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The Ides of March: Learning and Remembrance

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Operational Safety

Here are five (5) NIOSH Firefighter LODD Event report summaries for incidents that occurred in the March 4th through the 8th time frame in the years 1998, 2001, 2002, 2008.

Take the time to look over the event summaries, discuss and comment on the factors that lead to the events and the recommendations formulated from the subsequent investigations.

Take the opportunity to identify the common themes and apparent causes that were identified and discuss with your company, team or station, relevant considerations that may have a direct or indirect relationship to your organization, past incident calls or district risk profile.

What are your capabilities?

What are your gaps?

How can you prevent a similar situation from occurring?

Promote questions and dialog related to operational issues such as these;

  • Coordinated multi-company operations; how “coordinated” is your incident scene?
  • Do rapidly changing incident conditions get identified promptly and communicated to Command in rapid succession for actions?
  • How effective is the base line knowledge and skill set of company and command officers in “reading the building”?
  • What is the adequacy of your training for conducting operations above the fire floor?
  • When was the last time you “tested” the effectiveness of your RIT/FAST Team? Can they truly perform under the most demanding of incident conditions?
  • When was the last time you trained or drilled on Fire Behavior or on Building Construction?
  • Are you training on calling the mayday and personal survival techniques?
  • Have you implemented and trained on procedures for rapid and efficient transition in operational modes on the fireground?
  • Do you implement a 360 when applicable and delegate when needed?
  • What parameters are you operating under when assuming risk on the fireground?
  • What drives your incident operations: Are they Tactically Drive or Risk Managed?

Down load the complete NIOSH Reports and expand on the lessons learners and their applicably to your organization and capabilities.

Manlius, New York

Floor Collapse and Fire Conditions:
On March 7, 2002, a 28-year-old male volunteer fire fighter and a 41-year-old male career fire fighter died after becoming trapped in the basement. One firefighter manned the nozzle while second firefighter provided backup on the handline as they entered the house. After entering the structure, the floor collapsed, trapping both victims in the basement.

A career fire fighter captain joining the fire fighters near the time of the collapse was injured trying to rescue one of the fire fighters. Crew members responded immediately and attempted to rescue the victims; however, the heat and flames overcame both victims and eliminated any rescue efforts from the garage entrance.

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

  • Ensure that the Incident Commander is clearly identified as the only individual responsible for the overall coordination and direction of all activities at an incident
  • Ensure that the Incident Commander conveys strategic decisions to all suppression crews on the fireground and continually reevaluates the fire condition
  • Ensure that Incident Command conducts an initial size-up of the incident before initiating fire fighting efforts and continually evaluates the risk versus gain during operations at an incident
  • Ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts
  • Ensure that fire fighters report conditions and hazards encountered to their team leader or Incident Commander
  • Ensure fire fighters are trained to recognize the danger of operating above a fire

NIOSH REPORT: http://www.cdc.gov/niosh/fire/reports/face200206.html

Wall Collapse and Fire Conditions
On March 7, 2008, two male career fire fighters, aged 40 and 19 were killed when they were trapped by rapidly deteriorating fire conditions inside a millwork facility in North Carolina. The captain of the hose line crew was also injured, receiving serious burn injuries.

The victims were members of a crew of four fire fighters operating a hose line protecting a firewall in an attempt to contain the fire to the burning office area and keep it from spreading into the production and warehouse areas. The captain attempted to radio for assistance as the conditions deteriorated but fire fighters on the outside did not initially hear his Mayday. Once it was realized that the crew was in trouble, multiple rescue attempts were made into the burning warehouse in an effort to reach the trapped crew as conditions deteriorated further.

Three members of a rapid intervention team (RIT) were hurt rescuing the injured captain. One firefighter was located and removed during the fifth rescue attempt. The second firefighter could not be reached until the fire was brought under control.

The fourth crew member had safely exited the burning warehouse prior to the deteriorating conditions that trapped his fellow crew members. Key contributing factors identified in this investigation include radio communication problems (unintelligible transmissions in and out of the fire structure that may have led to misunderstanding of operational fireground communications), inadequate size up and incomplete pre-plan information, a deep-seated fire burning within the floor of the office area that was able to spread into the production and warehouse facility, the procedures used in which operational modes were repeatedly changed from offensive to defensive, lack of crew integrity at a critical moment in the event, and weather which restricted fireground visibility.

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

  • Ensure that detailed pre-incident plan information is collected and available when needed, especially in high risk structures
  • Limit interior offensive operations in well-involved structures that are not equipped with sprinkler systems and where there are no known civilians in need of rescue
  • Develop, implement, and enforce clear procedures for operational modes. Changes in modes must be coordinated between the Incident Command, the command staff and fire fighters
  • Ensure that Rapid Intervention Crews (RIC) / Rapid Intervention Teams (RIT) have at least one charged hose line in place before entering hazardous environments for rescue operations
  • Ensure that the incident commander establishes the incident command post in an area that provides a good visual view of the fire building and enhances overall fireground communication
  • Ensure that crew integrity is maintained during fire suppression operations
  • Encourage local building code authorities to adopt code requirements for automatic protection (sprinkler) systems in buildings with heavy fire loads.

NIOSH REPORT http://www.cdc.gov/niosh/fire/reports/face200807.html

Floor Collapses in Residential Fire - North Carolina

 

Floor Collapse
On March 4, 2002, a 22-year-old male career fire fighter was injured and subsequently died and a 25-year-old male Captain was injured when the floor collapsed while they were fighting a residential fire.

The Captain was transported by ambulance to an area hospital where he was admitted overnight for first- and second-degree burns. The victim was conscious and was transported by medical helicopter to a State medical center where he died 2 days later.

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

  • Ensure that each Incident Commander conducts a size-up of the incident before initiating fire-fighting efforts, after command is transferred, and continually evaluates the risk versus gain during operations at an incident
  • Ensure fire fighters are trained to recognize the dangers of searching above a fire
  • Ensure that an Incident Safety Officer, independent from the Incident Commander, is appointed
  • Ensure that ventilation is closely coordinated with fire attack
  • Ensure that a Rapid Intervention Team is established and in position immediately upon arrival
  • Ensure that adequate numbers of staff are available to operate safely and effectively

NIOSH REPORT http://www.cdc.gov/niosh/fire/reports/face200211.html

 

Fall Through Floor Fighting a Structure Fire at a Local Residence - Ohio

 

Floor Collapse
On March 8, 2001, a 38-year-old male career fire fighter fell through the floor while fighting a structure fire, and died 12 days later from his injuries. At 1231 hours, Central Dispatch notified the career department of a structure fire with reports of the occupants still inside. The Assistant Chief arrived on the scene along with Engine 70 and assumed Incident Command (IC).

The IC immediately called for the second alarm, began conducting the initial size-up of the structure, and confirmed heavy fire in the left front section. At that time, the neighbors approached the IC and informed him that the occupants were trapped inside. The IC ordered the fire fighters on scene to commence search and rescue efforts, and then verified the stability of the structure through radio and face-to-face communications.

Engine 68 arrived on the scene at approximately 1250 hours with an Assistant Chief and the victim. The Assistant Chief provided tactical command of the fire ground, and along with the victim, conducted search and rescue operations. Other crews conducted searches with a thermal imaging camera of the first floor and basement level of the residence with no sign of any occupants. During these searches the stability of the structure was diminishing due to the intense fire that was now venting through the roof.

