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 San Francisco and extended to an additional 750,000 visitors and workers during the business day. Resources consist of 42 engine companies, 19 truck companies, 22 ambulances, two heavy rescue squads, two fireboats and multiple specialty units. Fire suppression companies are organized in two divisions and are further divided into nine battalions. The Airport Division is comprised of three firefighting companies at San Francisco International Airport.

Each engine company is staffed with an officer and three firefighters, rescue squads are staffed with an officer and three firefighters, and truck companies are staffed with an officer and four firefighters. In 2008, the San Francisco Fire Department logged 249,803 responses to 109,388 incidents.

Our sincere thanks to SFFD Chief of Department Joanne Hayes-White, Assistant Deputy Fire Chief Tom Siragusa and the men and women of the department, especially those who operated at this scene, for their cooperation in the development of this month's column.

It should be noted that Chief Hayes-White selected Assistant Deputy Chief Siragusa in the early-morning hours of Feb. 5, 2009, just following the Felton Street fire, to head a Safety Investigation Team tasked with compiling information and producing an investigative report. Unfortunately, chiefs must know ahead of time "who" in a fire department would be the most appropriate and qualified lead person in the event of a serious or tragic event. Even today, unfortunately, many chiefs fail to follow up with a comprehensive report to determine what went wrong — and what can be learned. These reports are always of value internally to the chiefs who have the courage to direct they be done. In many cases, chiefs share the findings with the fire service as a whole so that we all may learn. We applaud Chief Hayes-White for setting an example for other chiefs and officers in letting the information be shared. The most important thing any of us can do to honor any firefighters seriously injured or killed in the line of duty is to learn what happened, train on the issues and minimize the chance of history being repeated.

Assistant Deputy Chief Siragusa is a 27-year veteran of the SFFD and highly respected within the department and the fire service for his operational expertise, professionalism and vigilance regarding execution of a single action plan, safety, consistency and accountability on the fireground. As Chief Hayes-White wrote us: "Tom and his team did an excellent job in conducting a comprehensive investigation and completing a transparent, factual account of the events that occurred at the Felton Street fire."

The following account is provided by Assistant Deputy Chief Tom Siragusa of the San Francisco Fire Department:

On Feb. 5, 2009, at 12:26 A.M., the San Francisco Fire Department was dispatched to a report of a fire in the building at 627 Felton St. in the city's Portola neighborhood. This fire was determined to be an arson fire with accelerants used. First units arriving on the scene observed fire on the second floor in the left-rear corner of the two-story, wood-frame, detached building.

An aggressive interior fire attack was initiated through the front door, which is on the second floor. A truck company was assigned to perform vertical ventilation. A truck company assigned to the rear of the building discovered fire on the first-floor, left-rear area of the building and provided this information to the incident commander (IC), who promptly informed all units operating on the second floor that there was fire below them. The Fire Attack Group supervisor acknowledged this information and requested updates from the IC. The IC ordered companies to open the garage door and to lead hoselines into the garage to extinguish fire.

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:

• 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."

About a dozen years ago, I was riding with John Salka, fellow Firehouse® Magazine contributing editor (see page 126), fire operations junkie and chief of the FDNY's 18th Battalion in the Bronx. When we ride together, we catch some fires. This tour was no different. Upon arrival and while operating at a working project fire, a company did not do what it was ordered and expected to do. At that fire, the officer and his company decided to what they wanted to do. Dumb move. When John was done with the fire, and done with the officer of that company, it was crystal clear who gave the orders on the fireground and who was expected to follow them. Follow your orders as ordered. A chief must expect and demand no less from those under his or her command.

There are chiefs and officers on the fireground for a reason — they are there for officers and companies to do as ordered and expected. When you are operating interior, you have your limited, but critical perspective. The IC outside has a larger, better perspective (including details from your reports), so generally the IC knows best. And while doing as ordered, be sure to communicate with them any unusual circumstances that may prohibit their desired outcome. The fireground is not a debate club meeting or a place where we can take time to discuss and barter tasks while the fire burns. When operating at a working fire, follow and comply with orders immediately with full discipline.

• Who is assisting command? While some communities have "chiefs' aides" on the first alarm, what do you have? What is the plan at your fire department to ensure command staffing initially to support companies arriving and operating?
• Tracking and accountability. It's almost 2010 and we must operate with full command and control on the fireground — and that means all aspects of the ICS know where all the firefighters are operating. This also means for all firefighters to understand the conditions around them, including crowding within the interior, and a means to get out. Tight, confined areas can be a nightmare to firefighters operating — especially when having to escape due to conditions. Maintaining company discipline both on and off the fireground — such as during training — will result in a more survivable fireground.
• Policy. What's the policy? Any policy? Seriously, determine any task that you are expected to perform on the fireground and then go find your fire department's policy on it. Have you found it? Good. Now train on it and follow it while at a fire. That's why we have policy.

Policy is:

1. Developed based on accepted practices, history and standards.
2. Trained upon to ensure that all members operating understand exactly what the policy and the related tasks are. Training includes instruction and hands on to ensure that we really understand and can perform the task.
3. Followed and complied with by all members while responding to and operating at the fireground.
4. Enforced by officers for the survival and safety of the members.
5. Enforced by administration, including corrective action when necessary, to ensure that members violating policies understand why they can't do that — and sends a message of fairness and consistency throughout the department that the policies are how the department will operate.

While there are many cases when officers must be trusted to make decisions, policy is what provides overall direction on how — based on standards, laws and experience by those who know — we are expected to perform from the moment we start probie school until the last run we make.

Can't find the policy? That's an entirely new issue for discussion, but in short form, raise the issue to those in charge and provide them with a suggested or sample version. It's impossible to expect a positive outcome and a disciplined fireground without clear, understood, trained-on, respected and enforced policies.

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 [email protected].