of the building, fire size, fire location, fire burn time, condition of the building, and fuel load, makes the task very difficult
Building Risk and Severity Considerations Building construction system and type; Building size and volume: number of large open span assembly spaces and individual occupancy compartments (rooms); Building age, vintage and condition; Degree of alterations, renovations and make-overs over an extended period of decades Degree of roof compartmentation: connectivity of roof truss-loft (attic spaces) compartments and high probability for unstopped concealed spaces; Structural collapse characteristics of wood truss roofing systems; structural integrity and collapse considerations; Presence of extruded concrete interlocking roof tiles;
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Inherent structural compromise and collapse potential-internal due to mixed-construction systems, materials and structural assemblies; Physical arrangement of primary occupancy (restaurant) and impacts from smoke tunneling, compartment ventilation, multiple flow paths routes, ventilation-limited or fuel-limited conditions, tenability and connectivity of spaces-fire dynamics; Fire loading and potential for significant heat release rates/effects on fire suppression; Identifiable and measurable safety parameters; Adequacy of fire flow rates based on postulated fire growth; Probability of rapid fire travel and extension growth; Uncertainty of civilian occupancy load; Uncertainty of civilian occupancy reaction time and responsiveness to emergencies; Probability of fire department life hazard and risk threat; Resource intensive deployment requirements; Identified severity of risk level and acceptability of risk to organization;
Buildings on Fire Risk Assessment Matrix
Levels Severity of Risk
May Result in personnel Death; grave personnel injury; Catastrophic large scale destruction and perilous conditions
Critical May cause severe personnel injury, possible death; major property loss or significant degraded conditions
May cause or result in personnel injury, prominent property Marginal loss or degraded and compromised conditions
Hazards and conditions are consistent with generally accepted Fire Service work practices and operational parameters for adequately resourced and trained companies. Normal Operations may cause or result in some personnel injury, corresponding property loss or damage conditions consist with firefighting principle & practices
Conditions have minimal threat to the safety and wellbeing Negligible of companies operating under generally accepted Fire Service work practices and parameters
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Buildings on Fire Risk Assessment Matrix Courtesy of Buildingsonfire.com and the Command Institute, additional information can be accessed at http://buildingsonfire.com/buildings-on-fire-risk-assessment-matrix
Based on potential severity and urgency factors given a fire of any great magnitude or other initiating event, this would require judicious and thoughtful pre-fire planning. This is not only to identify postulated incident events and occurrences, but to also assess the potential demands for escalating incidents, resource needs and suggested incident management scenarios, situations, and consequences.
The probability for an impending multiple-alarm fire occurring in this complex creating limiting conditions of operations, high resource demands, operational severity, urgency and escalating incident growth issues were highly probable and could be expected. Therefore, precautions and instituted pre- fire plans could have been identified, formulated and implemented prior to the initiating incident that may have contributed towards increased operational and incident management efficiencies, operational effectiveness, control and amplified managed risks.
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Appendix Three Summary of Personal Protective Equipment Evaluation Status Investigation Report of four Self-Contained Breathing Apparatus Submitted By the Fire Department NIOSH Task Number TN-19199 (Note: Full report is available upon request)
Background
The National Institute for Occupational Safety and Health (NIOSH) has concluded its investigation conducted under NIOSH Task Number TN-19199. This investigation consisted of the inspection of four Scott Health and Safety AirPak 4.5, 45 minute, 4500 psig, Self-Contained Breathing Apparatus (SCBA). The SCBA units in question were contained inside individual cardboard shipping boxes and were delivered to the NIOSH facility in Bruceton, Pennsylvania, on June 13, 2013. The packages were taken to the NPPTL, Technology Evaluation Branch (TEB) Respirator Equipment Storage Area (Building 20) and stored under lock until the time of the examination and evaluation.
SCBA Inspection
An initial general inspection of the SCBA units was conducted on June 14, 2013. The units were identified as the Scott Health and Safety AirPak 4.5 models. In addition, Scott Health and Safety performed a down loading of the data logger present on one of the SCBA’s with NIOSH personnel present.
A complete visual inspection of the SCBA units was conducted on October 30, 2013 and February 11, 2014. The units were examined, component by component in the condition received, to determine conformance to the NIOSH-approved configuration. The visual inspection process was photographed.
The complete SCBA inspections are summarized in Appendix I of the enclosed Status Investigation Report. The condition of each major component was photographed with a digital camera. Images of the SCBA units are contained in the Appendix III of the report.
The SCBA units in question, Unit #1, Unit #2, Unit #3 and Unit #4 suffered heat damage, but exhibited other signs of wear and tear; and the units were covered lightly with general dirt, grime, foreign particulate material and soot. The cylinder valves as received on all units were in the opened position. The cylinder gauges that could be read as assembled to the backframe were approximately 0 psig for Units #2 and #3. The other gauges were un-readable.
The cylinder valve hand-wheels could be turned easily. The regulator and facepiece mating and sealing areas on the units were clean on Units #2 and #3. The mating and sealing areas on Units #1 and #4 were damaged. The facepiece and lens on all the units were damaged. Units #1 and #4 had
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extensive damage to the facepiece and lens. The harness webbing on the units was in fair to poor condition with some fraying on some of the units, heat damage on other but all the head harnesses were dirty. The PASS device on the Units #2 and #3 functioned. The NFPA approval label on Unit #3 was present and readable Units #1 and #4 could not be read and Unit #2 did not have a label. Visibility through the lenses of Units #1 and #4 were poor due to the extensive damage of the lens. Visibility through the lenses of Unit #2 and #3 were fair with some slight damage present.
Personal Alert Safety System (PASS) Device
The Personal Alert Safety System (PASS) devices on Units #2 and #3 were operable and functional. The PASS devices were activated and appeared to function normally. The other PASS units did not function. However, the units were not tested against the specific performance requirements of NFPA 1982, Standard on Personal Alert Safety Systems, (PASS), 1998 Edition. Because NIOSH does not certify PASS devices, no further evaluation was performed.
SCBA Compressed Air Cylinder Contents
During the inspection, it was noted that the compressed air cylinders of all the units were empty. No air sample was collected for analysis.
SCBA Testing
The purpose of the testing was to determine the SCBA conformance to the approval performance requirements of Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). Further testing was conducted to provide an indication of the SCBA conformance to the National Fire Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition.
NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 CFR 84): 1. Positive Pressure Test [§ 84.70(a)(2)(ii)] 2. Rated Service Time Test (duration) [§ 84.95] 3. Static Pressure Test [§ 84.91(d)] 4. Gas Flow Test [§ 84.93] 5. Exhalation Resistance Test [§ 84.91(c)] 6. Remaining Service Life Indicator Test (low-air alarm) [§ 84.83(f)]
National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 1997 Edition): 7. Air Flow Performance Test [Chapter 5, 5-1.1]
The testing of Units #2 and #3 were conducted on February 20 and 21, 2014, using substitute compressed air cylinders and facepiece supplied by the fire department. Neither SCBA Units #2 or #3
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passed all the testing. Units #1 and #4 were not tested as they had extensive damage and could not be tested safely.
Summary and Conclusions
Four SCBA units were submitted to NIOSH by the NIOSH Division of Safety Research for the affected fire department for evaluation on June 13, 2013. The SCBA’s were initially inspected on June 14, 2013. The units were identified as a Scott Health and Safety AirPak 4.5, 45 minute, 4500 psig SCBA (NIOSH approval number, TC-13F-212CBRN Unit #3 and unknown approvals for Units #1, #2 and #4). In addition on June 14, 2013, the SCBA data logger for SCBA Unit #3 was downloaded by personnel from Scott Health and Safety with NIOSH personnel present. In-depth inspections of the SCBA’s were conducted on October 30, 2013 and February 11, 2014. Two of the units were in mostly fair condition and two of the units in poor condition, with all the units having various levels of damage to the facepiece lens. The compressed air cylinders from Units #1 and #4 could not be determined to be in specification as the cylinders where discolored and the labels were unreadable. The cylinders for Units #2 and #3 were determined to be within specification. All these cylinders are required to be recertified every 5 years.
The integrated PASS unit on Units #2 and #3 were activated and appeared to function normally.
No air remained in the cylinders so no air samples were taken and analyzed.
The SCBA Units #2 and #3 were tested on February 20 and 21, 2013, utilizing replacement cylinders and facepiece that were supplied by the fire department. Units #1 and #4 were not tested due to the level of damage to each of the units. The Units #2 and #3 did not meet all the requirements as tested.
After the inspections and testing of the SCBA units, the respirators were placed back into storage pending the final disposition from the fire department. At the request of the fire department, Unit #2 was sent to Scott Health and Safety for further evaluation.
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Inspection and Test of SCBA #2 Scott Safety, Monroe, NC April 1, 2014 Discussion: NIOSH personnel provided an overview of the incident with a focus on SCBA #2. The results of the NIOSH testing of SCBA #2 were discussed. It was agreed to verify the performance of SCBA #2 on a Posi Check in the Scott Engineering lab and determine on the next step after reviewing the Posi Check results.
Initial Inspection The SCBA less facepiece was visually inspected and photographs supplied by NIOSH of the SCBA and facepiece were reviewed.
Testing SCBA #2 was installed on the Posi-Check using an AV3000 HT facepiece, the SCBA was pressurized slowly utilizing shop air (4500 psi).
Noise was detected from the area of the RIC/UAC/ High Pressure relief Valve /1st stage reducer; the noise is best described as a squealing sound.
A leak was detected at the High pressure Relief Valve.
The Vibralert EOSTI functioned.
The Posi-Check test was repeated two more times, erratic Vibralert operation was noted which may be caused by improper operation of the secondary circuit, also the “Press to Test” button was found to stick.
SCBA #2 remained positive through all Posi-Check tests performed at Scott for both NIOSH (40l/min) and NFPA (103L/min) breathing rates.
1st Stage Reducer disassembly and inspection It was agreed the next step is to disassemble the reducer and inspect the components for damage and debris in the air passages.
The primary and secondary seat plugs were found to be loose and were removed. The primary seat and shims were removed, the seat removed and debris noted on the seat and in the airway. The filter was removed with great difficulty and was found to be collapsed.
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Appendix Four Personal Protective Equipment Evaluation Examination of Fire Fighter Protective Ensemble Items
An examination was made of the personal protective equipment items worn by the captain of Engine 51, the Engineer/Operator detailed to Engine 51, and the two fire fighters assigned to Engine 68, who died in the restaurant fire on May 31, 2013. The examination was made at the department’s Arson Division on January 30, 2014.
A detailed review of the protective clothing and equipment items showed a range of different conditions of the clothing and equipment items with no specific patterns indicated. The degree of thermal damage observed on the clothing was attributed to extreme fireground conditions with the majority of firefighters (with the exception of the fire fighter assigned as E68C ) facing thermal conditions in excess of 1000oF for at least short periods of time. These exposures caused significant damage for portions of their protective clothing and equipment, including some areas of severe thermal degradation involving extensive charring and break open of all clothing principal protective layers. The orientation of the fire fighters during the ensuing period of collapse and recovery affected how their protective clothing and equipment fared.
The following is an evaluation of the personal protective equipment of each fire fighter: The captain of E51 experienced the worst thermal conditions as evidenced by the condition of his protective clothing and equipment with portions of front of his ensemble (helmet, coat, pants, and footwear) completely destroyed and missing. The protective clothing and equipment of the Engineer/Operator detailed to E51 sustained relatively severe thermal exposure conditions principally to the back of his clothing. The fire fighter, assigned to E68 (E68B), his personal protective equipment showed several areas of localized destruction, more than likely due to specific areas of burning debris and other debris, which would have shielded his body. The least amount of damage was shown on the other fire fighter from E68 (E68C). Her personal protective equipment sustained minimal damage. The primary damage was in the melting of the helmet faceshield and charring of her hood face opening.
Some items of protective clothing and equipment were not available for examination. Nevertheless, there was no finding of any specific problems with any of the protective clothing and equipment items examined. The condition of these items is consistent for what would be expected for an extended exposure on the fireground during a structural collapse entrapping firefighters in a closed area with continued periodic exposure to severe thermal conditions before their recovery. All protective clothing items were designed to provide protective performance well in excess of minimum industry standards.
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Appendix Five Use and Operations of Thermal Imagers
The temperature measurement feature on fire service thermal imagers should not be used for interior structural firefighting. Use of this feature MAY CAUSE ERRORS IN JUDGEMENT WHICH MAY RESULT IN SERIOUS INJURY OR DEATH.
Fire service thermal imagers may be equipped with a temperature measurement feature. Utilizing either a bar indicator or digital readout or both this feature displays the approximate surface temperature of a targeted surface.
The temperature measurement feature is a non-contact solid surface temperature measurement device that is not accurate.
Different materials or the same materials with different composition, surface textures, color and polish will not register temperature readings in the same way resulting in variations in the temperature readings.
Several factors including but not limited to: how much heat the material being measured and its ability to absorb or reflect heat (emissivity) the objects temperature the distance from the object being measured as well as the angle at which the object is being viewed the cleanliness of the lens as a result of steam or smoke; the object does not fully fill the center target area then a false reading may be obtained
Users must be aware and understand that the temperature measurement feature in a thermal imager will NOT provide atmospheric or air temperature readings.
Additionally the thermal imaging camera cannot see through walls. When attempting to view a source of heat behind a wall or above a ceiling the heat source will not be evident if it does not heat the wall itself. Consideration must be given to the thickness of the wall or ceiling as well as any additional layers of materials that may exist and further insulate or mask the true magnitude of the heat source. All of these factors may individually or collectively greatly affect the accuracy of the temperature measurement feature during interior structural firefighting situations.
Because interior structural firefighting is a rapidly changing dynamic environment with many unknown and uncontrolled variables the temperature measurement feature on thermal imagers should not be utilized or relied upon by fire fighters to make tactical interior structural fire-fighting decisions.
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Appendix Six Incident Commander’s Tactical Worksheet for “Mayday”
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Appendix Seven Sample SOP – Restricted Access for PPE/SCBA/Equipment
PURPOSE To provide the mechanism for the chain of custody, sealed access, and prevention from contamination of evidence, which may assist in determining the cause of malfunction, failure, accident or casualty.
SCOPE This applies to all Fire Department personnel, equipment, and personal protective equipment (PPE).
CFAI REFERENCE This policy applies to the following categories, criterion, and performance indicators of the Commission on Fire Accreditation International (CFAI): 7F.7
CONTENT The intent of these guidelines is to isolate equipment/PPE which, for the purpose of investigation, must be sequestered in as close to the same condition as at the time of the event. Information gathered from this process will assist the investigating officer(s) or agency(s) in cause determination.
PROCEDURE Any equipment/PPE (non-vehicular) that fails to operate in its designed and prescribed fashion, whether in training or on an emergency incident, shall be sequestered. Employees shall immediately notify either the Shift Safety Officer or a Battalion Chief to secure the item. The item(s) shall be maintained, as close as possible, in the same condition in which it malfunctioned or failed in order to preserve any evidence for investigation purposes.
When securing SCBA units the air will be turned off, the system bled down, and the “PASS” device turned off. Additionally, when sequestering a SCBA unit, the following shall be noted on the receipt: remaining air in tank; position of air cylinder valve (open/closed/1/2 open); Pass device status; and was the emergency bypass on or off. If the malfunction was due to free-flowing air, sequester the user’s mask also.
All equipment sequestered will be placed into the Restricted Access Bag, zippered shut, and sealed with a “zip” tie around the zipper tabs. To prevent cross contamination, separate items should be placed in separate bags. The sequestering officer will issue a receipt with a detailed inventory (to include all identifying inventory numbers) to the supervisor responsible for the equipment/PPE.
Once an item has been sequestered, the Shift Safety Officer will take control of the bag. Any time the Restricted Access Bag changes hands, a new receipt, as outlined above, will be issued. The Battalion Chief of Safety will maintain all original receipts at Fire Administration. Entry into the bag will be limited to only those parties authorized by the Battalion Chief of Safety, the Shift Safety Officer, or the Battalion Chief of Resource Management. An inventory of the Restricted Access Bag will be conducted any time the seal is broken and recorded on the inventory form.
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RESTRICTED ACCESS BAG RECEIPT
Date: ______Time: ______Incident #: ______
Location Item/Equipment Received: ______
Item/Equipment Sequestered: ______
City/Department ID#: ______
SCBA Information: remaining air in tank; ______psi. PASS: ON/OFF ______
Position of air cylinder valve (open/closed/1/2 open): ______
Emergency bypass on or off: ______
Item/Equipment Assigned To: ______
Reason for Sequestering: (Be as Specific as Possible)
Item/Equipment Received From: ______
Date: ______Time: ______
Item/Equipment Delivered To: ______
Date: ______Time: ______
Seal #: ______Date: ______Time Sealed: ______
Comments:
Original: Battalion Chief of Safety Canary: Sequestering Officer Pink: Member Releasing Inventory
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Appendix Eight Fire Department Update
The department undertook a number of actions to prevent the occurrence of similar injuries. The fire chief initiated a “Recovery Committee” from all ranks to review this incident and to develop recommendations and to move the department forward. Soon after, the Recovery Committee was established to begin looking into several areas directly related to this fire and attempt to understand just how such a tragic loss could occur. The four workgroups include: Fireground Operations Rescue & Safety Communications & Technology Timeline/Process/Procedures
The core of this project is to learn as much as possible, to evaluate the department’s procedures and practices, and then work to develop solutions for both the common and uncommon problems which occurred on May 31, 2013. Finally, this committee will develop a comprehensive report that narrates the events that occurred and provide sound strategic, tactical, and task level recommendations.
The department advised the investigators from the NIOSH FFFIPP that they have implemented a number of changes based on Committee recommendations.
The following is a summary of the changes reported to NIOSH:
(June 2013) 1. The Communications and Technology workgroup met with Motorola® to voice concerns about several problems that were discovered during the restaurant fire. Among the issues discussed were with the Digital delay and the need to research new technology that would provide shorter key-up time when no audio is transmitted. A follow-up meeting was scheduled for November, 2013.
(July 2013) 2. Radio Code Plug Changes and APX system re-programming occurred a. The Emergency Button was changed from a 1-second push to a 2-second push. b. The “Permission to Talk” time limit was shortened from 60 seconds to 30 seconds.
3. The city’s Radio Communication Systems (RCS) division requested Motorola® to research the following features in order to shorten delays and improve emergency radio communication. a. Quick-Key “Bonk” b. Create a transmission complete tone (user un-keys the radio) c. Different tones be created for “Out-of-Range” warnings versus a “Busy signal” d. No Audio: Time-out of 5 seconds
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4. An Electronic Command Board was being developed to assist Incident Commander’s with tracking fireground assignments.
5. The department began to re-designing and updating the Rapid Intervention Team equipment (RIT Packs). The department’s Rapid Intervention Team (RIT) standard operating guideline was also being re-evaluated and a new RIT Performance Standard was being developed.
(August 2013) 6. A new section was added to the department’s Protective Clothing Guideline II-02 to give Safety Officer’s direction on how to collect fire fighters PPE and fire-fighting equipment when an injury or significant event occurs. The purpose is to ensure that any equipment damaged at an incident is properly inspected and tested before being placed back on an apparatus or in-service.
(September 2013) 7. Radio prioritization was established that would provide District Chiefs with priority communications over all other radios on the fireground. The order of priority is as follows: a. 1st priority - OEC Dispatch Consoles / OEC Portables (Orange shell) b. 2nd priority - Deputy / District Chief / Safety Officer Mobile Radios c. 3rd priority - Deputy / District Chief / Safety Officer Portables (Red shell) d. Heavy Apparatus / All other Portable radios (Yellow shell)
8. The GRACE Accountability System was upgraded: a. Software was updated and additional training was provided to Incident Command Technicians (ICTs). b. All T-PASS devices (individual firefighter monitoring devices) were upgraded to the TPASS4 model.
9. The department’s Information Technology Unit began work on creating electronic personnel files. This measure was performed to help keep members’ emergency contact information current and readily available.
(October 2013) 10. The department’s Arson Bureau and the State Fire Marshal’s Office (SFMO) created a process that would limit the impact on members during an interview process. a. The SFMO provided the department’s Arson Bureau with documents that can be completed concurrently with department statement interviews so that members don’t have to repeat this process multiple times with different investigators.
11. A new Internal Disaster standard operating guideline was being drafted to help members during these types of events. a. This guideline is aimed at assisting members with decision making and overall management after a significant event has occurred that affects the normal day to day operations of our department.
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12. New fireground communication procedures were developed to help reduce radio transmissions. a. Incidents Commanders were instructed to begin using additional Talk-groups (Tac Channels) for support roles at an incident. b. Units that are responding on additional alarms, assigned to Staging, or in “Rehab” should be placed on a separate Talk-group. c. This process was designed to reduce excessive radio communication on the Fireground Talk- group. d. Communication on a monitored Fireground Talk-group should be reserved for Strategic and Tactical operations.
13. The city’s Radio Communication Services (RCS) worked to improve the infrastructure of the new Digital APX system. Areas targeted were populated areas of the city and ones that generate considerable call volume. Others locations across the city are still in various stages of upgrades. Equipment was added or adjustments made to the system to improve in-building coverage.
14. During the first quarter of FY2014, 12 Communication Captains positions were created to increase the total staffing numbers at the Office of Communication (OEC). These additional positions were added for several reasons however one of the biggest advantages was to enhance OEC capabilities when additional Talk-groups are requested for fireground communications.
15. OEC staff members began a ride along program with District Chiefs. a. This arrangement was made to provide an opportunity to open up dialogue between members in the field and Communication Captains.
16. The department’s training center began working on developing enhanced training in two critical areas. a. Incident Command Technicians (ICT) b. Building Collapse courses
(November 2013) 17. A follow-up meeting was held with Motorola® regarding the three items presented in June of 2013. a. “Digital Cliff” b. “Quick Key” c. A 5-second time out if no voice is transmitted Note: The department was informed that Engineers were still exploring these issues and new upgrades to the 700/800 Digital System may be available that address these concerns in the 3rd quarter 2014.
(December 2013) 18. A new city ordinance was being drafted that addresses buildings with poor radio coverage. This document will outline new requirements that property owners and management companies will need to accomplish in order to meet the standards set for firefighter safety regarding in-building coverage.
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(January 2014) 19. The project of issuing the updated RIT Packs was completed by Emergency Operations.
(February 2014) 20. The department began using a new style of fire-fighting glove. This glove was approved by the Personal Protective Equipment Committee in October of 2013
21. The Office of Emergency Response - Special Projects and the department’s training center established a partnership with Scott Industries® and began development of a new training video for Thermal Imaging Camera classes.
(March 2014) 22. A plan was implemented to have all Incident Command Technicians become subject matter experts (SME) for the GRACE Accountability System. a. Department Safety Officers conducted this training which included how to maintain routine updates to the system.
23. A department document was drafted to help the families of a deceased member for future planning after a catastrophic event. a. This document will be provided through the Firefighter Support Network and was originally developed by the National Fallen Firefighters Foundation.
(April 2014) 24. The Digital Sandbox program was introduced to District Chiefs in a 3-hour training session. This new platform will provide the ability for electronic storage and retrieval of building assessments in the field with as well as offer real time information. Most Tactical Evaluation and Assessment Plans (TEAPS) that are currently on file in the department are being entered into the system. Future use will include information that is shared by other city departments and regional agencies.
25. Grant Funding was secured to upgrade the Mobile Data Terminals (MDT’s) in each emergency response vehicle to ToughPads®.
26. The Eagle-X Thermal Cameras that were returned to the department’s resource management when the new model of TIC was delivered, were issued to all Incident Command Vehicles.
27. Shift Commanders on all four shifts began “Situational Awareness/Building Construction” training. This hour long presentation was given on a District level.
(May 2014) 28. A committee was formed to evaluate a “Blended Fire/EMS Response” for multiple Task level duties including IRIT and RIT.
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29. Temple Transducer Headsets were purchased through Grant funding. This equipment is being issued to “Command” vehicles to enhance the communication capabilities of the Incident Commander (IC), the Incident Command Technicians (ICTs) and Accountability Officer’s (AO).
30. The administration began reviewing department guidelines pertaining to on-scene video recording. The use of helmet cameras, “Dash cams” and other portable recording devices are being evaluated for future use.
(November 2014) 31. All Emergency Response deputy chiefs, district chiefs, and safety officers were provided training in Fire Fighter Safety through Advanced Research (FSTAR). This presentation focused on improving fire fighter safety by incorporating the evolving scientific research being conducted at the Underwriters Laboratories (UL) Fire Fighters Safety Research Institute and the National Institute of Standards and Technology (NIST) Fire Research Division.
(November 2014) 32. The department applied for an “Assistance to Firefighters” Grant which is a program provided through the U.S. Department of Homeland Security to fund the delivery of the International Association of Fire Fighters (IAFF) Fireground Survival training to all members of the Emergency Operations division who operate in the hazard zone. This training was scheduled to begin in November 2014 and designed to be completed in a three (3) Phase process. Phase I – On November 6, 2014, twenty-nine (29) members became certified instructors by completing the 32 hour IAFF-FGS Facilitator (Train-the-Trainer). Phase II – (January 2015): all classified members assigned to Emergency Operations and OEC were required to begin and complete the IAFF-FGS on-line Course by March 15, 2015. (February 2015) the first cadet class was trained in IAFF-FGS prior to graduation Phase III – (April 2015): the IAFF-FGS certified facilitators are slated to begin the on-duty training of all members of Emergency Operations who operate within the hazard zone. This project should be completed by the first quarter of 2016.
(January 2015) 33. The department has applied for Urban Area Security Initiatives (UASI) funding that will be used to continue the Blue Card Command Certification Program. This is an interactive Incident Command System training program that provides a certification for officers that function as the Incident Commander. Twenty (20) members in the department were selected to evaluate the course and it is now planned for all officers in the department to become certified.
(February 2015) 34. The city’s Radio Communication Division (RCS) conducted a Radio Code Plug change and APX system re-programming after Motorola provided a new Firmware upgrade. The three of the four items presented to Motorola (July of 2013) were resolved and updates performed. a. Quick-Key “Bonk” eliminated; b. Different tones were created for an “Out-of-Range” signal and a “Busy” signal;
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c. A 5-second time out was created when a radio was keyed but no audio was transmitted
(February 2015) 35. The department implemented an electronic version of each members Permanent Personnel Form (Electronic Form 42). This record is now accessible for each member on the department’s district chief Staffing Worksheet. This form provides any supervisor with a members work history, attendance record, and access to emergency contact information when needed.
(February 2015) 36. The department introduced the first guideline that provides specific strategies and tactics for structural fire-fighting. The department’s Guideline Volume No. II-47 “Structure Fire Incidents” is meant to develop a consistent approach and improve fireground safety. The vision is based on research and lessons learned during the Firefighter Safety through Advanced Research (FSTAR) training.
(February 2015) 37. The department scheduled a “Modern Fire Dynamics Presentation” to be one (1) of eight (8) mandatory multi-company drills for 2015. The presentation is a compilation of research conducted by Underwriters Laboratories (UL), Fire Safety Research Institute (FSRI), and the National Institute of Standards and Technology (NIST) along with the information from the Fire Fighter Safety through Advanced Research (FSTAR) training that all Chief Officers attended (November 2014). This course was developed and presented by the officers assigned to the department’s Training Center.
The five (5) key areas being presented include; Changing Fire Environment Understanding of Fire Dynamics Fire Dynamics in Structure Fires Getting the “Science to the Streets” Putting it all together
Page 106 NIOSH Report # F2013-16 Appendix Five Use and Operations of Thermal Imagers
The Temperature Measurement Feature on Fire Service Thermal Imagers should not be used for interior structural firefighting.
USE OF THIS FEATURE MAY CAUSE ERRORS IN JUDGEMENT WHICH MAY RESULT IN SERIOUS INJURY OR DEATH.
Fire service thermal imagers may be equipped with a temperature measurement feature. Utilizing either a bar indicator or digital readout or both this feature displays the approximate surface temperature of a targeted surface.
The temperature measurement feature is a non-contact solid surface temperature measurement device that is not accurate.
Different materials or the same materials with different composition, surface textures, color and polish will not register temperature readings in the same way resulting in variations in the temperature readings.
Several factors including but not limited to: • how much heat; • the material being measured and its ability to absorb or reflect heat (emissivity) • the objects temperature; • the distance from the object being measured as well as; • the angle at which the object is being viewed and also; • the cleanliness of the lens as a result of steam or smoke; • the object does not fully fill the center target area then a false reading may be obtained
Users must be aware and understand that the temperature measurement feature in a thermal imager will NOT provide atmospheric or air temperature readings.
Additionally the thermal imaging camera cannot see through walls. When attempting to view a source of heat behind a wall or above a ceiling the heat source will not be evident if it does not heat the wall itself. Consideration must also be given to the thickness of the wall or ceiling as well as any additional layers of materials that may exist and further insulate or mask the true magnitude of the heat source.