Fire fighter #3 and the victim were at the front entrance conducting a defensive attack as the third emergency evacuation signal was sounded. The neighbors were still insisting to the IC and fire fighters that the occupants were trapped inside, and one of the occupants was handicapped. The victim and one other fire fighter conducted another search of the structure.

The heat and flames were now extending from the basement level to the first floor when the fire fighter’s low air alarm sounded. The victim and the fire fighter were backing out of the structure when the floor beneath the victim gave way, causing him to fall through the floor and become trapped in the basement.

Attempts were made from the first floor to rescue the victim by utilizing a handline and an attic ladder, but they were unsuccessful due to the intense heat and flames. Two Rapid Intervention Teams (RIT #1 & RIT #2) were deployed simultaneously from separate entrances into the basement to perform a search and rescue operation for the downed fire fighter. The RITs were able to locate and remove the victim on their initial entry. He sustained third degree burns to over half of his body and died 12 days later.

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

  • Ensure that Incident Command continually evaluates the risk versus gain during operations at an incident
  • Ensure that a separate Incident Safety Officer independent from the Incident Commander is appointed
  • Ensure that fire fighters are trained in the tactics of defensive search
  • Ensure that fire fighters performing fire fighting operations under or above trusses are evacuated as soon as it is determined that the trusses are exposed to fire
  • Ensure consistent use of Personal Alert Safety System (PASS) devices at all incidents and consider providing fire fighters with a PASS integrated into their Self-Contained Breathing Apparatus which provides for automatic operation
  • Ensure that personnel equipped with a radio, position the radio to receive and respond to radio transmissions

NIOSH REPORT: http://www.cdc.gov/niosh/fire/reports/face200116.html

 

Roof Collapse and Fire Conditions
On March 8, 1998, one male fire fighter, the Captain on Engine 57, died while trying to exit a commercial structure after his egress was cut off by the wooden trussed roof that collapsed. Task Force 66 was the first on scene and reported light smoke showing from a one-story commercial building. A ventilation team from Truck 66 proceeded to the roof of the building and commenced roof ventilation. Forcible entry into the building required about 7 ½ to 9 ½ minutes from arrival on scene to force open the two metal security doors in the front. While fire companies waited for the security doors to be opened, fire conditions changed dramatically on the roof.

Fire was coming from the ventilation holes opened by the ventilation crew. As soon as the security doors were opened, three engine crews (Engine 66, Engine 57, and Engine 46) advanced hand lines through the front door in an attempt to determine the origin of the fire. Approximately 15 feet inside the front door, the fire fighters encountered heavy smoke with near zero visibility conditions. The engine crews advanced their hose lines approximately 30 to 40 feet inside the building.

As conditions continued to deteriorate inside the building, the members from the four engine companies involved in the fire attack began to withdraw. During this time the victim became separated from his crew and remained in the building. The victim was subsequently located by the Rapid Intervention Team and cardiopulmonary resuscitation was performed immediately and en-route to the hospital, where the victim was pronounced dead.

NIOSH investigators conclude that, to prevent similar occurrences, fire departments should:

  • Ensure that incident command conducts an initial size up of the incident before initiating fire fighting efforts, and continually evaluate the risk versus gain during operation at an incident
  • Ensure that incident command always maintains close accountability for all personnel at the fire scene
  • Ensure communications are established between the interior and exterior attack crews, e.g., the ventilation crew and the interior fire attack crew should communicate conditions among themselves and back to incident command
  • Ensure that Rapid Intervention Teams are in place before conditions become unsafe
  • Ensure that some type of tone or alert that is recognized by all fire fighters be transmitted immediately when conditions become unsafe for fire fighters
  • Ensure sufficient personnel are available and properly functioning communications equipment are available to adequately support the volume of radio traffic at multiple-responder fire scenes
  • Consider placing a bright, narrow-beamed light at the entry portal to a structure to assist lost or disoriented fire fighters in emergency egress.

NIOSH REPORT: http://www.cdc.gov/niosh/fire/reports/face9807.html

 

Taking it to the Streets on Firefighternetcast.com

Taking it to the StreetsTM

Download the program from March 16th, 2011  Program

Featured a two part program on Near Miss Firefighter Reporting with Lt. Steve Mormino, FDNY (ret) and Capt. CJ Haberkorn, Denver (CO) Fire Department and  special guest, Captain Michael Long, who provided a personal Near-Miss Event account you won’t want to miss.

Check out the latest downloads of recent programs in the archives by visiting Taking it to the Street’s webpage on Firefighternetcast.com or for program insights at CommandSafety.com.

  • Download the program from March 16th, 2011  Program on Firefighternetcast.com HERE
  • Taking it to the Streets Radio Programs, HERE and HERE

Taking it to the StreetsTM is a monthly radio show featured on BlogTalk Radio and is hosted by Christopher Naum and is a Buildingsonfire.com Series and FireFighternetcast.com Production, © 2010-2012 All Rights Reserved

The Worcester 6

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On December 3, 1999, a five-alarm fire at the Worcester Cold Storage & Warehouse Co. building claimed the lives of six brave firefighters who responded to the call. These six heros, The Worcester 6, sacrificed their lives to try and rescue two individuals who were believed to be trapped inside the inferno. May the Worcester 6 always be remembered; “Fallen Heroes Never Forgotten.”

Firefighter Paul A. Brotherton
Firefighter
Paul A. Brotherton
Firefighter Timothy P. Jackson
Firefighter
Timothy P. Jackson
Firefighter Jeremiah M. Lucey
Firefighter
Jeremiah M. Lucey
Firefighter James F. Lyons
Firefighter
James F. Lyons
Firefighter Joseph T. McGuirk
Firefighter
Joseph T. McGuirk
Lieutenant Thomas E. Spencer
Lieutenant
Thomas E. Spencer

 

Mission Critical Reports, Links and Reading for the Company and Command Officer:

The Perfect Fire

It started with a candle in an abandoned warehouse. It ended with temperatures above 3,000 degrees and the men of the Worcester Fire De- partment in a fight for their lives.

Read more: http://www.esquire.com/features/perfect-fire-0700#ixzz1fUAOvMsZ

 

Three Firefighters Injured in Residential Collapse

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Cherokee County Fire and Emergency Services

 

Cherokee County Fire and Emergency Services

Cherokee County (GA) Fire and Emergency Services and Woodstock (GA) Fire Department personnel responded to a structure fire at 811 Commons Court, located in the Kingston Square Subdivision, off Highway 92, just east of Woodstock (GA) sunday night for a reported fire in a residential structure; with reports of trapped occupants. During suppression operations, three Cherokee County firefighters were trapped in the basement for a short period of time due the catastrophic collapse of a front wall-floor assembly resulting in the collapse of the entry porch floor system on the alpha division.

Cherokee County 911 received the call of the fire at 1:30 Sunday regarding a structure fire with possible entrapment. Firefighters quickly responded to the scene to find the house fully involved and began a defensive attack. Two Cherokee County firefighters and one Woodstock firefighters were standing on the porch of the structure when it collapsed. The three firefighters were pulled from the burning structure and were later taken by ambulance to Marietta’s Kennestone Hospital.

