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...
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- 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.