All of these factors may individually or collectively greatly affect the accuracy of the temperature measurement feature during interior structural firefighting situations.
Because interior structural firefighting is a rapidly changing dynamic environment with many unknown and uncontrolled variables the temperature measurement feature on thermal imagers should not be utilized or relied upon by fire fighters to make tactical interior structural fire- fighting decisions.
2014 19
January 24, 2017 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut
Executive Summary On October 7, 2014, a 48-year-old male career fire fighter died while conducting interior fire-fighting operations in a two- story residential apartment fire. At 1830 hours, Engine 16 was dispatched to a structure fire reported with smoke showing. The lieutenant from Engine 16 conducted a scene size-up and reported heavy fire showing from the second floor on Side Bravo. The lieutenant and right jumpseat fire fighter made entry into the front door with a 1¾-inch hoseline and started up the stairs to the second-floor apartment. The Ladder 4 crew went by them, went to the top of the stairs, and forced the door to the apartment. The Engine 16 crew entered the apartment, and Sides Alpha and Bravo of the fire building the lieutenant had the hoseline charged. (NIOSH photo.) The apartment was hot with zero visibility. The lieutenant had his fire fighter pencil the ceiling. Minutes later, the fire fighter’s vibra-alert activated, and the lieutenant told him to exit the building. The lieutenant started to exit the apartment but couldn’t find the fire fighter behind him. The lieutenant continued to search for the Engine 16 fire fighter and stated that he called a Mayday, but it was not acknowledged by Command. He then tried to radio the fire fighter. A fire fighter from Ladder 4 vented the picture window on Side Alpha of the second-floor apartment. The heat conditions increased in the apartment. Two fire fighters from Tactical Unit 1 were in the living room of the apartment, and due to the heat conditions, they got separated. One of the fire fighters from Tactical Unit 1 had been hit by a hose stream and momentarily lost consciousness, eventually causing him to fall out the Side Alpha picture window. He was transported to the hospital with burns and lacerations. The Engine 16 lieutenant came out of the building and the Engine 16 fire fighter was still not located. Command activated the rapid intervention crew and ordered Engine 5 and Tactical Unit 1 into the apartment. Engine 5 made entry to the apartment and heard a PASS alarm going off to the right of the door. The Engine 16 fire fighter was found lying on his right side near the door with his foot caught in a piece of furniture. The Engine 5 crew brought the fire fighter out of the building, and he was transported to the hospital but pronounced
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July 14, 2017 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio
Executive Summary
On December 28, 2015, a 28- year-old male career fire fighter died due to thermal injuries and smoke inhalation with severe pulmonary edema at a single- family residential structure fire. At 0113 hours, the fire department was dispatched to a report of residential structure fire. The dispatcher advised on the dispatch channel that heavy, black smoke was showing. The dispatcher advised at 0114 hours that two elderly people may be in the house. Additionally, the dispatcher stated there was smoke coming The initial attack hoseline went into the structure on the from the basement in the back Alpha/Bravo corner (Red Arrow). The fire fighter from of the house. These last two Quint 25 entered the living room and fell into the basement. transmissions were on the (Photo courtesy of the fire department.) dispatch channel and not simulcast on the tactical channel. Quint 25 responded at 0114 hours and was on-scene at 0117 hours. Upon arrival, the acting officer of Quint 25 met a police officer who advised him that the neighbors reported two residents possibly inside. Heavy smoke was showing from the front half of the house, but no flames were visible. The acting officer of Quint 25 told the fire fighter on Quint 25 to get the thermal imager and take the irons to the front porch (Side Alpha). The acting officer from Quint 25 walked along Side Bravo to Side Charlie. He then proceeded back to Side Alpha. He advised the dispatcher at 0118 hours that smoke was showing from three sides of a residential structure but he could see no visible fire. The acting officer of Quint 25 decided to enter the house through the front door, which was on Side Bravo/Side Alpha corner. The engineer from Quint 25 had stretched a 1¾- inch hoseline to the front door. The fire fighter from Quint 25 forced the front door. The fire fighter from Quint 25 made entry into the foyer and then turned right into the family/living room. The acting officer of Quint 25 was behind the fire fighter on the hoseline. The acting officer of Quint 25 stated that the smoke was about a foot off the floor but not hot. As the Quint 25 fire fighter crawled into the family/living room, the floor collapsed and the fire fighter immediately fell into the basement. Note: The term basement will be used in this report versus the term cellar. This is the term used by the fire
Page i Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio department in their reports and correspondence. The acting officer of Quint 25 started calling for the fire fighter. The acting officer from Quint 25 and the foyer were immediately enveloped in fire. The officer from Engine 24 called a Mayday at 0123 hours. Command ordered Tower 22 and Engine 21 to locate the missing fire fighter in the basement at 0125 hours. In approximately 10 minutes, the fire fighter from Quint 25 was located, placed in a Stokes basket, and removed from the basement. Once outside, the fire fighter was treated by six paramedics, moved to a stretcher, and transported in Medic 22 to the local hospital, where he was pronounced dead at 0226 hours.
Contributing Factors • Arson fire • Incomplete scene size-up • Wind-driven fire • Lack of tactical priorities (incident action plan) • Lack of resource status management • Lack of command safety • Ineffective dispatch center operations • Lack of a written professional development program
Key Recommendations • As part of the strategy and incident action plan, incident commanders should ensure a detailed scene size-up and risk assessment occurs during initial fireground operations, including the deployment of resources to Side Charlie. Scene size-up and risk assessment should occur throughout the incident • Incident commanders should ensure that the strategy and tactics (incident action plan) match the conditions encountered during initial operations and throughout the incident • Fire departments should develop and implement a standard operating procedure, training programs, and tactics for wind-driven fires.
The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit.
For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
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July 14, 2017 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio
Introduction
On December 28, 2015, a 28-year-old male career fire fighter died after falling into the basement at a residential structure fire. On December 28, 2015, the United States Fire Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On January 6–13, 2016, an investigator and an occupational physician from the NIOSH Fire Fighter Fatality Investigation and Prevention Program traveled to Ohio to investigate this incident.
The NIOSH investigators met with the city’s public safety director, fire chief, and executive staff of the fire department; the department’s fire marshal and his staff; the SCBA maintenance and repair staff; the International Association of Fire Fighters local union; physicians with the county medical examiner’s office; investigators from the fire department; and the county’s dispatch center. The NIOSH investigators reviewed the fire department’s standard operating procedures, training records from the department and the state of Ohio training records, and dispatch and tactical channel radio transmissions. The NIOSH investigators visited and photographed the fire scene. During the investigation, witness statements were reviewed. Interviews were conducted with the fire fighters, fire officers, and deputy chiefs who responded to the incident. The NIOSH investigators inspected and photographed the personal protective clothing (turnout gear) and SCBA of the affected fire fighter, which was under control of the city’s fire department investigator.
Fire Department This career fire department consists of five fire stations protecting 22 square miles and a population of 63,000. The city has a council-manager form of government. The city’s public safety director oversees the fire and police departments. The fire department consists of 96 members. The rank structure is fire chief, deputy chief, captain, lieutenant, and fire fighter/paramedic. Front line apparatus include four engines, one quint, one tower ladder, three medic units (Life Squads), and one battalion chief command vehicle (deputy chief). One engine and the tower ladder are cross-staffed by an officer and two fire fighters. Depending on the incident, either apparatus responds. The minimum staff on fire apparatus is an officer and two fire fighters. Each fire station has a house captain. The department operates three shifts (24/48) with a Kelly Day every 7 shifts. Within the past several years, the city closed one fire station and laid off five fire fighters. Seven frontline units have been reduced to five frontline units. The minimum daily staffing was reduced from 28 fire fighters to the current level of a minimum of 22 fire fighters. The battalion chief operates without a staff aide or field incident technician. The department has a deputy chief assigned as the training officer plus a deputy chief assigned as the fire marshal with one fire inspector. A fire fighter is assigned as a fire investigator with full police powers.
Page 1 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio For working incidents, the fire department and the county fire dispatcher assign back-fills or fill-ins for empty department fire stations. The fire department also uses the callback of off-duty personnel as necessary. The shift commander (Battalion 20) has the discretion on the fill-in/backfill process.
The majority of the fire department’s responses are calls for emergency medical service (EMS). In 2015, the fire department responded to 13,702 incidents, and 10,211 incidents were for emergency medical service response. The fire department has a hazardous materials team with 50 members certified to the technician level. Also, the fire department has members trained for swiftwater, ice water, and surface rescue compliant with NFPA 1006, Standard for Technical Rescuer Professional Qualifications, Level II.
The hiring process for the fire department is administered by the city’s Civil Service Commission. The Civil Service Commission for the fire department is comprised of three citizens appointed by the city council. This Civil Service Commission is responsible for overseeing the department’s hiring and promotional processes. The commissioners have staggered terms of 1, 2, and 3 years. To become a member of the fire department, the hiring process is as follows: • The candidate must be 18 years old. • The candidate must possess a high school diploma or GED. • The candidate must be certified as a paramedic by the state of Ohio. • The candidate must be certified as a NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II. • The candidate must complete a competitive written examination. • The candidate must complete a physical fitness evaluation, fire-based. • Background investigation and polygraph examination are administered. • 10 names are submitted to the Civil Service Commission for employment. • Selected candidates are given a health maintenance evaluation, which complies with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.
Training and Experience The state of Ohio has three certification levels for fire fighters: Volunteer, Fire Fighter Level I, and Fire Fighter Level II: • Volunteer Fire Fighter requires 36 hours of training in basic concepts, equipment, and techniques. This training does not include live fire training. After successful completion, the student may take the state certification examination. • Fire Fighter I requires a minimum of 156 hours training that includes a comprehensive introduction of basic fire-fighting concepts and skills and permits the students to practice the skills, including live fire training. • Fire Fighter II requires a minimum of 104 hours of training that includes additional practice of skills on advanced rescue and prevention concepts, including participation in live fire training evolutions. Level II certification is required for full-time paid (career) fire fighters.
Page 2 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio With the exception of full-time career fire fighters, the state of Ohio permits the authority having jurisdiction to determine the level of fire fighter certification. The state also requires continuing education credits after certification. For Fire Fighter I and Fire Fighter II, any certification after 2012 requires 56 hours of continuing education every 3 years.
Prior to applying for a position as a fire fighter, the fire department requires candidates to have completed NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II, and must be a paramedic certified by the state of Ohio. This training can be obtained through a community college, college, or vocational school. Additionally, the fire department requires a fire fighter/paramedic to complete a 36-month apprenticeship program that includes monthly written evaluations as well as monthly practical skill training. The Training Bureau is responsible for test development, test administration, and all associated record keeping. Certified apprentices will receive a “Certificate of Completion of Apprenticeship” from the United States Department of Labor.
The fire fighter from Quint 25 was hired by the fire department in April 2015. Prior to his employment with the fire department, he had worked 6 years as a part-time fire fighter for two other fire departments in Ohio. The fire fighter had completed the following training and possessed these certifications: NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II; state of Ohio Paramedic; ICS 100, Introduction to ICS; ICS 200, Basic ICS; ICS 300, Intermediate ICS; ICS 400, Advanced ICS; IS-00700, Introduction to the National Incident Management System; IS-00701.a, NIMS Multiagency Coordination System (MACS); IS-00800.B, An Introduction to the National Response Framework; Swiftwater Rescue Technician; Fire Apparatus Operator; Basic Ice Rescue Course, Technician Level; Basic and Advanced Auto Extrication; Incident Response to Terrorist Bombings; and University of Cincinnati–Associate in Technical Services. The fire fighter had 682 hours of company-level training with two previous fire departments.
The acting lieutenant of Quint 25 had 16 years on the job with this fire department and 20 years total fire service experience. He had completed the following training and possessed these certifications: NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II; National Registry of Emergency Medical Technicians – Emergency Medical Technician; ICS 100, Introduction to ICS; ICS 200, Basic ICS; IS-00700, Introduction to the National Incident Management System; IS-00701.a, NIMS Multiagency Coordination System (MACS); IS-00800.B, An Introduction to the National Response Framework; IS-00120.a, An Introduction to Exercises; IS-200, Basic ICS for Federal Disaster Workers; IS-00130, Exercise Evaluation and Improvement Planning; Urban Search and Rescue, Basic Emergency Rescue Technician; Rope Rescue Tech Course; FEMA NIMS, All Hazard Incident Management Team; Ohio Fire Academy Incident Safety Officer; Swiftwater Tech Course; HAZWOPER, 8-hour Refresher Course; Structural Collapse Rescue; Fire Fighter “Certificate of Completion of Apprenticeship” from the United States Department of Labor; Fire Fighter Self- Rescue Training Course; and the IAFF 8-hour Fire Ground Survival Awareness Course.
The acting deputy chief for Battalion 20 had 13 years on the job with this fire department, 4 years as a lieutenant and 4 years as a captain. He had completed the following training and possessed these
Page 3 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio certifications: NFPA 1001, Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II; National Registry of Emergency Medical Technicians – Emergency Medical Technician Basic; ICS 100, Introduction to ICS; ICS 200, Basic ICS; IS-00700, Introduction to the National Incident Management System; IS-00701.a, NIMS Multiagency Coordination System (MACS); IS-00800.B; Fire Safety Inspector; Hazardous Materials Technician; Swiftwater Technician; Rope Rescue Technician Course; Fire Fighter “Certificate of Completion of Apprenticeship” from the United States Department of Labor; Confined Space Rescue Technician Course; Fire Fighter Self- Rescue Training Course; the IAFF 8-hour Fire Ground Survival Awareness Course; Fire Department Incident Safety Officer; and NFPA 1851, Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting Course – Advanced Inspection and Advance Cleaning.
Equipment and Personnel The county in which the fire department is located operates the 9-1-1 and dispatch center under the direction of the sheriff’s office. In addition to answering calls for the sheriff’s office, the regional dispatch center answers calls for 9 law enforcement agencies and 17 fire/EMS departments in the county. Dispatchers also process calls related to animal control, probation officers, and other county agencies. A computerized phone system brings hundreds of thousands of emergency and non- emergency calls into the dispatch center annually from wireless and wireline telephones. The radio designation for the dispatch center is 9Com.
The staffing for the dispatch center is 43 personnel. Each shift has a supervisor and 6 -7 dispatchers. The shift schedule for dispatchers is 0600 hours–1400 hours, 1400 hours–2200 hours, and 2200 hours– 0600 hours.
Every officer and fire fighter is assigned a portable radio with a spare battery, which is checked daily. The fire fighter from Quint 25 had a portable radio in his turnout coat, though the portable radio was not turned on during this incident.
Each portable radio identifies the user: e.g., E24“A” (officer of Engine 24), E22“B” (right jumpseat of Engine 22), T22“C” (left jumpseat of Tower 22), and Q25“D” (fire apparatus operator of Quint 25). Every portable radio has an emergency button. When the emergency button is pressed, this opens (keys) the microphone for 10 seconds and gives this radio priority. The radio microphone remains keyed for 60 seconds unless the portable radio is re-set or cleared.
Building Construction The structure involved was a two-story wood frame with aluminum/vinyl exterior, a full basement (unfinished), and a balloon frame construction. Note: Balloon frame construction is defined as a wooden structure in which all vertical studs in the exterior bearing walls extend the full height from the bottom frame (sill), which is bolted to the foundation and to the roof. There are no firestops within the walls [Brannigan and Corbett 2007].
Page 4 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio The structure was built in 1932 and had three bedrooms on the 2nd floor. The 1st floor consisted of a family/living room in the front of the house (Side Alpha), a dining room in the middle of the house, and a kitchen on Side Charlie. A stairwell to the 2nd floor was accessible through the dining room. The total available living space was 1,576 square feet. The 1st floor was approximately 46 feet long by 18 feet wide. The structure had been wrapped with vinyl siding. Access to the 1st floor was from a front porch, which covered the front of the house (Side Alpha) around to the entrance on Side Bravo (See Photo 1, Diagram 1, and Diagram 2). Also, one door on Side Charlie provided access to the 1st floor through the kitchen.
Photo 1. The fire building looking at Side Alpha and Side Bravo. Due to the balloon construction, the fire is running the walls on Side Bravo and Side Delta. The fire is running the walls on Side Bravo in the photograph. (Photo courtesy of the fire department.)
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Diagram 1. The first floor of the fire building.
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st Diagram 2. The dimensions of the 1 floor of the fire building. Note: A1 is the front porch dimensions; A2 is the front foyer dimensions; A3 is the rear porch dimensions; A0 st is the dimensions of the 1 floor. (Diagram courtesy of the fire department)
The house had tongue-and-groove flooring. The floor joists (2-inch x 8-inch) were completely burned through in the basement near Side Alpha where the fire fighter from Quint 25 fell through the floor. The floor joists were 12 inches on center and ran east and west.
The basement was unfinished and primarily used for storage. The storage consisted of lawn equipment, shelving, and furniture. The hot water heater and furnace were located on the Side Bravo wall in the basement. The dimensions of the basement were approx imately 46 feet long and 18 feet wide. The only entrance to the basement was through the Bilco® doors on the Charlie/Delta corner
(See Diagram 3 and Photo 2).
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Diagram 3. The basement of the fire building.
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Photo 2. The Bilco® doors leading to the basement of the fire building. When the police officers arrived on-scene, one of the doors was open with heavy smoke showing. This was the only access to the basement. As noted, the entire structure had been wrapped in vinyl siding. (NIOSH photo.)
Timeline The following timeline is a summary of events that occurred as the incident evolved. Not all incident events are included in this timeline. The times are approximate and were obtained by studying the dispatch records, audio recordings, witness statements, and other available information. This timeline also lists the dispatch communications and fire department response, as well as fireground communications and fireground operations. The timeline is not intended, nor should it be used, as a formal record of events.
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Dispatch Communications & Fire Time Fireground Communications & Department Response Fireground Operations 9Com received a telephone call from 0103
an alarm company for a residential Hours burglar alarm at a single-family residence. 9Com dispatched the city police 01:05:38
department for burglar alarm at a Hours single-family residence. Police department reported on-scene 01:11:04
with heavy smoke showing from the Hours residence. Police reported an elderly couple lived at this residence. It was unknown if the couple was at home. 9Com dispatched Engine 21, Engine 01:12:29
24, Engine 26, Medic 22, Medic 25, Hours Quint 25, Tower 22, and Battalion 20 for a structure fire at the residence. Police on-scene advised that heavy 01:14:09
smoke was coming from the cellar with Hours one door open. Police officers advised
they were not opening any doors or windows. 9Com advised units there is smoke 01:15:13
coming from the cellar door in the rear. Hours Battalion 20 assigned Engine 21 as 01:16:29
RAT (Rapid Assistance Team). Engine Hours 21 acknowledged. 01:17:24 Quint 25 reported on-scene. Quint 25A Hours reported: “Heavy smoke is showing from 3 sides of the structure. Engine 26 please make our water supply for us. Preparing to conduct a 360-degree walk- around.”
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Dispatch Communications & Fire Time Fireground Communications & Department Response Fireground Operations 01:18:12 Quint 25 asked Battalion 20 if Hours confirmation had been made that the occupants were out of the structure. Medic 25 arrived on-scene. 01:18:16 Hours Battalion 20 arrived on-scene. Battalion 01:20:12 20 requested the response of a safety Hours officer. Battalion 20 assumed Command. Engine 24 arrived on the scene. 01:20:21 Hours Medic 22 arrived on the scene. 01:20:33 Hours 01:21:40 Quint 25 (PAR 2) made entry through Hours the front door after Quint 25A advised they had their 2-in and 2-out. Tower 22 arrived on-scene. 01:22:12 Hours Engine 21 arrived on-scene. 01:22:45 Hours 01:23:11 Command ordered everyone out of the Hours building. The fire fighter from Quint 25 fell through the first floor in the basement. 9Com dispatched mutual aid Engine 01:23:23 212. Hours 01:23:26 Engine 24A called a Mayday on the Hours fireground channel and stated, “We got a guy that’s inside.” 01:23:42 Engine 24 advised: “We have a fire Hours fighter inside. It’s flashed.” Command asked 9Com to dispatch 01:24:04 another engine. Hours
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Dispatch Communications & Fire Time Fireground Communications & Department Response Fireground Operations Car 211 asked 9Com if there was a 01:24:14 Mayday. Hours Car 211 asked 9Com again if there was 01:25:01 a Mayday. Hours 9Com responds: “Negative. No 01:25:06 Mayday.” Hours 01:25:13 Engine 24 to Command, “Making entry Hours to find missing fire fighter.” 01:25:36 Engine 21 reported, “Command, there is Hours heavy fire in the basement.” Command ordered Tower 22 and Engine 21 to locate the Quint 25 fire fighter in the basement. 9Com dispatched mutual aid Engine 01:26:24 211. Hours Engine 212 arrived on-scene and 01:26:47 reported to Command. Hours Medic 24 was dispatched. 01:27:55 Hours 01:28:18 Engine 24 reported, “Command, he is in Hours the basement.” 01:28:53 Command acknowledged, “Injured fire Hours fighter is in the basement.” 01:29:08 Engine 26 reported they were operating Hours with Engine 24 at the front door. 01:29:24 Engine 21 advised they were operating a Hours 2½-inch hoseline on Side Bravo. 01:29:33 Engine 24 reported: “I can hear the Hours PASS alarm sounding. I need another hoseline. This one is burned through.” 01:30:08 Tower 22 reported they were in the Hours basement and could hear a PASS alarm.
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Dispatch Communications & Fire Time Fireground Communications & Department Response Fireground Operations Command requested 9Com dispatch 01:30:52 Car 20. Hours 01:33:04 Tower 22 reported they had found the Hours Quint 25 fire fighter. Engine 211 arrived on-scene. 01:35:47 Hours 01:36:55 Medic 25 advised Command, “They Hours have the fire fighter out and are going to the squad.” 01:37:11 Command called for a PAR. Hours 01:38:15 PAR completed with Engine 21, Engine Hours 24, Engine 26, Tower 22, and Engine 212. 01:40:52 Command ordered Engine 212 out of the Hours structure. 01:43:18 Engine 212 reported they are out of the Hours building. An additional mutual aid fire 01:43:51 department were dispatched by 9Com. Hours Medic 22 responded to the hospital 01:44:35 with the Quint 25 fire fighter. Hours
01:48:41 Fireground operations changed from Hours offensive to defensive. Medic 22 arrived at the hospital. 01:51:36
Hours Police Unit 150 contacted 9Com 01:58:37
advising them a nephew said the Hours occupants were in Las Vegas. Command advised 9Com that the fire 0358
was under control. The overhaul Hours process was started.
Page 13 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Personal Protective Equipment At the time of the incident, the Quint 25 fire fighter was wearing turnout pants, turnout coat, protective hood, helmet, boots, and gloves meeting current National Fire Protection Association (NFPA) requirements. The self-contained breathing apparatus (SCBA) and the personal alert safety system (PASS) that the victim was using were certified to the 2002 edition of NFPA 1981, Standard on Open Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services. The department’s fire investigator took possession of all personal protective equipment and clothing following the incident. All personal protective equipment and clothing were secured in a locked room at fire department headquarters.
The Quint 25 fire fighter was on air at the time of the collapse. He was found in the basement. When he was located by Tower 22, his facepiece, protective hood, gloves, and turnout boots had been removed. His helmet was off but he was wearing the impact cap from his helmet. At fire department headquarters, the NIOSH investigators inspected the Quint 25 fire fighter’s helmet, protective hood, turnout coat, turnout pants, gloves, and boots. The turnout coat and turnout pants had been cut off the fire fighter to provide emergency medical care. The turnout coat had thermal damage along the right shoulder, arm, and back. The turnout pants had thermal damage to the right hip and thigh area and near the bottom of both pants legs. The helmet and impact cap had separated. The outer shell of the helmet was not damaged. The impact cap was damaged at some point after the fire fighter was removed from the structure. The boots, gloves, and protective hood were covered with debris but had no thermal damage. The personal protective equipment was not considered to be a contributing factor in this incident. The personal protective equipment was not further evaluated or tested by NIOSH.
The fire fighter was carrying a fire department-issued portable radio designated as Quint 25B. The radio was not turned on during this incident. When evaluated by NIOSH investigators, the portable radio was turned on but was not recognized by the radio system. Investigators were not sure why the portable radio was not recognized by the radio system.
The SCBA with integrated personal alert safety system (PASS) was also inspected at fire department headquarters by NIOSH investigators. The fire department requested that NIOSH National Personal Protective Testing Laboratory (NPPTL) evaluate and test this SCBA unit. The SCBA unit was hand- delivered by a NIOSH investigator to the NIOSH NPPTL facility in Morgantown, West Virginia, on January 13, 2016. As delivered, the SCBA unit was contained within a black plastic bag. The unit was placed in secured storage.
On May 3, 2016, NIOSH NPPTL personnel evaluated and tested the SCBA and the summary evaluation report is included as “Appendix One: Summary of Personal Protective Equipment Evaluation—SCBA.”
Page 14 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Weather Conditions At 0053 hours on December 28, 2015, the following weather conditions were reported. The temperature was 40 degrees Fahrenheit (40o F), the dew point was 31.1 degrees Fahrenheit (31.1o F), the relative humidity was 83%, and the winds were 11.5 miles per hour (MPH) from the east northeast and gusting to 30 MPH. The sky was overcast with 10 miles visibility. There had been 0.085 inches of precipitation (rain) in the past 24 hours [Weather Underground 2015].
Investigation On December 28, 2015, the county dispatcher center (9Com) received a telephone call at 0103 hours from an alarm company who reported a burglar alarm at a single-family residence. 9Com dispatched two city police officers at 0106 hours. At 0111 hours, two police officers arrived on-scene and reported “heavy smoke showing” from the residence. As the police officers were responding, they stated they could see smoke from several blocks away and knew this was a “working fire.” When the officers arrived on-scene, a yellowish gray smoke was blowing across the street, east to west (from the rear of the house toward the front). There was so much smoke in the street, that the neighbors across the street were not sure which house was on fire. The neighbors advised the police that an elderly couple lived at this residence. The police officers walked around the house and found an open cellar door with smoke pushing out. One police officer went to the 2nd floor using the outside stairs. He knocked on the door, but there was no answer.
At 0113 hours, the fire department was dispatched to a report of residential structure fire. 9Com dispatched Engine 21, Engine 24, Engine 26, Medic 22, Medic 25, Quint 25, Tower 22, and Battalion 20 for a structure fire at the residence. The fire dispatcher advised on the dispatch channel that heavy, black smoke was showing. The fire dispatcher advised at 0114 hours that two elderly people might be in the house. Additionally, the dispatcher transmitted there was smoke coming from the basement in the back of the house. These transmissions were on the dispatch channel only and not simulcast on the tactical channel. Note: During the interviews, most fire fighters and fire officers said they did not hear these radio messages. They had already switched to the fireground tactical channel. Also, most fire fighters were putting on their turnout gear and had not turned on the apparatus radio.
Quint 25 responded at 0114 hours and arrived on-scene at 0117 hours. Upon arrival, the acting officer of Quint 25 met a police officer who advised him that the neighbors reported possibly two victims inside. Heavy smoke was showing from the front half of the house. The acting officer of Quint 25 told the fire fighter on Quint 25 to take the thermal imager and irons to the front porch. The acting officer from Quint 25 walked from Side Alpha along Side Bravo to the corner of Side Charlie before stopping and retracing his steps back to the Side Alpha. Note: The acting officer did not walk the entire length of Side Charlie, and the raised porch prevented the acting officer from seeing the open Bilco® door leading to the basement (See Photo 2). At 0118 hours, the acting officer of Quint 25 advised the dispatcher that smoke was showing from three sides of a residential structure but could see no visible fire. The wind was coming from the west at about 12 mph with gusts up to 30 mph and, although shifting, was generally coming from Side Charlie. The acting officer of Quint 25 stated that at one
Page 15 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio point the smoke was pushing through the front half of the house. This observation was consistent with the wind blowing directly through the open Bilco® door into the basement.
Battalion 20, Engine 24, and Medic 22 arrived on-scene at 0120 hours. Battalion 20 (a captain acting as the shift commander) parked in the church parking lot across the street from the residence. Battalion 20 assumed Command and requested a safety officer respond. Battalion 20 took the accountability board and walked to Side Delta of the structure. The basement windows were intact and had not vented. Heavy smoke was now showing on Side Alpha and the Alpha/Bravo corner, and the smoke was hanging. A 1¾-inch hoseline was pulled to the front door and a 1¾-inch backup line was pulled to the Alpha/Bravo corner. Command ordered Engine 24 to assist Quint 25.
The acting officer of Quint 25 decided to enter the house through the front door, which was on the Alpha/Bravo corner. The fire fighter from Quint 25 forced the front door. The smoke had a brownish, grayish tint. Quint 25 made entry into the foyer and then the family/living room. The acting officer of Quint 25 stated that the smoke was about a foot off the floor but was not hot. The time was 0123 hours (See Diagram 4).
