This is the second part of a report about a fire that occurred on Nov. 21, 2009, in which two firefighters from the Wheat Ridge, CO, Fire Department became trapped and initiated a Mayday while operating on the interior of a working fire in a single-family dwelling. The Mayday was transmitted in response to an increasing lack of visibility, uncontrolled growth of fire conditions within the room, a loss of the primary means of egress and the lack of equipment needed to extinguish the fire. Our sincere thanks to Chief Steven Gillespie and the members of the Wheat Ridge Fire Department, West Metro Fire Rescue and Pridemark Paramedic Services for their willingness to share their story.
Details leading up to the Mayday event and the investigation:
A review of the dispatch tapes and Wheat Ridge Police Department report indicate that the woman who rented the property said she was home watching TV with her two sons, ages 1 and 5, when she smelled smoke. She investigated the source of the smoke and said she believed it was coming from her bathroom. She said she had been home the day before when a plugged-in space heater in the southeast bedroom (bedroom 1) caused a fuse to blow. She unplugged the heater without incident, but noted that some power in her kitchen, bathroom and bedroom 1 was not working on the day of the fire. That morning, the landlord replaced a fuse, restoring power to the areas affected.
When interviewed by a fire investigator, the occupant said her husband smokes outside, but he had not been home in three weeks due to work. She further stated that all lighters in the house were secured and inaccessible by her sons. The occupant's teenage daughter was not home at the time of the fire.
All electrical breakers and gas-supply valves to the house were noted in the off position. Firefighters document securing these utilities during fire suppression operations. No fire alarms or detectors were noted in the structure. Examination of the structure confirms firefighter statements and revealed damage in bedroom 1 consistent with a room-and-contents fire and subsequent overhaul.
Examination of bedroom 1 revealed a room containing contents consistent with that of young children, including books, clothing, toys and a bunk bed. Due to the report of electrical failure, a thorough evaluation of the room's electrical components was made. Two outlets with no evidence of arcing, short or radiant heat exposure were on the west wall with nothing plugged into them. A lamp was also adjacent to the west wall along with an extension cord and power strip. They were intact and showed no signs of internal arcing or short and only minor exposure to radiant heat. The space heater was along the east wall. It was not plugged in and showed no signs of arcing or short and only limited exposure to radiant heat.
A TV set along the south wall adjacent to the lower-level bunk bed showed extensive exposure to radiant heat. The TV was plugged into the unplugged power strip and extension cord. The TV consisted primarily of plastic exterior components and showed signs of melting on its east-facing side due to radiant heat exposure. Examination of the area just east of the TV revealed a bunk bed with mattress damage and frame charring most severe on the southern and southeast side of the lower bunk. The upper-bunk mattress and frame were damaged on the southernmost end but, as with the lower bunk, the damage and charring became less severe toward the north end of the bed. Two areas of clean burn were noted on the south and east walls consistent with the location of the lower-level bunk bed. Examination of the mattress springs after removal indicate sustained heat exposure in two areas directly adjacent to the areas of clean burn noted on the south and east walls. These areas of sustained heat exposure, or annealing, are identified by loss of tensile strength and compression of the mattress springs in those locations.
Examination of the area under the bed revealed a rug/carpet remnant and miscellaneous items that had evidence of heat exposure. The rug directly under the bunk bed and rug/carpet remnant was pristine in nature, after being cleared of debris, as was the area to the west of the bed and showed no signs of exposure to radiant heat or direct flame impingement. Based on these observations, the lower-level bunk bed is determined to be the fire's area of origin. It is further determined that the area of origin and the vicinity surrounding the area of origin are void of all potential ignition sources.
While excavating debris from the northeast area of bedroom 1, a disposable cigarette lighter was found along the north wall adjacent to the hinged side of the closet door. The female occupant said in her interview that all lighters in her residence should be secure and there was no legitimate reason a disposable lighter should be in a child's bedroom.
The investigation concludes that the fire was set in the lower-level bunk bed with an unknown external ignition source as no ignition or heat sources were in the area of fire origin. Furthermore, after a complete, thorough and extensive site analysis and excavation, the only identifiable source of ignition noted in the room was the disposable lighter.
Investigators hypothesize that the fire was set by the 5-year-old male occupant in the lower level of the bunk bed with the cigarette lighter that was discovered in the room of origin. The fire developed slowly and was controlled while in its early growth phase by the limited amount of oxygen available. The room is very small and the door to it was closed. Both factors would contribute to the limited availability of oxygen to the fire. Once the door to bedroom 1 was opened by the interior crew, additional oxygen was rapidly introduced into the room and significantly enhanced the conditions necessary for rapid fire development. Further enhancing the conditions necessary for rapid fire growth was the fuel package and arrangement. The combustible nature of the fibrous composition of the mattresses, combined with the upper mattress being exposed to heat on the underside from the fire below, created ideal conditions for rapid fire growth.