According to information posted on the Cherokee County Fire and Emergency Services web site and other published media reports,  two Cherokee County Firefighters were treated and released and one firefighter  is still in ICU at a local hospital, struggling to survive; with smoke inhalation and lung injuries resulting from the falling bricks that struck him during the collapse.

According to one report, the three engine company firefighters were operating a handline for an exended period of time on the porch of the home  (Alpha side) when the floor and wall assembly gave way beneath them, sending them tumbling into the basement below. The adjacent wall and canopy fell on top of the firefighters after falling into the area below.  An aerial view of the residence shows a raised ranch style structure with a garage and basement configuration below the main floor. According to public records, the single family wood frame house was built in 1986 and was comprised of 1,910 square feet of occupied space, with three bredrooms.

Aerial View of the Residential Occupancy (Bing)

Unfortunately due to the degree of fire involvment and susequent collapse, firefighters were unable to reach the elderly couple, a 78 year old man and his 77 year old wife, who perished in the early morning fire. The couple’s daughter and her 25 year old son were also living with the couple and they escaped without injury.

We posted some extensive information over at CommandSafety.com related to two past LODD events from 2006 and 2009 along with a number of pertainent informational links realted to floor collapse, firefighter near miss events involving floor compromise and collapse.

Take some time to link over to our sister site and check out the information. (HERE)

We’ll follow up on this event to see if we can gain further insights related to the structural conditions, construction features and contributing factors that lead to the floor collapse.

 
 
 
 

 

Deployment Decisions: Defining Operations on the First-Due

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First-due company operations are influenced by a number of parameters and factors; some deliberate and dictated, others prescribed and prearranged and yet others subjective, biased, predisposed or at times accidental, casual and emotional. For many of you riding the seat or arriving assuming command; you understand the connotations and implications I’m making here.

Here’s an excellent discussion and debate point to bring up, when time permits today or this evening with your company or personnel; one that leads to a multitude of viewpoints, opinions and divisions.

On the first-due; what are the three or four key parameters when confronted with arrival indications of a fire within a structure that define your deployment and transition into operations?

Now, before everyone gets worked up; we all realize there are numerous variables affecting key decision-points that must be recognized, imputed, synthesized , analyzed and decisions made, assignments formulated and the task deployed; this list can be long – very long.

However, giving a building and occupancy with indications of a fire within, what has your experience provided you with the KEY influencing parameters? Are there key factors, or are there “lists” of factors based upon yet another “list” of conditions. The question is rhetorical the answeres are not.

Is it occupancy type, occupancy risk, fire behavior or fire dynamics, time, risk, communicated information, past performance factors (experience), presumed or known life hazards, predicated building or system performance, crew KSA sets or other factors, etc? Does naturalistic or RPDM decision-making influence; is the deployment tactically driven or predisposed by SOP, SOG or personal attributes and biases? Safety Conscious or aggressively driven? You get the picture…..

Try to distill them down to three or four mission critical key issues (if you can). This is a great exercise to see what everyone else considers the key factors to be or should be when deploying and  going into operations; sometimes it’s more complex than just “pulling the line” or getting in….

Take the time to use some critical thinking and don’t be subjective….think about the responses and ask why?

Texas Captain; 2010 LODD Report Issued with Lessons Learned

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Captain Thomas Araguz III

 

Captain Araguz, a 30 year old, 11-year veteran of the Wharton Volunteer Fire Department made Captain in 2009. He lost his life while battling a multiple alarm fire a the Maxim Egg Farm located at 3307 FM 442, Boling, Texas on July 3, 2010.  The Texas State Fire Marshal’s Office issued the Fire Fighter Fatality Investigation Report, SFMO Case Number FY10-01 that provides a detailed examination of the incident, operations and yeilds findings and recommendations. A full version of the report is available at the Texas SFMO web site HERE.

 On July 3, 2010, Wharton Volunteer Fire Department Captain Thomas Araguz III was fatally injured during firefighting operations at an egg production and processing facility. At 9:41 PM, Wharton County Sheriff’s Office 911 received a report of a fire at the Maxim Egg Farm located at 3307 FM 442, Boling, Texas. Boling Volunteer Fire Department and the Wharton Volunteer Fire Department responded first, arriving approximately 12 minutes after dispatch. Eventually, more than 30 departments with 100 apparatus and more than 150 personnel responded. Some departments came as far as 60 miles to assist in fighting the fire.

Aerial View

 

The fire involved the egg processing building, including the storage areas holding stacked pallets of foam, plastic, and cardboard egg cartons and boxes. It was a large windowless, limited access structure with large open areas totaling over 58,000 square feet. A mixed construction, it included a two-story business office, the egg processing plant, storage areas, coolers, and shipping docks. It was primarily metal frame construction with metal siding and roofing on a concrete slab foundation with some areas using wood framing for the roof structure.

Captain Araguz responded to the scene from the Wharton Fire Station, approximately 20 miles from the fire scene, arriving to the front, south side main entrance 20 minutes after dispatch. Captain Araguz, Captain Juan Cano, and Firefighter Paul Maldonado advanced a line through the main entrance and along the south, interior wall to doors leading to a storage area at the Southeast corner.

Maldonado fed hose at the entry door as Captains Araguz and Cano advanced through the processing room. Araguz and Cano became separated from the hose line and then each other. Captain Cano found an exterior wall and began kicking and hitting the wall as his air supply ran out. Firefighters cut through the exterior metal wall at the location of the knocking and pulled him out. Several attempts were made to locate Captain Araguz including entering the building through the hole and cutting an additional hole in the exterior wall where Cano believed Araguz was located. Fire conditions eventually drove the rescuers back and defensive firefighting operations were initiated.

Captain Cano was transported to the Gulf Coast Medical Center where he was treated and released. Captain Araguz was recovered at 7:40 AM, the following morning. Initially transported by ambulance to the Wharton Funeral Home then taken to the Travis County Medical Examiner’s Office in Austin, Texas for a post-mortem examination.

Site Plan of Building Complex

Building Structure and Systems

The fire incident building was located on the property of Maxim Egg Farm, located within an unincorporated area of Wharton County. The 911 address is 580 Maxim Drive, Boling, Texas 77420.

Wharton County has no adopted fire codes, or model construction codes, and no designated Fire Marshal on staff that conducts fire safety inspections within their jurisdiction.

National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2009 Edition, is adopted by the State Fire Marshal’s Office, and is the applicable standard for fire and life safety inspections in the absence of an adopted fire code within unincorporated areas of a county by an applicable authority. All references regarding evaluation of the incident building in relation to minimum life safety requirements are based on NFPA 101, Life Safety Code, 2009 Edition.

Maxim Farm property includes 23 chicken coops known as layer barns that average 300 feet long and 50 feet wide holding between 15,000 to 25,000 chickens each. These layer barns inter-connect to a central processing building by a series of enclosed conveyor belts transporting over one million eggs daily.

  • The property includes integrated feed silos, water tanks, and waste management facilities. Additional areas on the property include equipment barns, shipping offices, loading docks, coolers, storage areas, and business offices.

 Overall Building Description

The main processing structure was an irregularly shaped mixed construction of metal, concrete block, and wood framing on a concrete slab foundation with approximately 58,000 square feet of space. Three dry-storage rooms connected by a wide hallway lined the east side of the plant. A concrete block (CMU) wall separated the egg processing area from the East Hallway and storage rooms. Coolers were located north of the processing room with the loading docks along the west side of the structure. The loading docks were accessible from the processing room, Cooler 3, and Cooler 2. Cooler 1 was located at the north end of Dry Storage 2. A two-story building housing the business office was attached to the main processing plant at the southwest corner.

Construction Features

The building construction was classified as an NFPA 220, Type II-000 construction with an occupancy classification by the Life Safety Code as Industrial with sub-classification as special-purpose use. The Life Safety Code imposes no minimum construction requirements for this type of occupancy.

The predominant use of the building was to process and package fresh eggs for shipment after arriving by automated conveyor directly from a laying house adjacent to the building. The general floor plan of the building consisted of a large egg processing room, with surrounding areas used for storage of packing materials and two large drive-in coolers for holding packaged eggs prior to shipping.

Building construction consisted of a combination of steel and wood framing with a sheet metal exterior siding and roofing over a low-pitch roof on a concrete slab foundation. Structural elements within the interior of the building were exposed and unprotected with no fire-resistance rated materials applied. The load bearing structural elements consisted of steel beams, and steel pipe columns, with steel open web trusses supporting the roof structure.

  • Wood components were also used as part of the load bearing elements and wall framing.
  • Perimeter walls of the cooler compartments were constructed of concrete masonry units (CMU).
  • The building was not separated between other areas of use by fire-resistance rated assemblies.
  • Ancillary facilities located within the building used for administrative offices and other incidental spaces were constructed of wood framing with a gypsum wallboard finish.

Detailed Construction Features

The front of the structure faced to the south where the main entrance to the processing room and business offices was located approximately 4 feet above the parking lot grade level and accessed by a series of steps. The business office was a two-story wood frame construction with a vinyl exterior siding under a metal roof on a concrete slab foundation. Additional separate, single-story, wood frame structures with offices located to the west of the main business office connected by covered walkways.

Processing Room

The egg processing room was 141 feet along the east and west walls and approximately 100 feet along the north and south walls. The processing room received the eggs transported from the layer barns on the conveyer belt system. The room contained the processing equipment and conveyor systems where eggs were cleaned, graded, packaged and moved to large coolers to await shipment. The construction of the processing room was sheet metal panels embedded into the concrete slab foundation supported by 8-inch wide metal studs. Sheet metal panels lined the exterior and interior sides of the south and west walls with fiberglass insulation sandwiched between.

Main Processing Area

The north wall separated the processing room from Cooler 3 and consisted mainly of interlocking insulated metal panels embedded into the slab locked at the top in metal channels. Their interior surface was polyurethane laminate.

The east wall was mainly of concrete block (CMU) construction. A USDA office and a mechanics room were accessed through doors in the east wall of the processing room. The northeast corner of the processing room extended into the north end of the east hallway, forming an 18 feet by 18 feet area with wood frame construction on a concrete stem wall with fiber cement board (Hardy board) and metal panel siding. A 6-feet wide opening between the processing and dry-storage areas with a vinyl strip door allowed unrestricted access.

Along the south wall of the processing room, a walkway between the processing equipment and exterior wall led to swinging double doors at the southeast corner to enter into Dry Storage 3. Conveyors carried the eggs from the north and south layer barns through openings in the walls of the extension of the processing room. The conveyors from the north and south layer barns entered the building suspended overhead. As the conveyors approached the entrance to the main processing room, they gradually descended to 3.5 feet above floor level and were supported by metal brackets attached to the floor. Electric drive motors attached to the conveyors at several points along their lengths to power their movement.

The roof consisted of steel columns and girders with metal panel roofing attached to metal purlins supported by steel rafters. Wire mesh supported fiberglass insulation under the roof deck. The roof gable was oriented north to south.

 

Dry Storage

The plant included three dry-storage rooms along the eastern side of the building connected by an east hallway. Dry Storage 1 and Dry Storage 2 were located in the northeast corner of the plant under a common sloping metal roof. The dry-storage rooms held pallets of containers including polystyrene egg crates, foam egg cartons, pulp egg cartons, and cardboard boxes.

 

Dry Storage 1 was approximately 123 feet long and 50 feet wide and was 4 feet below the grade of the rest of the plant. It was added to the east side of Dry Storage 2 in 2008. Dry Storage 1 was a concrete slab and 4-feet high concrete half wall topped with wood framing and metal siding. The metal roof sloped from 11 feet high above the west side to 10 feet high above the east wall. The roof attached to 2 inch x 8 inch wood joists supported by two rows of steel support columns and steel girders. The two rows of seven columns were oriented in a north-south direction.

A concrete ramp at the south end facilitated access to the East Hallway and Dry Storage 2 and the main level of the processing room. A concrete ramp at the northeast corner of Dry Storage 1 provided access to the rear loading dock. The rear dock was secured on the interior at the top of the ramp by a wood frame and metal double door with a wooden cross member and a chain and padlock. An additional wood frame and screened double door secured on the interior.

The conveyor belt from the north layer barns ran the length of the west side of Dry Storage 1 where it turned to the west, crossing Dry Storage 2 and the East Hallway into the main processing room.

Dry Storage 1 contained 29 rows of pallets, seven to eight pallets deep, of mainly Styrofoam egg crates stacked between 7 and 10 feet high, depending on their location. Corridors between the rows were maintained to provide access to the pallets with an electric forklift. Fluorescent light fixtures attached to the wood rafters in rows north to south with their conductors in PVC conduit. Skylights spaced evenly above the west side allowed for natural light. Pallets of stock material were single stacked below the locations of the light fixtures to keep clearance and prevent damage.

Dry Storage 2, located west of and 4 feet above Dry Storage 1, stored pallets of flattened cardboard box stock. The room was approximately 81 feet long and 40 feet wide. The south wall was the processing room extension and was approximately 25 feet long. The east side of the room was open to Dry Storage 1 with 4 inch x 4 inch unprotected wood studs spaced unevenly from 4 feet to 9 feet, supporting the metal roof. The west wall was CMU construction and was the exterior wall of Cooler 3. The metal roof sloped from the top of the west wall approximately 12 feet high to approximately 11 feet above the east side.

The room was accessed from the south end at the top of the ramp leading down into Dry Storage 1. Pallets of folded cardboard boxes were stacked along the entire length of the west wall extending 16 to 20 feet to the east. The rows of pallets were without spacing for corridors. One row of six fluorescent light fixtures attached to wood rafters near the north-south centerline.

The East Hallway was approximately 118 feet long and 37 feet wide running along the length of the east side of the processing room. The East Hallway connected Dry Storages 1 and 2 with Dry Storage 3 by a corridor at the south end. The East Hallway allowed access between the storage room areas and into utility rooms including the Boiler Room at the north end and a mechanics room and small utility closet. Pallets of polystyrene egg crates were stored along the east wall in rows of three pallets each. Seven pallets of polystyrene egg crates were stored along the conveyors.

The west wall was concrete block construction (CMU) until it connected to the extension of the processing area constructed of wood frame covered by Hardy board and sheet metal. The east wall was sheet metal embedded in the concrete slab supported by 2 inch x 4 inch wood studs with Hardy board interior. The metal roof sloped from a height at 12 feet at the west wall to 10 feet high at the east wall, supported by 4 inch x 6 inch wood columns and 2 inch x 8 inch wood joists.

Two conveyors entered the south end of the east hallway from Dry Storage 3. The conveyors ran parallel for approximately 80 feet along the west wall and entered the processing room through openings in the extension at the north end of the east hallway. They were 6 feet from the west wall and gradually descended from a height of 9 feet at the south end to 3.5 feet at the north. Each conveyor was 31 inches wide and combined was approximately 7 feet wide. Two compressor machines and a pressure washer were located along the west wall near the south end.

The Boiler Room, located at the northeast corner of the East Hall, housed two propane fired boilers, a water treatment system and two vacuum pumps. It was wood frame construction with metal siding under a metal roof on a combination concrete slab and concrete pier and wood beam foundation. A small utility room with service panels was constructed of concrete block on a concrete slab under a metal roof and was also located along the west wall of the East Hallway. An approximately 10 feet wide corridor connected the East Hallway to Dry Storage 3.

Dry Storage 3 extended south from the main processing room and East Hallway to the south dock area where tractor-trailers parked to unload the pallets of supplies. Two parallel conveyors suspended 9 feet overhead from the roof extended along the length of the east wall where it passed through the south wall toward the south layer houses.

The plant’s main power conductors entered the west wall of Dry Storage 3 from load centers and transformers mounted to the slab outside approximately 15 feet south of the main processing room exterior wall. Stacks of wood pallets were stored in Dry Storage 3. Corridors wide enough for forklifts provided access to the south cargo dock area.

Fire Ground Operations and Tactics

Note: The following sequence of events was developed from radio transmissions and firefighter witness statements. Those events with known times are identified. Events without known times are approximated in the sequence of the events based on firefighter statements regarding their actions and/or observations. A detailed timeline of radio transmissions is included in the appendix.

On July 3, 2010, at 21:41:10, Wharton County Sheriff’s Office 911 received a report of a fire at the Maxim Egg Farm located on County Road 442, south of the city of Boling, Texas. The caller, immediately transferred to the Wharton Police Department Dispatch, advised there was a “big fire” in the warehouse where egg cartons were stored. Boling Volunteer Fire Department was dispatched and immediately requested aid from the Wharton Volunteer Fire Department. Wharton VFD became Command as is the usual practice for this county.

Wharton Assistant Chief Stewart (1102) was returning to the station having been out on a response to a vehicle accident assisting the Boling Volunteer Fire Department when the call came in for the fire. He responded immediately and at 21:50 reported seeing “heavy fire” coming from the roof at the northeast corner of the building as he approached the plant from the east on County Road 442. When he arrived he was eventually directed to the east side of the building (D side) to the rear loading dock. Asst. Chief Stewart worked for several minutes with facility employees to gain access to the fire building before being led to the northeast loading dock.

An employee directed him on the narrow caliche drive behind the layer barns and between the waste ponds to the loading dock. Wharton Engine 1134 followed 1102 to the east side and backed into the drive leading to the loading dock. Asst. Chief Stewart’s immediate actions included assessing the extent of the fire on the interior of the building by looking through the doors at the loading dock to Dry Storage 1. Unable to see the fire through the smoke at the doors of the loading dock, an attack was eventually accomplished by removing a metal panel from the east exterior wall of Dry Storage 1 and using one 1¾”-inch cross lay. After a few minutes, the deck gun on Engine 1134 was utilized, directing water to the roof above the seat of the fire near the south end of Dry Storage 1.

Water supply became an immediate concern and 1102 made efforts to get resources for resupply. Requests for mutual aid to provide water tankers were made to area communities. During the incident, re-supplying tankers included a gravity re-fill from the on-site water supply storage tanks and from fire hydrants in the City of Boling, 3 miles from the scene and the City of Wharton, nearly 11 miles. The City of Boling water tower was nearly emptied during the incident.

The radio recording indicates there were difficulties accessing the location of the fire as apparatus were led around the complex by multiple employees. Heavy rains during the previous week left many roadways muddy and partially covered with water, which added to problems with apparatus access. In addition, fire crews were not familiar with the layout of the facility and there are no records of pre-fire plans. Asst. Chief Stewart worked for several minutes with facility employees to gain access to the fire building before being led to the northeast loading dock.

Wharton Fire Chief Bobby Barnett (1101) arrived on scene at 21:56:14, and ordered incoming apparatus to stage until he could establish an area of operations at the front, south side of the plant (A side). Chief Barnett directed Engine 1130 to position approximately 50 feet from the front main entrance of the plant. At 22:09:16, Chief Barnett (1101) established a command post on A side and became the Incident Commander; 1101 directed radio communications for the fireground to be TAC 2 and called for mutual aid from the Hungerford and El Campo Fire Departments. Chief Barnett described the conditions on side A as smoky with no fire showing. Light winds were from the east, side D, pushing the smoke toward the area of the processing room, and the front, side A, of the building.

Maxim Egg Farm Manager David Copeland, a former Wharton VFD Chief, advised Command and firefighters that the fire was in the area of the Boiler Room and should be accessed by breaching an exterior wall in the employee break area. Chief Barnett ordered Wharton crews to the breach attempt. Captain Thomas Araguz III, Captain John Cano and Firefighter Paul Maldonado were involved with this operation. The crews working in this area were in full structural personnel protective clothing and SCBA.

At 22:10, Command ordered Engine 1130 and Tanker 1160 to set up at the front entrance using Tanker 1160 for portable dump tank operations for water re-supply.

On D side, difficulty accessing the fire from the exterior of the building was reported by Asst. Chief Stewart and the crews. Heavy doors, locked loading dock doors and steel exterior paneling, required the crews to spend extra time forcing entry.

At 22:17:23, Wharton County Chief Deputy Bill Copeland (3122), once a Wharton FD volunteer firefighter, notified Command that the fire was now through the roof over Dry Storage 1.

Chief Barnett noticed smoke conditions improving at the main plant doorway and ordered crews to advance lines into the processor room. Chief Barnett stated he assigned Captain Araguz, Captain Cano and Firefighter Maldonado because they were the most experienced and senior crews available.

Positive Pressure Ventilation (PPV) was in place at the main entry door when Captain Cano, Captain Araguz and Firefighter Maldonado entered the structure into the processing room. There are no radio transmissions to verify exact entry times.

Captain Cano stated that an employee had to assist fire crews with entry into the main plant through a door with keypad access. Captain Cano reported the door to processing was held open by a three-ring binder that he jammed under the door after entry. Cano stated there was low visibility and moderate heat overhead. Captain Cano and Captain Araguz made entry on a right-hand wall working their way around numerous obstacles. The line was not yet charged and they returned to the doorway and waited for water. Wharton Engine 1130’s driver reported in his interview that he had difficulty establishing a draft from the portable tank later determined to be a linkage failure on the priming pump. 1160 connected directly to 1130 and drafted from the folding tank.

As the crew entered into the structure through the main entry door, several plant employees began entering into the administration offices through the area of the main entry door to remove files and records. This was reported to Command at 22:23 and after several minutes Chief Barnett ordered employees to stay out of the building and requested assistance from the Sheriff’s Office to maintain scene security.

