Lessons Learned In San Francisco

The San Francisco, CA, Fire Department's goals are to provide the highest quality of emergency services and to promote community participation in fire prevention and disaster preparedness. Protection is provided to those residing in the 49 square miles of...


The San Francisco, CA, Fire Department's goals are to provide the highest quality of emergency services and to promote community participation in fire prevention and disaster preparedness. Protection is provided to those residing in the 49 square miles of San Francisco and extended to an...


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The IC observed smoke conditions on the second floor and the roof change dramatically. The smoke became thicker, darker and more intense in its pressure. The incident commander ordered companies to back out of the second floor and off the roof because he believed the situation was changing for the worse.

The IC and the battalion chief (BC) assigned to fire attack on the second floor were advised by a firefighter that there was a firefighter down. The fire attack BC went to investigate and initiate rescue operations. The IC assigned the rapid intervention crew to assist in locating and removing the firefighter in distress. The firefighter was located, removed from the building and transported to San Francisco General Hospital. A fire captain, fire lieutenant and three firefighters working in the same area were also injured during the firefight. The fire attack BC suffered smoke inhalation and overexertion during the rescue. During the escalation of fire behavior, the IC ordered an evacuation of the building and a subsequent personnel accountability report (PAR) to ensure that all members were safe and accounted for. Seven firefighters were treated for various injuries as a result of this incident.

The investigation could not identify a single factor that caused the rapid change in conditions, but rather several events in rapid succession that led to extreme fire behavior. The chief of the department, recognizing this was a significant event resulting in many injuries, directed the department safety officer to conduct a safety investigation of this incident. A battalion chief and two captains were assigned to this team and immediately began gathering evidence, conducting interviews and sketching diagrams. All of this information was analyzed to assist in providing recommendations to the department.

The focus of this investigation was to identify what occurred and gain situational awareness to prevent this from happening in the future. The Safety Investigation Team examined every facet of the incident during the past months. The primary objective of the team's investigation and subsequent report was to identify the facts surrounding the incident, particularly actions or inactions that contributed to the injuries. The report contains the team's findings and recommendations, which are intended to correct the identified deficiencies and to prevent other firefighter injuries or fatalities at structure fires. The Safety Investigation Team recognizes and respects that crews encountered a challenging incident. On-scene personnel made split-second decisions and took action.

Command and control of any incident in the San Francisco Fire Department is acquired and maintained through the use of the Incident Command System (ICS). The system provides the tools for a plan, clear objectives, clear and acknowledged communications, and accountability for all members assigned to an incident. From these findings, the report makes recommendations for several areas of the department, including:

  • Training
  • Equipment
  • Policy enforcement
  • Policy development

The Safety Investigation Team gathered and analyzed many facts and conducted interviews of members directly involved in this incident. The team identified several events that occurred and that contributed to the injuries at this incident. These events include:

  • This was an intentionally set fire with the use of accelerants; therefore, fire behavior was erratic and unpredictable.
  • Orderly evacuation was compromised because the hallway and stairs were overcrowded.
  • There were water supply and pressure problems.
  • The 200-foot ready line that Engine 42 was operating suddenly "lunged" forward. This was immediately followed by the nozzle firefighter of Engine 42 requesting assistance.
  • Vertical ventilation was not completed due to the incident commander ordering the truck off of the roof.
  • There was a delay in the first floor (garage level) being checked for fire and a line being led to this area.
  • There was a dramatic increase in temperature from the floor and ceiling of the dining room and living room areas.

After conducting the investigation, the Safety Investigation Team suggests that the department: