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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  • Develop a policy for regularly checking radios for properly functioning microphones and batteries; identify who is responsible and what the procedure is
  • Purchase and install voice amplifiers on all self-contained breathing apparatus (SCBA) masks
  • Purchase and place reflective names on all turnout coats. During an emergency, this can be a life saver, in addition to normal accountability procedures
  • Research the latest technology in hood material
  • Develop a training bulletin/policy for stairway and hallway management
  • Conduct a comprehensive review of the emergency traffic policy
  • Conduct a comprehensive review of the operational evacuation policy
  • Develop a major injury/line-of-duty-death investigative team policy
  • Develop and enforce a policy on a standard location for command posts
  • Standardize and enforce the policy on assumption and transfer of command

An incident commander MUST:

  • Use the Incident Command System to ensure accountability on fireground
  • Use the ICS 201 form per the department ICS manual or the white board in the back of the chief's buggy to maintain accountability on the fireground
  • Ensure that an incident support specialist (ISS) assists the IC with command post operations
  • Establish a stationary and visible location for the command post that allows for proper command, control and accountability
  • Notify the Department of Emergency Communications of the location of the command post
  • Provide a plan with clear objectives when assigning an Operations Section chief
  • Ensure that there is a single ordering point for all resources requested for the incident
  • Establish and announce to all companies on the fireground the location of treatment, triage and transportation areas
  • Follow the department's rapid intervention crew policy
  • Ensure that crew/team continuity is maintained during fire suppression operations

The battalion chief at an incident when assigned as a division or group supervisor MUST:

  • Know the companies' positions and locations assigned to him or her before leaving the command post

Officers of the department MUST:

  • Ensure proper selection and deployment of hoselines
  • Remember that the preferred method of supplying another engine is backing down rather than driving by
  • Manage stairways and hallways to maintain safe fireground operations
  • Use the thermal imaging camera assigned to their company and advise the IC of findings
  • Have a single action plan
  • Designate at roll call the assignments of individuals on their crew and enforce those designations
  • Maintain discipline on the fireground
  • Check in with the IC prior to engaging in fireground activities or operations
  • Keep the IC updated on their locations, conditions, actions and needs

The members of the department MUST:

  • Not hesitate to use "emergency traffic" to relay critical information to the IC
  • Follow orders of the IC
  • Maintain company unity
  • Maintain the "buddy system" (enter, work with and exit a fire building with a partner)
  • Fulfill their apparatus assigned positions
  • Avoid overcrowding of stairways and hallways as to maintain safe fireground operations
  • Acknowledge and be aware that there may be fire on lower floors during firefighting operations

With regard to 800-MHz portable radios:

  • Not remove their microphones from their radios
  • Remove the remote microphone after fires and ensure that the connection between the remote microphone and the radio is clean and dry
  • Check the antenna for a snug connection
  • Remove radio ID tags, keys, and other metal devices from radios as to prevent interference

The Department of Emergency Communications MUST:

  • Adhere to the SFFD dispatch policies and procedures
  • Not initiate any action including an evacuation order and/or tone without being ordered to do so by the IC
  • Review emergency traffic and rapid intervention crew procedures
  • Synchronize all electronic data for times such as computer-aided dispatch (CAD), mobile data terminal (MDT) and audio tapes as to provide an accurate accounting of events

The following are observations and comments from Chief Goldfeder based on discussions with the writer as well as those involved in the incident:

Chief Siragusa provides an excellent summary of the incident and here are some specific areas worthy of further discussion:

  • Compliance with orders. All of us at one time or another have been operating at a fire, and when directed to stop or change a task, ask for "just a few more seconds" or minutes or whatever. And while it is admirable that we really do want to succeed in what we were originally tasked to do, we must do what we are ordered. No debate. No discussion. As they say, "Just do it."