NIOSH Report 2010-10 is out, and it ain’t pretty.
Pretty? Pretty hard to swallow…again.
The report once again shines the tired spotlight upon familiar factors that continue to injure and kill firefighters despite our commitment to “never forget.”
But we are forgetting.
First, a short review of the findings made by NIOSH on this interior attack on a well-involved residence with the report of people trapped inside.
On March 30, 2010 The Homewood (IL) Fire Department arrived and found heavy fire conditions at the rear of the house and moderate smoke conditions elsewhere inside. A search crew immediately entered to rescue a civilian trapped in the rear of the house, and a handline crew quickly advanced a 2 ½ inch line into the front door.
conditions as crews went interior (photo by Warren Skalski)
From the report, a photo of the A-B corner showing conditions prior to the hostile fire event in which thick, black smoke can be scene billowing out the front door, A-side. Although difficult to see in this photo, the A-side picture windows are covered in soot. What can we determine is going on inside as two are searching and two are operating a hoseline?
Here’s a shot of smoke blowing out horizontally from the B-side window after just being broken out by the firefighter there. Smoke is now pumping out with more speed from the front door. What is going on “inside the box” where the hoseline and search crews are operating? Now are we at a point in which we’re just about to kill firefighters?
At this moment, interior crews observed thick black rolling (moving) smoke banked down to knee level. As ventilation was taking place, the search crew saw flames rolling over through the smoke near the ceiling.
Then it happened.
That which we now all see from the comfort of our laptops and computer monitors- that which we have seen coming for quite some time in this story- moreover that for which we have been trained constantly- a hostile fire event (in this case a flashover) occurs.
It was inevitable here, and it was deadly here.
photo by Warren Skalski
According to the report, the search crew yelled to the hose crew to “get out” as they exited the building, then returned inside to rescue an injured hoseline firefighter. Once she was brought out, they returned in to find the victim firefighter trapped in his ruptured 2 ½” line with is SCBA facepiece removed. He was quickly removed and worked on the scene by paramedics before being transported to the hospital where he was pronounced dead.
What can you do, reader, to keep this from happening the next time you find yourself on this type of incident, all too common for firefighters throughout the nation?
Let’s see what NIOSH identified as factors which contributed to the death of one firefighter and the injury of another:
- Well involved fire with entrapped civilian upon arrival
- Incomplete 360 degree situational size-up
- Inadequate risk-versus-gain analysis
- Ineffective fire control tactics
- Failure to recognize, understand, and react to deteriorating conditions
- Uncoordinated ventilation and its effect on fire behavior
- Removal of self-contained breathing apparatus (SCBA) facepiece
- Inadequate command, control, and accountability
- Insufficient staffing.
From their investigation, NIOSH offers recommendations which can be extremely useful for any fire department member, officer, training officer, and command staff to get across to their organization before they respond to a similar incident. Here are their recommendations:
Recommendation #1: Fire departments should ensure that a complete 360 degree situational size-up is conducted on dwelling fires and others where it is physically possible and ensure that a risk versus-gain analysis and a survivability profile for trapped occupants is conducted prior to committing to interior fire fighting operations.
photo by John Ratko
According to this report, a 360 was not done prior to the interior attack, and here’s what they would have seen in this photo shot from the C-side.
Recommendation #2: Fire departments should ensure that interior fire suppression crews attack the fire effectively to include appropriate fire flow for the given fire load and structure, use of fire streams, appropriate hose and nozzle selection, and adequate personnel to operate the hoseline.
The report looks at the handline selection of the interior crew, pointing out the relative maneuverability that an 1 ¾” line has over the deuce and a half used here.
“Fire fighters and officers need to understand that while a 2½-inch hoseline provides a greater flow, fire fighters need to be able to move the line quickly and efficiently interiorly, especially when performing a search and experiencing deteriorating fire conditions.”
Recommendation #3: Fire departments should ensure that fire fighters maintain crew integrity when operating on the fireground, especially when performing interior fire suppression activities.
The report describes a point where the hoseline team became separated. The 2010 IAFC ROE of Structural Firefighting states, “Go in together, stay together, come out together.”
Recommendation #4: Fire departments should ensure that fire fighters and officers have a sound understanding of fire behavior and the ability to recognize indicators of fire development and the potential for extreme fire behavior.
From the report: “The search and rescue crew (operating without the protection of a hoseline) were able to make a quick determination that the conditions within the house were imminent to flashover. They made an attempt to alert the victim and injured fire fighter/paramedic, but were too late.”
“If conditions are right for a flashover, there are only seconds to make a decision. Fire fighters will be met with a sudden increase in heat and rollover within the ceiling level. The injured fire fighter/paramedic was unaware that the conditions she was operating in deteriorated quickly. She remembers thick, black smoke pushing down to the floor while in the structure and then “the room and everything in it caught fire.”
“Prior to the flashover, windows on the B-side were vented and thick, black and heavily pressurized smoke billowed from these windows. The IC, and individuals working on the exterior, need to recognize this as a potential for extreme fire behavior and evacuate interior crews. Obtaining proper training and hands-on experience through the use of a flashover simulator may assist interior fire fighters in making sound decisions on when to evacuate a structure fire.”
Recommendation #5: Fire departments should ensure that incident commanders and fire fighters understand the influence of ventilation on fire behavior and effectively coordinate ventilation with suppression techniques to release smoke and heat.