Suddenly, the smoke changed color, and then fire started blowing out the front door onto the porch. On the fireground tactical channel, Command radioed everyone out of the building. At approximately the same time, the Quint 25 fire fighter crawled into the family/living room when the floor collapsed underneath him. The Quint 25 fire fighter immediately fell into the basement (See Photo 3). The acting officer of Quint 25 started calling for the fire fighter from the foyer but was immediately enveloped in fire. At 0123 hours, the officer from Engine 24 called a Mayday. The engineer from Tower 22 picked up the backup line and knocked the fire down around the acting officer of Quint 25. Note: Command transmitted the Mayday to the dispatcher on the fireground tactical channel, not on the dispatch channel. The dispatcher does not monitor the fireground tactical channel. The dispatcher did not know that the fire fighter from Quint 25 had fallen into the basement. The fire department’s standard operating procedure SOP 1.10 - Radio System Procedures requires that when a Mayday occurs on the fireground, Command must communicate the Mayday on the Fire Dispatch Channel. The dispatcher is automatically required to dispatch an extra alarm consisting of two engines, one ladder/quint or tower ladder, and two medic units, or as otherwise specified by the incident commander. These units should have been automatically dispatched by the dispatcher to respond and report to staging.
At approximately 0125 hours, Command ordered Tower 22 and Engine 21 to locate an entrance to the basement and find the Quint 25B. Tower 22 forced the rear door going into the kitchen. Heavy, black smoke poured out of the doorway. At 0125 hours, Engine 24 made entry to the foyer. Engine 24A radioed there was heavy fire in the basement and after the collapse, used the thermal imager to check the basement while operating from the foyer. The thermal imager “whited” out when pointed at the basement. Engine 24 continued operating a 1¾-inch hoseline in the foyer and doorway of the family/living room, knocking down the fire on the 1st floor and the basement. At approximately 0128 hours, Engine 24A radioed Command that he could hear a PASS alarm from the basement. Engine 21
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Diagram 4. The initial fire attack by Quint 25. The officer and fire fighter entered the front door on Side Bravo and went into family/living room. The time was approximately 0121 hours.
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Photo 3. Looking up from the basement at the hole in the 1st floor that was generated when the Quint 25 fire fighter moved into the family/living room. (Photo courtesy of the fire department.) was operating a 2½-inch hoseline in the basement window on Side Bravo. Engine 21 removed an air conditioner from the basement window on Side Bravo to improve water flow into the basement. At 0130 hours, Tower 22 radioed Command that they were in the basement as part of the Rapid Assistance Team (RAT) and had been joined by Engine 21. Tower 22A said he could hear a PASS alarm sounding toward Side Alpha. Tower 22 located the fire fighter from Quint 25 in the basement directly underneath the hole in the 1st floor (See Diagram 5).
Tower 22 could see fire in the rafters as they moved toward Side Alpha in the basement. Approximately 2 feet of water was in the basement. Quint 25B was found lying on his left side. When he was located by Tower 22, his facepiece, protective hood, gloves, and turnout boots had been removed. The impact cap from the helmet was still on his head. Tower 22 tried to move Quint 25B, but he was entangled. Quint 25B’s foot was entangled and had to be freed from burned chairs and storage items.
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Diagram 5. The location of Quint 25B in the basement. Engine 24 and Engine 21 are operating hoselines into the basement trying to protect Quint 25B. Tower 22 is entering the basement trying to locate Quint 25B. The time was approximately 0130 hours.
Page 19 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio The Tower 22 officer radioed Command for webbing and a stokes basket. While Tower 22 was trying to secure the fire fighter in the Stokes basket with webbing, Engine 21 was clearing a path to the Bilco® doors.
They moved Quint 25B to the basement entrance with the help of Engine 21. The time was approximately 0137 hours. In less than 10 minutes, the fire fighter was placed in a Stokes basket and removed from the basement. Once outside the house, Q25B was moved to a stretcher. Quint 25B was then moved to Medic 22. Six medics from Medic 22, Medic 24, and Medic 25 started treatment on Quint 25B. Medic 22 transported Quint 25B to the local trauma center at 0144 hours and arrived at 0152 hours. The fire fighter from Quint 25 was pronounced dead at 0226 hours by the medical staff in the emergency room of the local trauma hospital.
While the rapid assistance team (RAT) operation was occurring in the basement, Command had Engine 212 take a hoseline to the 2nd floor to search for possible victims. At 0137 hours, Engine 212 (PAR 3) entered the 2nd floor by the exterior steps. Engine 212 conducted a complete search of the three bedrooms on the 2nd floor. At 0141 hours, Engine 212 reported the 2nd floor “all clear.” Command ordered Engine 212 out of the building. Engine 212 reported to Command, they were out of the building at 0143 hours.
After Quint 25B was transported to the hospital, Command temporarily stopped fireground operations. The duty shift commander (deputy chief) and the deputy chief in charge of training had arrived on- scene. The priority was to evaluate members and to contact Quint 25B’s immediate family and get them to the hospital. Several members left the scene for various assignments. Additional mutual aid companies responded to assist with fireground operations.
At approximately 0149 hours, Command switched from an offensive strategy to a defensive strategy. Quint 25’s ladder pipe was used until the automatic nozzle malfunctioned. Tower 22 was moved from behind Quint 25 to facing Quint 25 (See Diagram 6). The ladder pipe from Tower 22 and several handlines were used to knock down the fire. The deputy chief in charge of training assumed Command of the incident at this time. During this time, preparations were being made to get the critical incident stress management process started at the fire department headquarters (Fire Station 22). The fire was knocked down and placed under control at approximately 0358 hours. Overhaul of the structure was started at this time. At approximately 0500 hours, the incident commander declared the fire was out.
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Diagram 6. The apparatus and hoseline placement when the incident commander changes the strategy to defensive operations. The time was approximately 0200 hours.
Page 21 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Wind Driven Fires Wind has been recognized as a contributing factor to fire spread in wildland fires and large-area conflagrations. Wildland fire fighters are trained to account for the wind in their tactics. While structural fire departments have recognized the impact of wind on fires, in general, the standard operating procedures for structural fire-fighting have not changed to address the hazards created by a wind-driven fire inside a structure.
The results of the "no-wind" and "wind" fire simulations demonstrate how wind conditions can rapidly change the thermal environment from tenable to untenable for fire fighters working in a single-story residential structure fire, in a multi-family residential structure fire, and high-rise structure fire. The simulation results emphasize the importance of including wind conditions in the scene size-up before beginning and while performing fire-fighting operations and adjusting tactics based on the wind conditions [Madrzykowski and Kerber 2009; Weinschenk, Overholt, and Madrzykowski 2015].
Adjusting fire-fighting tactics to account for wind conditions in structural fire-fighting is critical to enhancing the safety and the effectiveness of fire fighters. Studies have demonstrated that applying water from the exterior into the upwind side of the structure can have a significant impact on controlling the fire prior to beginning interior operations. It should be made clear that in a wind-driven fire, it is most important to use the wind to your advantage and attack the fire from the upwind side of the structure, especially if the upwind side is the burned side. Interior operations need to be aware of potentially rapidly changing conditions [FDNY 2013a; Madrzykowski and Kerber 2009; Weinschenk, Overholt, and Madrzykowski 2015].
A 360-degree scene size-up by arriving fire fighters can help determine the location of the fire and identify potential flow paths within a structure. Door control can also be used to avoid creating inlet and outlet vents that could result in the establishment of a flow path. First fire-fighting efforts should take place at the same level as the fire (i.e., fight basement fires from the basement level) with the wind at the back of fire fighters. Ongoing research by National Institute of Standards and Technology (NIST), Underwriters Laboratories (UL), and others has demonstrated that applying water from the exterior into the fire area of a structure (prior to the start of interior operations) can significantly improve the safety of fire fighters by reducing the thermal hazard from the fire and reducing the potential for developing high velocity hot gas flows within the structure [Weinschenk, Overholt, and Madrzykowski 2015].
There have been many previous fire incidents in which changes in the flow paths are thought to have had an adverse impact on fire fighter and occupant safety. Table 1 includes a list of NIOSH fire fighter fatality investigation reports where a flow path played a role in the outcome of a wind- driven incident. This table lists the NIOSH report number, the outcome, and a brief description of the flow path details.
Based on a review of these incidents, it is clear that fires with rapidly developing or changing ventilation may lead to flow paths that are a significant hazard to fire fighters during a response. The
Page 22 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Fire Fighter Line-of-Duty
NIOSH Report Number Deaths Injuries Flow Path Details 99-F01 3 0 From apartment into hallway on the 10th floor of a high-rise apartment building 99-F21 2 2 Basement to 1st floor F2000-04 3 0 1st floor to 2nd floor (3 civilians) F2000-16 1 1 2nd floor hallway through 2nd floor apartment F2000-23 1 2 From ground floor to the 1st floor, then to the 2nd floor, and flow exited through the ceiling F2000-43 1 serious 1st floor to 2nd floor 2 minor F2001-13 2 0 Lower level up the stairs, through the entry door, and into the garage F2004-02 1 0 1st floor to basement
F2005-02 1 4 Rear to the front of the building F2005-04 1 9 Basement to 1st floor F2007-09 1 2 3-story training burn-flow through all levels F2007-35 0 4 1st floor to the 2nd floor F2009-11 2 0 Rear to the front of the building F2011-31 1 0 Fire extended from the lower level apartment F2012-28 1 1 Attic fire that extended into a closed porch and then into the 2nd floor F2014-09 2 13 Fire extended from the basement to the 1st floor via the stairwell
Table 1. Wind driven fires with flow path related line-of-duty deaths/injuries from NIOSH Fire Fighter Fatality Investigation and Prevention Program reports over a 15-year period.
Page 23 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio development of (or changes to) a flow path could be caused by the failure of a component of the structure, such as a door, window, or portion of a ceiling, wall or floor. Environmental conditions such as wind can generate hazardous thermal conditions within a flow path. Uncoordinated ventilation procedures can also be the cause of increased thermal hazards within a flow path [Weinschenk, Overholt, and Madrzykowski 2015].
The research conducted by NIST also provides potential guidance for fire fighters as a part of a scene size-up and when approaching the room of fire origin. Note: Fire fighters should check for wind conditions in the area of the fire, look for “pulsing flames” or flames not exiting a window opening, examine smoke conditions around closed doors within the potential flow path, and maintain control of doors within the flow path. Even if flames are being forced out of adjacent windows with a high amount of energy, there could still be sufficient energy flows on the fire floor to create a hazard for fire fighters.
Fire Origin and Cause The fire cause was determined to be arson. The fire started in the basement of the structure. The homeowner has been charged with two counts of aggravated arson and murder. Another individual has been charged with aggravated arson and murder.
Contributing Factors Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that ultimately led to the fatalities: • Arson fire • Incomplete scene size-up • Wind-driven fire • Lack of tactical priorities (incident action plan) • Lack of resource status management • Lack of command safety • Ineffective dispatch center operations • Lack of a written professional development program
Cause of Death The county medical examiner listed the cause of death due to smoke inhalation with severe pulmonary edema, carbon monoxide toxicity (12.7%), and thermal injury—second-degree and third-degree burns to 40–50% of the body surface.
Page 24 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Recommendations Recommendation #1: As part of the strategy and incident action plan, incident commanders should ensure a detailed scene size-up and risk assessment occurs during initial fireground operations, including the deployment of resources to Side Charlie. Scene size-up and risk assessment should occur throughout the incident.
Discussion: Occupancies define the space inside the class of building. Construction types/classes of construction define how the building is constructed with either combustible or non-combustible materials. Occupancies exist inside the constructed building. SOPs must consider numerous factors that affect fire-fighting operations. This will ensure essential strategic-, tactical-, and task-level functions are performed by the incident commander, division/group supervisors, and fire fighters. Additionally, this process compliments the defined knowledge, skills, abilities, competencies, and fireground experience to assist: • Incident commanders to plan and implement an effective strategy and incident action plan. • Division/group supervisors to formulate and follow tactics. • Company officers to successfully carry out assigned tasks. • Individual members to effectively perform their duties [FDNY 2009].
At any incident, life safety is always the 1st priority, followed by incident stabilization (2nd priority) and then property conservation (3rd priority). The ability to ensure for the safety of fire fighters is a continuous process throughout the incident. A sound risk management plan ensures that the risks are evaluated and matched with the actions and conditions. The following risk management principles should be used by the incident commander: • Activities that present a significant risk to the safety of fire fighters shall be limited to situations that have the potential to save endangered lives. • Activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of fire fighters, and the actions shall be taken to reduce or avoid these risks. • No risk to the safety of fire fighters shall be acceptable where there is no possibility to save lives or property [Brunacini 2002].
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. The priority is to get a fire department resource or unit to Side Charlie as quickly as possible. However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received. If physical barriers make the 360-degree size-up impractical for the 1st arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be delegated to another engine company or other resource on the 1st Alarm. Even if a 360-degree size-up can be conducted, recourses should be assigned to Side Charlie. Resources could be any unit—engine, truck, medic unit, or chief—preferably an engine company with a hoseline.
Page 25 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio A radio report of conditions, including those on Side Charlie, should be transmitted over the assigned tactical channel to the incident commander and the dispatch center. The transmission should include the following: • Smoke and fire conditions, with an emphasis on identifying the seat of the fire. The initial radio report from the first arriving unit for a structural fire should include the signal for a working fire, number of stories, type of occupancy, and location of fire. This lays the foundation for additional reports and serves as notification to responding units as to the type of SOP to implement. • If there were critical building description information through the critical incident dispatch system (CIDS) for the address, then this information would aid in implementing or adjusting SOPs. CIDS could contain information that would necessitate alternative actions to fulfill said operational goals. • Building features: e.g., number of stories (particularly if there is a difference between Side Alpha and Side Charlie). • Basement access and type. • Any other life or safety hazards.
Any change to operational priorities or responsibilities based on the above size-up shall be clearly communicated to Command, all responding units, and the dispatch center via the assigned tactical radio channel [Modern Fire Behavior 2014; TSFRS 2013]. Command is then obligated to re-broadcast and receive acknowledgement from all operating companies.
The tasks that need to occur at any fire regardless of the occupancy are initial on-scene report upon arrival, initial risk assessment, situational report, water supply, deployment of handlines and back-up handlines, search and rescue, ventilation, rapid intervention crews (RIC), ground and aerial ladder placement, fire attack and extinguishment, and salvage and overhaul.
The fire service has recently been introduced to (and many fire departments have adopted) the acronym SLICE-RS by the International Society of Fire Service Instructors. This process has been specifically designed to help 1st arriving company officers apply recent research on modern fuels and fire dynamics to their early strategic and tactical decisions on the fireground. • Size up all scenes. • Locate the fire. • Identify and control the flow path. • Cool the heated space from a safe location. • Extinguish the fire. • Rescue and Salvage (are actions of opportunity that must be considered not only at the initiation of operations but throughout the incident) [Modern Fire Behavior 2014].
The acronym SLICE-RS is not designed to replace the well-known RECEO-VS method that was developed by Lloyd Laymen and has been widely adopted by the fire service over the years. SLICE-RS is to be used by the first arriving company officer as well as RECEO-VS [Modern Fire Behavior 2014].
Page 26 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio In his book Fire Fighting Tactics, Lloyd Layman used S-RECEO-VS. The “S” is for size up. The first arriving officer or fire department resource should size up or provide an estimate of the situation upon arrival. Chief Layman promoted the importance of size up just as SLICE-RS supports this process today [Layman 1953]. This information is important to the fire service when discussing fireground tactics (See Diagram 7).
Diagram 7. Lloyd Layman’s “Basic Division of Fire-Fighting Tactics” S-RECEO-VS is: • Size up or estimate of the situation • Rescue • Exposures • Confinement • Extinguishment • Overhaul • Ventilation • Salvage [Layman 1953].
A flow path is composed of at least one inlet opening, one exhaust opening, and the connecting volume between the openings. The direction of the flow is determined by difference in pressure. Heat and smoke in a high pressure area will flow through openings toward areas of lower pressure. Based on varying building configurations, several flow paths may be within a structure. The importance of identifying and using flow path information cannot be underestimated. While trying to locate the fire, cooling the heated space from a safe location while ensuring for the safety of the fire fighters is important. Operations conducted in the flow path, between where the fire is and where the fire wants to go, places fire fighters at significant risk due to the increased flow of fire, heat, and smoke toward their
Page 27 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio positions. This risk is true for natural-ventilation cases with or without wind. In cases with the potential for wind to affect the heat release rate and the movement of the fire, it is important to keep the wind at your back and to attack the fire from the upwind side. Once the fire is under control, the fire can be completely extinguished. The rescue and salvage operations are self-explanatory—if anything can be saved, save it. These two actions are always active, right from sizing up to extinguishing. The identification of flow path is critical during initial fireground operations and communicated to the incident commander. In addition, this issue should find its way into every after-action review of an incident.
Establishing a continuous and uninterrupted water supply is vital and one of the most critical elements of fireground operations. This must be done before or in conjunction with committing crews to interior operations. To ensure a water supply is secured, many fire departments require, per standard operating procedure (SOP), that the 2nd due engine company and 4th due engine company should secure a water supply for the 1st due engine company and 3rd due engine company [Fire and Rescue Departments of Northern Virginia 2013].
Procedures developed for fireground operations should be flexible enough to allow the change due to: • Life hazard (must be given first priority). • Problems with water supply and water application. • Volume and extent of fire, requiring large caliber streams. • Location of the fire, inaccessible for hoseline operations. • Materials involved in the fire and explosion potential compounding the problem. • Exposure problems where further fire spread would be a major concern. • Stability of the structure, which would be dependent on the condition of the structural components of the building and the intensity and duration of the fire [Brunacini 2002].
At this incident, initial information communicated to responding units stated there was a possibility of an elderly couple inside the home. Also, 9Com never communicated to the fire department that the police department was on-scene for a burglar alarm. Life safety became the focus of the fire department efforts, but the initial scene size-up was not completed (no view of conditions on Side Charlie or Side Delta), the 2nd floor access (exterior stairs) to the bedrooms was not assessed, and the rear entrance was not assessed. The officer of Quint 25 stated the smoke was in the front half of the house and nothing in the rear.
As outlined in this recommendation, a methodical process for the 1st arriving officer is to initiate the size-up process, risk assessment, and initial fireground operations. Also, resources should be deployed to Side Charlie during the initial response. This officer must communicate this information to all responding companies.
Page 28 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Recommendation #2: Incident commanders should ensure that the strategy and tactics (incident action plan) match the conditions encountered during initial operations and throughout the incident.
Discussion: Fireground operations are very dynamic and fast-paced. The incident commander must determine a strategy and then develop the incident action plan (IAP) to ensure that the proper actions take control of the incident. The incident commander must follow the decision making model that includes identifying incident critical factors (through a situational evaluation or “size up”), consider the standard risk management plan, declare the strategy (offensive or defensive), and then set tactical objectives. This model will lead to the development of the IAP, which serves as the tactical road map to effectively manage the incident. The IAP defines where and when resources will be assigned throughout the incident, along with tasks and objectives [NFPA 2014a].
To ensure a standard outcome of each incident, the incident commander should match the standard conditions to standard actions. This is the core of the incident command system and is the basis for all operations. Standard conditions are identified as the incident’s current critical factors: • Identify the incident’s critical factors before taking any action. • Initial and ongoing size-up of the incident’s critical factors must produce the information that becomes the basis for the current incident strategy and IAP. • Current, accurate, and relevant information provides the foundation for effective initial and ongoing action. • The goal of this systematic evaluation process continually produces standard, safe, well- managed incident outcomes [MABAS 2015]
The IAP should match the defined strategy established by the incident commander for a particular incident. The defined strategy describes the overall approach to incident operations and drives the IAP. The IAP provides the tactical assignments required to achieve the offensive/defensive objective. The order of occurrence is key—the strategic goals are developed first and then followed by the tactical objectives. At each incident, the incident commander should start with a standard placement-oriented operational plan that develops a strong, dependable beginning for command and control of the incident. While developing the strategic goal for the incident is the first component, the incident commander needs to produce detailed tactical objectives that can be assigned to responding companies. This is the purpose of the IAP [Brunacini 2002; Fire and Rescue Departments of Northern Virginia 2013].
The initial incident commander, most often, is a company officer who arrives on-scene prior to a chief officer. The company officer should provide a detailed size-up, which is communicated to all responding resources including the dispatch center. The company officer assumes command and makes a decision regarding the strategy and IAP. The company officer may not have the ability or time to record the IAP on paper and provide documentation when transferring command. In this case, a verbal IAP is appropriate. As with this or any incident, events can occur very quickly before a detailed tactical worksheet or written IAP is developed [Brunacini 2002].
Page 29 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio The IAP can be as simple as a verbal transmission to all units assigned to an incident. Once an officer assumes command, the mode of command (Investigative Mode, Fast Attack Mode, or Command Mode) is determined, and the overall strategy offensive or defensive is communicated. Command can make specific assignments to arriving companies along with tactical objectives such as search, rescue, fire attack, ventilation, utility control, and exposure protection. The responding chief officer should be monitoring radio communications and documenting tactical objectives on a tactical worksheet if possible. When the chief officer arrives on-scene, an update from the initial incident commander can occur (face-to-face or by radio). The chief officer will then assume command at a stationary location. By following this process, the initial and subsequent incident commanders will be in a stronger position to manage an incident should an emergency event occur [NFPA 2014a].
NFPA 1561 defines an IAP as a verbal plan, tactical worksheet, written plan, or combinations thereof that reflects the overall incident strategy, tactics, risk management, and member safety that are developed by the incident commander. NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety [NFPA 2014a] requires the following regarding an incident action plan: • 5.3.12.1 The incident commander shall be responsible for developing and/or approving an incident action plan (IAP). • 5.3.12.2 This IAP shall be communicated to all staged and assigned members at an incident. • 5.3.20 the incident commander shall be responsible for reviewing, evaluating, and revising the IAP and overall strategy of the incident (See Diagram 8).
The following are guidelines for developing an IAP for offensive and defensive operations.
Offensive Incident Action Planning When an incident’s critical factors and the risk management plan indicate an offensive strategy, Command will define the tactical objectives for entering the structure (hazard zone) to attempt to control the incident hazards. An offensive IAP is based on the standard offensive tactical priorities.
Offensive strategy tactical priorities and their corresponding completion benchmarks are: • Fire Control (F/C)—“Under Control” • Life Safety—Primary and Secondary “All Clear” • Property Conservation—“Loss Stopped” • Customer Stabilization—Short term
The offensive tactical priorities establish the major operational activities required for a complete, integrated effort, and they identify the three major functions needed to establish the overall incident response [MABAS 2015].
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Diagram 8. A guide for developing an incident action plan at Type V and Type IV incidents. For these types of incidents, the incident action plan is most often communicated verbally. Note: A larger diagram is found in Appendix Two. (Courtesy of FireFighterCloseCalls.com.) Defensive Incident Action Planning A defensive situation is where the incident problem has evolved to the point that lives and property are no longer savable and offensive tactics are no longer effective or safe. The entire defensive strategy is based on protecting fire fighters.
Fire fighter safety is the No. 1 defensive priority.
Defensive strategy tactical priorities and their corresponding completion benchmarks:
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• Define the hazard zone • Establish cut-offs—Forward progress stopped • Search exposures—Primary and Secondary “All Clear” • Protect exposures—“Fire Control”—Loss Stopped
Defensive operations represent a standard organizational response to situations that cannot be controlled with offensive tactics. When conditions go beyond the safety systems required for interior operations, Command must conduct defensive operations from outside the hazard area. Command must write off lost property and decide where the cut-off will take place. If defensive operations are conducted from the onset of the incident, a primary search will not be completed for the involved structure(s). During defensive campaign operations, Command will coordinate the rotation of crews. A basic defensive IAP includes the following tasks: • Identify critical fireground factors. • Determine the need for additional resources. • Evaluate fire spread/write-off lost property. • Search exposures. • Protect exposures. • Prioritize master streams; provide big, well-placed streams. • Surround and drown [MABAS 2015].
As an incident progresses, Command needs to continually review and update the IAP. The following list serves as a guide for Command to consider. This continuous review and evaluation should occur when benchmarks are met or conditions change and benchmarks have not been achieved. • Fire fighter safety • Does the current strategy match the current conditions • Location of fire attack • Effect of the fire attack • All affected areas searched (“All clear”) • Timing and support • Adequate back-up • Adequate staffing and resources • What is Plan B • Corrective actions to the current conditions (Fire Control, All Clear, Loss Stopped) [MABAS 2015].
At this incident, the communications from 9Com and the police officer regarding the possible victims in the house redirected the focus of fireground operations. Obviously, life safety is the initial priority at an incident. The incident commander must consider this information in order to develop and implement proper tactics. All incidents are dynamic, unpredictable and can change at any time. As described in the diagram, the incident commander must consider all factors in developing an effective IAP, regardless of the compressed time frame. This process will continue throughout the duration of the incident.
Page 32 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Recommendation #3: Fire departments should develop and implement a standard operating procedure, training programs, and tactics for wind-driven fires.
Discussion: Based on the analysis of this incident and results from current research and NIOSH fire fighter fatality investigation reports, adjusting fire-fighting tactics to account for wind conditions in structural fire-fighting is critical to enhancing the safety and the effectiveness of fire fighters. A wind- driven fire may be one of the most dangerous operations fire fighters will encounter. The term “wind- driven” fire is used to describe a fire in which the wind has the potential to, or is already causing, a dramatic and sudden increase in fire, heat, and smoke conditions. Experienced fire officers and fire fighters who have survived wind-driven fires have all described the following: • Upon arrival, conditions appeared to be routine. • Within seconds, fire, heat, and smoke conditions changed without warning “from routine to life-threatening.” • An operating 2½-inch hoseline flowing from the downwind position or into the exhaust portion of the flow had little or no effect on the incredible heat being produced; flowing water into the intake or inlet side of the flow path is very effective. • Directly attacking these fires with one or even two 2½-inch hoselines proved ineffective and ultimately led to fire fighters incurring serious injuries [FDNY 2013a].
When responding to a reported structure fire, an overriding consideration concerning size-up must be wind conditions and its potential effect on the fire. The key to successfully operating at wind-impacted fires in a structure depends on recognizing the wind-impacted fire conditions that may change a seemingly routine fire into a “blowtorching” fire. “Blowtorching” is the appropriate description of what will occur when fire conditions are impacted by wind conditions.
The impact of the wind will be affected by the size of the window opening, the fuel load, and the stage of the fire when the window failed. When wind-impacted fire conditions exist in a structure, the incident commander should notify the dispatcher so this information can be relayed to all responding units. In addition, the incident commander needs to make an announcement on the tactical channel as well. Once the contributing factors are identified, steps can be taken to minimize the hazards to fire fighters [FDNY 2013a].
Fire departments should develop a standard operating procedure for incidents with high-wind conditions and for areas where high-wind conditions are likely. It is important that fire officers and fire fighters develop an understanding of how wind conditions influence fire behavior. This greatly impacts the fireground tactics under wind-driven conditions. Wind conditions can have a major influence on structural fire behavior. When wind speeds exceed 10 mph (16 km/hr), the incident commander, division/group supervisors, company officers, and fire fighters should use caution and take wind direction and speed into account when selecting a strategy and developing tactics. The National Institute of Standards and Technology (NIST) has determined that wind speeds as low as 10 mph (16 km/hr) are sufficient to create wind-driven fire conditions if the flow path is uncontrolled [Madrzykowski and Kerber 2009]. NIST, in a recent study on wind-driven fires in structures, has
Page 33 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio shown that wind speeds as low as 10 mph can turn a routine “room and contents fire” into a floor to ceiling fire storm or “blowtorch effect,” generating untenable conditions for fire fighters, even outside of the room of origin. Temperatures in excess of 600ºC (1,100ºF) and total heat fluxes in excess of 70 kW/m² were measured at 4 feet above the floor along the flow path between the fire room and the downwind exit vent. These conditions were attained within 30 seconds of the flow path being formed by an open vent on the upwind side of the structure and an open vent on the downwind side of the structure [Madrzykowski and Kerber 2009].
Fire departments are encouraged to develop and implement a standard operating procedure addressing such issues as obtaining the wind speed and direction, considering the possible fuel load associated with a particular occupancy, determining proper strategy and tactics for fireground operations, consideration of ventilation, and establishing possible scenarios associated with the wind speed based upon risk assessment. Under wind-driven conditions, an exterior attack from the upwind side of the fire may be necessary to reduce fire intensity to the extent that fire fighters can gain access to the involved compartments [Madrzykowski and Kerber 2009].
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. If physical barriers make the 360-degree size-up impractical for the first arriving officer, the size-up of Side Charlie may be delegated to another fire department unit. However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received [Fire and Rescue Departments of Northern Virginia 2013].
