Firehouse® Magazine Contributing Editor Steve Meyer and I worked together on this column. Steve reported on the incident, obtained official investigation reports and interviewed the fire chief at length. Additional facts and commentary are based on my subsequent discussions and meetings with Wessel.
Part one was based largely on Wessel’s description of the fireground operations, including his decision to leave the scene to transport a child to the hospital. This installment focuses on the aftermath of the tragedy, the investigation and the lessons learned. Please read this gripping story as well as our related recommended practices and comments.
As to why he, as incident commander, left the scene, Wessel explained his rationale at the time:
- No one else was available to care for the baby. All other responders were committed.
- No EMS transport was available. The baby needed to get to the hospital immediately. The chief was doing CPR on the baby on the sidewalk when a police officer pulled up and asked if he needed help. The hospital was only six blocks away.
- His assistant chief on the inside had 25 years of experience. Two of the victims were out of the building, and the third victim was in the hands of a firefighter and on the way out.
“I thought to myself, we’ve got this thing handled,” Wessel recalled. “But leaving the scene was a horrible decision, one that I will toss around in my head for the rest of my life. Was it right or wrong? Would things have changed if I had stayed there? I don’t know. Non-emergency services people who armchair quarterback, if they have a decision to make, they have the luxury of people they can consult with. In the emergency services, we don’t have that luxury. We make a lot of critical decisions in a short period. This is another thing we’ve learned: you don’t have a lot of time. A situation that looks stable can go to hell in seconds.”
The incident reports detail that Wessel left the scene at 8:35 A.M. He was gone for three minutes, transporting the baby to the hospital, and was back on scene at 8:38. It was in that brief period that the tragedy unfolded and was discovered when another firefighter went to the door of the house to find that the 11¼2-inch hose stream stretched inside was burned in half and free-flowing water.
Toward Greater Awareness
Wessel reflected on what the incident has done to the department’s demeanor: “Prior to the incident, this department had turned into an island. Now, there is more of an appetite to go out and see how other departments do things and look at new ideas. There’s an awareness within the department now that there is greater knowledge out there than what we knew from what experience we’ve had. I think that if we were confronted with a similar situation today, the decision that would be made is, what can we do to maximize firefighter safety?
“With the experience we have here now, we’ve realized that trying to conduct rescue operations without also conducting ventilation and fire suppression is very risky. We don’t have more engine and truck companies coming in to do those functions, so we have to limit ourselves to doing only what we can do. We do have excellent relations with our neighboring volunteer fire departments and they are responding with us faster and much more often, as determined by the IC (incident commander). If we see someone in a window that needs help, that’s where we’re going to concentrate our efforts. But, if we’ve got someone trapped inside, we’ve got to gain control of the situation first, whether it be ventilation or fire suppression that accomplishes that, before we can attempt the rescue. That’s where tradition and pride has to take a back seat.
“I don’t want to have to go visit the family of another firefighter as now it is clear – my firefighters are my number-one priority. If our new philosophy means a delay in our ability to rescue a civilian, then that’s what it means. My mindset has changed significantly in regard to life safety. I think the trickle-down effect from focusing on firefighter safety will only enhance civilian life safety. We’re not doing our civilians any good if we’re not operating safely ourselves.”
Investigators later determined that low-density fiberboard ceiling tile and other interior finish components were contributing factors to the rapidity of the flashover that killed the three firefighters. It was also determined that there had been an extensive burn time before firefighters arrived; that, in combination with the structure’s balloon construction, played a role in the fire’s behavior.
The National Institute of Standards and Technology (NIST) participated in the investigation along with the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) and the National Institute for Occupational Safety and Health (NIOSH) and did computer modeling of the fire scenario. One lesson learned from the fire modeling was that opening the front door, along with the window that the mother had opened when she escaped, caused fire dynamics that resulted in what NIST investigators termed a “thermal blast.”
The computer modeling brought another stark realization to Wessel.
“From watching the computer models and looking back on my career here,” he said, “I had to ask myself, how many times have we come this close? How many times have we skirted disaster? I remember a fire we had in the basement of an old hotel one night several years back. Four of us went down into it with two hoselines. The smoke was thick and dark, and the heat was searing. The only other person on scene was a rookie at the control panel of the truck. There’s no reason why we should have been down there.”
Wessel has an interesting observation regarding the management philosophy of hazardous materials incidents and fires: “We’re not killing firefighters at hazardous materials calls because of the cautious way we respond to them, but we’re killing firefighters when we respond to fires.” So, he suggests firefighters be as cautious in their approach to fires as hazardous materials incidents by:
“If you can’t do a job safely,” Wessel said, “then the only thing you can do is figure out what you can do to minimize its impact.”
Operational Safety
Wessel documents several steps the department has now taken operationally to ensure enhanced safety for its personnel. First, implementing a rapid intervention team policy and determining what can be done to get off-duty personnel and mutual aid resources on scene quicker. An obvious observation is that if we don’t place our firefighters in “beyond capability harm’s way,” the need for a rapid intervention team is minimized. “Of course, we want to do what any other firefighter wants to do – save lives – but we must protect our firefighters as the top priority, even before those who call us.”