At 22:31, once the line was charged, the two captains continued into the processor on the right wall leaving Maldonado at the doorway to feed hose. Captain Cano was first with the nozzle and described making it 20 feet into the building.

Cano states in his interview that he advised Command over the radio that there was high heat and low visibility, although the transmission is not recorded. Cano also reported in his interview, he could not walk through the area and had to use a modified duck walk. Cano projected short streams of water towards the ceiling in a “penciling” motion and noted no change in heat or smoke conditions. They advanced until the heat became too great and they retreated towards the center of the processor. Cano stated that they discussed their next tactic and decided to try a left-handed advance.

At 22:33, Chief Barnett advised, “advancing hose streams in main building to try to block it.”

Captain Araguz took the nozzle and Captain Cano advanced with him holding onto Araguz’ bunker gear. The crew advanced along the south wall of the processing room toward the double doors to Dry Storage 3 and lost contact with the hose line.

The investigation found the couplings between the first and second sections of the hose lodged against a threaded floor anchor (see photo) preventing further advancement of the line. How the team lost the hose line remains uncertain.

Captain Cano stated in his interview that Captain Araguz told him to call a Mayday. Captain Cano stated that he was at first confused by the request, but after some time it became apparent they lost the hose line. Captain Cano reported calling Mayday on the radio but never received a reply. Captain Cano now believes he may have inadvertently switched channels at his previous transmission reporting interior conditions. Captain Araguz had a radio but it was too damaged to determine operability. There are no recorded transmissions from Captain Araguz.

At 22:37, Deputy Chief Copeland advised Command that the fire had breached a brick wall and was entering the main packing plant. Command responded that there was a hose team inside.

At 22:42:50, Command radioed “Command to hose team 1, Cano.” This was the first of several attempts to contact Captain Cano and Captain Araguz. At 22:47:17, Command ordered Engine 1130 to sound the evacuation horn. At 22:50:44, Command announced Mayday over the radio, stating “unlocated fireman in the building.”

  • Captain Cano stated in his interview that they made several large circles in an attempt to locate the fire hose.
  • Cano became entangled in wiring, requiring him to doff his SCBA.
  • After re-donning his SCBA, Captain Cano noted he lost his radio, but found a flash light. He remembered that his low air warning was sounding as he and Araguz searched for the hose. Cano stated that they made it to an exterior wall and decided to attempt to breach the wall. Working in near zero visibility,
  • Captain Cano reported losing contact with Captain Araguz while working on breaching the wall.
  • Shortly after he lost contact, Captain Cano ran out of air and removed his mask. Captain Cano continued working to breach the exterior wall until he was exhausted.

At 22:54, crews working on the exterior of the building near the employee break area reported hearing tapping on the wall in the area of the employee break room.

  • Crews mustered tools and began to cut additional holes through the building exterior.
  • After making two openings, Captain Cano was located and removed from the building.
  • Captain Cano reported that Captain Araguz was approximately 15 feet inside of the building ahead of him.
  • Firefighters made entry through the exterior hole but were unsuccessful in locating Captain Araguz. Cano was escorted to the folding water tank and got into the tank to cool down.

Rapid Intervention Crews (RIC) were established using mutual aid members from the Hungerford and El Campo Fire Departments. The first entry made was at the main entry door where Firefighter Maldonado was located. Maldonado was relieved and escorted to the ambulance for rehab. An evacuation horn sounded and the first RIC abandoned the interior search and exited the building.

A rescue entry by a second RIC was through the breached wall of Dry Storage 3. After several minutes inside, the evacuation signal sounded due to the rapidly spreading fire and deteriorating conditions. Two additional RICs entered the structure through the loading dock doors of Dry Storage 3. Chief Barnett states that there were a total of four RICs that made entry after the Mayday. After approximately 45 minutes, all rescue attempts ceased.

As the fire extended south toward Dry Storage 3, smoke conditions became so debilitating that Chief Barnett ordered all crews staged near the front of the building on side A to move back and apparatus to relocate. Command assigned Chief Hafer of the Richmond Fire Department to “A” side operations and defensive operations were established. Captain Cano and Firefighter Maldonado were transported to Gulf Coast Medical Center and treated for smoke inhalation.

Fire ground operations continued through the night. Captain Araguz was recovered at approximately

07:40 AM. Command transferred to the Richmond Fire Department Chief Hafer at approximately

07:56 AM as 1101 and the Wharton units escorted Captain Araguz from the scene. All Wharton units cleared the scene at 08:02 AM.

Captain Araguz was transported to the Travis County Medical Examiner’s Office for autopsy. The Travis County Medical Examiner’s Office performed post mortem examinations on July 4, 2010. Captain Araguz died from thermal injuries and smoke inhalation.

Findings and Recommendations

  • Recommendations are based upon nationally recognized consensus standards and safety practices for the fire service.
  •  
  • All fire department personnel should know and understand nationally recognized consensus standards, and all fire departments should create and maintain SOGs and SOPs to ensure effective, efficient, and safe firefighting operations.

There were several factors that, when combined, may have contributed to the death of Captain Araguz. It is important that we honor him by learning from the incident.

  • Water supply became an immediate concern.
  • Although there are two water storage tanks on the facility with the combined capacity of nearly 44,000 gallons, refilling operations to tankers were slow, accomplished by gravity fill through a 5-inch connection.
  • A fire department connection attached to the plant’s main water supply pump and plant personnel familiar with the system could have sped up the refilling process at the plant.
  • Most tankers were sent to hydrants in the City of Boling 3 miles away, which in turn quickly depleted the city water supply.
  • Other tanker refilling was accomplished at hydrants on the City of Wharton water system, as far as 15 miles away.

Fire protection systems are not required by National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2009 Edition for this classification of facility. Fire sprinkler and smoke control systems may have contained the fire to one area, preventing the spread of fire throughout the plant.

Findings and recommendations from this investigation include:

 

FINDING 1:

There were no lives to save in the building. An inadequate water supply, lack of fire protection systems in the structure to assist in controlling the spread of the smoke and fire, and the heavy fire near the windward side facilitated smoke and fire spread further into the interior and toward “A” side operations. Along with the size of the building, the large fuel load, and the time period from fire discovery, interior firefighters were at increased risk.

Recommendation: Fire departments should develop Standard Operating Guidelines and conduct training involving risk management and risk benefit analysis during an incident according to Incident Management principles required by NFPA 1500 and 1561.

The concept of risk management shall be utilized on the basis of the following principles:

(a)  Activities that present a significant risk to the safety of personnel shall be limited to situations where there is a potential to save endangered lives

(b) Activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of personnel, and actions shall be taken to reduce or avoid these risks.

(c) No risk to the safety of personnel shall be acceptable where there is no possibility to save lives or property.

(d) In situations where the risk to fire department members is excessive, activities shall be limited to defensive operations. NFPA 1500 Chapter 8, 8.3.2

NFPA 1500 ‘Standard on Fire Department Occupational Safety and Health Program’, 2007 ed., and NFPA 1561’Standard on Emergency Services Incident Management System’, 2008 ed. Texas Commission on Fire Protection Standards Manual, Chapter 435, Section 435.15

(b)  The Standard operating procedure shall:

(1) Specify an adequate number of personnel to safely conduct emergency scene operations;

(2) limit operations to those that can be safely performed by personnel at the scene;

FINDING 2:

Initial crews failed to perform a 360-degree scene size-up and did not secure the utilities before operations began.