In simulations and in previous full-scale experiments, it has been demonstrated that wind can increase the thermal hazards of a structure fire [Madrzykowski and Kerber 2009]. Therefore, wind must be considered as part of the initial size-up of the fire conditions and must be monitored and reported throughout the fire incident. It is critical that fire fighters not be in the exhaust portion of the fire flow path. The directional nature of the fire gas flow path results in temperatures higher than the area adjacent to the flow path or upwind of the fire. The flow path can be controlled by limiting ventilation. Previous studies demonstrated that applying water from the exterior into the upwind side of the structure can have a significant impact on controlling the fire prior to beginning interior operations [ISFSI 2013; NIST 2009].
Some current fire control training guides state, “Whenever possible, approach and attack the fire from the unburned side to keep it from spreading throughout the structure.” It should be made clear that in a wind-driven fire, it is most important to use the wind to your advantage and attack the fire from the upwind side of the structure, especially if the upwind side is the burned side. The unexpected ventilation from a broken window can suddenly change the interior thermal conditions. Interior operations must be aware of potentially rapidly changing conditions.
A fire department should incorporate the following into their training and education component on wind-impacted fires:
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• Ensure that an adequate initial size-up and risk assessment of the incident scene is conducted before beginning interior fire-fighting operations. • Conduct a 360-degree size up to determine the best attack/entry point. • Ensure that fire fighters, company officers, division/group supervisors, and the incident commander have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior (such as smoke [color, velocity, and density], visible fire, and heat). • Ensure that fire fighters and company officers are trained to recognize the potential impact of windy conditions on fire behavior and implement appropriate tactics to mitigate the potential hazards of wind-driven fire. • Ensure the incident commander’s strategy considers high-wind conditions, if present. • Ensure that fire fighters understand the influence of ventilation on fire behavior and effectively apply ventilation and fire control tactics in a coordinated manner. • Ensure that fire fighters and officers understand the capabilities and limitations of thermal imagers. • Ensure a thermal imager is used as part of the size-up process. • Ensure that fire fighters are trained to check for fire in overhead voids upon entry and as charged hoselines are advanced. • Develop, implement, and enforce a comprehensive Mayday standard operating procedure and train and educate fire fighters to ensure they understand the process and know how to initiate a Mayday. • Ensure fire fighters are trained in fireground survival procedures. • Ensure all fire fighters on the fireground are equipped with radios capable of communicating with the incident commander and the dispatch center [FDNY 2013b; IFSTA 2013; NIOSH 2014].
At this incident, the wind (12 mph with gusts to 30 mph) was blowing against the fire building on Side Charlie. One basement door on Side Charlie was left open prior to the arrival of the fire department. When the front door was opened and the fire fighter from Quint 25 fell through the floor, enough air (oxygen) was provided for the fire to ignite the basement and the 1st floor of the house.
Recommendation #4: Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational practices by developing standard operating procedures, conducting live fire training, and revising fireground tactics.
Discussion: The National Institute of Standards and Technology (NIST) and Underwriters Laboratories (UL) have conducted a series of live-burn experiments designed to replicate conditions in modern homes and residential structures and to validate previous testing done in laboratory settings. The results of these experiments will enable fire fighters to better predict and react to effects of new materials and construction on fire. The fire research experiments were conducted in cooperation with the Fire Department of New York; Chicago Fire Department; Spartanburg, South Carolina, Fire and
Page 35 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Rescue; and other agencies. The live-burn tests are aimed at quantifying emerging theories about how fires are different today, largely due to new building construction and the composition of home furnishings and products. In the past, these products were mainly composed of natural materials, such as wood and cotton, but now contain large quantities of petroleum-based products and synthetic materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a room once took approximately 20 minutes to “flashover”—igniting all the contents—this can happen with today’s furnishings in as little as 4 to 5 minutes [NIST and UL 2013].
In addition, modern living spaces tend to be more open, to be less compartmentalized, and are better insulated than homes built years ago. As a result, an interior residential fire can generate an oxygen- depleted, fuel-rich environment within minutes. This fire condition of hot, fuel-rich smoke is highly reactive to the introduction of oxygen. Introducing oxygen to this environment by opening a door or venting a window may result in a rapid transition to flashover. These same conditions can occur in commercial structures as seen in the Charleston, South Carolina, Sofa Super Store fire [NIOSH 2009a].
The NIST and UL experiments evaluated individual and combinations of methods for strategically ventilating and isolating fires to prevent flashover—or at least delay it. In contrast, kicking a door open or breaking a window without knowledge of conditions inside could create a portal for air that can literally fan the flames by introducing oxygen into an oxygen-limited fire environment.
Traditionally, fire suppression operations were conducted from the interior of the structure as a means to reduce water damage and limit fire damage to structures. These operations must be coordinated with the ventilation operations. Previous research and examinations of line-of-duty deaths have shown that ventilation events occurring with fire fighters in the structure prior to suppression have led to tragic results [NIOSH 2012a, 2013a, 2013b]. One method of eliminating the possibilities of this occurrence would be a transitional attack. Water is directed into the structure from the exterior to cool the fire gases and reduce the heat-release rate of the fire, prior to the fire fighters entering the building. The major concern with this type of operation is the potential harm that might occur to people trapped in the structure or the amount of water damage to the structure. Therefore, measurements are needed to document the changes of the thermal environment within the structure and the impact on the viability of people, who might be trapped in the structure [NIST and UL 2013].
Based upon the NIST and UL research, the following fireground operations should be considered for implementation. • Size-Up Size-up must occur at every fire. Consideration must be given to the resources available and situational conditions, such as weather, fire location, size of the fire and building, and the construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical plan for each fire must be developed, communicated, and implemented.
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• Ventilation Fire departments should manage and control the openings to the structure to limit fire growth and spread and to control the flow path of inlet air and fire gases during tactical operations. All ventilation must be coordinated with suppression activities. Uncontrolled ventilation allows additional oxygen into the structure, which may result in a rapid increase in the fire development and increased risk to fire fighters due to increased heat-release rates within the flow path. • Fire-fighting Operations Given the fuel-rich environment that the fire service operates in today, water should be applied to the fire as soon as possible. In many cases, water application through an exterior opening into a fire compartment may be the best first action, prior to committing fire-fighting resources to the interior. Fire departments should cool the interior spaces of a fire building with water from the safest location possible, prior to committing personnel into spaces with, or adjacent to, fully developed or smoldering (ventilation-limited) fire conditions. • Rapid Intervention Fire department rapid intervention procedures should be updated to provide water on the fire as soon as possible and ventilation openings controlled during fire fighter Mayday incidents [NIST and UL 2013].
This information is presented to educate the fire service and to ensure that fire departments consider a change in fireground tactics based upon the current research presented by NIST and UL. Much of this research has been directed toward developing a better understanding of the characteristics of the modern fire. This modern research provides members of the fire service with the information and knowledge needed to modify essential fire-fighting tactics. While fire-fighting will never be without risk, this research represents a vital contribution to overall efforts to reduce risks and to save lives.
A flow path is composed of at least one inlet opening, one exhaust opening, and the connecting volume between the openings. The direction of the flow is determined by difference in pressure. Heat and smoke in a high pressure area will flow through openings toward areas of lower pressure. Based on varying building designs and the available ventilation openings (doors, windows, etc.), several flow paths can exist within a structure. Any operation conducted in the exhaust portion of the flow path will place members at significant risk due to the increased flow of fire, heat, and smoke toward their position. Operations conducted in the flow path, between where the fire is and where the fire wants to go, places fire fighters at significant risk due to the increased flow of fire, heat, and smoke toward their positions. This risk is true for natural-ventilation cases with or without wind. In cases with the potential for wind to affect the heat release rate and the movement of the fire, it is important to keep the wind at your back and to attack the fire from the upwind side [FDNY 2013a; NIST 2013a].
Fire fighters must be aware and understand that the critical first step in evaluating the potential for a wind-impacted fire is recognition of any smoke movement in the flow path, wind speed, smoke being forced under doors, and/or pulsing smoke or fire. The incident commander and company officers must be notified immediately when any of these conditions are observed. The communication of this
Page 37 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio critical information to the incident commander and company officers operating inside the building must be acknowledged.
At this incident, prevailing winds were blowing toward Side Charlie at 12 miles per hour with gusts up to 30 miles an hour. Prior to the arrival of law enforcement and the fire department, one of the Bilco® doors to the basement was open. The first arriving police officer radioed 9Com and stated: “Also heavy smoke coming from the basement. There is an open basement door in the back.” This information was relayed to the fire department on the dispatch channel but not the tactical channel. During the fireground operations, Engine 26 opened the other Bilco® door.
Recommendation #5: Fire departments should develop and implement a standard operating procedure for tactical operations involving cellar or basement fires.
Discussion: One of the most dangerous and most difficult fire locations in a structure for a fire fighter is a below-grade area. Below-grade fires can include basements, cellars, and sub-cellars. A basement or cellar is defined as a section of a structure either partially or fully below grade. The difference between a basement and a cellar can be defined as a cellar is more than 50% below grade or ground level. A basement is less than 50% below grade. Another way to define a cellar and a basement is by use. If the room is unfinished, the term used is a cellar. If the room is finished, the room is called a basement. Regardless of the term, either requires some type of descent to reach. This can be interior steps and an exterior entrance [Smith 2002]. In this incident, the only access was through the Bilco® doors and steps into the basement (See Photo 2).
Recognizing a cellar or basement fire is essential to ensuring the proper strategy and tactical objectives are developed for the incident. These types of fires are low-frequency/high-risk events for several reasons. Cellar or basement fires may be difficult to initially detect; may be difficult to access; and requires adequate staffing for hoseline placement, operation, and ventilation; and fire fighters may be working over the fire. Additionally, the increased risk to fire fighters is due to: • Limited entry and egress into a basement • Working above the fire • Weakened floor joists and rafters • Being caught in the fire’s exhaust portion of the flow path • Unknown fire loading • Ventilation concerns • Utility panels and meters plus connections • Hanging wires • Furniture and appliances
Key factors in recognizing a below-grade fire are: • Fire or smoke venting from a cellar window, smoke pushing from the chimney (especially during warmer weather). • Heavy smoke with no visible fire on the 1st floor.
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• Hot floorboards on the 1st floor or smoke showing from baseboard areas on the 1st floor. Floorboards may not be hot. Smoke from attic windows or louvered vents especially in older homes with balloon frame construction [Kerber et al. 2012; Madrzykowski and Kent 2011].
Basement fires in dwellings with balloon construction may extend to the attic via hidden voids. Units operating above the cellar must stretch enough hoseline to reach the upper floors. Intermediate floors must be checked for fire before a hoseline is committed to the top floor because floor construction can isolate the fire. Flooring systems and floor coverings are good insulators and may not transfer a significant amount of heat from a basement fire. Experiments have shown that post-flashover basement fires, even after starting to lose the structural integrity of the floor supports: • May not generate high heat conditions on the floor above. • May not provide clear information on the level of hazard to a thermal imager. • May hold up to a strike from a tool during sounding but may not be able to carry the weight of a fire fighter, or fire fighters [Kerber et al. 2012; Madrzykowski and Kent 2011].
Standard operating procedures must consider numerous factors that affect fire-fighting operations. This will ensure essential strategic-, tactical-, and task-level functions are performed by the incident commander, division/group supervisors, company officers, and fire fighters. Additionally, this process compliments the defined knowledge, skills, abilities, competencies, and fireground experience to assist: • The incident commander to plan and implement an effective strategy and incident action plan. • Division/group supervisors to formulate and follow tactics. • Company officers to successfully carry out assigned tasks. • Fire fighters to effectively perform their duties and functions [FDNY 2013c].
The fire department’s standard operating procedure on cellar or basement fires needs to include the following topics: • Community risk assessment • Scene size-up • Building construction • Strategy and tactics • Use of a thermal imager • Ventilation considerations • Proper size and adequate hoselines
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. The priority is to get a fire department unit to the rear of the structure on Side Charlie. However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received. If physical barriers make the 360-degree size-up impractical for the 1st arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be delegated to another engine company on the 1st Alarm. Even if a 360-degree can be conducted, the 2nd due engine company
Page 39 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio or 3rd due engine company and the 2nd due truck company should be assigned to Side Charlie [Fire and Rescue Departments of Northern Virginia 2013].
Cellar or basement fires are one of the most challenging situations fire fighters encounter. As with all fires, a risk assessment and an occupant survivability profile should be conducted to evaluate what is at risk, lives or property. Fire departments should conduct a post incident analysis for significant incidents, especially cellar or below-grade fires. Also, fire departments should periodically update their community risk assessment program and standard operating procedures based on recommendations from post incident analysis reports.
At this incident, the fire department did not have a standard operating procedure for fighting basement fires. The fire in the basement was not identified until the fire fighter from Quint 25 fell into the basement.
Recommendation #6: Fire departments should ensure that a communication standard operating procedure is in place for dispatchers to support fireground operations and the incident commander.
Discussion: Effective fireground radio communication is an important tool to ensure fireground command and control as well as helping to enhance fire fighter safety and health. The radio system must be dependable, consistent, and functional to ensure that effective communications are maintained, especially during emergency incidents. Fire departments should have a “Communications” standard operating procedure (SOP) that outlines the communication procedures for fireground operations. This SOP should be periodically reviewed and updated. Fire departments should ensure that the Communication or Dispatch Center is part of this revision process. Another important aspect of this process is an effective education and training program for all members of the department and the dispatchers [Kunadharaju et al. 2010].
NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety provides basic requirements for fireground communications in Chapter 6, “Communications and Information Management” [NFPA 2014a]. The chapter addresses the key components for effective fireground communications, such as the requirements for a dispatch radio channel, a command radio channel, and a tactical radio channel; use of plain text for transmitting strategic modes of operation and situational reports; emergency traffic including Mayday; and telecommunicator (dispatcher) support [NFPA 2014a].
One of the consistent factors, defined in line-of-duty death investigation reports is the incident commander can be overwhelmed with fireground radio communications. This is especially true if the incident commander has to monitor the dispatch channel and the fireground tactical channel. Fire departments need to ensure that fireground radio communication systems are designed and operated to take this issue into account. Among the reasons an incident commander may miss messages include being engaged in face-to-face communications, operating the command board and tactical worksheet, reviewing or preparing incident documentation, ambient noise conditions, radios accidentally being
Page 40 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio turned down, radio failure, simultaneous transmissions on separate channels, or simply being distracted with other tasks [NFPA 2014a; Varone 2003].
There are several ways to ensure that the incident commander can effectively manage fireground communications. The best solution is to have a trained dispatcher monitoring the fireground radio channel. Dispatchers should meet the requirements of NFPA 1061, Professional Qualifications for Public Safety Telecommunications Personnel [NFPA 2014b]. The dispatcher is in a secure environment, isolated from fireground distractions and noise. The dispatcher should have access to playback technology with the ability to listen to hard-to-understand messages. The dispatcher should also have access to "identifier" information, which identifies the portable radio making the transmission. Like any other aspect of the fire service, all personnel need to be properly trained before being assigned to a critical task. In the world of fireground operations today, effective radio communications are critical, and the dispatcher is one of the most critical components in the radio communications systems. Proper training of a dispatcher involves more than teaching which buttons to push and how to figure out what companies to send where. Dispatchers need a thorough understanding of the incident management system, fireground strategy and tactics, and fire-fighting vernacular. Most important is to define the dispatcher’s role during emergency operations with such responsibilities as fireground benchmarks, notifying the incident commander of lapsed time intervals for a personnel accountability report, emergency traffic, a Mayday, roll calls, or building evacuations. Dispatchers understand the critical role they play in the incident management system [NFPA 2014a; Varone 2003].
Another important function for the dispatcher is to communicate with the incident commander about critical incident benchmarks. One responsibility of the dispatcher is to ensure that a personnel accountability report is conducted every 10–15 minutes during the incident. The dispatcher should prompt the incident commander every 10–15 minutes to conduct a personnel accountability report. Other responsibilities are to ensure that the incident commander communicates critical fireground benchmarks during the incident, such as a complete scene size-up with declared strategy, water is on the fire, a primary search is completed with outcome, command is being transferred, a Mayday has occurred and a request has been made for additional tactical channels and emergency traffic, fire is knocked down, and fire is out. This is not an all-inclusive list, but an idea of critical fireground benchmarks [NFPA 2014a]. The job of dispatching should not be assigned to a new fire fighter or to a police dispatcher who does not have adequate training in fireground radio communications. Numerous line-of-duty death reports are of incidents in which the dispatcher had information that a fire fighter was in distress yet failed to act on that information [NFPA 2014b]. Effective communication involves a thorough understanding of the message. The sender (dispatcher) transmits a clear message and the receiver (incident commander) must acknowledge the transmission so the sender (dispatcher) knows that the transmission was understood. This process would work the same way if the incident commander transmits a message to the dispatcher (See Diagram 9).
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Diagram 9. Communications loop between the dispatcher and the incident commander.
Dispatching is not a job that should be left to just one person who may be called away from monitoring the fireground radio to field telephone calls or dispatch runs. Dispatchers who monitor a fireground radio channel must be able to put 100% of their concentration into listening for missed messages and providing support to resources on-scene. Ideally, one dispatcher should be assigned to each fireground channel in use [Varone 2003]. Many fire departments assign a tactical radio operator or dispatcher to the assigned fireground tactical channel. This dispatcher is assigned the incident until Command clears the tactical channel.
Another solution is to provide the incident commander with a staff assistant or staff aide. A battalion chief or district chief must monitor and comprehend radio traffic while enroute to the incident and then on-scene. Additionally, a battalion chief or district chief must address deployment issues, develop a strategy for the incident based upon communications from the first arriving resource, and develop an incident action plan for the incident. A staff assistant or staff aide can assist the battalion chief or district chief with processing information without distraction. Once on-scene, the staff assistant or staff aide can maintain fireground communications with the dispatcher. For fire departments that do not have a staff assistant or staff aide, another officer or fire fighter can be designated to function in this position [NFPA 2014a].
Every fire fighter and company officer should take responsibility to ensure their portable radio is turned on and on the correct channel. A company officer’s responsibility is to ensure that all members of the crew comply with these requirements [IAFF 2010].
At this incident, the protocol for the county fire dispatch center (9Com) was to monitor the fire dispatch channel and not the fireground tactical channel. The Mayday was transmitted on the
Page 42 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio fireground tactical channel only. This prevented the fire dispatcher from sending an automatic response of resources to the incident scene per the fire department’s standard operating procedure SOP 1.10 - Radio System Procedures. The information regarding law enforcement on-scene prior to their arrival was not communicated to the fire department. This and other information needs to be simulcast over both the dispatch channel and the assigned fireground tactical channel.
Recommendation #7: Fire departments should ensure that the incident commander uses a tactical worksheet during initial fireground operations and maintains the tactical worksheet throughout the incident.
Discussion: The tactical worksheet is a vital piece of equipment because it helps the incident commander organize the incident from the initial onset of the incident. The benefit of using a tactical worksheet is that critical information is documented and that it provides reminders, prompts, and a convenient workspace for tracking companies and apparatus. For fire departments that provide a staff assistant or incident command technician, the district chief or battalion chief has the ability of starting the tactical worksheet while responding to the incident. The incident commander has the ability to record vital information that may help them make future operational decisions. By documenting the assignments of division/group supervisors and division/group resources, the incident commander creates a visual reference of the overall fireground organization and deployment [NFPA 2014a].
The use of a tactical worksheet can assist the incident commander in tracking various task assignments on the fireground. It can be used along with preplan information and other relevant data to integrate information management, fireground operations, and decision-making. The tactical worksheet should record unit status and benchmark times and include a diagram of the fireground, occupancy information, activities checklist(s), and other relevant information. The tactical worksheet can also help the incident commander in continually conducting a situation evaluation and maintaining personnel accountability [NFPA 2014a].
The advantages of using a tactical worksheet are: • Includes a location to quickly note individual assignments. • Provides prompts for the incident commander, such as time, air management, and strategy. • Provides tactical benchmarks, such as “primary search complete,” “fire under control,” and “loss stopped.” • Facilitates consistent, organized information. • Documents assignments and responsibilities. • Expedites passing of command or support for the incident commander. • Provides and maintains resource status [NFPA 2014a].
The tactical worksheet is also an excellent tool when the "passing of command" must occur. On the fireground, the officer taking over command can quickly check the worksheet and obtain a strong understanding of the initial deployment of resources, the need for additional apparatus and equipment, and the status of units in the staging area.
Page 43 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio The tactical worksheet is a vital resource because it helps the incident commander organize fireground operations. Also, the tactical worksheet provides reminders, prompts, and a convenient workspace for tracking companies and apparatus. It allows the incident commander to slow down during an incident (although the worksheet can be used for fires big and small, as well as EMS incidents, to help develop proficiency) and record vital information that may help make future operational decisions.
In order to effectively command and control an incident, fire departments should ensure that the incident commander be in or operates from a command vehicle. The command vehicle should include radio and communication capabilities, a tactical worksheet, and accountability board.
Recommendation #8: Fire departments should ensure the personnel accountability system is properly used to account for all resources assigned to an incident. The personnel accountability system should be managed by a dedicated accountability/resource status officer.
Discussion: A personnel accountability system is a system that readily identifies both the location and function of all members operating at an incident scene [NFPA 2013a, 2014a]. The philosophy of the personnel accountability system starts with the same principles of an incident management system— company unity and unity of command. Unity can be fulfilled initially and maintained throughout the incident by documenting the situation status and resource status on a tactical worksheet.
One of the most important functions of command safety is for the incident commander to initiate an accountability system that includes the functional and geographical assignments at the beginning of operations until the termination of the incident. It is very important for the first on-scene resource to initiate an accountability system. This initial system allows the passing or transfer of information to the next officer who assumes command upon arrival [NFPA 2014a].
A functional personnel accountability system requires the following: • Development and implementation of a departmental SOP • Necessary components and hardware • Training all members on the operation of the system • Strict enforcement during emergency incidents
Many different methods and tools can be used for resource accountability. Some examples are: • Tactical worksheets • Command boards • Apparatus riding lists • Company responding boards • Electronic bar-coding systems • Accountability tags or keys (e.g., PASSPORT System) [NFPA 2014a]
Resource accountability should be assigned to personnel who are responsible for maintaining the location and status of all assigned resources at an incident. As the incident escalates, resource status
Page 44 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio would be placed under the Planning Section. This function is separate from the role of the incident commander. The incident commander is responsible for the overall command and control of the incident. Due to the importance of responder safety, resource status should be assigned to a dedicated member as the size and complexity of the incident dictates. A number of positions could function in this role, including an incident command technician, staff assistant, chief officer, or other defined member. This position should be maintained throughout the incident preferably by the same individual to ensure consistency and effectiveness of operations.
As the incident escalates and tactical-level management components (e.g., divisions or groups) are assigned, the resource status officer (accountability officer) works with the division or group supervisors to maintain an on-going tracking and accountability of members [FIRESCOPE 2012]. A properly initiated and enforced personnel accountability system enhances fire fighter safety and survival. It is vital that resources can be identified and located in a timely manner.
An important aspect of a personnel accountability system is the personnel accountability report (PAR). A PAR is an organized on-scene roll call in which each supervisor reports the status of their crew when requested by the incident commander [NFPA 2014a]. The PAR should be conducted every 10–15 minutes or when benchmarks are met.
In order for the personnel accountability system to properly function, the process should include a standard operating procedure that defines each function’s responsibility in making this process successful on the fireground. Also a training component—both classroom and practical—should occur to ensure this process operates properly during emergency incidents.
At this incident, the fire department did not have a staff assistant for the battalion chief. The battalion chief utilizes a driver from a piece of apparatus or medic unit to function as the personnel accountability officer. The driver of Medic 22 started as the personnel accountability officer, but the function was abandoned when the collapse occurred. A personnel accountability report was not conducted until 0138 hours.
Recommendation #9: Fire departments need to incorporate the principles of Command Safety into the incident management system during the initial assumption of command. This ensures that the strategic-level safety responsibilities are being incorporated into the command functions throughout the incident.
Discussion: The purpose of command safety is to provide the incident commander with the necessary resources on how to use, follow, and incorporate safety into the incident management system at all incidents. Command safety is used as part of the eight functions of command developed by Fire Chief Alan V. Brunacini (Retired). The principles of command safety describe how the incident commander must use the regular, everyday command functions to complete the strategic-level safety responsibilities during incident operations. Using the command functions creates an effective way to ensure a close connection between incident safety and incident command.
Page 45 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio The eight functions of command are: • Assumption/confirmation/positioning • Situation evaluation • Communications • Deployment • Strategy/incident action planning • Organization • Review/revision • Transfer/continuation/termination [Brunacini 2002; NFPA 2014a].
A vital command function involves the incident commander using the initial scene size-up, consideration of critical factors (building type, occupancy, life safety, fire conditions, and available resources), the standard risk management plan, the forecast of incident conditions, and a standardized decision-making process. The choice of strategy is independent of location (inside or outside) as it relates to the hazard area or hazard zone. The strategy may change over the course of an incident, but only one of the two strategies can be in use at any one time [MABAS 2015].
An offensive strategy means that personnel are actively and directly attempting to correct the identified problem. This might mean that they are doing CPR on the pulseless patient, directing water streams into the burning structure, or trying to plug the leaking vessel. A defensive strategy is where the incident commander decides the best course of action is to contain the problem. Fire fighters might build containment around a leak or only put water on threatened exposures. Any change of strategy must be the result of deliberate defendable thought and must be communicated.
The two separate strategies create a simple, understandable plan that describes in primitive terms how close the emergency responders will get to the incident’s hazards. The incident’s overall strategic decision is based on the incident’s critical factors weighed against the risk management plan (See Diagram 10). Declaring the incident strategy up front, as part of the initial radio report will: • Announce to everybody the overall incident strategy. • Eliminate any question on where fire fighters will be operating on the incident scene inside the structure [MABAS 2015].
Offensive and defensive strategies should not be combined.
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Diagram 10: This model conforms the decision-making process into a standard sequence. The incident commander identifies the incident’s significant critical factors and develops a risk management plan. The incident commander then bases the strategy and incident action plan on the evaluation of those factors. This leads to the tactical priorities for the incident (Diagram courtesy of MABAS Division 201[MABAS 2015].)
Once the overall incident strategy has been determined and the incident action plan developed, the incident commander should manage the completion of the tactical priorities for the chosen strategy. Each strategy has a different set of tactical priorities to complete. Tactical priorities provide the incident commander with a simple, short list of major categories that are designed to act as a practical guideline during the difficult initial stages of fireground planning. The incident action plan must be short and simple. A complicated incident action plan tends to break down during this critical time.
Generally, the incident commander tries to achieve the same basic objectives from one incident to the next. Tactical priorities offer a regular set of tools on which the incident commander can utilize for tactical activities in order to develop a standard approach to solving incident problems. With this standard approach, the incident commander can manage the basic work sequence at every incident, in the same manner.
Page 47 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio In this incident, the 1st arriving officer was the incident commander, but he never formally assumed command of the incident. Based upon his size-up and risk assessment, the officer of Quint 25 decided to operate in the fast-attack mode. This mode is applied when quick, immediate action can prevent life loss or injury. These situations require immediate action to stabilize the incident and require the company officer’s direct involvement in the attack. In this mode, the company officer accompanies the crew to provide the appropriate level of supervision. Command may be passed to the next arriving officer, upon their arrival. Command shall not be passed to an officer who is not on-scene. Where fast intervention is critical, use of a portable radio will permit the company officer’s involvement in the attack without neglecting incident commander’s responsibilities. The fast-attack mode can only be used for a rescue attempt or when 2-in and 2-out is established. The fast-attack mode should not last more than a few minutes.
Dispatch centers should contact the incident commander every 10–15 minutes on the assigned fireground tactical channel with elapsed-time reminders. These 10–15 minute notifications reminders serve as cues for the incident commander to re-evaluate conditions, restate the current strategy, and consider the length of time fire fighters have been operating in the hazard zone. The incident commander develops the strategy and the incident action plan based on the initial size-up of the incident’s critical factors. These critical factors are very dynamic. Incident operations are either getting better or they are getting worse, but they never stay the same. The incident conditions drive the strategy, the incident action plan, and the risk-management plan [MABAS 2015; NFPA 2014a].
When a change occurs in the strategic mode—going from offensive mode to defensive mode—the incident commander needs to ensure that the accountability system or resource status accounts for all assigned resources. Assigned resources are fire fighters who have been entered into the accountability system and assigned work tasks on an incident. The system is designed to ensure that fire fighters do not become lost or missing in the hazard zone. An integral part of the personnel accountability system is to make sure that all assigned resources working in the hazard zone are initially accounted for based upon the system that a fire department uses for accountability (e.g., PASSPORT System). Periodically throughout the incident, a personnel accountability report is conducted to ensure that all assigned resources are accounted for by the accountability officer.