National Fire Protection Association (NFPA) 921, Guide for Fire and Explosion Investigations, defines a flashover as "a transitional phase in the development of a compartment fire in which surfaces exposed to thermal radiation reach ignition temperature more or less simultaneously and fire spreads rapidly throughout the space, resulting in full room involvement of the compartment or closed space." Based on this definition, the fire contained in bedroom 1, while intense, did not likely experience flashover.
Contributing factors leading to and resulting in the Mayday:
- Delay in the initial response to the fire. The fire occurred in the portion of the district covered by Station 71, but both lead apparatus were at Station 72. Neither lead engine was first due on scene and ultimately staged away from the incident scene.
- Delay in deployment of correct and appropriate equipment. A thermal imager (TI) was requested twice by the interior attack team, but was never provided. The apparatus-arrival sequence and on-scene apparatus placement as a result of factor 1 contributed to this problem since the TIs are located on the lead apparatus only.
- Delay in identifying the location of the fire within the structure. Fifteen minutes elapsed between the initial dispatches and locating the fire in the Alpha/Delta corner. The apparatus arrival sequence and on-scene apparatus placement as a result of factor 1 as well as the lack of appropriate equipment as a result of factor 2 contributed to this problem.
- Difficulty in accessing portions of the structure including the room of origin. The bedrooms, including bedroom 1, were down an extremely narrow hallway with multiple rooms requiring a search. To remain more mobile and to expedite a search of these rooms for the source of the smoke, the interior attack crew left the charged hoseline in the kitchen before entering the hallway. The remainder of the search was completed without a means of fire extinguishment. Once the fire was located, the interior attack crew could not immediately initiate a fire attack.
- Some instructions issued by the incident commander were not effectively carried out. Firefighter reports indicate that an officer ordered the firefighter instructed to deliver the TI to first rejoin his team. It took time for that team to regroup and delayed delivery of the TI to where it was not able to be used.
- Inaccurate radio communications led to a delay in action. While in the room of origin, the interior attack team requested horizontal ventilation at a window they perceived to be on the Alpha/Delta corner. However, the window was actually at about the middle of the Alpha side. There was a garage between the Alpha window and the Alpha/Delta corner. The ventilation crew initially responded to the Alpha/Delta corner only to find a garage and no windows, delaying ventilation to the Alpha-side window.
- Crew integrity was not maintained, leading to inaccurate and confusing personnel accountability measures and results. The interior attack crew was assembled with personnel off two separate apparatus. Initial reports immediately after the Mayday call could not confirm whether the interior team consisted of two or three firefighters. This resulted in significant initial confusion as to the location and status of some firefighters operating at the incident.
- The interior attack crew did not maintain control of their primary means of egress. Ultimately, the door to bedroom 1 closed with the interior attack team inside. This, combined with firefighter disorientation due to worsening fire conditions, eventually led to the attack team having to activate a Mayday.
- The interior attack crew did not maintain control of a means to extinguish the fire because the hoseline had been left in the kitchen as a result of factor 4.
- The interior attack crew did not maintain situational awareness. The initial incident commander and the attack team did not adjust their strategy or tactics to accommodate the rapidly changing conditions. As a result, the attack crew became disoriented and could not locate the exit door.
- Rapid fire progression. The following conditions supported extremely rapid fire growth:
- The arrangement of the fuel package. Two bunk bed mattresses with one being suspended above the initial fire and being heated from the underside.
- The small room size. This let the fire consume available oxygen quickly and therefore limiting growth until additional oxygen was introduced into the room. Furthermore, the ratio of room size to the available fire load fostered an environment where a significant amount of heat buildup occurred in a relatively short period during the growth stage of the fire.
- Sequence of ventilation. The dynamics of this fire were complicated by the lack of timely ventilation. Fire growth was controlled once the fire consumed the available oxygen in the small bedroom. No additional oxygen was introduced into the room until firefighters opened the door. Exterior horizontal ventilation would have lessened the speed with which the fire grew once the firefighters opened the bedroom door and would have altered the direction of fire spread.