Recommendation: Fire departments should develop Standard Operating Guidelines that require crews to perform a complete scene size-up before beginning operations. A thorough size up will provide a good base for deciding tactics and operations. It provides the IC and on-scene personnel with a general understanding of fire conditions, building construction, and other special considerations such as weather, utilities, and exposures. Without a complete and accurate scene size-up, departments will have difficulty coordinating firefighting efforts.

Fireground Support Operations 1st Edition, IFSTA, Chapter 10 Fundamentals of Firefighting Skills,

NFPA/IAFC, 2004, Chapter 2  

FINDING 3

The Incident Commander failed to maintain an adequate span of control for the type of incident. Safety, personnel accountability, staging of resources, and firefighting operations require additional supervision for the scope of incident. Radio recordings and interview statements indicate the IC performing several functions including: Command, Safety, Staging, Division A Operations, Interior Operations and Scene Security.

Recommendation: Incident Commanders should maintain an appropriate span of control and assign additional personnel to the command structure as needed. Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision. In ICS, the span of control of any individual with incident management supervisory responsibility should range from three to seven subordinates, with five being optimal. The type of incident, nature of the tasks, hazards and safety factors, and distances between personnel and resources all influence span-of-control considerations.

U.S. Department of Homeland Security – Federal Emergency Management Agency Incident Command Systems http://www.fema.gov/emergency/nims/ICSpopup.htm#item5 NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed.

 

FINDING 4

The interior fire team advanced into the building prior to the establishment of a rapid intervention crew (RIC).

Recommendation: Fire Departments should develop written procedures that comply with the Occupational Safety and Health Administration’s Final Rule, 29 CFR Section 1910.134 (g) (4) requiring at least two fire protection personnel to remain located outside the IDLH (Immediate Danger to Life or Health) atmosphere to perform rescue of the fire protection personnel inside the IDLH atmosphere. One of the outside fire protection personnel must actively monitor the status of the inside fire protection personnel and not be assigned other duties. NFPA 1500 8.8.7 At least one dedicated RIC shall be standing by with equipment to provide for the rescue of members that are performing special operations or for members that are in positions that present an immediate danger of injury in the event of equipment failure or collapse.

U.S. Occupational Safety and Health Administration Respiratory Protection Standard, CFR 1910.134 (g) (4); Texas Commission on Fire Protection Standards §435.17 – Procedures for Interior Structure Fire Fighting (2-in/2-out rule) NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed. NFPA 1720 Standard on Organization and Deployment Fire Suppression Operations by Volunteer Fire Departments, 2004 ed.  

FINDING 5

The interior team and Incident Commander did not verify the correct operation of communications equipment before entering the IDLH atmosphere and subsequently did not maintain communications between the interior crew and Command. Although Chief Barnett stated he communicated with Captain Cano, there was no contact with Captain Araguz.

Recommendation: Fire Departments should develop written policies requiring the verification of the correct operations of communications equipment of each firefighter before crews enter an IDLH atmosphere. Fire Departments should also include training for their members on the operation of communications equipment in zero visibility conditions.

U.S. Occupational Safety and Health Administration Respiratory Protection Standard, CFR 1910.134(g)(3)(ii) NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed.

 

FINDING 6

The interior operating crew did not practice effective air management techniques for the size and complexity of the structure. Interviews indicate the crew expended breathing air while attempting to breach an exterior wall for approximately 10 minutes, then advanced a hose line into a 15,000 square feet room without monitoring their air supply. During interviews Captain Cano estimated his consumption limit at 15 – 20 minutes on a 45 minute SCBA.

Recommendation: Crews operating in IDLH atmospheres must monitor their air consumption rates and allot for sufficient evacuation time. Known as the point of no return, it is that time at which the remaining operation time of the SCBA is equal to the time necessary to return safely to a non-hazardous atmosphere. The three basic elements to effective air management are:

  • Know your point of no return (beyond 50 percent of the air supply of the team member with the lowest gauge reading).
  • Know how much air you have at all times.
  • Make a conscious decision to stay or leave when your air is down to 50 percent.

IFSTA [2008]. Essentials of Fire Fighting and Fire Department Operations, 5th ed., Chapter 5, Air Management, page 189 Fundamentals of Firefighter Skills, 2nd edition, NFPA and International Association of Fire Chiefs, Chapter 17, Fire Fighter Survival.

 

Finding 7

Captains Araguz and Cano became separated from their hoseline. While it is unclear as to the reason they became separated from the hose line, interviews with Captain Cano indicate that while he was finding an exterior wall and took actions to alert the exterior by banging and kicking the wall, he lost contact with Captain Araguz.

**Captain Cano credits his survival to the actions he learned from recent Mayday, Firefighter Safety training.

Recommendation: Maintaining contact with the hose line is critical. Losing contact with the hose line meant leaving the only lifeline and pathway to safety. Team integrity provides an increased chance for survival. All firefighters should become familiar with and receive training on techniques for survival and self-rescue.

United States Fire Administration’s National Fire Academy training course “Firefighter Safety: Calling the Mayday” Fundamentals of Firefighter Skills, 2nd edition, NFPA and International Association of Fire Chiefs, Chapter 17, Fire Fighter Survival.

Additional References Related to Surviving the Mayday and RIT operations from 2011 Safety Week at CommandSafety.com;

Day One: Fire/EMS Safety, Health & Survival Week 2011: Day One- Are You Ready?

Day Two: Fire/EMS Safety, Health and Survival Week: Day Two- Building Knowledge = Fire Fighter Safety

Day Three: Fire/EMS Safety, Health and Survival Week: Day Three-The New Rules of Engagement

Day Four: Fire/EMS Safety, Health and Survival Week: Day Four -The New Fire Ground

Day Five: Fire/EMS Safety, Health and Survival Week 2011: Day Five: Near-Misses, Maydays and Floor Collapses

Day Six: Fire/EMS Safety, Health and Survival Week 2011, Day Six; From Waldbaum’s to Hackensack-Worcester to Charleston; Legacies for Operational Safety

Day Seven: Fire/EMS Safety, Health and Survival Week 2011, Day Seven; Fire Fighter, Fire Officer and Command Training and Preparedness

Day Eight Plus One: Mayday and Rapid Intervention Realities: The Phoenix Perspective

188 Days of Opportunity to make a Difference: Surviving the Fire Ground

Other Links:

Operational Integrity and Command Fortitude

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CR1999 Roger B. Conant

Today December 3, 2010 marks the 11th anniversary of the Worcester Cold Storage Warehouse fire that resulted in the line of duty death of six courages brother firefighters.

For those of you who remember this event, take the time to reflect and honor the sacrifice made this day; to those of you who have not heard about the fire before- take the time to learn about the incident, the firefighters, the building, the operational factors and challenges, the courage, fortitude and convictions that define the American Fire Service, it’s honor, tradition and brotherhood.

The Worcester Six;

  • Firefighter Paul Brotherton Rescue 1
  • Firefighter Jeremiah Lucey Rescue 1
  • Lieutenant Thomas Spencer Ladder 2
  • Firefighter Timothy Jackson Ladder 2
  • Firefighter James Lyons Engine 3
  • Firefighter Joseph McGuirk Engine

Take the time today or over the weekend to read for the first time or review both the USFA report and the NIOSH Report on the Worcester Cold Storage Warehouse fire. Start thinking about or reminding yourself what it is that we do as firefighters, fire officers and commanders.