The accountability officer should request a personnel accountability report from each division or group supervisor whenever there is a change in conditions that could create an unsafe operation such as an “emergency traffic” announcement to “all companies evacuate the building.” When a tactical-level management component supervisor is requested to conduct a personnel accountability report, this supervisor is responsible for reporting on the accountability of all companies or members working within their area of responsibility [NFPA 2014a]. With a strategic mode change, a personnel accountability report should occur to ensure that all assigned resources are accounted for and are out of the hazard zone. Defensive operations should not start until the personnel accountability report is completed and all members are accounted for by the accountability officer.
Page 48 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Following this incident, the fire department should address command safety issues as part of their recovery process. The eight functions of command serve as the foundation for addressing command safety issues. The incident commander must follow each of these functions in order without skipping or missing any function. Automatically connecting and integrating safety with command becomes a simple and essential way that the incident management system protects assigned resources at an incident. These functions serve as a practical performance foundation for how the incident commander completes their responsibility as the strategic-level incident manager and the overall incident safety manager [Brunacini 2002].
Recommendation #10: Fire departments should provide a checklist for the incident commander regarding procedures in the event of Mayday.
Discussion: When a Mayday is transmitted for whatever reason, the incident commander has a very narrow window of opportunity to locate the lost, trapped, or injured member(s). The incident commander must restructure the strategy and incident action plan (tactics) to include a priority rescue [NFPA 2014a].
Some departments have adopted the term “LUNAR”—location, unit assigned, name, assistance needed, and resources needed—to gain additional information in identifying a fire fighter who is in trouble and in need of assistance. The incident commander, division/group supervisors, company officers, and fire fighters need to understand the seriousness of the situation. It is important to have the available resources on-scene and to have a plan established prior to the Mayday [Brunacini and Brunacini 2004; NFPA 2014a].
A checklist is provided in “Appendix Three: Incident Commander’s Tactical Worksheet for Mayday.” This checklist can assist the incident commander to ensure the necessary steps are taken to clear the Mayday as quickly and safely possible. This checklist serves as a guide and can be tailored to any fire department’s Mayday procedures. The intent of the checklist is to provide the incident commander with the essential actions to be taken in the event of Mayday. This format allows the incident commander to follow a structured worksheet. This process is too important to operate from memory and risk missing a vital step that could jeopardize the outcome of the rescue of a fire fighter who is missing, trapped, or injured.
At this incident, when the Mayday occurred, the incident commander contacted 9Com to request additional resources. The incident commander then conducted a personnel accountability report to determine if any other members were lost or missing. The intent of this Mayday worksheet, like the tactical worksheet, is to assist the incident commander during a very difficult and stressful time on the fireground.
Page 49 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Recommendation #11: Fire departments should ensure that a safety officer is appointed and utilized at working structure fires.
Discussion: With the advent of the Incident Command System, the goal is to ensure that the incident commander is responsible for the safety and welfare of all members and other first responders who are on-scene at an incident [NIMSC 2008].
The following items shall be considered regarding the appointment of a safety officer: • The safety officer must be assigned as early in the incident as possible. • The safety officer reports directly to the incident commander. • The safety officer recons the incident to identify existing or potential hazards or risks and informs the incident commander. • The safety officer recommends to the incident commander any changes to the incident action plan as a result of the ongoing surveys. • At an emergency incident where the safety officer judges activities unsafe or an imminent hazard, the safety officer shall have the authority to alter, suspend, or terminate those activities. The safety officer shall immediately inform the incident commander of any actions taken to correct imminent hazards at the emergency scene. • At an emergency incident where a safety officer identifies unsafe conditions, operations, or hazards that do not present an imminent danger, the safety officer should take appropriate action through the incident commander to mitigate or eliminate the unsafe condition, operations, or hazard at the incident scene. • When operating in forward or otherwise hazardous positions, the safety officer must be attired in appropriate personal protective equipment—including self-contained breathing apparatus and radio communication equipment—and be accompanied by another responder [NFPA 2014a; NIOSH 2012b].
Upon arrival at the incident, the designated safety officer should meet with the incident commander to confirm the safety officer assignment and to be integrated into the personnel accountability system. Upon confirmation, the safety officer should obtain the following information: • Overall situation status and resource status. • Incident action plan. • Identification of known hazards and concerns plus the establishment of control zones especially collapse zone(s). • Status and location of rapid intervention crews.
Additionally, the safety officer should: • Ensure the establishment of the rehabilitation group. • Confirm that radio communication channels have been established (command channel, tactical channels) [NFPA 2014a, 2015a; NIMSC 2008].
Page 50 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Based upon the size and complexity of the incident, such as a commercial structure with accessibility problems, the incident commander should consider the appointment of assistant safety officers. Types of incidents that might require expansion of the safety officer role include the following: • Incidents covering a large geographical area (e.g., commercial structure fire) that include numerous divisions or groups. • Incidents where significant acute or chronic responder health concerns require coordination and input to the Planning Section (responsible for accounting for the organizational structure, availability of resources, deployment of resources, and the situation status reports). • Incidents requiring interface with local, state, federal, or other health and safety representatives. • Multi-agency incidents where Unified Command is established. • Incidents where Area Command is established [FIRESCOPE 2012; NFPA 2015a; NIMSC 2008; NIOSH 2012b].
Assistant safety officers assigned to branches, divisions, or groups can be addressed according to their area of responsibility. For example, an assistant safety officer assigned to Alpha Division can be addressed as "Alpha Division assistant safety officer." The assistant safety officers assigned to divisions or groups report to and follow direction from the safety officer who is part of the command staff. The assistant safety officer works with the supervisory person in the assigned division or group to ensure safety conditions are being met [FIRESCOPE 2012; NFPA 2015a; NIMSC 2008; NIOSH 2012c].
At this incident, the incident commander requested the response of the safety officer at 0120 hours. The shift commander was off duty. He heard the Mayday and responded to the scene. He arrived as the fire fighter from Quint 25 was prepared for transport in Medic 22. Upon arrival, he functioned as the safety officer.
Recommendation #12: Fire departments need to ensure that members who function as acting officers have the necessary training and competencies.
Discussion: NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, Chapter 5, “Training, Education and Professional Development,” states in paragraph 5.1.9, “As a duty function, members shall be responsible to maintain proficiency in their skills and knowledge and to avail themselves of the professional development provided to members through department training and education programs” [NFPA 2013a]. Fire departments should develop and implement a written training program that ensures members are trained and competencies are maintained in order to effectively, efficiently, and safely execute all responsibilities [NFPA 2000]. This is consistent with the organizational statement for the fire department, which establishes the existence of the fire department, the services the fire department is authorized and expected to perform, and the organizational structure.
An important component of the training program is to ensure that fire fighters and fire officers who function in acting positions receive the proper education, training, and competencies. Fire departments need to prepare fire fighters and fire officers through the same education and training programs used
Page 51 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio for members who are promoted to these positions. NFPA 1021, Standard for Fire Officer Professional Qualifications serves as the foundation to ensure that fire fighters and fire officers possess the knowledge, skills, and abilities to perform in various positions as fire officers [NFPA 2014c]. The intent of this standard is to provide clear and concise job performance requirements, which are used for evaluation and certification [NFPA 2014c].
One of the best methods for ensuring the competency of members functioning in acting positions is the use of a training and education program coupled with position task book. This system is one in which the primary criteria for qualification is individual performance as observed by an evaluator using approved standards. The position task books are the primary tool for observing and evaluating performance. The position task book contain the “approved standards” in the form of tasks, which have been established by experts from various fire agencies and organizations. After members complete the necessary education and training programs as defined and provided by the fire department, a member is given a task book to be completed. The task book lists the performance requirements (tasks) for a specific position in a format that allows the member to be evaluated against written procedures and policies. Successful completion of all tasks, as observed and recorded by evaluators, will result in a recommendation that member be issued certification [SMFD 2006].
Position task books are designed with a specific focus on a particular position. Therefore, they contain a more narrow set of skills and knowledge than may be necessary to be successful in that position. As a result, each position task book includes a presumption that the member has the requisite knowledge of the position subordinate to the position task book being initiated. For example, the member who initiates a Lieutenant Task Book must have the knowledge, skills, and abilities contained in the Fire Fighter Position Task Book in order for successful completion of Lieutenant Position tasks [SMFD 2006].
In order for a fire fighter or fire officer to become certified at a specific level, the member should successfully complete the job performance requirements in sequence. Before a job performance evaluation can be taken, all requisite knowledge and skills must be satisfied. The job performance requirements covered in the position task book should meet or exceed all NFPA published standards for the particular certification level at the time of completion.
At this incident, the fire department did not have a program in place to certify fire fighters and fire officers as acting officers. Fire fighters and fire officers who are detailed to acting positions must be adequately prepared to function in these various positions. Fire departments should develop a training and education program, coupled with the position task book program, to ensure fire fighters and fire officers have the necessary knowledge, skills, abilities, and competencies to function as acting officers.
Page 52 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Recommendation #13: Fire departments should ensure that all members engaged in emergency operations receive annual proficiency training and evaluation on fireground operations.
Discussion: In order to ensure for the proficiency and competency of fire department members, the fire department should conduct annual skills evaluations to verify minimum professional qualifications. This annual evaluation should address the qualifications specific to the member’s assignment and job description. This process should be structured in a manner where skills are evaluated on a recurring cycle with the goal of preventing the degradation of skills and abilities and ensuring for the safety of members. Proficiency evaluation and training provides an opportunity to ensure that all fire officers and fire fighters are competent in the knowledge, skills, and abilities of fireground operations. NFPA 1500, Standard on Fire Department Occupational Safety and Health Program requires a fire department to establish and maintain a training, education, and professional development program with the goal of preventing occupational deaths, injuries, and illnesses. This ensures members are trained and competencies are maintained in order to effectively, efficiently, and safely execute all responsibilities [NFPA 2013a].
This process is consistent with the organizational statement that establishes the existence of the fire department. The services the fire department is authorized and expected to perform, the organizational structure, and the job descriptions and functions of fire department members are essential in defining a structured training program [NFPA 2013a]. The primary goal of all training, education, and professional development programs is the reduction of occupational injuries, illnesses, and fatalities. As members progress through various job duties and responsibilities, the department should ensure the introduction of necessary knowledge, skills, and abilities to members who are new in their job titles as well as ongoing development of existing skills [NFPA 2013a].
NFPA 1410, Standard on Training for Emergency Scene Operations defines basic evolutions that can be adapted to local conditions and serves as a method for the evaluation of minimum acceptable performance during initial fireground operations [NFPA 2015d]. Proficiency training for fireground operations and emergency incidents should be conducted annually. This training should include, but not be limited to, scene size-up, situational awareness, use of the incident management system, personnel accountability system, strategy and tactics, search and rescue, hoseline operations, ladder operations, ventilation, thermal imaging cameras, fireground communications, use of rapid intervention teams, and Mayday operations.
At the time of this incident, the department was not conducting annual proficiency training for fireground operations.
Recommendation #14: Fire departments should review the standard operating procedure on the use and operations of thermal imagers.
Discussion: Another valuable tool that enhances situational awareness is the thermal imager. The thermal imager provides a technology with potential to enhance fire fighter safety and improve the
Page 53 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio ability to perform tasks such as size-up, search and rescue, fire attack, and ventilation. Thermal imagers should be used in a timely manner. Fire fighters should be properly trained in the use of a thermal imager and be aware of their limitations [NFPA 2015c; NIOSH 2009b; SAFE-IR 2013].
The application of thermal imaging on the fireground may help fire departments accomplish their primary mission, which is saving lives. This mission can be accomplished in many ways. First and foremost, in near-zero visibility conditions, primary searches may be completed quickly and with an added degree of safety. The use of thermal imaging technology may also be invaluable when fire fighters are confronted with larger floor areas or unusual floor plans [SAFE-IR 2013]. Searching for trapped civilians is part of a fire department’s primary mission. Thermal imagers may provide a method for fire fighters to track and locate other fire fighters in very-limited-visibility conditions. This process can enhance fire fighter accountability before an issue arises [SAFE-IR 2013].
Thermal imagers are used in a wide variety of thermal environments. For example, a fire fighter might encounter high temperatures, open flames, pools and sprays of water, and thick smoke; therefore, it is important that thermal imagers are capable of seeing in these obstructive conditions with a minimum amount of interference from the surrounding environment. Fire service thermal imagers are generally designed to detect radiant thermal energy in the 8 μm–14 μm spectral range. This energy is radiated from solid surfaces, particulates, and some gases. A characteristic of the radiating surfaces and gases called emissivity affects how the thermal radiation intensity relates to the actual temperature in a way that can make the surface or gas appear to have a temperature that is different from reality. A surface or gas having an emissivity of 1 is said to be a blackbody, meaning that it absorbs and re-emits all energy incident upon it and thus is representative of its actual temperature. A surface or gas having an emissivity of 0 reflects all energy, making the surface or gas appear colder than it actually is. In general, surfaces that are flat black in color and somewhat rough in texture tend to have high emissivities, and surfaces that are shiny and smooth tend to have low emissivities. Most thermal imagers are designed to use a constant emissivity value of 0.95 to convert the radiant energy signal to a temperature value. The further an object’s emissivity is from 0.95, the less accurate that object’s surface temperature will appear to be. The term apparent temperature is used to account for temperature deviations caused by differences in emissivity [NFPA 2015c].
Thermal imagers typically sense energy radiated from a surface of a solid. If the solid object is a good insulating material such as a wood floor or an insulated wall or ceiling, the apparent temperature might not be representative of the thermal hazard on the other side of the solid object [NFPA 2015c].
In other situations, the fire environment could change, resulting in rapidly increasing smoke temperatures. With a thermal imager looking through smoke at a wall, the apparent temperature could be significantly less than the actual temperature of the gas. In other words, a thermal imager is an unreliable thermometer. It should be used to look for thermal contrasts, movement, and heat signatures. It should not be relied on to determine the temperature of a compartment, through either a digital readout or a color scale [NFPA 2015c].
Page 54 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio While the use of a thermal imager is important, research by Underwriters Laboratories has shown that there are significant limitations in the ability of these devices to detect temperature differences behind structural materials, such as the exterior finish of a building or outside compartment linings (i.e., walls, ceilings, and floors) [NIOSH 2009b]. The most common misconception about temperature measurement is that it estimates air temperatures. Thermal imagers do not read air temperature. Thermal imagers read surface temperature. Thermal imagers operate solely based on differences in surface temperatures. Although occasionally a thermal imager may show superheated or cryogenic gases, in general, thermal imagers do not "see" or measure gases. Fire fighters should not be lulled into a mistaken sense of security because the temperature measurement on the thermal imager seems relatively low or has not reached its scale maximum.
At a structure fire, the thermal imager may help identify the location of the fire or the extent of fire involvement prior to fire fighters being deployed into a structure. Knowing the location of the fire may help fire fighters determine the best approach to the fire. The thermal imager may provide additional information for a crew(s) making the fire attack that they would not previously have had due to poor visibility and building construction. Using this information, fire fighters may be able to locate the fire more quickly and should also ensure that the water application is effective. From a ventilation perspective, fire fighters can use the thermal imager to identify areas of heat accumulation, possible ventilation points, and significant building construction features. This helps ensure proper and effective ventilation that successfully removes smoke and heat from a building [SAFE-IR 2013].
At this incident, Engine 24A used the thermal imager to check the basement after the collapse while operating from the foyer. The thermal imager “whited” out when pointed at the basement. A thermal imager was not used during any other fireground operations.
Recommendation #15: Fire departments should ensure adequate incident scene rehabilitation is established in accordance with NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises.
Discussion: NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises establishes the minimum criteria for developing and implementing a rehabilitation process for fire department members at incident scene operations and training exercises while operating within an incident management system [NFPA 2015b]. The physical and mental condition of personnel should be monitored as part of the overall assessment. This ensures a fire fighter’s health does not deteriorate to the point it affects the safety of other fire fighters or endangers the safety and integrity of the operation. An incident commander should consider the circumstances of each incident and make suitable provisions for rest and rehabilitation for personnel. This process should include medical evaluation and treatment, food and fluid replenishment, and rest and relief from extreme climatic conditions.
NFPA 1584 states that an incident commander should establish rehabilitation operations when emergency operations pose a safety or health risk to fire fighters and other responders. Rehabilitation
Page 55 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio operations should be provided in accordance with fire department SOPs, NFPA 1500, Standard on Fire Department Occupational Safety and Health Program and NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety [NFPA 2013a, 2014a, 2015b].
Incident scene rehabilitation (“Rehab”) is a term often used for the care given to fire fighters and other responders while performing their duties at an emergency scene. When the size of the operation or geographic barriers limit member’s access to the rehabilitation area, the incident commander should establish more than one rehabilitation area. The site should be a sufficient distance from the effects of the operation where members can safely remove their personal protective equipment and can be afforded physical and mental rest [USFA 2008]. Once “Rehab” area(s) have been established, this information must be communicated over the radio so all members know the location of “Rehab” or know where to report when assigned to “Rehab.”
Several considerations for rehabilitation sites are as follows: • Should be in a location that will provide physical rest by allowing the body to recuperate from the demands and hazards of the emergency or training evolution. • Should be far enough away from the scene that personnel may safely remove their turnout gear and SCBA and be afforded physical and mental rest from the stress and pressure of the emergency or training evolution. Provisions should be available to have SCBA cylinders refilled. • Should provide suitable protection from the prevailing environmental conditions. During hot weather it should be in a cool, shaded area, and during cold weather it should be in a warm, dry area. • Should enable personnel to be free of exhaust fumes and noise from apparatus, vehicles, or equipment, including those involved in the rehabilitation group operations. • Should be large enough to accommodate multiple crews based on the size of the incident. • Should be easily accessible by emergency medical service units. • Should allow prompt re-entry back into the emergency operation upon complete recuperation. • Crews assigned to rehab will be instructed to turn portable radios off and/or have radio and thermal imager portable batteries recharged or exchanged [USFA 2008] (See Diagram 11).
The Rehab Group Supervisor should secure all necessary resources required to adequately staff and supply the rehabilitation area. The supplies should include the following items: • Fluids: water, activity beverage, oral electrolyte solutions, and ice • Food: soup, broth, or stew in hot/cold cups • Medical devices: blood pressure cuffs, stethoscopes, oxygen administration devices, cardiac monitors, intravenous solutions, and thermometers • Other: awnings, fans, tarps, fans, heaters, dry clothing, extra equipment, floodlights, blankets and towels, traffic cones, and fire line tape (to identify the entrance and exit of the rehabilitation area) • Hygiene facilities to decontaminate all exposed skin surfaces • Restroom facilities [USFA 2008].
Page 56 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio
Diagram 11. An example of how a “Rehab” area can be organized. There are many ways to establish an effective “Rehab” area.
At this incident, no formal rehab process was established. It is essential at any incident to have rehab established. At this incident, the weather conditions required the ability to get fire fighters out of the environment, provide medical monitoring, and provide rest. Add the mental stress of this incident; this supports the need for a formal rehab process during fireground operations that would continue into the investigation phase.
Recommendation #16: Fire departments should consider upgrading SCBA to the current edition of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services.
Discussion: Fire departments should develop a plan for the replacement or upgrades to their SCBA for two reasons: when SCBA reaches the end of its service life and new requirements and technology improvements are made to NFPA 1981.
NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services underwent significant revisions in the 2013 edition. Key revisions included a new radiant heat panel test for the facepiece and increased heat and flame requirements for the SCBA harness and components [NFPA 2013b].
Other significant improvements to the 2013 edition of NFPA 1981 included testing for emergency breathing safety systems (EBSS) or buddy breather connections, enhanced communication testing
Page 57 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio (electronic and mechanical), and additional testing for electronic accessories such as integrated PASS alarms and other electronic components. A significant change was in the end-of-service-time indicator (EOSTI) that increased the emergency reserve air from 25% +/- 2% to 33% to give fire fighters more emergency reserve air [NFPA 2013b].
Additionally, with each new SCBA standard, most manufacturers offer upgrade kits to existing SCBA to take advantage of some of these benefits.
The integrated PASS devices on SCBA were significantly improved in the 2007 edition of NFPA 1982, Standard on Personal Alert Safety System (PASS), which included enhanced heat and moisture protection and sound levels [NFPA 2013c]. Additionally, some of the changes in the 2007 edition of NFPA 1982 include the following: • New testing requirement where the PASS is exposed to 350°F for 15 minutes and then submerged in 1.5 meters (4.9 feet) of water, also for 15 minutes, for each of six cycles. The PASS is then examined to determine no water ingress. • All PASS signals must function properly, and electronic data logging functions must operate properly. Following this, the PASS is re-immersed in the test water for an additional 5 minutes with the power source compartment(s) open. • After 5 minutes, the PASS is removed from the water and wiped dry, and then the electronics compartment is opened and examined to determine no water ingress. • Revised high-temperature resistance requirements, added new high-temperature functional requirements, and testing procedures where the PASS is mounted in a circulating hot-air oven at 500°F for 5 minutes. • The PASS alarm signal must function at or above the required 95-dBA sound level, electronic data logging functions must operate properly, and no part of the PASS can show evidence of melting, dripping, or igniting. • New tumble-vibration requirements and testing in which the PASS is "tumbled" in a rotating drum for 3 hours. The PASS alarm signal must function at the required 95-dBA sound level, and electronic data logging functions must operate properly. • New "muffling" of the alarm signal requirements and testing in which the PASS is mounted on a test subject and evaluated in five positions (face down with arms extended, supine left, supine right, fetal right with knees drawn to chest, fetal left with knees drawn to chest), and the alarm signal must function at or above the required 95-dBA sound level at 3 meters. • Data-logging (time stamping the power on, pre-alarm, alarm, and reset functions) is to be a new requirement for all PASS devices in the 2013 edition of NFPA 1982 [NFPA 2013c].
Fire departments should contact their PASS device manufacturers and ask if there are any reported problems with the devices and what upgrades they may be offering, if any, that can be made to allow current devices to meet the most current edition of NFPA 1982.
The SCBA involved in this incident was a Survivair Panther 30-minute, 4500 psi with NIOSH Approval Number TC-SU-5134-310, certified to 2002 edition of NFPA 1981, Standard Open-Circuit
Page 58 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Self-Contained Breathing Apparatus (SCBA) for Emergency Services. This SCBA was evaluated and tested by the National Personal Protective Testing Laboratory at the NIOSH facility in Morgantown, West Virginia. The SCBA passed all NIOSH certification tests and the NFPA airflow performance test. This SCBA was equipped with a heads-up-display (HUD) mounted on the second-stage regulator.
The NIOSH investigation team believes fire departments should consider upgrading SCBA to the latest edition of NFPA 1981 based upon the significant improvements including the heat and flame tests [NFPA 2013b].
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Investigator Information This incident was investigated by Murrey E. Loflin, an investigator with the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, West Virginia and Dr. Tom Hales (MD, MPH) Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS) in Cincinnati, Ohio. An expert technical review was provided by Robert Callahan, Deputy Fire Chief, District of Columbia Fire and EMS. Also, an expert review was provided by Dan Madrzykowski, Research Engineer with the UL Fire Safety Research Institute and Stephen Kerber, Director of the UL Fire Safety Research Institute. The NFPA Division of Public Fire Protection also provided a technical review of this report.
Additional Information Modern Fire Behavior This site is meant to serve as a clearinghouse of news and training information related to modern fire behavior and modern building construction research, tactics, and practices, along with actual street experiences. http://modernfirebehavior.com/
National Institute for Standards and Technology (NIST) and Underwriters Laboratories (UL) These two agencies provide information including training videos showing the findings from NIST and UL research conducted in cooperation with the Fire Department of New York on Governor’s Island in 2012. http://www.firecompanies.com/modernfirebehavior/governorsislandonlinecourse/story.html. Flashover TV, sponsored by FireRescue.com, includes a series of training presentations by NIST researcher Dan Madrzykowski. http://flashovertv.firerescue1.com/videos/1875870-nist-and-ul- research-on-fire-dynamic-case-studies-part-4/. Information on completed fire-fighting research studies is available at the NIST website at http://www.nist.gov/el/fire_research/firetech/index.cfm. The information on completed fire-fighting research studies is available at the UL Firefighter Safety Research Institute website at www.ULfirefightersafety.com.
Page 63 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio International Association of Fire Fighters (IAFF) Fire Ground Survival Program The purpose of the IAFF Fire Ground Survival Program is to ensure that training for Mayday prevention and Mayday operations are consistent between all fire fighters, company officers, and chief officers. Fire fighters must be trained to perform potentially life-saving actions if they become lost, disoriented, injured, low on air, or trapped. Funded by the IAFF and assisted by a grant from the U.S. Department of Homeland Security through the Assistance to Firefighters (FIRE Act) grant program, this comprehensive fireground survival training program applies the lessons learned from fire fighter fatality investigations conducted by the National Institute for Occupational Safety and Health (NIOSH) and has been developed by a committee of subject matter experts from the IAFF, the International Association of Fire Chiefs (IAFC), and NIOSH. http://www.iaff.org/HS/FGS/FGSIndex.htm.
NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety (2014 edition) The primary focus of the revision to NFPA 1561 in the 2014 edition is to develop requirements directly aimed at reducing and eliminating fireground injuries and fireground deaths of fire department members. The most apparent change to this edition is the inclusion of “Command Safety” in the document title and the creation of a new chapter, “Command Safety.” This chapter is intended to provide a foundation on how to incorporate the incident management system at all emergency incidents, especially Type V and Type IV incidents.
The chapter on Command Safety clearly defines the requirements for the incident commander to meet, including establishing a fixed command post, personnel accountability, the use of staff aides, rapid intervention crews, the appointment of a safety officer and assistant safety officer(s)(as needed), plus the expectations and authority of the safety officer. Annexes cover Functional Assignments for High- Rise Building Incidents, Development of Subordinate Officers or Implementing a More Efficient Management System, Incident Management for the Fire Service on Type 5 or Type 4 Incidents, and Structural Fire-Fighting—Risk Assessment and Operational Expectation.
NFPA 1561, Standard on Emergency Services Incident Management System and Command Safety (2014 edition) can be purchased from the National Fire Protection Association at http://www.nfpa.org.
Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced in this document were accessible as of the publication date.
Page 64 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Appendix One Summary of Personal Protective Equipment Evaluation Status Investigation Report of one Self-Contained Breathing Apparatus Submitted by the NIOSH Division of Safety Research for the Fire Department
NIOSH Task Number 20731 (Note: Full report is available upon request)
Background As part of the National Institute for Occupational Safety and Health (NIOSH), Fire Fighter Fatality Investigation and Prevention Program (FFFIPP), the National Personal Protective Technology Laboratory (NPPTL) agreed to examine and evaluate a self-contained breathing apparatus (SCBA) unit identified as a Survivair Panther 30-minute, 4500 psi unit.
This SCBA status investigation was assigned NIOSH Task Number 20731. The NIOSH Division of Safety Research (NIOSH DSR) and the Fire Department were advised that NIOSH NPPTL would provide a written report of the inspection and any applicable test results.
The SCBA unit was delivered, in a cardboard box, to the NIOSH facility in Morgantown, West Virginia on January 13, 2016. The SCBA unit was taken to the H building and locked in the evidence cage located in laboratory 1513 until the inspection was conducted on March 3, 2016. The unit was placed back into the locked evidence cage until the testing evaluations on May 3, 2016.
SCBA Inspection The unit was removed from the packaging in the Testing Lab 1513 and inspected on March 3, 2016 by Jay Tarley, Karis Kline, and Jeremy Gouzd. The SCBA was identified as a Survivair Panther 30 minute, 4500 psi with NIOSH Approval Number TC-SU-5134-310 and the unit submitted by the Fire Department. The SCBA unit was extensively examined, component by component, in the condition received to determine how well the SCBA conformed to the NIOSH-approved configuration. The visual inspection process was documented photographically. Once all the inspections were completed, the SCBA unit was repackaged and placed back in the evidence cage in laboratory 1513.
SCBA Testing The purpose of the testing was to determine how well the SCBA conformed to the approval performance requirements of Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). Further testing was conducted to provide an indication of the SCBA’s conformance to the National Fire
Page 65 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 2013 Edition.
NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 CFR 84):
1. Positive Pressure Test [§ 84.70(a)(2)(ii)] 2. Rated Service Time Test (duration) [§ 84.95] 3. Static Pressure Test [§ 84.91(d)] 4. Gas Flow Test [§ 84.93] 5. Exhalation Resistance Test [§ 84.91(c)] 6. Remaining Service Life Indicator Test (low air alarm) [§ 84.83(f)]
National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 2013 Edition):
7. Air Flow Performance Test [Chapter 7, 7-1.1]
Summary and Conclusions One SCBA unit was submitted to NIOSH NPPTL by NIOSH DSR for the Fire Department for evaluation and testing. The SCBA unit was delivered to NIOSH in one shipment on January 13, 2016 and extensively inspected on March 3, 2016. The unit was identified as a Survivair Panther model, 4500 psi 30 minute SCBA with NIOSH Approval Number TC-SU-5134-310. After inspection, the unit was deemed testable, having suffered only slight damage from the incident on December 28, 2015.