The following comments from Chief Goldfeder are based on discussions and recommendations from the department's internal "after-action" report:
As we have seen before, firefighter close calls and worse are often the result of a "chain of events" that, in many cases, are seemingly minor in nature, but when combined, they lead to near-tragic or tragic outcomes. In this case, the lessons learned include:
- Take all necessary steps to prevent the accidental loss of an established means of egress and train all firefighters in techniques on how to maintain and protect a means of egress. All firefighters should be issued equipment (door chocks/door hangers) necessary to assist in maintaining control of a means of egress. In a recent line-of-duty death elsewhere, firefighters were unable to find their way out due to numerous factors, but one factor was abandoning the hoseline during extreme heat conditions. Basic and advanced training of knowing how to "get out alive" and "saving our own" can go a long way in minimizing risk.
- Develop, implement and enforce written standard operating procedures (SOPs) for all fireground operations. SOPs should be based on nationally accepted standards and best practices. Once they are developed, members must be trained on them so their actions reflect the intent of the SOPs. Periodically, SOPs must be reviewed and considered for change based upon new or adjusted recommendations, practices or standards. Keep in mind that some may be SOPs (policies, which are generally strictly adhered to) as opposed to SOGs (standard operating guidelines, which allow significant discretion based on conditions). Chiefs should determine which tasks are expected to be SOGs versus SOPs. (Note: If a fire department has SOPs, but does not train on them, does not operate based on them and officers do not enforce them, the department has accepted a significant and clearly predictable liability. It is essential that the way we operate matches the policies that direct how we should be operating!)
Ensure that all firefighters are trained on proper radio discipline and operation in order to effectively communicate with the incident commander. The fire department should reinforce the importance of efficient and accurate communications through incident command training and through clear and concise SOPs. Members should drill using radios and their training should include every possible feature of the radios and the radio system to especially ensure they (including the dispatchers) understand what their function and role is during Mayday incidents.
All firefighters should also be training on what to do during a Mayday, both if they are the Mayday firefighters or operating on the scene. Keeping what is required simple and minimal is critical, especially with Mayday-related procedures. Radios and radio systems are often taken for granted, but must not be. Today's modern digital systems are significantly different that former VHF/UHF systems and the fireground is not the place to find out those differences and issues.
- Ensure that the tasks assigned by the incident commander are carried out timely and efficiently and that actions are not taken to impede or distract from those tasks. The fire department should aggressively stop "freelancing" and encourage the efficient completion of assigned tasks through incident command training and through clear and concise SOPs that all are trained on.
- Ensure that a rapid intervention team (RIT) is available to immediately respond to emergencies and that a RIT is established as soon as is practical. In the best-case scenario, a RIT company should be a part of the first-alarm assignment, which may require automatic mutual aid in some communities. RIT companies also must be just that: RIT trained. Not every company arriving on every fireground is RIT trained.
- Ensure that team continuity is maintained and that personnel accountability systems and procedures are implemented quickly and completely. All firefighters should be trained regularly on maintaining team continuity. Furthermore, the personnel accountability system used by the fire department should be implemented on fire scenes immediately — and used on all incidents, fire alarms included — to ensure members operate within that system as second nature. The efficient and timely implementation of the personnel accountability system should be reinforced through incident command training and through clear, concise and trained-on SOPs.
- Ensure that all firefighters understand the importance and impact of the individual decision-making process on an incident and that each firefighter is prepared to implement a decision-making process that is both safe and effective. Training should address the need for each firefighter to develop the skills and abilities necessary to analyze a situation, evaluate options, and make strategic, tactical and safe decisions. Classroom, tabletop and hands-on training will help support that goal.
We are often asked for the one solution to minimizing a close call or worse. While so many answers can be included, the one common denominator in nearly every case is training, training and more training. From the day we join the fire department until we hang up our turnout coats, training can carry us all the way — if we want it to. While every fire department has the responsibility to provide the needed training, it is also up to us to do what we can do individually to ensure we exceed what is expected in relation to our ability (and interest) to train and operate as firefighters, officers or commanders.
WRFD Assistant Chief/Fire Marshal Kelly Brooks was the lead investigator and wrote the "after-action" report. For a copy of the report, please contact Kelly Brooks at email@example.com.
WILLIAM GOLDFEDER, EFO, a Firehouse® contributing editor, is a 33-year veteran of the fire service. He is a deputy chief with the Loveland-Symmes Fire Department in Ohio, an ISO Class 2 and CAAS-accredited department. Goldfeder has been a chief officer since 1982, has served on numerous IAFC and NFPA committees, and is a past commissioner with the Commission on Fire Accreditation International. He is a graduate of the Executive Fire Officer Program at the National Fire Academy and is an active writer, speaker and instructor on fire service operational issues. Goldfeder and Gordon Graham host the free and noncommercial firefighter safety and survival website www.FirefighterCloseCalls.com. Goldfeder may be contacted at BillyG@FirefighterCloseCalls.com.