Again, from the report: “During this incident, uncoordinated ventilation occurred while the hoseline and search and rescue crews were inside the house. The victim and other fire fighters, within the small house, were between the fire and the ventilation source. One fire fighter accounts heavy, turbulent, black smoke pushing from a window on the B-side after it was broken. Shortly after, the house sustained an apparent ventilation-induced flashover.”
Recommendation #6: Fire departments should ensure that fire fighters use their self-contained breathing apparatus (SCBA) and are trained in SCBA emergency procedures.
The victim firefighter was found with his facepiece removed. No conclusion has been drawn as to whether he removed it or whether it became dislodged from an exterior force. But the report emphasizes that firefighters be trained on those SCBA emergency procedures which have been shown to offer the best possible chance for survival.
Recommendation #7: Fire departments should ensure that adequate staffing is available to respond to emergency incidents.
See if you’ve heard this type of staffing report before:
“During this incident, the victim’s department responded with three personnel on the engine and two personnel on the ambulance, but the Still assignment also consisted of an engine, two ladder trucks, and a squad, with four fire personnel on each. It was routine to have an ambulance respond with an engine on a first due fire assignment. Due to short staffing, the ambulance personnel were tasked with fire suppression activities, thus taking them out-of-service as a medical unit.”
“Also, due to short staffing, the lieutenant/acting officer (IC) was required to ride and operate as the officer of E534. This removed him from his command response vehicle which would have allowed him to command at a tactical level versus having to potentially perform tasks.”
[Reader: Insert your emotional comment here]
Recommendation #8: Fire departments should ensure that staff for emergency medical services is available at all times during fireground operations.
During this incident, the victim and the injured fire fighter/paramedic responded in an ambulance. Upon their arrival to the scene, the IC immediately tasked them with interior operations due to staffing issues. The IC did not request an additional ambulance to respond to the scene for medical care until after the victim was down within the house. Additional resources (e.g., apparatus and personnel) arrived minutes after the ambulance’s arrival.
Recommendation #9: Fire departments and dispatch centers should ensure they are capable of communicating with each other without having to monitor multiple channels/frequencies on more than one radio.
During this incident, the IC had to monitor more than one radio and even had to go to the cab of his engine to accomplish this task. Having to monitor multiple radios and potentially take your eyes off the scene for a moment could be extremely detrimental to the management of the incident.
Recommendation #10: Fire departments should ensure that the incident commander, or designee, maintains close accountability for all personnel operating on the fireground.
During this incident, the accountability system was never set in place and a PAR was not conducted following the Mayday.
Recommendation #11: Fire departments should ensure that fire fighters wear a full array of turnout clothing and personal protective equipment appropriate for the assigned task while participating in fire suppression.
During this incident, the victim was discovered without a hood over his head or rolled down on his neck. NIOSH investigators could not determine whether this equipment was properly donned prior to the incident.
Recommendation #12: Fire departments should ensure that a separate incident safety officer, independent from the incident commander, is appointed at each structure fire.
Although there is no evidence that this recommendation, or certain others made above would have prevented this fatality, it is being provided as a reminder of a good safety practice.
Recommendation #13: Fire departments should ensure that all fire fighters are equipped with a means to communicate with fireground personnel before entering a structure fire.
During this incident, the victim did have a radio, but it was positioned in the back pocket of his station pants. Thus, when he donned his bunker pants, his radio became inaccessible during the incident.
Recommendation #14: The National Fire Protection Association (NFPA) should consider developing more comprehensive training requirements for fire behavior to be required in NFPA 1001 Standard for Fire Fighter Professional Qualifications and NFPA 1021 Standard for Fire Officer Professional Qualifications.
Here, here! Let’s not forget the basics: Building Construction and Fire Behavior! Check this out and compare it to your training records:
“According to documented training reviewed by NIOSH investigators, the victim, injured fire fighter/paramedic, and IC had a combined 24 hours of fire behavior training out of 5,654 total combined training hours. Additional fire behavior training to include such areas as theory, chemistry, physics, smoke reading, current research, and the cause and effects of tactics during fire suppression operations may improve fire fighter safety.”
24 HOURS BETWEEN THE THREE OF THEM!
Again, I ask you, “How can the death of brother firefighter Brian Carey teach us that his life was not lost in vain?”
Again, I tell you: “Learn from what happened from that day. Then perform a long hard look at the way your organization operates, and utilize what you’ve learned here to make the changes necessary to ensure you and your brothers head home after the fire.
I can tell you that the news reports here in Chicago are all approaching this story from the standpoint that the fire department was “ill-prepared” in this case. Imagine how this sucks for this fire department, and each of the members that have to re-live the events of that night all over again- this time while being publicly undressed in the press.
Then empathize with them and ask yourself how you would feel- as a proud firefighter- if this had been your department?
Don’t allow yourself the superficial response of pointing your finger at this department. That won’t help now. Instead, turn the finger back toward yourself and create from this tragic story a positive learning experience and opportunity to improve your situation.
To donate to the Brian Carey Memorial Fund, visit www.rideforboo.org. The site also offers registration for those interested in taking part in the ride to Colorado. Donations also can be made at any First Midwest Bank branch or can be mailed to: Brian Carey Memorial Fund, P.O. Box 1171, Homewood, IL 60430. For more information about any of the events, contact Mike Bell at (708) 653-1394
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