The corresponding cylinder was also found to be in testable condition, however, it was missing a date for hydrostatic testing. Under the applicable U.S. Department of Transportation (DOT) exemption, the air cylinder is required to be hydro tested every five years. For the air cylinder on this unit, the hydro date was not found, therefore, a hydrostatic test would need to take place before it would be deemed safe to test this unit. The cylinder with the unit had some scratches and dirt present. The cylinder was open and it was empty. This unit passed the NIOSH tests and NFPA airflow test.
The unit did come with a corresponding facepiece. The overall condition of the unit and facepiece was fair to good with some dirt and debris. There was visible heat damage to the straps on the unit. In light of the information obtained during this investigation, NIOSH has proposed no further action on its part at this time. The SCBA unit has been returned to Fire Department.
If this unit is to be placed back in service, the SCBA must be repaired, tested, cleaned, and any damaged components replaced and inspected by a qualified service technician, including such testing and other maintenance activities as prescribed by the schedule from the SCBA manufacturer. Typically, a flow test is required on at least an annual basis, at a minimum.
Page 66 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Appendix Two Incident Action Plan
Page 67 Report # F2015-19 Fire Fighter Falls Through Floor and Dies at Residential Structure Fire—Ohio Appendix Three Incident Commander’s Tactical Worksheet for Mayday
Page 68 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut dead upon arrival. The Engine 16 lieutenant sustained injuries but was treated and released. The Tactical Unit 1 fire fighter who had fallen out the window remained in the hospital for 23 days.
Contributing Factors • Fireground tactics • Crew integrity • Personnel accountability • Air management • Mayday procedures • Fireground communications • Ventilation • Personal protective equipment use • Live fire training • Unsprinklered occupancy Key Recommendations • Fire departments should ensure that risk assessments are conducted prior to initial operations and throughout the incident and that the strategy and tactics match the assessment. • Fire departments should ensure that crew integrity is properly maintained by voice or radio contact when operating in an immediately dangerous to life or health (IDLH) atmosphere. • Fire departments should ensure that fire fighters and officers are properly trained in air management including out-of-air emergencies. • Fire departments should use a personnel accountability system that accounts for all resources assigned to an incident. • Fire departments should ensure that incident commanders incorporate the principles of command safety into the incident management system. • Fire departments should ensure fire fighters are properly trained in Mayday procedures. • Fire departments should provide the incident commander with a Mayday tactical checklist for use in the event of a Mayday. The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future. The agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit.
For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page ii 2014 19
January 24, 2017 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut
Introduction On October 7, 2014, a 48-year-old male career fire fighter died while conducting interior operations in a two-story residential apartment. On October 9, 2014, the U.S. Fire Administration notified the National Institute for Occupational Safety and Health (NIOSH) of this incident. On October 14–24, 2014, a general engineer, an occupational safety and health specialist, and an investigator from the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) traveled to Connecticut to investigate this incident. The NIOSH FFFIPP investigators met with members of the career fire department, International Association of Fire Fighters local union, Connecticut State Police, Connecticut Division of Occupational Safety and Health, and the city dispatch center. NIOSH FFFIPP investigators interviewed the incident commander and fire fighters who were on-scene at the time of the incident. The NIOSH FFFIPP investigators visited the incident site, took photographs, and collected and reviewed training records, standard operating procedures, and medical records. The self- contained breathing apparatus (SCBA) from the Engine 16 fire fighter (Engine 16B) and Tactical Unit 1 fire fighter were evaluated by the NIOSH National Personal Protective Technology Laboratory. Fire Department The career fire department involved in this incident serves a city with a population of over 125,000 and has a total area of 17.38 square miles. The fire department employs 395 personnel and averages about 23,053 response calls annually. The fire department is subdivided into two main fields of operation: Emergency Services and Support Services. The Support Services is comprised of the Fire Administration staff and the Employee Assistance Program. Under command of the Support Services Division are the Fire Marshal’s Office, Equipment Maintenance Division, Fire Alarm Communications Technology Division, Fire Training Division, and Special Events Unit.
The Emergency Services Division is comprised of 12 fire stations, which are divided into 2 districts. Each district is commanded by a district chief. Each shift is commanded by a deputy fire chief. The apparatus fleet consists of 11 engines, 5 ladders, 1 tactical unit (Heavy Rescue), and numerous special, support, and reserve units. All front-line apparatus are staffed with a minimum crew of three fire fighters and an officer (captain or lieutenant). The fire department uses the following designations for riding assignments on the fire apparatus: Officer is “A,” right jumpseat is “B,” left jumpseat is “C,” and the engineer operator is “D.”
Emergency medical service is provided by two separate ambulance companies. Each ambulance company is assigned a response area within one of the two districts in the city.
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Training and Experience The fire department involved in this incident requires potential candidates for employment as a fire fighter to have a high school diploma or GED and a valid state driver’s license and to successfully pass a background check and an entry-level civil service test.
Once selected as a candidate, the initial step is to attend the 16-week recruit training program at the department’s fire academy. The curriculum covers all of the National Fire Protection Association's (NFPA) qualifications for NFPA 1001 Standard on Fire Fighter Professional Qualifications. This includes Fire Fighter I, Fire Fighter II, Hazardous Materials Awareness, Hazardous Materials Operations, and emergency medical care [NFPA 2013a].
Upon completion of recruit school, the fire chief assigns the recruit to a station where they become a probationary fire fighter for 1 year. Upon completion of probation, the fire fighter trainee becomes a fire fighter. After 5 years of experience, a fire fighter can take the lieutenant test. A fire fighter can test for an apparatus operator after 3 years in-grade. After being promoted to the lieutenant rank, the officer can test for the next rank of captain, district chief, and deputy chief after 3 years in-grade.
The department’s training academy has a full complement of staff. However, due to budgetary constraints, the staff is not authorized overtime and the facilities are in need of repairs. The training academy has a burn building, but it hasn’t been used for years and is currently condemned. Also, the fire academy adjoins the police academy with an operational firing range. No fire fighter training can take place outside when the firing range is in use due to rounds ricocheting onto the training grounds.
Table 1. Summarizes the documented training of the Engine 16 right jumpseat fire fighter (Engine 16B), the Engine 16 lieutenant (Engine 16A), and the incident commander (District Chief 2).
Fire Fighter Training Courses Years Experience
Fire Fighter B Basic Fire Fighting (Fire Fighter I, Fire Fighter II), 6 (Engine 16B) Introduction to the Incident Command System (IS- 100), ICS for Single Resources and Initial Action Incidents (IS-200), Rail Safety for Emergency Responders, various fire-fighting procedures, and various other administrative and technical courses.
Lieutenant Basic Fire Fighting (Fire Fighter I, Fire Fighter II), 19 (Engine 16A) Pump Operator, Introduction to the Incident Command System (IS-100), ICS for Single Resources and Initial Action Incidents (IS-200), National Incident Management System (NIMS) An
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Introduction (IS-700.a), and various other administrative and technical courses.
District Chief 2 Basic Fire Fighting (Fire Fighter I, Fire Fighter II), 26 (Incident Commander) Introduction to the Incident Command System (IS- 100), ICS for Single Resources and Initial Action Incidents (IS-200), National Incident Management System (NIMS) An Introduction (IS-700.a), and various other administrative and technical courses.
Note: All fire fighters must complete training equivalent to the NFPA 1001 Standard for Fire Fighter Professional Qualifications, Fire Fighter I and Fire Fighter II [NFPA 2013a]. Structure The two-story apartment building was built in 1953 and constructed of a wood frame on a poured concrete basement foundation (see Photos 1–4). The two-story structure consisted of 2,016 square feet of total living space between the two apartments. Each floor consisted of five rooms that included two bedrooms, a living room, a kitchen, and a bathroom. The exterior was covered with vinyl siding, and the pitched roof was covered with asphalt shingles. The structure had a front entrance with two doors: the one on the left opened to an interior stairway to the second floor, and the one on the right to the first-floor apartment. At the top of the stairway was a door with a dead bolt and a second door to the right with a normal entry knob. There was a rear entrance to both floors via a covered porch with stairs to the second floor. The structure had an unoccupied third apartment in the finished basement with an exterior entrance in the rear (Side Charlie) of the structure. The building’s utilities were electric and natural gas heating.
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Photo 1. Side Alpha—street view of the duplex. Engine 16 and Ladder 4 made entry into the building through the left doorway. (NIOSH photo.)
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Photo 2. Side Bravo—street view of the duplex. Origin of fire near the Bravo/Charlie corner on the second floor. (NIOSH photo.)
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Photo 3. Side Charlie of the structure. An unoccupied apartment was in the basement. The entrance to the basement apartment is on the Bravo/Charlie corner. (NIOSH photo.)
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Photo 4. Side Delta of the structure. A rear entrance leads to the first- and second-floor apartments on the Delta/Charlie corner (NIOSH photo.)
Equipment and Personnel On October 7, 2014, the dispatch center transmitted an alarm for a structure fire with smoke showing. The initial units dispatched included Engine 16, Engine 14, Engine 7, Ladder 4, Ladder 3, Tactical Unit 1, and District 2. Upon arrival, Engine 16 advised this was a working fire. This upgraded the alarm to a working-fire dispatch, which added another district chief and two engines. Table 2 identifies the apparatus and staff dispatched on the first-alarm assignment and the working-fire assignment, along with their approximate dispatch times and on-scene arrival times rounded to the nearest minute.
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Table 2. First-alarm and working fire equipment and personnel dispatched.
Resource Designation Staffing Dispatched On-scene (rounded to minute) (rounded to minute) Engine 16 lieutenant, engine 1830 hrs 1832 hrs operator, and 2 fire fighters Ladder 4 lieutenant, engine 1830 hrs 1834 hrs operator, and 2 fire fighters Engine 14 lieutenant, engine 1830 hrs 1834 hrs operator, and 2 fire fighters District Chief 2 district chief and 1830 hrs 1834 hrs (Incident Commander) chief’s aide Ladder 3 lieutenant, engine 1830 hrs 1836 hrs operator, and 2 fire fighters Tactical Unit 1 lieutenant, and 4 fire 1830 hrs 1837 hrs fighters Engine 7 lieutenant, engine 1830 hrs 1838 hrs operator, and 2 fire fighters Engine 5 lieutenant, engine 1832 hrs 1840 hrs operator, and 2 fire fighters District Chief 1 district chief and 1835 hrs 1840 hrs chief’s aide Engine 2 lieutenant, engine 1835 hrs 1840 hrs operator, and 2 fire fighters
Timeline An approximate timeline summarizing the significant events of the incident is listed below. The times are approximate and were obtained by studying available dispatch records, photos, run sheets, witness statements, and fire department records. The times are rounded to the nearest minute. The timeline is not intended, nor should it be used, as a formal record of events.
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• 1830 Hours Engine 16, Engine 14, Engine 7, Tactical Unit 1, Ladder 4, Ladder 3, and District 2 are dispatched to a structure fire with smoke showing.
• 1832 Hours Engine 5 is dispatched as the rapid intervention team (RIT); Engine 16 arrives on-scene and assumes command.
• 1833 Hours District Chief 2 is en route and on the air; Engine 16 reports a 2½-story wood frame with heavy smoke showing. Engine 16 advises this would be a “working fire.”
• 1834 Hours District Chief 2 advises the dispatch center that Engine 16 said this would be a working fire; Ladder 4, Engine 14, and District Chief 2 arrive on-scene.
• 1835 Hours District Chief 1 and Engine 2 are dispatched to a working fire.
• 1836 Hours Ladder 3 arrives on-scene; Engine 14 at hydrant.
• 1837 Hours Tactical Unit 1 arrives on-scene; Engine 14 brings hoseline around to Side Charlie.
• 1838 Hours Engine 7 arrives on-scene. Engine 16 enters the stairwell to second floor with Ladder 4.
• 1839 Hours Engine 5, District Chief 1, and Engine 2 arrive on-scene; District Chief 1 assigned as Safety Officer; Engine 14 and Ladder 3 make entry on second floor rear with a charged 1¾-inch hoseline.
• 1840 Hours Engine 16 makes entry to second-floor apartment with a charged 1¾-inch hoseline.
• 1842 Hours Engine 14 puts water on fire from exterior of Side Charlie.
• 1844 Hours Command requests reports from Engine 16 and Engine 14. Replies are inaudible.
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• 1845 Hours Engine 16 calls a Mayday but is not acknowledged by Command or any other personnel.
• 1846 Hours Command orders evacuation of the structure and requests medic unit.
• 1847 Hours Command requests a status of injuries and a PAR. Ladder 3 requests tone for all companies out of the building.
• 1849 Hours Engine 16A tries to radio Engine 16B; Engine 14 has PAR.
• 1850 Hours Engine 16A tries to radio Engine 16B; Engine 7 charges their hoseline on Side Bravo.
• 1851 Hours Engine 16A tries to radio Engine 16B.
• 1852 Hours Command requests second alarm.
• 1853 Hours Command orders Ladder 4 to open up the roof. Command contacts Engine 16A, who is changing his SCBA cylinder, and asks where Engine 16B is located. Engine 16A states they are on the second floor in the room on the right; Command activates the RIT (Engine 5 and Tactical Unit 1).
• 1854 Hours Engine 5 hears PASS device going off to the right and locates Engine 16B.
• 1855 Hours RIT crew moves Engine 16B down the stairway.
• 1857 Hours Engine 7 knocks down the fire in the Bravo/Charlie corner, second-floor bedroom.
• 1900 Hours Medic unit en route to hospital.
• 1909 Hours Engine 2 and Ladder 5 crews complete the extinguishment of the fire on the second floor.
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Personal Protective Equipment The Engine 16B fire fighter was wearing a work station uniform, turnout coat and pants, gloves, boots, helmet, self-contained breathing apparatus (SCBA) with an integrated personal alert safety system (PASS), and a portable radio.
Engine 16B’s and Tactical Unit 1’s SCBAs were evaluated by the NIOSH National Personal Protective Technology Laboratory and a summary report is enclosed as Appendix I. The evaluation showed that Engine 16B’s SCBA failed the Remaining Service Life Indicator Test, in which the secondary bell failed to operate within the parameters but passed all other NIOSH tests. Tactical Unit 1’s SCBA did not meet the requirements for the 30-minute minimum duration test but passed all other NIOSH tests. The full report is available upon request. Weather Conditions According to data from the Weather Underground, the sky conditions were clear with 10-mile visibility. The temperature was 92 degrees F. Dew point was 73 degrees F. Relative humidity was 78%. Wind speed was 8.1 miles per hour and wind direction was south. Barometric pressure was 29.99 [NOAA 2015]. Investigation On October 7, 2014, a 48-year-old male career fire fighter died while conducting interior operations in a two-story residential apartment. At 1830 hours, Engine 16, Engine 14, Engine 7, Ladder 4, Ladder 3, Tactical Unit 1, and District 2 were dispatched to a structure fire with smoke showing. Upon confirmation of a working fire, Engine 5, Engine 2 and District 1 were added to the alarm. The Engine 16 lieutenant (Engine 16A) observed heavy smoke in the air from a block and half away. Engine 16 laid into the fire from a hydrant approximately a block and half away from the fire building. A fire fighter (left jump seat) from Engine 16 (Engine 16C) was the hydrant man and made the connection and waited for the order to charge the supply line. Engine 16 pulled past the building to allow space for Ladder 4. A fire fighter from Engine 16 (Engine 16B) pulled a 1¾-inch hoseline while Engine 16A radioed heavy fire was showing on Side Bravo. At approximately 1834 hours, Ladder 4, Engine 14, and the chief from District 2 (District Chief 2) arrived on-scene. District Chief 2 assumed command while Engine 14 laid in from a hydrant two blocks away. Ladder 4 forced the first-floor door to the second-floor apartment. Engine 16A and Engine 16B made entry into the stairwell and started up the stairs to the second-floor apartment. The crew from Ladder 4 went by Engine 16 and went to the top of the stairs. In near zero visibility, Ladder 4 felt a dead bolt on the door at the top of the stairs in front of them but no door knob, then felt a locked door knob on a door to their right, which Ladder 4 forced open. The Engine 14 crew had a back-up 1¾-inch line out front and were redirected by Command to go to the rear (Side Charlie) and make entry up the stairs. The crew from Engine 7 replaced Engine 14 in the front to back up Engine 16. At approximately 1839 hours, Engine 14, with the help of Ladder 3, made entry on the second-floor rear with a charged 1¾-inch hoseline. Engine 5, District Chief 1, and Engine 2 arrived on-scene. Command assigned District Chief 1 as the Safety Officer, Engine 5 as RIT, and Engine 2 as rehab.
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Upon entry, Engine 16A reported the apartment was hot with zero visibility. At approximately 1840 hours, Engine 16A had the line charged and had Engine 16B pencil the ceiling. Ladder 4 also reported the second-floor apartment was hot with zero visibility and began a right-hand search on their knees.
Minutes later, Ladder 3 reported to Command that Engine 14 was hitting the fire from Side Charlie. Engine 16C had gone to the rear with Engine 14. About this time, the Engine 16B’s vibra-alert sounded and the lieutenant told him to exit. Tactical Unit 1 had made entry from the rear stairwell to the second-floor apartment. They passed Ladder 3 and Engine 14 in the kitchen area. Tactical Unit1 began pulling ceiling in the living room looking for fire.
A fire fighter from Ladder 4 vented the picture window on Side Alpha of the second-floor apartment. The Ladder 4 lieutenant reported a rapid increase in heat in the apartment and ordered his crew out. Engine 16A headed for the door but lost contact with Engine 16B. Engine 16A found the hoseline with the nozzle shut off near the door. Due to the extreme heat in the room, Engine 16A opened up the nozzle to cool down the room. Three members of Tactical Unit 1’s crew who were in the living room near the kitchen pulling ceiling, were struck by a hose stream coming from somewhere near Side Alpha of the living room. The crew became separated. One member of Tactical Unit 1 exited out the rear stairwell through the kitchen. The other two fire fighters reported being hit in the face and chest and momentarily became disorientated. One member made it to the kitchen and located the lieutenant and a fire fighter who had also been hit by a hose stream. Engine 14’s hoseline had become loose but they were able to secure it. All the fire fighters who were hit with the hose stream had their helmets knocked off and SCBA facepieces dislodged. An Engine 14 fire fighter became disorientated and confused having been hit twice with the hose stream. He needed assistance exiting the structure.
The third fire fighter from Tactical Unit 1 had taken a direct hit to the face; he lost his helmet, his facepiece was dislodged, and he was knocked down by the hose stream. He stated he was unconscious for a brief period of time. He was unable to locate his helmet and facepiece and stated that his head and eyes were burning from the extreme heat in the apartment. He used his wet gloves to try to cool his head and face. He was unable to locate any fire fighters or use his radio. He ended up at the Side Alpha picture window that Ladder 4 had previously vented. Fire fighters on the ground noticed him at the window and tried to communicate to him that they were getting a ground ladder. At approximately 1846 hours, he lost consciousness and tumbled out the window to the ground. Command ordered everyone out of the structure and requested a medical unit. The EMS crew arrived and he was transported to the hospital. Note: The Tactical Unit 1 member sustained burns to his head, ears, neck, shoulder, and wrist; he was hospitalized in a burn unit for approximately 23 days.
Engine 16A continued the search for Engine 16B until his vibra-alert activated. Engine 16A stated that he called a Mayday, but it was not acknowledged; he also tried to radio Engine 16B. Engine 16A crawled out of the apartment with no air left in his cylinder and exited the structure. Upon his exit, Engine 16A had noticed that a fire fighter was being attended to on the ground on Side Alpha. On several occasions, Command tried to contact Engine 16A with no response. For several minutes, the lieutenant tried to locate Engine 16B with no success. At approximately 1856 hours, the lieutenant
Page 12 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut notified Command that he couldn’t find his fire fighter. Immediately, Command tried to radio Engine 16B but got no response.
At approximately 1858 hours, Command activated the rapid intervention crew, which sent Engine 5 and Tactical Unit 1 into the apartment. Engine 5 made entry into the second-floor apartment. The Engine 5 officer looked at his thermal imager and the screen was white, but he heard a PASS alarm going off to the right of the door. Engine 16B was found lying on his right side near the door. The crew grabbed Engine 16B but he appeared to be caught on something. Engine 16B’s lower right leg and foot were entangled in a piece of wrought iron furniture (see Diagram 1). The RIC crew untangled him and carried him down the stairs to EMS waiting outside. Engine 16B’s SCBA was intact and properly donned on his face but the air cylinder was empty. At approximately 1900 hours, EMS started CPR on Engine 16B. Engine 16B was transported to the hospital but pronounced dead upon arrival. Engine 16B did not appear to have sustained any burns or other life-threatening injuries.
At approximately 1909 hours, Engine 2 and Ladder 5 crews knocked down the fire in the bedroom on the Bravo/Charlie corner.
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Approximate location of where E16B Fire Fighter was found.
Diagram. Floor plan of second floor, path of attack crews, and location of fire fighters found. (Diagram courtesy of the fire department.)
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Fire Behavior The origin and cause of the fire is still under investigation by the Connecticut State Police’s Fire and Explosion Investigation Unit. By all accounts, the fire originated on the second floor, in the bedroom on the Bravo/Charlie corner of the fire structure.
Indicators of significant fire behavior • Smoke on Bravo/Charlie corner upon arrival • Fire showing on Side Bravo • Heat and heavy, black smoke throughout the second floor • Fire self-vents out two windows on Bravo/Charlie corner and extended up the exterior wall • Heavy fire at Bravo/Charlie corner on second floor and attic • No vertical ventilation at this time • Heat and heavy, black smoke continue to fill second floor • Side Alpha window removed, creating a flow path for the fire • Fire knocked down approximately 41 minutes after arrival Contributing Factors Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following items as key contributing factors in this incident that led to the fatalities: • Fireground tactics • Crew integrity • Personnel accountability • Air management • Mayday procedures • Fireground communications • Ventilation • Personal protective equipment use • Live fire training • Unsprinklered occupancy Cause of Death According to the chief medical examiner’s report, the cause of death of the fire fighter was lack of breathing gas. The report listed cardiac hypertrophy as a contributing factor.
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Recommendations Recommendation #1: Fire departments should ensure that risk assessments are conducted prior to initial operations and throughout the incident and that the strategy and tactics match the assessment. Discussion: Occupancies define the space inside the class of building. Construction types/classes of construction define how the building is constructed with either combustible or noncombustible materials. Occupancies exist inside the constructed building. Standard operation procedures (SOPs) must consider numerous factors that affect fire-fighting operations. This will ensure essential strategic-, tactical-, and task-level functions are performed by the incident commander, division/group supervisors, and fire fighters. Additionally, this process compliments the defined knowledge, skills, abilities, competencies, and fireground experience to assist: • The incident commander to plan and implement an effective strategy and incident action plan [NFPA 2014]. • Division/group supervisors to formulate and follow tactics. • Company officers to successfully carry out assigned tasks. • The individual members to effectively perform their duties [ULFSRI and FirefightersCloseCall.com, no date].
At any incident, life safety is always the first priority, followed by incident stabilization and then property conservation. Ensuring the safety of fire fighters is a continuous process throughout the incident. A sound risk management plan ensures that the risks are evaluated and matched with actions and conditions. The following risk management principles should be utilized by the incident commander: • Activities that present a significant risk to the safety of fire fighters should be limited to situations that have the potential to save endangered lives. • Activities that are routinely employed to protect property should be recognized as inherent risks to the safety of fire fighters, and actions should be taken to reduce or avoid these risks. • No risk to the safety of fire fighters should be acceptable where there is no possibility to save lives or property [Brunacini 2002].
The strategy and tactics of an incident are dictated by the size-up, initial risk assessment, and situational report by the first arriving officer. The priority is to get a fire department unit to the rear of the structure (Side Charlie). However, unless an obvious life safety issue exists (e.g., visible victims requiring immediate assistance), interior fire-fighting operations should not commence until a report from Side Charlie is received. If physical barriers make the 360-degree size-up impractical for the first arriving officer, the size-up of Side Bravo, Side Charlie, and Side Delta may be delegated to another engine company on the first alarm. Even if a 360-degree size-up can be conducted, the second-due engine company or third-due engine company and the second-due truck company should be assigned to Side Charlie.
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A radio report of conditions, including those on Side Charlie, should be transmitted over the assigned tactical channel to the incident commander and the dispatch center. The transmission should include the following: • Smoke and fire conditions, with an emphasis on identifying the seat of the fire. The initial radio report from the first arriving unit for a structural fire should include the signal for a working fire, the number of stories, type of occupancy, and location of fire. This lays the foundation for additional reports and serves as notification to responding units as to the type of SOP to implement. • If there were critical building description information through the critical incident dispatch system (CIDS) for the address, then this information would aid in implementing or adjusting SOPs. CIDS could contain information that would necessitate alternative action to fulfill operational goals. • Building features—e.g., number of stories (particularly if there is a difference between Sides Alpha and Charlie. • Basement access and type. • Other life or safety hazards.
The incident commander must conduct an initial and ongoing situational assessment of the incident [NFPA 2014]. Any change to operational priorities or responsibilities based on the above size-up should be clearly communicated to Command, all responding units, and the dispatch center via the assigned tactical radio channel [Township of Spring Fire Rescue 2013; ULFSRI and FirefightersCloseCall.com, no date]. Command is then obligated to re-broadcast and receive acknowledgement from all operating companies.
Stretching and operating hoselines is the primary function of an engine company. All members must realize the importance of an initial charged hoseline stretched at a structural fire. The majority of structural fires are controlled and extinguished by this initial line. The first line is placed between the fire and any persons endangered by it. This is accomplished by stretching the hoseline via the primary means of egress, usually the main stairway. This tactic: • Provides a base for confining and controlling the fire. • Allows occupants to evacuate via the stairs. • Allows fire fighters to proceed above the fire for search operations [FDNY 2013].
In most cases, the first line is stretched via the interior stairs to the location of the fire. The purpose of this line is to protect the primary means of egress for occupants evacuating the building and to confine and extinguish the fire. Prior to opening the door to the fire area for advancement of the line, the engine company officer must ensure that no fire fighters will be exposed in the hallway or on the stairs above as the fire attack is initiated. This can be done via portable radio or in person [FDNY 2013].
When the fire attack is being initiated, the engine company officer shall announce via portable radio to Command that “water is on the fire.” This is a significant incident benchmark being met. If the engine
Page 17 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut company officer can’t get water or there is a delay of getting water on the fire, this must be communicated to Command as well [Brunacini 2002].
All members must be alert to fireground communications concerning hoseline placement and the commencement of fire-fighting operations so that crews can avoid opposing hoselines and getting hit with high-pressure water and debris.
At any fire, there are tasks that need to occur regardless of the occupancy: initial on-scene report upon arrival; initial risk assessment; situational report; water supply; deployment of handlines and back-up handlines; search and rescue, ventilation, and rapid intervention crews; ground and aerial ladder placement; fire attack and extinguishment; and salvage and overhaul. Over the past few years, fire fighters have adopted an acronym that details the steps to take when confronted with a fire: SLICERS. • Size up all scenes. • Locate the fire. • Identify and control the flow path (if possible). • Cool the heated space from a safe location. • Extinguish the fire. • Rescue and Salvage are actions of opportunity that may occur at any time [ULFSRI and FirefightersCloseCall.com, no date].
The “flow path” of a fire is the movement of a fire determined by incoming and outgoing vents for air, since air is what allows a fire to burn. Identifying and controlling the flow path is about knowing where the air comes from and where it’s headed. The importance of identifying and using flow path information cannot be underestimated. The identification of flow path is an item that should find its way into every after-action review. While trying to locate the fire, cooling the heated space from a safe location while ensuring for the safety of the fire fighters is important. Once the fire is under control, the fire can be completely extinguished.
The rescue and salvage operations are self-explanatory—if anything can be saved, save it as long as fire fighters are not placed at risk. These two actions are always active, right from sizing up to extinguishment.
Procedures developed for fireground operations should be flexible enough to allow the change in the incident action plan due to: • Life hazard (must be given first priority). • Problems with water supply and water application. • Volume and extent of fire, requiring large-caliber streams. • Location of the fire, inaccessible for hand-line operations. • Materials involved in the fire and explosion potential compounding the problem. • Exposure problems where further fire spread would be a major concern. • Stability of the structure, which would be dependent on the condition of the structural components of the building and the intensity and duration of the fire [Brunacini 2002].
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At this incident, the exterior fire on the Bravo/Charlie corner was not controlled by knocking down what fire could be reached due to the limited access to that area prior to sending in interior attack crews. The interior attack crews weren’t able to get water on the fire in a timely manner due to several obstacles, and horizontal ventilation took place causing a flow path that affected interior crews. Perhaps a second interior attack crew to back up the first line at the top of the stairs in the door way could have seen Engine 16’s crew and assisted them in evacuating.