Reflect upon the incident parameters, the building, the report and conditions upon arrival, command and operational integrity, company level responsibilities and duties, command fortitude and accountability. Think about your understanding of building construction, operational demands and training and skill set competencies.

More importantly, think about the duty, honor, courage, integrity  and sacrifice reflected in all the men and women on that day in 1999 and especially the brother firefighters who will always be known as the Worcester Six, but who were much, much more….

For a detailed overview of the Worcester Cold Storage Warehouse fire, go to Commandsafety.com HERE for a comprehensive posting.

IAFC FRI Company & Command Officer Leadership Symposiums

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The International Association of Fire Chiefs (IAFC) recently held its annual Fire Rescue International (FRI) Conference in the great City of Chicago. A stellar addition to extensive pre-conference and workshop presentations was the IAF’s comprehensive Flagship programs entitled; The Company Officer Leadership Symposium (COLS) and the newest addition, The Chief Officer Leadership Symposium.

New to 2010, The Chief Officer Leadership Symposium consisted of three days of education geared toward those newly promoted to battalion chief. Similar to the Company Officer Leadership Symposium (COLS), this program was built around and into a three-level course for those in various stages of their career. This year at FRI, the IAFC introduced level one for recent graduates of The Company Officer Leadership Symposium (COLS) program and those looking for education specifically geared toward battalion chiefs.

The three-day Company Officer Leadership Symposium (COLS) provided the perfect mix of what company officers are looking for and what chief’s want for their company officers. The program offerings at FRI 2010 provided in-depth leadership education like for newly promoted company officers and those transitioning to battalion chief. Take a look at the program offerings at FRI for both programs HERE and HERE.

Some Key Reasons that drew participates to these programs included:

  • Great takeaways: All Company Officer participants received their own copy of the IAFC Officer Development Handbook
  • Unparalleled networking: build relationships as company officers and other battalion chiefs and commander that will benefit participants throughout their career and as they move up the ranks.
  • Returning company officers could build on their education and skills. Additionally, graduating from this program demonstrates exceptional professional growth for promotional assessments.
  • Participation in these symposiums is a professional development and mentoring opportunity that will benefit company officers, chiefs and the whole department.
  • No other program offers such comprehensive classes taught by industry leaders
  • New responsibilities come with this new title. Learn from those who have successfully made the transition to company officers and battalion chiefs and how to do effectively.
  • Strategic thinking. These sessions were designed to meet the needs of incident commanders out on the fireground while dealing with interpersonal dynamics in the station.
  • Learn from the best. According to the IAFC, no other program offers such comprehensive classes taught by prominent national fire service leaders.

TheCompanyOfficer.com and CommandSafety.com’s Christopher Naum, provided a key note general session delivery at the end of day one of the three day symposium and presented a powerful and insightful look at the Doctrine of Combat Fire Engagement 2010. Presented to a joint session of students from The Company Officer Leadership Symposium (COLS), the Chief Officer Leadership Symposium and participants of the iWomen’s 2010 Leadership Conference, the multi-media lecture was presented to a standing room only crowd of over 325 participants. The Doctrine of Combat Fire Engagement 2010 examined common attributes and emerging insights related to buildings, structures and occupancies that comprise typical response districts and the unique challenges during structural fire attack that require new insights and skill sets for company and command officers and fire service personnel.

Christopher Naum's Joint Session Presentation at IAFC FRI

The program examined and advocated strong principled new views of various buildings and occupancies, providing examples that define and determine how firefighters access, react and expect similar structures and occupancies to perform at a given alarm. Naum introduced defining new concepts related to Tactical Patience, Command Compression, Tactical Entertainment and aligned the Anatomy of Buildings on Fire, Building Construction and Reading Building Profiles and Occupancy Risk while stressing the importance of the emerging Tactical Renaissance and continued emphasis on the Everyone Goes Home Program and 16 Fire Fighter Life Safety Initiatives. The Predictability of Building Performance and the emphasis on dynamic command risk assessment aligned with defined fire suppression operations filled the two hour session.

If you are an emerging, newly appointed or practicing company or command officer, the IAFC ‘s Company Officer Leadership Symposium (COLS) and the newest addition, The Chief Officer Leadership Symposium should be on your radar screen for attendance at IAFC FRI 2011 in Atlanta, Georgia. Keep track of 2011 FRI announcements on the IAFC web page, HERE.

3*4*3 Reports

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I recently posted an article on CommandSafety.com that addressed a series of Major Influencing Fire Service Reports, Issues and Focus areas that should be on your radar screen. This was also the theme at the premiere of Taking it to the Streets on Fire Fighter Netcast.com . As an emerging, practicing or upward mobile fire officer, commander or leader; those are but a few key ares that you must be  knowledgeable in, have insights and proficiency based technical skills to function with a level of competencies demanded of, in today’s  fire service.

After a recent training program, we discussed in a smaller group setting common, contributing and apparent causes related to three prominent fire incidents and reports that were shared both within the lecture program and also within the CS post. Based upon that dialog, the dynamic and passionate discussion and the frank, straight forward opinions I’m suggesting you take the time; three hours to read three reports and focus on the lesson learned, the gaps that were identified and the recommendations AND actions that were implemented to limit, if not eliminate the likely hood that a similar event could happen in that organization.

The continuing challenge is not allowing the circumstances and situations that were present at those events, cause you and your organization to have a History Repeating Event (HRE).

Set aside three hours for three reports; invest the time appropriately and focus your undivided attention. Think about those firefighters who answered that call, in the same manner and fashion as all of us do, when we board the apparatus and the company rolls out of quarters on the way to the alarm. The only difference…..they didn’t come home- you did. Learn, understand, comprehend, relate and apply.

Then take the time to share your insights with those within your inner circle and start recognizing that there’s likely something that you can go in your house or station, or organization that honors the sacrifices made by those LODD events your read about, so those lessons can be moved forward to make the job, a little bit safer.

Three for Three (343)

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

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

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

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

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

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

Knowledge of Building Construction; Are you Prepared?

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Check out the latest posting at our sister site Commandsafety.com for the latest release of Buildingsonfire.com’s Building Construction Training and Lecture Series for 2010. Recently updated with a series of new seminar and training program topics addressing the emerging training and educational needs of the fire service, these programs provide timely and relevant information and insights on Building Construction, Command Risk Management, Dynamic and Extreme Fire Behavior, Occupancy Situational Awareness, Engineered Structural Systems and Fire Fighter Safety.

These programs also present and integrate cutting edge research and emerging concepts on Tactical Patience, Tactical Entertainment, Command Compression, Structural Anatomy of Buildings, Five Star Command Model, Predicative Strategic Process, refined Tactical Deployment Models integrating intelligent Structural Anatomy and Predictive Occupancy Profiling and much more.  You can download the training brochure at the following link also; Building Construction Training Brochure 2010

What’s your level of knowledge, skills and education on Building Construction, Fire Dynamics, Extreme Fire Behavior, Occupancy Profiling and Combat Fire Engagement?

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