Recommendation #2: Fire departments should ensure that crew integrity is properly maintained by voice or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere. Discussion: When an engine company enters a structure, the members must remain in contact by visual (eye-to-eye contact), verbal (radio or face-to-face), or direct (touch) contact. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 8.5.5, states, “Crew members operating in a hazardous area shall be in communication with each other through visual, audible, or physical means or safety guide rope, in order to coordinate their activities,” and 8.5.4 states, “Members operating in hazardous areas at emergency incidents shall operate in crews of two or more” [Gagliano et al. 2008]. Additionally, NFPA 1500, 8.5.6, states, “Crew members shall be in proximity to each other to provide assistance in case of an emergency” [NFPA 2013c].
The International Association of Fire Chiefs, Safety, Health, and Survival Section has redefined the Rules of Engagement for Structural Firefighting. One of its objectives is to ensure that fire fighters always enter a burning building as a team of two or more members and no fire fighter is allowed to be alone at any time while entering, operating in, or exiting a building. A critical element for fire fighter survival is crew integrity. Crew integrity means fire fighters stay together as a team of two or more. They must enter a structure together and remain together at all times while in the interior, and all members come out together. Crew integrity starts with the company officer ensuring that all members of the company understand their riding assignment, have the proper PPE, and have the proper tools and equipment. Upon arrival at the incident, the company is given a task to perform by the incident commander. The company officer communicates to the members of the company what their assignment is and how they will accomplish their assignment. To ensure that crew integrity is maintained, all the members of a company should enter a hazardous environment together and leave together. If one member has to leave, the whole company leaves [IAFC 2009].
It is the responsibility of every fire fighter to stay connected with crew members at all times. All fire fighters must maintain the unity of command by operating at all times under the direction of the incident commander, division/group supervisor, or their company officer. The ultimate responsibility for crew integrity and ensuring no members get separated or lost rests with the company officer. While operating in a hazard zone they must maintain constant contact with their assigned members by visual observation, voice, or touch. They must ensure they stay together as a company or crew. If any of these elements are not adhered to, crew integrity is lost and fire fighters are placed at risk.
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NFPA 1500, 8.4.4–8.4.6 states: • The incident commander shall maintain an awareness of the location and function of all companies or crews at the scene of the incident. This can be accomplished using a tactical worksheet/accountability board. • Officers assigned the responsibility for a specific tactical-level management component at an incident shall directly supervise and account for the companies and/or crews operating in their specific area of responsibility. • Company officers shall maintain an ongoing awareness of the location and condition of all company members [NFPA 2013c].
If a fire fighter becomes separated and cannot immediately get reconnected with his/her crew, the fire fighter should attempt to communicate via portable radio with the company officer. If the fire fighter and officer do not rejoin after three radio attempts or they are not rejoined within 1 minute, a Mayday should be declared. If conditions are rapidly deteriorating, the Mayday must be declared immediately. As part of a Mayday declaration, the fire fighter must next activate the radio’s emergency alert button (where provided), followed by manually turning on the PASS alarm. Similarly, if the company officer or other company member(s) recognize they have a separated member, they should immediately attempt to locate the member by using their radio or by voice. If contact is not established after three attempts or within 1 minute, a Mayday should be declared immediately [IAFC 2009].
In this incident, the Engine 16 fire fighter (Engine 16B) became separated from his lieutenant after his low-air alarm went off and his lieutenant said to exit. The lieutenant searched and tried to contact his fire fighter. He then called a Mayday that went unheard. Also, the Engine 16 fire fighter (Engine 16C) went to the rear with Engine 14.
Recommendation #3: Fire departments should ensure that fire fighters and officers are properly trained in air management including out-of-air emergencies. Discussion: Chief Bobby Halton, retired chief and editor in chief of Fire Engineering notes: “If you run out of air in a working fire today, you are in mortal danger. There is no good air at the floor anymore, no effective filtering methods, no matter what others may say to the contrary” [Gagliano et al. 2008]. The only protection for fire fighters in the toxic smoke environments in today’s fires is the air that they carry on their backs. Like SCUBA divers, fire fighters must manage their air effectively and leave enough reserve air to exit in case of unforeseen occurrences while inside a structure fire. Fire fighters must manage their air so that they leave the immediately dangerous to life and health (IDLH) atmosphere before the low-air alarm activates. This leaves an adequate emergency air reserve and removes the noise of the low-air alarm from the fireground [Gagliano et al. 2008].
Air management is a program that the fire service can use to ensure that fire fighters have enough breathing air to complete their primary mission and allow enough reserve air for the fire fighter to escape an unforeseen emergency. Fire departments and fire fighters need to recognize that the smoke in modern construction is an IDLH atmosphere and manage their air along with their work periods so the fire fighters exit the IDLH atmosphere with their reserve air intact. NFPA 1404 Standard for Fire
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Service Respiratory Protection Training states that fire fighters should exit from an IDLH atmosphere before the consumption of reserve air supply begins, and a low-air alarm is notification that the individual is consuming the reserve air supply and that immediate action is required by the individual and the fire-fighting team [NFPA 2013b].
Fire fighters and command officers need to recognize and communicate their air status and use air management on the fireground. Air management happens at the individual fire fighter level, the crew level, and the command level. Fire fighters need to ensure their air supply is adequate (full cylinder) at the start of the shift and need to monitor their air usage during an event. They must be able to recognize the 50% HUD light flash and then communicate that information to his/her crew members. Fire fighters need to understand principles of air management, such as the need to exit the IDLH atmosphere before they go into their emergency reserve air and their end-of-service-time indicator (EOSTI) alarms. If they are not out of the IDLH atmosphere and go into their emergency reserve air, they need to immediately communicate with their crew and Command as this can now be considered an emergency. Fire fighters should not wait until their EOSTI alarms or they are out of air to communicate.
Fire-fighting crews need to understand and communicate their air supply status among the crews so they can plan accordingly to notify Command of the need to exit and still have their reserve/emergency air available. One method is to have the first person on a crew who reaches their 50% (flashing yellow light on HUD) notify the crew leader and he/she can then estimate the amount of work period left so they can leave the structure (or IDLH atmosphere) before the person with the least amount of air goes into their emergency reserve air.
Command needs to understand air management at the command level. This means that someone at the command post is monitoring not only accountability of the crews, but how long they have been working (estimating air supply usage) and checking on air status through PAR checks and then rotating crews with enough time to ensure that crews exit the IDLH atmosphere with their emergency reserve air intact.
Too often fire fighters may not pay attention to their air usage and remaining air until they get into their emergency reserve air and their EOSTI sounds or vibrates. This can be due to a number of reasons, including lack of familiarity with a new SCBA (with heads-up display [HUD]) or a different model or a lack of training. Another reason may be the old culture of waiting to take an action based on the old “low-air alarm.” Fire fighters in the past didn’t have HUDs and relied on the “low-air alarm” to warn them of their low air status. It was very difficult if not impossible in some fire-fighting incidents to read the over-the-shoulder gauge. With the addition of HUDs or heads-up displays, fire fighters now have the ability to know their approximate air supply status by reading the lights in their facepiece. The four lights in the facepiece start in the illuminated and green position and then turn off as the air supply decreases. Once the SCBA air supply reaches approximately 50%, the light begins to flash. Some change color to yellow when below 50% then change to red in the EOSTI mode. This is designed to alert the fire fighter to take an action that would ensure they have enough escape time to exit the building with their reserve air intact. Once the air supply reaches the EOSTI level, the SCBA
Page 21 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut will provide another signal (bell, whistle, and/or vibration signal) that alerts the user they are nearing the end of the usable air in the cylinder. On pre-2013 edition SCBAs, this level was approximately 25% (+/-2), but on the 2013 and newer editions SCBAs, this EOSTI level was increased to 33%.
Repetitive skills training with a SCBA is vital for the safety of fire fighters working inside an IDLH atmosphere. SCBA skills training is an ongoing process that should be performed regularly to ensure that fire fighters "know their SCBA." The benefits of repetitive skills training with a SCBA are an increased comfort and competency level, decreased anxiety, lower air consumption, increased awareness of the user's air level (noticing and using the HUD), and an automatic muscle memory response for the vital function controls, such as the don/doff buttons, main air valve, emergency bypass operating valve, and auxiliary air connections (i.e., rapid intervention crew/universal air connection [RIC/UAC] connection and the buddy breather connection). Repetitive skills training also provide the user with an increased ability to operate these functions and controls in a high-anxiety moment or an emergency. Many times, using these skills will be necessary with gloved hands, limited vision, and reduced ability to hear commands from others. Performed in conditions that are non-IDLH, repetitive skills training helps build the fire fighters' muscle memory so their hands will be able to activate the controls with gloves on and the operation will be a conditioned or second-nature response in case of an emergency [NIOSH 2011, 2012].
The first step in overcoming an SCBA out-of-air emergency is complete familiarization with your specific SCBA and your breathing air requirements and usage. Fire fighters need to understand that many SCBA out-of-air emergencies are caused by fire fighters not recognizing the remaining air supply relative to the mission and then another event occurs, such as becoming separated from their crew or hoseline and becoming lost. There are other events that can challenge a fire fighter’s ability to overcome an out-of-air emergency, such as facepiece becoming dislodged, hose entanglement, vomiting in a facepiece, or mechanical issues with the SCBA. A fire fighter’s ability to overcome these events is directly related to their repetitive muscle memory skill, which is only achieved through training and experience with their current SCBA.
One helpful hint for departments to understand is that fire fighters need sufficient “cockpit time” with their particular model SCBA so they can operate in fire environments without undue concentration on their SCBA. If a fire fighter has limited experience with a particular SCBA, whether it is because they are a new fire fighter or an experienced fire fighter with a new SCBA model or manufacturer, they may be concentrating so much on using their SCBA that they miss fire environment signs such as fire growth, smoke behavior, orientation of the room, other crew members actions, and other conditions that require attention. This undue concentration on using the SCBA may even be subtle, and when faced with a condition that needs a trained muscle memory response, such as activating the bypass or checking the cylinder wheel, the fire fighter may not have the automatic response necessary to overcome the initial event. In addition, increased anxiety further complicates the steps to overcome the situation. Many uncontrolled SCBA out-of-air emergencies can be overcome by repetitive skills training.
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In this incident, the fire fighter’s low-air alarm was going off and his officer told him to exit, but he became separated and ran out of air. During the interview process, investigators were informed that cylinders would often be allowed to go down to 3,800 psi before filling to 4,500 psi, since the stations did not have a cascade system to fill them in-house. It is possible that the fire fighter entered the structure with only 84% of his cylinder air. The fire fighter was found with his mask on and out of air. The medical examiner’s cause of death was lack of breathing gas. It is unknown why the fire fighter did not remove his mask and follow the hoseline to the door.
NIOSH investigators have identified air management as a contributing factor on many investigations of fire fighter line-of-duty deaths. Fire departments need to ensure that training on air management occurs at all levels of the command structure [NIOSH 2011, 2012].
Recommendation #4: Fire departments should use a personnel accountability system that accounts for all resources assigned to an incident. Discussion: The personnel accountability system was designed and is operated to ensure that fire fighters do not become lost or missing in the hazard zone. The system tracks fire fighters by location and function. An integral part of the accountability system is to make sure that the fire fighters who are assigned and operating in the hazard zone are accounted for, starting with the initial operations and throughout the entire incident. Also, a process must be in place to periodically check to make sure that all members operating in the hazard zone are accounted for.
A personnel accountability system readily identifies both the location and function of all members operating at an incident scene [Bachrach and Egstrom 1987; Corbin 2000]. The philosophy of the personnel accountability system starts with the same principles of an incident management system— company unity and unity of command. Unity can be fulfilled initially and maintained throughout the incident by documenting the situation status and resource status on a tactical worksheet.
One of the most important functions of command safety is for the incident commander to initiate an accountability system that includes the functional and geographical assignments at the beginning of operations and until the termination of the incident. It is very important for the first on-scene resource to initiate an accountability system. This initial system allows the passing or transfer of information to the next officer who assumes command upon his/her arrival [Bachrach and Egstrom 1987].
A functional personnel accountability system requires the following: • Development and implementation of a departmental standard operating procedure. • Necessary components and hardware. • Training all members on the operation of the system. • Strict enforcement during emergency incidents.
Some methods and tools for resource accountability are: • Tactical worksheets • Command boards
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• Apparatus riding lists • Company responding boards • Electronic bar-coding systems • Accountability tags or keys (e.g., PASSPORT System) [Bachrach and Egstrom 1987]
Resource accountability should be assigned to personnel who are responsible for maintaining the location and status of all assigned resources at an incident. As the incident escalates, resource status would be placed on the implemented accountability system [NFPA 2014]. This function is separate from the role of the incident commander. The incident commander is responsible for the overall command and control of the incident. Due to the importance of responder safety, resource status should be assigned to a dedicated member as the size and complexity of the incident dictates. A number of positions could function in this role including an incident command technician, staff assistant, chief officer, or other designated member. As the incident escalates and tactical-level management components (e.g., divisions or groups) are assigned, the resource status officer (accountability officer) works with the division or group supervisors to maintain on-going tracking and accountability of members [Bastain 2003]. A properly initiated and enforced personnel accountability system enhances fire fighter safety and survival. It is vital that resources can be identified and located in a timely manner.
An important aspect of a personnel accountability system is the personnel accountability report (PAR). A PAR is an organized on-scene roll call in which each supervisor reports the status of their crew when requested by the incident commander [Bachrach and Egstrom 1987]. The PAR should be conducted every 15–20 minutes or when benchmarks are met.
In order for the personnel accountability system to function, it must include a standard operating procedure that defines each function’s responsibility in making this process successful on the fireground. Also a training component—both classroom and practical—should occur to ensure this process operates properly during emergency incidents.
In this incident, accountability was not established until late on the fireground.
Recommendation #5: Fire departments should ensure that incident commanders incorporate the principles of command safety into the incident management system. Discussion: The principles of command safety provide the incident commander with the necessary resources on how to use, follow, and incorporate safety into the incident management system at all incidents. Command safety is used as part of the eight functions of command developed by Fire Chief Alan V. Brunacini (retired). Command safety defines how the incident commander must use the regular, everyday command functions to complete the strategic-level safety responsibilities during incident operations. Using the command functions creates an effective and a close connection between the safety officer and the incident commander. The eight functions of command are: • Assumption/confirmation/positioning • Situation evaluation, which includes risk management
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• Communications • Deployment • Strategy/incident action planning • Organization • Review/revision • Transfer/continuation/termination [Clark 2008; NFPA 2013d]
A major objective of the incident management system is to establish and support an incident commander. The incident commander will direct the geographical and functional needs of the entire incident on the task, tactical, and strategic levels. Issues develop for the incident commander when these three standard levels are not in place, operating, and effectively connected. One of the most important components is to ensure the incident commander operates on the strategic level from the very beginning of the incident and stays on the strategic level as long as fire fighters are operating in an immediately dangerous to life and health (IDLH) environment [Clark 2008; NFPA 2013d]. The incident commander uses the incident management system as the basic foundation for managing the strategic-level safety function. Command safety ensures the highest level of safety for fire department members operating at emergency incidents. The incident commander completes the operational and safety responsibility to the fire fighters by performing the eight command functions. These functions serve as a very practical performance foundation for how the incident commander completes their responsibility as the strategic-level incident manager and the overall incident safety manager [Corbin 2000].
At this incident, several elements of command safety, such as communications, incident action planning, and risk management, needed to be further evaluated and updated.
Recommendation #6: Fire departments should ensure that fire fighters are properly trained in Mayday procedures. Discussion: It is essential to train fire fighters to recognize when they are in trouble, know how to call for help, and understand how incident commanders and others must react to a responder in trouble [Jakubowski and Morton 2001].
One of the most difficult situations a fire fighter can face is when they realize they need to declare a Mayday. Recognizing that they are (or about to be) in a life-threatening situation is the first step in improving the fire fighters’ chances to survive a Mayday event. Many fire departments don’t have a simple procedure for what to say when a fire fighter gets into trouble—i.e., a critical situation where communications must be clear [Jakubowski and Morton 2001]. A Mayday declaration is such an infrequent event in any fire fighter’s career that they need to frequently train in how to recognize the need for a Mayday, how to declare the Mayday, and what steps to take to improve their chances for survival.
Fire fighters must understand that when they are faced with a life-threatening emergency, there is a very narrow window of survivability, and any delay in egress and/or transmission of a Mayday
Page 25 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut message reduces the chance for a successful rescue. Knowledge and skill training on preventing a Mayday situation or how to call a Mayday should be mastered before a fire fighter engages in fireground activities or other immediately dangerous to life and health (IDLH) environments.
Fire fighter training programs should include training on such topics as air management, crew integrity, reading smoke, fire dynamics and behavior, entanglement hazards, building construction, signs of pending structural collapse, and familiarity with a self-contained breathing apparatus (SCBA), a radio, and personal protective equipment (PPE).
A fire fighter's knowledge, skill, and ability to declare a Mayday must be at the mastery level of performance. This performance level should be maintained throughout their career through training offered more frequently then annually [IAFF 2010; Sendelbach 2003].
Fire fighters need to also understand that their PPE and SCBA do not provide unlimited protection. Fire fighters should be trained to stay low when advancing into a fire as extreme temperature differences may occur between the ceiling and floor. When confronted with an emergency situation, the best action to take may be immediate egress from the building or to a place of safe refuge (e.g., behind a closed door in an uninvolved compartment, in a staging area on a lower floor) and manually activating the PASS device. A charged hoseline should always be available for a tactical withdrawal while continuing water application or as a lifeline to be followed to egress the building. Conditions can become untenable in a matter of seconds.
Presently there are no Mayday standards for fire fighters to be trained on, and most states do not have Mayday standards. Mayday rules and training are not included in the job performance requirements in NFPA Fire Fighter 1 or 2 standards. It is up to each authority having jurisdiction to develop rules and performance standards for a fire fighter to call a Mayday. Fire departments should ensure that any personnel who may enter an IDLH environment meet the standards for Mayday competency for the authority having jurisdiction [IAFF 2010; Clark 2008].
The National Fire Academy has two courses addressing the fire fighter Mayday Doctrine, Q133 Firefighter Safety: Calling the Mayday, which is a 2-hour program covering the cognitive and affective learning domain of the fire fighter Mayday Doctrine, and H134 Calling the Mayday: Hands-on Training, which is an 8-hour course that covers the psychomotor learning domain of the fire fighter Mayday Doctrine. These courses are based on the military methodology used to develop and teach fighter pilots ejection doctrine. A training CD is available to fire departments free of charge from the U.S. Fire Administration Publications office [Clark 2005; USFA 2006]. Also, the International Association of Fire Fighters (IAFF) Fire Ground Survival Program is another resource fire departments can use and was developed to ensure that training for Mayday prevention and Mayday operations are consistent between all fire fighters, company officers, and chief officers [IAFF 2010].
Any Mayday communication must contain the location of the fire fighter in as much detail as possible and, at a minimum, should include the division (floor) and quadrant. When in IDLH environments, fire fighters must know their location at all times to effectively be able to give their location in the event of
Page 26 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut a Mayday. Once in distress, fire fighters must immediately declare a Mayday. The following example uses LUNAR (Location, Unit, Name, Assignment/Air, Resources needed) as a prompt: "Mayday, Mayday, Mayday, Division 1 Quadrant C, Engine 71, Smith, search/out of air/vomited, can't find exit." When in trouble, a fire fighter's first action must be to declare the Mayday as accurately as possible. Once the incident commander and rapid intervention team (RIT) know the fire fighter's location, the fire fighter can then try to fix the problem, such as clearing the nose cup, while the RIT is en route for rescue [USFA 2006].
A fire fighter who is breathing carbon monoxide (CO) quickly loses cognitive ability to communicate correctly and can unknowingly move away from an exit, other fire fighters, or safety before becoming unconscious. Without the accurate location of a downed fire fighter, the speed at which the RIT can find them is diminished, and the window of survivability closes quickly because of lack of oxygen and high CO concentrations in an IDLH environment [Clark 2005, 2008].
Fire fighters also need to understand the psychological and physiological effects of the extreme level of stress encountered when they run low on air; become trapped during rapid fire progression; or become lost, disoriented; or injured. Most fire training curricula do not include discussion of the psychological and physiological effects of extreme stress, such as encountered in an imminently life- threatening situation, nor do they address key survival skills necessary for effective response. Understanding the psychology and physiology involved is an essential step in developing appropriate responses to life-threatening situations. Reaction to the extreme stress of a life-threatening situation, such as being trapped, can result in sensory distortions and decreased cognitive processing capability [Grossman and Christensen 2008].
Fire fighters should never hesitate to declare a Mayday. There is a very narrow window of survivability in a burning, highly toxic building. Any delay declaring a Mayday reduces the chance for a successful rescue [Clark 2005]. In the book Stress and Performance in Diving, the author notes that while all training is important, We know that under conditions of stress, particularly when rapid problem-solving is crucial, over-learning responses is essential. The properly trained individual should have learned coping behavior so well that responses become virtually automatic requiring less stop and think performance [Bachrach and Egstrom 1987].
The word Mayday is easily recognizable and is an action word that can start the process of a rescue. The use of other words to declare an emergency situation should be discouraged because it is not as recognizable as an immediate action word that will start a rescue process. During this incident, the fireground radio traffic was busy and many different communications were taking place. A Mayday message transmitted over the radio much earlier in the event may have gotten the attention of command officers and other fire fighters when a rescue attempt might have had a better chance of locating the fire fighter.
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In this incident, the fire fighter never called a Mayday and never activated his emergency button (emergency buttons were inoperable) or PASS device. His officer called a Mayday that went unacknowledged and a second one that was not recorded on the radio transmission log.
Recommendation #7: Fire departments should provide the incident commander with a Mayday tactical checklist for use in the event of a Mayday. Discussion: When a Mayday is transmitted for whatever reason, the incident commander has a very narrow window of opportunity to locate the lost, trapped, or injured member(s). The incident commander must restructure the strategy and incident action plan (tactics) to include a priority rescue [Bachrach and Egstrom 1987].
Some departments have adopted the term LUNAR—location, unit assigned, name, assistance needed, and resources needed—to gain additional information in identifying a fire fighter who is in trouble and in need of assistance. The incident commander, division/group supervisors, company officers, and fire fighters need to understand the seriousness of the situation. It is important to have the available resources on-scene and to have a plan established prior to the Mayday [Bachrach and Egstrom 1987; Corbin 2000].
A checklist is provided in Appendix Two, “Incident Commander’s Tactical Worksheet for Mayday,” which can assist the incident commander in the necessary steps for clearing the Mayday as quickly and safely possible. This checklist serves as a guide and can be tailored to any fire department’s Mayday procedures. The checklist format allows the incident commander to follow a structured worksheet. This process is too important to operate from memory and risk missing a vital step that could jeopardize the outcome of the rescue of a fire fighter.
At this incident, when the Mayday occurred, the incident commander quickly called for additional resources and conducted a personnel accountability report to determine if any companies were lost or missing. Due to the influx of resources, trying to determine the location of companies and identifying crews that were missing, the incident commander was quickly overwhelmed. The intent of this Mayday worksheet, like the tactical worksheet, is to assist the incident commander during a very difficult and stressful time on the fireground operations.
Recommendation #8: Fire departments should develop and implement a fireground communication standard operating procedure that includes a communication protocol and specifies equipment and capacity of the communication system. Discussion: Effective fireground radio communication is an important tool to ensure fireground command and control as well as helping to enhance fire fighter safety and health. The radio system must be dependable, consistent, and functional to ensure that effective communications are maintained especially during emergency incidents. Fire departments should have a “communications” standard operating procedure (SOP) that outlines the communication procedures for fireground operations. Fire departments should ensure that the communications division and communication center are part of this
Page 28 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut process. Another important aspect of this process is an effective education and training program for all members of the department.
Radio frequency usually refers to the radio frequency of the assigned channel. A radio channel is defined as the width of the signal depending on the type of transmissions and the tolerance for the frequency of emission. A radio channel is normally allocated for radio transmission in a specified type of service or by a specified transmitter. Fire departments should ensure that an adequate number of radio channels are available. Multiple radio channels are necessary at large-scale or complex incidents, such as a commercial structure fire, mass-casualty incident, hazardous materials incident, or special operations incident [NFPA 2014; FIRESCOPE 2012]. A fire department should provide the necessary number of radio channels for complex or large-scale incidents needing multiple tactical channels. NFPA 1561 Standard on Emergency Services Incident Management System and Command Safety states in Paragraph 6.1.4, “The communications system shall provide reserve capacity for complex or multiple incidents.” This would require fire departments to preplan radio channel usage for all incident levels based upon the needs of an emergency incident including large-scale or complex incidents [NFPA 2014].
Fire departments should preplan for not only large-scale or complex incidents, but also for the ability to handle daily operations. Standard operating procedures, radio equipment (e.g., mobile radios, portable radios, mobile data terminals, laptop computers), other hardware (e.g., CAD system), and dispatch and communications protocols should be in place to ensure that these additional channels are available when needed [NFPA 2014].
Every fire fighter and company officer should take responsibility to ensure radios are properly used. Ensuring appropriate radio use involves both taking personal responsibility to have your portable radio turned on and to the correct channel. A company officer’s responsibility is to ensure that all members of the crew comply with these requirements. Portable radios should be designed and carried in a position that allows a fire fighter to monitor and transmit a clear message [IAFF 2010; Varone 2003].
A fire department’s SOP on communications should address issues on what to do if your Mayday transmission is not acknowledged, such as activating your emergency button. If there is a complete radio failure, the fire fighter should evacuate the building as a matter of safety. In this incident, a Mayday was not acknowledged and the emergency button was not functionally activated by the fire department.
When a fire department responds to an incident, the incident commander should forecast for the incident to determine if there is potential for being a complex or long-term operation that may require additional resources, including demands on the communications system. As incidents increase in size, the communication system has to keep up with the demands of the incident. The incident commander must be able to communicate with company officers and division/group supervisors [FIRESCOPE 2012]. Before communications become an issue, the incident commander must consider options for alleviating excessive radio traffic. Several options are:
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• Assign non-fireground resources (e.g., Staging, “Rehab”) to a separate tactical channel or talk- group channel. • Designate a “command channel,” which is a radio channel designated by the fire department to provide for communications between the incident commander and the division/group supervisors or branch directors during an emergency incident [NFPA 2014]. • For incidents involving large geographical areas, designate a tactical channel or talk-group for each division.
Communications between the incident commander and tactical-level management units and/or company officers is essential for successful fireground operations. Communication during the fire attack may be difficult at times due to the noise created by the hose stream striking walls, ceilings, and furnishings. However, the engine company officer must monitor the portable radio for critical information that may affect the engine company. This includes ventilation delays, water supply difficulties, collapse potential, and Mayday and/or "urgent" transmissions. The engine company officer can provide the incident commander with vital information that may affect how the fire operation is handled. Messages such as those listed below should be transmitted to the incident commander, other units, or individual members on the scene: • "Start a 1¾-inch line to the second floor." • "Start water." • "We have two rooms knocked down; making progress." • "Main body of fire has been extinguished." • "Increase/decrease pressure." • "We need a back-up line to the second floor" [Brunacini 2002].
In this incident, there were several breakdowns in communication, including transmissions not being understood, a Mayday not acknowledged, and transmissions not getting through.
Recommendation #9: Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational procedures by developing standard operating procedures, conducting live fire training, and revising fireground tactics. Discussion: The National Institute of Standards and Technology (NIST) and Underwriters Laboratories (UL) have conducted a series of live burn experiments designed to replicate conditions in modern homes and residential structures and to validate previous testing done in laboratory settings. The results of these experiments will enable fire fighters to better predict and react to effects of new materials and construction on fire. The fire research experiments were conducted in cooperation with the Fire Department of New York, Chicago Fire Department, Spartanburg, South Carolina Fire and Rescue, and other agencies. The live burn tests were aimed at quantifying emerging theories about how fires are different today, largely due to new building construction and the composition of home furnishings and products. In the past, these products were mainly composed of natural materials, such as wood and cotton, but now contain large quantities of petroleum-based products and synthetic
Page 30 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut materials that burn faster and hotter and generate large volumes of fuel-rich smoke. Where a fire in a room once took approximately 20 minutes to “flashover”—igniting all the contents—this can happen with today’s furnishings in as little as 4 to 5 minutes [NIST 2013; ULFSRI and FirefightersCloseCall.com, no date].
In addition, modern living spaces tend to be more open, less compartmentalized and are better insulated than homes built years ago. As a result, interior residential fires can generate an oxygen- depleted, fuel-rich environment within minutes. This fire condition of hot, fuel-rich smoke is highly reactive to the introduction of oxygen. Introducing oxygen to this environment by opening a door or venting a window may result in a rapid transition to flashover. These same conditions can occur in commercial structures as seen in the Charleston, South Carolina, Sofa Super Store fire [NIOSH 2009a].
The NIST and UL experiments evaluated individual and combinations of methods for strategically ventilating and isolating fires to prevent flashover—or at least delay it. In contrast, kicking a door open or breaking a window without knowledge of conditions inside could create a portal for air that can literally fan the flames by introducing oxygen into an oxygen-limited fire environment.
Traditionally, fire suppression operations were conducted from the interior of the structure as a means of reducing water damage and limiting fire damage to structures. These operations must be coordinated with the ventilation operations. Previous research and examinations of line-of-duty deaths have shown that ventilation events occurring with fire fighters in the structure prior to suppression have led to tragic results [Brunacini 2002; FDNY 2013; NIOSH 2009a]. One means of eliminating the possibilities of this occurrence would be a transitional attack, in which water is directed into the structure from the exterior to cool the fire gases and reduce the heat-release rate of the fire, prior to the fire fighters entering the building. The major concern with this type of operation is the potential harm that might occur to people trapped in the structure or the amount of water damage to the structure [NIST 2013].
Based upon the NIST and UL research, the following fireground operations should be considered for implementation. • Size-Up Size-up must occur at every fire. Consideration must be given to the resources available and situational conditions, such as weather, fire location, size of the fire and building, and the construction features. Ensure a 360-degree size-up is conducted whenever possible. A tactical plan for each fire must be developed, communicated, and implemented. • Ventilation Fire departments should manage and control the openings to the structure to limit fire growth and spread and to control the flow path of inlet air and fire gases during tactical operations. All ventilation must be coordinated with suppression activities. Uncontrolled ventilation allows additional oxygen into the structure, which may result in a rapid increase in the fire development and increased risk to fire fighters due to increased heat release rates within the flow path.
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• Fire-fighting Operations Given the fuel-rich environment that the fire service operates in today, water should be applied to the fire as soon as possible. In many cases, water application through an exterior opening into a fire compartment may be the best first action, prior to committing fire-fighting resources to the interior. Fire departments should cool the interior spaces of a fire building with water from the safest location possible, prior to committing personnel into spaces with, or adjacent to, fully developed or smoldering (ventilation-limited) fire conditions. • Rapid Intervention Fire department rapid intervention procedures should be updated to ensure that during fire fighter Mayday incidents, water is provided on the fire as soon as possible and ventilation openings are controlled [FDNY 2013].
This information is presented to educate the fire service and to ensure that fire departments consider a change in fireground tactics based upon the current research presented by NIST and UL. Much of this research has been directed toward developing a better understanding of the characteristics of the modern fire. This modern research provides members of the fire service with the information and knowledge needed to modify essential fire-fighting tactics. While fire-fighting will never be without risk, this research represents a vital contribution to overall efforts to reduce risks and to save lives.
At this incident, coordinated vertical ventilation was not conducted on the second floor in a timely manner.
Recommendation #10: Fire departments should review standard operating procedures regarding the use and operation of thermal imagers. Discussion: Another valuable tool that enhances situational awareness is the thermal imager. The thermal imager provides a technology with potential to enhance fire fighter safety and improve the ability to perform tasks such as size-up, search and rescue, fire attack, and ventilation. Thermal imagers should be used in a timely manner. Fire fighters should be properly trained in the use of a thermal imager and be aware of their limitations [SAFE-IR 2013; NIOSH 2009b].
The application of thermal imaging on the fireground may help fire departments accomplish their primary mission, which is saving lives. This mission can be accomplished in many ways. First and foremost, in near zero visibility conditions, primary searches may be completed quickly and with an added degree of safety. The use of thermal imaging technology may also be invaluable when fire fighters are confronted with larger floor areas or unusual floor plans [SAFE-IR 2013]. Thermal imagers may provide a method for fire fighters to track and locate other fire fighters in very limited visibility conditions. This can enhance fire fighter accountability before an issue arises [SAFE-IR 2013]. While the use of a thermal imager is important, research by Underwriters Laboratories has shown that there are significant limitations in the ability of these devices to detect temperature differences behind structural materials, such as the exterior finish of a building or outside compartment
Page 32 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut linings (i.e., walls, ceilings, and floors) [NIOSH 2009b]. The most common misconception about temperature measurement using a thermal imager is that it estimates air temperatures. Thermal imagers do not read air temperatures; they read surface temperatures. Although occasionally a thermal imager may show superheated or cryogenic gases, in general, thermal imagers do not "see" or measure gases. Fire fighters should not be lulled into a mistaken sense of security because the temperature measurement on the thermal imager seems relatively low or has not reached its scale maximum [Corbin 2000].
At a structure fire, the thermal imager may help identify the location of the fire or the extent of fire involvement prior to fire fighters being deployed into a structure. Knowing the location of the fire may help fire fighters determine the best approach to the fire. The thermal imager may provide additional information for a crew making the fire attack that they would not previously have had due to poor visibility and building construction features. Using this information, fire fighters may be able to locate the fire more quickly and may also ensure that the water application is effective. From a ventilation perspective, fire fighters can use the thermal imager to identify areas of heat accumulation, possible ventilation points, and significant building construction features. This helps ensure proper and effective ventilation that successfully removes smoke and heat from a building [SAFE-IR 2013; Bastain 2003].
Per department protocol, the first arriving officer provides a temperature reading as they enter the structure as part of the initial size-up. The thermal imager does not provide an accurate assessment of the total room temperature. In all reality, the temperature readings and color variations that a thermal imager provides are best suited to establish differences of an area being entered, rather than the true atmospheric temperature [SAFE-IR 2013; Bastain 2003].
Additional information is provided in Appendix Three. The intent of this recommendation and the appendix material is to ensure that the fire service clearly understands the concept, use, and limitations of thermal imagers.
In this incident, Engine 16’s thermal imager was out of service. Engine 5 did use a thermal imager when they were searching for the missing fire fighter.
Recommendation #11: Fire departments should ensure that proper use of structural fire-fighting protective hoods is enforced. Discussion: NFPA 1500 Standard on Fire Department Occupational Safety and Health Program contains the general recommendations for fire fighter protective clothing and protective equipment [NFPA 2013c]. Chapter 7.1.1 specifies that “the fire department shall provide each member with protective clothing and protective equipment that is designed to provide protection from the hazards to which the member is likely to be exposed and is suitable for the tasks that the member is expected to perform.” Chapter 7.1.2 states, “Protective clothing and protective equipment shall be used whenever the member is exposed or potentially exposed to the hazards for which it is provided.” Chapter 7.2.1 states, “Members who engage in or are exposed to the hazards of structural fire fighting shall be provided with and shall use a protective ensemble that shall meet the applicable requirements of NFPA
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1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting” [NFPA 2013d].
NFPA 1500 Standard on Fire Department Occupational Safety and Health Program states: “The fire department shall provide each member with protective clothing and protective equipment that is designed to provide protection from the hazards to which the member is likely to be exposed and is suitable for the tasks that the member is expected to perform. … Protective clothing and protective equipment shall be used whenever a member is exposed or potentially exposed to the hazards for which the protective clothing (and equipment) is provided” [NFPA 2013c].
NFPA 1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting has established minimum requirements for structural fire-fighting protective ensembles and ensemble elements designed to provide fire-fighting personnel limited protection from thermal, physical, environmental, and bloodborne pathogen hazards encountered during structural fire-fighting operations [NFPA 2013d]. These requirements will assist in protecting fire fighters, but only if they wear the protective ensembles as recommended by the manufacturer.
In this incident, the fire department did not require fire fighters to wear hoods. The fire department has recently changed their policy and now requires fire fighters to wear hoods. A number of fire fighters were hit by a hose stream and had their helmets knocked off. Also, numerous fire fighters were not using their chin straps on their helmets. Proper use of the helmet requires using the chin strap.
Recommendation #12: Municipalities should ensure that an ambulance is dispatched on every working fire. Discussion: History has shown and numerous NIOSH fatality reports have documented how routine fires can change in minutes and cause critical injuries. When this occurs, seconds count and having an ambulance (preferably advance life support capability) on-scene can make a significant difference in the outcome for the patient. When it is confirmed that there is a working fire, an ambulance should be dispatched along with the additional fire service resources as a general practice.
In this incident, ambulance service was provided by two ambulance companies that cover the city by a north and south divider, and an ambulance was not called until it was needed. However, if an ambulance had been present, it is believed that the outcome may not have changed.
Recommendation #13: Municipalities, building owners, and authorities having jurisdiction should consider requiring sprinkler systems be installed in mixed occupancy structures. Discussion: Fire development beyond the incipient stage is one of the greatest hazards that fire fighters are exposed to. This exposure and risk to fire fighters can be dramatically reduced when fires are controlled or extinguished by automatic sprinkler systems. NFPA statistics show that most fires in sprinklered buildings are controlled prior to fire department arrival by the activation of one or two sprinkler heads. The presence of automatic fire sprinklers also reduces the exposure risk to fire fighters in rescue situations by allowing the safe egress of building occupants before the fire department arrives
Page 34 Report # F2014-19 Career Fire Fighter Dies From an Out-of-air Emergency in an Apartment Building Fire—Connecticut on -scene. Finally, by controlling fire development, the exposure to hazards such as building collapse and overhaul operations are greatly reduced, if not eliminated.
In this incident, the structure was not equipped with a sprinkler system. References Bachrach A, Egstrom G [1987]. Stress and performance in diving. San Pedro, CA: Best Publishing.
Bastain J [2003]. Temperature measurement and thermal imaging cameras. Fire Engineering, December, http://www.fireengineering.com/articles/print/volume-156/issue- 12/departments/technology-today/temperature-measurement-and-thermal-imaging-cameras.html.
Brunacini AV [2002]. Fire command. Quincy, MA: National Fire Protection Association.
Clark BA [2005]. 500 Maydays called in rookie school. Firehouse, October, http://www.firehouse.com/article/10498807/500-maydays-called-in-rookie-school.
Clark BA [2008]. Leadership on the line: firefighter Mayday doctrine—where are we now? Firehouse, September, http://www.firehouse.com/podcast/10459336/leadership-on-the-line-firefighter-mayday- doctrine-where-are-we-now.
Corbin DE [2000]. Seeing is believing. Occupational Safety and Health 69(8):60–67.
FDNY [2013]. Taxpayer fires. In: Firefighting procedures. Vol 1. Book 4. New York, NY: Fire Department of New York. http://sageauthoring.com/fdny/construction/tp01.pdf
FIRESCOPE [2012]. Field operations guide. Riverside, CA: FIRESCOPE, ICS 420-1.
Gagliano M, Phillips C, Jose P, Bernocco S [2008]. Air management for the fire service. Tulsa, OK: Penn Well Corporation.
Grossman D, Christensen L [2008]. On combat: the psychology and physiology of deadly conflict in war and peace. 3rd ed. Millstadt, IL: Warrior Science Publications.
IAFC [2009]. Rules of engagement for structural firefighting, increasing firefighter survival. Fairfax, VA: International Association of Fire Chiefs, Safety, Health, and Survival Section.
IAFF [2010]. IAFF Fire Ground Survival Program. Washington, DC: International Association of Fire Fighters, http://www.iaff.org/HS/FGS/FGSIndex.htm.
Jakubowski G, Morton M [2001]. Rapid intervention teams. 1st ed. Stillwater, OK: Fire Protection Publications.
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NFPA [2013a]. NFPA 1001 Standard for fire fighter professional qualifications. Quincy, MA: National Fire Protection Association.
NFPA [2013b]. NFPA 1404 Standard for fire service respiratory protection training. Quincy, MA: National Fire Protection Association.
NFPA [2013c]. NFPA 1500 Standard on a fire department occupational safety and health program. Quincy, MA: National Fire Protection Association.
NFPA [2013d]. NFPA 1971 Standard on protective ensembles for structural fire fighting and proximity fire fighting. Quincy, MA: National Fire Protection Association.
NFPA [2014]. NFPA 1561: Standard on emergency services incident management system and command safety. Quincy, MA: National Fire Protection Association.
NIOSH [2009a]. Career probationary fire fighter and captain die as a result of rapid fire progression in a wind-driven residential structure fire—Texas. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE Report F2009-11, http://www.cdc.gov/niosh/fire/pdfs/face200911.pdf.
NIOSH [2009b]. Preventing deaths and injuries of fire fighters working above fire-damaged floors. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2009-114, http://www.cdc.gov/niosh/docs/wp-solutions/2009-114/default.html.
NIOSH [2011]. Career fire fighter dies while conducting a search in a residential house fire— Kansas. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, F2010-13, http://www.cdc.gov/niosh/fire/reports/face201013.html.
NIOSH [2012]. A career captain dies and 9 fire fighters injured in a multistory medical building fire— North Carolina. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, F2011-18, http://www.cdc.gov/niosh/fire/reports/face201118.html.
NIST [2013]. Wind driven fires. Gaithersburg, MD: National Institute of Standards and Technology, http://www.nist.gov/fire/wdf.cfm.
NOAA [2015]. Climate data online search. Washington, DC: Department of Commerce, National Oceanic and Atmospheric Administration, http://www.ncdc.noaa.gov/cdo-web/results.
SAFE-IR [2013]. Thermal imaging training for the fire service: about the thermal imager. New York: SAFE-IR, Inc., http://www.safe-ir.com/index.php/about-the-thermal-imager.
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Sendelbach TE [2003]. Managing the fireground Mayday: the critical link to firefighter survival. Firehouse, May, http://www.firehouse.com/article/10541890/managing-the-fireground-mayday.
Township of Spring Fire Rescue [2013]. Initial fireground assessment standard operating procedure, section 3: response to alarms, subsection 3.00.01. Township of Spring, PA: Township of Spring Fire & Rescue. Contact information: Township of Spring Fire Department, 2301 Monroe Ave., West lawn, PA 19609. Phone: 610-898-1452.
ULFSRI, FirefightersCloseCall.com [no date]. S.L.I.C.E. – R.S. Columbia, MD: Underwriters Laboratory Fire Safety Research Institute. FirefightersCloseCall.com, http://modernfirebehavior.com/s-l-i-c-e-r-s/.
USFA [2006]. Mayday CD Q133 Firefighter safety: calling the Mayday and H134 Calling the Mayday: hands on training. Emmitsburg, MD: U.S. Department of Homeland Security, U.S. Fire Administration, National Fire Academy.
Varone C [2003]. Fire fighter safety and radio communication. Fire Engineering, March, http://www.fireengineering.com/articles/print/volume-156/issue-3/features/firefighter-safety-and- radio-communication.html. Investigator Information This incident was investigated by Matt E. Bowyer, General Engineer, Stephen Miles, Occupational Safety and Health Specialist, and Murrey Loflin, Investigator, with the Fire Fighter Fatality Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of Safety Research, NIOSH located in Morgantown, West Virginia. An expert technical review was provided by John J. Salka, Jr., Battalion Chief (ret.), FDNY, and Fire Command Training Instructor. A technical review was also provided by the National Fire Protection Association, Public Fire Protection Division. Disclaimer Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced in this document were accessible as of the publication date.
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Appendix I
Self-Contained Breathing Apparatus
National Personal Protective Technology Laboratory Technology Evaluation Branch
Disclaimer Investigator Information The SCBA inspection and this report were written by Thomas D. Pouchot, General Engineer, the Technology Evaluation Branch, National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health, located in Bruceton, Pennsylvania. The purpose of Respirator Status Investigations is to determine the conformance of each respirator to the NIOSH approval requirements found in Title 42, Code of Federal Regulations, Part 84. A number of performance tests are selected from the complete list of Part 84 requirements and each respirator is tested in its “as received” condition to determine its conformance to those performance requirements. Each respirator is also inspected to determine its conformance to the quality assurance documentation on file at NIOSH. In order to gain additional information about its overall performance, each respirator may also be subjected to other recognized test parameters, such as National Fire Protection Association (NFPA) consensus standards. While the test results give an indication of the respirator’s conformance to the NFPA approval requirements, NIOSH does not actively correlate the test results from its NFPA test equipment with those of certification organizations which list NFPA-compliant products. Thus, the NFPA test results are provided for information purposes only. Selected tests are conducted only after it has been determined that each respirator is in a condition that is safe to be pressurized, handled, and tested. Respirators whose condition has deteriorated to the point where the health and safety of NIOSH personnel and/or property is at risk will not be tested.
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Status Investigation Report of One Self-Contained Breathing Apparatus
Submitted By the NIOSH Division of Safety Research NIOSH Task Number 19908 The National Institute for Occupational Safety and Health (NIOSH) has concluded its investigation conducted under NIOSH Task Number TN-19908. This investigation consisted of the inspection of two Scott Health and Safety AirPak 4.5, 30 minute, 4500 psig, Self Contained Breathing Apparatus (SCBA). The SCBAs in question were packaged inside a paper bag and shipped inside a plastic shipping box and were delivered to the NIOSH facility in Morgantown, WV, on October, 28, 2014. The SCBA units were then transported to Building 20 in Pittsburgh for inspection and stored under lock until the time of the evaluations on November 21, 2014. SCBA Inspection: An initial general inspection of the SCBA units was conducted on November 18, 2014. The units were identified as the Scott Health and Safety AirPak 4.5 model. In addition, Scott Health and Safety performed a downloading of the data logger present on one of the SCBA units, with NIOSH personnel present, on November 25, 2014. The other SCBA did not have a data logger. A complete visual inspection of both SCBA units was conducted on November 18, 2014. The units were examined, component by component in the condition received, to determine conformance to the NIOSH-approved configuration. The visual inspection process was photographed. Both SCBA units exhibited some signs of wear and tear; and the units were covered lightly with general soot and grime. The cylinder valve as received on the unit was in the closed position. The cylinder gauge could be read and indicated that there was no air remaining in either cylinder. The cylinder valve hand-wheels on both units could be turned. The regulator and facepiece mating and sealing area on both of the units were relatively clean. The units had only slight scratches on the lenses. Visibility through the facepiece lens of both units was good as the condition of the lenses was fair. The facepiece head harness webbing on the both units was in fair condition with only a slight amount of dirt. The PASS on both units functioned. The NFPA SCBA approval label on Unit #1 and Unit #2 were present and readable. Personal Alert Safety System (PASS) Device The Personal Alert Safety System (PASS) device on both Units #1 and Unit #2 were operable and functional. The PASS devices were activated and appeared to function normally. However, the units were not tested against the specific performance requirements of NFPA 1982, Standard on Personal Alert Safety Systems, (PASS), 2007 Edition. Because NIOSH does not certify PASS devices, no further evaluation was performed. SCBA Compressed Air Cylinder Contents During the inspection, it was noted that the compressed air cylinders of both units were empty. SCBA Testing
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The purpose of the testing was to determine the SCBA conformance to the approval performance requirements of Title 42, Code of Federal Regulations, Part 84 (42 CFR 84). Further testing was conducted to provide an indication of the SCBA conformance to the National Fire Protection Association (NFPA) Air Flow Performance requirements of NFPA 1981, Standard on Open-Circuit Self-Contained Breathing Apparatus for the Fire Service, 1997 Edition. NIOSH SCBA Certification Tests (in accordance with the performance requirements of 42 CFR 84): 1. Positive Pressure Test [§ 84.70(a)(2)(ii)] 2. Rated Service Time Test (duration) [§ 84.95] 3. Static Pressure Test [§ 84.91(d)] 4. Gas Flow Test [§ 84.93] 5. Exhalation Resistance Test [§ 84.91(c)] 6. Remaining Service Life Indicator Test (low-air alarm) [§ 84.83(f)] National Fire Protection Association (NFPA) Tests (in accordance with NFPA 1981, 1997 (Edition): 7. Air Flow Performance Test [Chapter 5, 5-1.1] The testing of both units was conducted on November 21, 2014. SCBA Unit #1 failed the remaining service life indicator test, secondary alarm. Unit #2 failed the positive pressure test and the rated service time test. Appendix II of the Status Investigation Report contains complete NIOSH and NFPA test reports for both SCBA Units. Tables One through Four summarize the NIOSH and NFPA test results. Summary and Conclusions Two SCBA units were submitted to NIOSH National Personal Protective Technology Laboratory (NPPTL) by the NIOSH Division of Safety Research (DSR) for the Connecticut Fire Department for evaluation. The SCBA units were delivered to NIOSH on October 28, 2014 and extensively inspected on November, 18, 2014. Both units were identified as a Scott Health and Safety model AirPak 4.5, 4500 psi, 30-minute, SCBA (NIOSH approval numbers, TC-13F-0076, Unit #1 and TC-13F- 0076CBRN, Unit #2). Scott Health and Safety performed a downloading of the Unit #2 data logger on November 25, 2014. The units suffered very slight amounts of damage but exhibited other signs of wear and tear and the units were slightly covered with general dirt. The cylinder valves, as received, on Unit #1 and Unit #2 were in the closed position. The cylinder gauges showed no pressure. The cylinder valve hand-wheels could be turned on both units. The regulator and facepiece mating and sealing area on both units were relatively clean. The units had only slight scratches on the lenses. Visibility through the facepiece lenses of Units #1 and #2 were good to fair with the lenses having slight scratches. The facepiece head harness webbing on both units were in fair condition and were slightly dirty with some fraying at the connection points. The NFPA approval label on Unit #1 and Unit #2 were present and readable after some dirt was wiped away. The personal alert safety system (PASS) on both units functioned.
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The air cylinder on Unit #1 had a manufactured date of 01/04. Under the applicable DOT exemption, the air cylinder is required to be hydro tested every 5 years. For the air cylinder on Unit #1, a retest date before the last day of 01/09 is required. The retest label was readable on Unit #1 with a retest date of 4/13; therefore, the cylinder was within the hydro certification when last used. The cylinder on Unit #1 was in fair to good condition with surface scratches and gouge repairs present on the outer coating. There was no air remaining in the cylinder. Although the cylinder was within the hydro testing requirements, it was determined that it may not be safe to pressurize. Another cylinder and facepiece was requested from the Fire Department. The SCBA Unit #1 was tested as it was received as no other maintenance or repair work was performed on the unit at any time. The air cylinder on Unit #2 had a manufactured date of 01/04. Under the applicable DOT exemption, the air cylinder is required to be hydro tested every 5 years. For the air cylinder on Unit #2, a retest date before the last day of 01/09 is required. The retest label was not present on Unit #2 and could not be pressurized safely. The cylinder on Unit #2 was in fair to good condition with surface scratches and gouge repairs present on the outer coating. There was no air remaining in the cylinder. Another cylinder and facepiece was requested from the Fire Department. The SCBA Unit #2 was tested as it was received as no other maintenance or repair work was performed on the unit at any time. Unit #1 failed the Remaining Service Life Indicator Test. The secondary bell failed to operate within the parameters. SCBA Unit #1 did meet the requirements of the NIOSH Positive Pressure Test, as the unit did maintain a positive pressure for the 30 minute minimum duration of the unit. The unit passed all of the other NIOSH tests. SCBA Unit #2 did not meet the requirements of the NIOSH Positive Pressure Test, as the unit did not maintain positive pressure throughout the 30 minute minimum duration of the unit. The unit passed all of the other NIOSH tests. In light of the information obtained during this investigation, NIOSH has proposed no further action on its part at this time. The SCBA units were returned to the Fire Department. If these units are to be placed back in service, the SCBAs must be repaired, tested, cleaned and any damaged components replaced and inspected by a qualified service technician, including such testing and other maintenance activities as prescribed by the schedule from the SCBA manufacturer. Typically a flow test is required on at least an annual basis. From the information obtained during this investigation, NIOSH proposes no further action on its part at this time. The investigation under task number TN-19908 will be considered closed.
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Appendix II Incident Commander’s Tactical Worksheet for Mayday
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Appendix III Use and Operations of Thermal Imagers
The temperature measurement feature on fire service thermal imagers should not be used for interior structural firefighting. Use of this feature MAY CAUSE ERRORS IN JUDGEMENT WHICH MAY RESULT IN SERIOUS INJURY OR DEATH. Fire service thermal imagers may be equipped with a temperature measurement feature. Utilizing either a bar indicator or digital readout or both this feature displays the approximate surface temperature of a targeted surface. The temperature measurement feature is a non-contact solid surface temperature measurement device that is not accurate. Different materials or the same materials with different composition, surface textures, color and polish will not register temperature readings in the same way resulting in variations in the temperature readings. Several factors including but not limited to: • how much heat • the material being measured and its ability to absorb or reflect heat (emissivity) • the objects temperature • the distance from the object being measured as well as • the angle at which the object is being viewed • the cleanliness of the lens as a result of steam or smoke; • the object does not fully fill the center target area then a false reading may be obtained Users must be aware and understand that the temperature measurement feature in a thermal imager will NOT provide atmospheric or air temperature readings. Additionally the thermal imaging camera cannot see through walls. • When attempting to view a source of heat behind a wall or above a ceiling the heat source will not be evident if it does not heat the wall itself. Consideration must be given to the thickness of the wall or ceiling as well as any additional layers of materials that may exist and further insulate or mask the true magnitude of the heat source. All of these factors may individually or collectively greatly affect the accuracy of the temperature measurement feature during interior structural firefighting situations. Because interior structural firefighting is a rapidly changing dynamic environment with many unknown and uncontrolled variables the temperature measurement feature on thermal imagers should not be utilized or relied upon by fire fighters to make tactical interior structural fire-fighting decisions.
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Public Comment No. 4-NFPA 1410-2018 [ Global Input ]
Type your content here ... 5.2.5 shall should be changed to should.
Statement of Problem and Substantiation for Public Comment
shall designates it is to happen. Similar verbiage is used in other sections, I.E. ladder companies should be staffed as..... Related Item • Ladder companies
Submitter Information Verification
Submitter Full Name: ryan power Organization: colville fire Street Address: City: State: Zip: Submittal Date: Thu Nov 01 15:46:16 EDT 2018 Committee: FIY-AAA
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Public Comment No. 5-NFPA 1410-2018 [ Global Input ]
Type your content here ... A.7.2.(2) reference to safety team, is this consistant termnology? Use back up or RIT.
Statement of Problem and Substantiation for Public Comment
inconsistent terminology
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 4-NFPA 1410-2018 [Global Input] Public Comment No. 3-NFPA 1410-2018 [Section No. 5.2.5] Related Item •
Submitter Information Verification
Submitter Full Name: ryan power Organization: colville fire Street Address: City: State: Zip: Submittal Date: Thu Nov 01 15:50:30 EDT 2018 Committee: FIY-AAA
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Public Comment No. 3-NFPA 1410-2018 [ Section No. 5.2.5 ]
5.2.5 A minimum of two fire fighters shall be SHOULD be used on each hose line to keep interior attack lines under control.
Additional Proposed Changes
File Name Description Approved .1539715454350 1410
Statement of Problem and Substantiation for Public Comment
When two people shall be on the line for control, this inhibits rescue or search, when the line can be controlled by one individual.
Related Public Comments for This Document
Related Comment Relationship Public Comment No. 5-NFPA 1410-2018 [Global Input] Related Item • PI
Submitter Information Verification
Submitter Full Name: ryan power Organization: Colville Fire Dept Street Address: City: State: Zip: Submittal Date: Tue Oct 16 14:43:13 EDT 2018 Committee: FIY-AAA
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Public Comment No. 2-NFPA 1410-2018 [ Section No. 8.2.2 ]
8.2.2 The initial attack line shall provide Establishment of an effective water flow application rate of 300 gpm (1140 L/min) from two handlines, each of which has a minimum flow rate of 100 gpm (400 380 L/min) from the nozzle with each handline operated by a minimum of two members to effectively and safely maintain the line .
Statement of Problem and Substantiation for Public Comment
Submitted through me because government has single NFPA account.
Chief Buchanan,
It's the same change I sent to you previously, dealing with the primary and backup lines flow rates. Changing the wording to say the same as NFPA 1710.
Current version: Section 8.2.2, The initial attack line shall provide a minimum flow of 100 gpm (400 L/min) from the nozzle. Section 8.2.3, The required flow from the backup line shall be a minimum of 200 gpm (750 L/min).
Change to: Establishment of an effective water flow application rate of 300 gpm (1140 L/min) from two handlines, each of which has a minimum flow rate of 100 gpm (380 L/min) with each handline operated by a minimum of two members to effectively and safely maintain the line.
Thank you again.
V/R Charles A. Volhein Jr. Captain NSA Naples Fire & Emergency Services DSN: 314-629-4999 Cell: 39 348-055-3374 Email: [email protected] Related Item • Section 8.2.2
Submitter Information Verification
Submitter Full Name: W. Edward Buchanan Organization: Hanover Fire EMS Department Affiliation: Comment from Charles Volhein, Street Address: City: State: Zip: Submittal Date: Mon Oct 08 13:44:13 EDT 2018 Committee: FIY-AAA
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