Enhancing accountability at the emergency scene is critical – and that means radios that work. Securing enhanced communications so the location of every firefighter and what he or she is doing is known. Before this incident, just the officer had a portable radio. Now every firefighter has one. The department is getting away from “10” codes and going to plain-English in radio communications.
New Policy on Mutual Aid
“This incident has certainly changed our policy as far as calling in neighboring volunteer departments for mutual aid,” noted Wessel. “We are now more conscious of our limitations and because of the amount of support we received from our neighboring departments, our relationship with other departments has greatly improved. We relied on our neighbors to protect our district while we were crippled. I hate it, but there’s always been this barrier between volunteer and career firefighters. I’ve learned that there are volunteer and career firefighters. Both have professionals in their ranks and both have members who are less than desirable. I’d like to see the gap between the two removed, but I’m not sure it ever will be. I don’t care what anyone says, a good firefighter isn’t in it for the money. It’s something inside of them and that’s it.” The KFD also trains regularly with the volunteer departments that participate on mutual responses.
“I also feel it is my duty in the budgetary process to request more personnel, but the city budget is such that just keeping numbers where they are is difficult. It is something I will continue to strive for, particularly in light of NFPA 1710. Another thing firefighters need to understand is the limitations of the equipment we use. Our guys had both integrated PASS (personal alert safety system) alarms and personal PASS alarms. They all failed. If you’re inside of a room when it flashes over, your gear may survive the heat and the flames, but your body won’t.
“OSHA investigators arrived on Jan. 18, less than a month following the incident. The only thing the department was written up for was not having a written respiratory protection (SCBA) program, and that was regarded as an ‘other than serious’ violation. There was no fine. I felt very good about the way all the OSHA investigators conducted themselves. They came in and did not act in a way that intimidated anyone in any way. In fact, I actually found them to be some help and comfort through the early phases of dealing with this.
“The real bottom line is if you really want to increase the safety factor for firefighters and civilians, you need a good comprehensive smoke detector program in your community. A 95-cent battery could have saved all six of these people’s lives...
“The deaths of three Keokuk firefighters have left a void that for years to come will not go away. The loss is one that many will never understand and hopefully will never have to understand. I believe the department is a closer, more cohesive team now, working harder than ever to provide the protection this community deserves. The absence of our brothers from our midst is difficult to accept, but it does not even compare to the pain and sorrow that has devastated the families of the three. The loss of a husband and father have had insurmountable affects on the loved ones left behind. My career has been full, from the best of times to the worst of times. If granted one wish in life, I would change that day, that fire, those moments.”
Chief Goldfeder comments:
Some of you are reading this and thinking that there really isn’t anything “new” about this fire and the lessons learned – and that’s correct. In this country, we continue to injure and kill firefighters the same way over and over. In many, many cases, this kind of fire, the “bad” fire, is what I have started calling the “101st fire.” The 101st fire (or “101st incident”) is the fire that “finally” catches up to us after we get caught doing things a certain specific way over time.
As Wessel stated, the Keokuk firefighters had been to fires like this dozens of times before, but this time something went terribly wrong. The 101st fire may not be 101 fires away – it can happen a lot quicker – but knowing this and maintaining an attitude of NOT wanting to experience it, the 101st fire potential can be reduced significantly. Yes, this fire in Keokuk killed three firefighters and was, essentially, a horrible close call for the remaining chief, lieutenant and firefighter. But, in the case of the KFD, an aggressive want and need to change set the plan for the future. How many “bad events” have occurred at other fire departments where there was no change following the tragic results?
What can be done to work on preventing the 101st fire? Planning ahead now and looking honestly at the obvious changes needed in your department is the first step. Sometimes, that’s not so easy to see, but by using national standards and related experiences such as this fire (and so many others) and applying relevant and interesting regular training, the “odds” are decreased greatly. Every day must be a training day.
Sharing What We Learn
What are some of the items on a “check list” you can look for to help improve the survivability of your firefighters? One of the best and most recent documents made available is the Cincinnati Fire Department’s very well-written, detailed, highly professional and frank report reviewing the recent tragic loss of Firefighter Oscar Armstrong. As discussed in a recent editorial in Firehouse®, the entire report can be viewed at http://www.wcpo.com/news/2004/ local/03/30/report.pdf.
While the 200-plus-page report provides critical and highly detailed insights on the tragic fire, we urge all firefighters, officers, chiefs and commissioners to at least pay specific attention to Chapter 7, titled “Lessons Learned and Reinforced.” This section covers 47 specific, easy-to-understand points that can and should be used by any fire department as a “map” and guide to preventing firefighter injury and death.
So many fire departments have not shared their lessons learned for a variety of reasons. In this Close Calls column, the members of the Keokuk Fire Department, and specifically Chief Mark Wessel, have gone out of their way to help other departments to not go through what they went through. Additionally, the Cincinnati Fire Department has opened up its experience to the fire service so, again, others will not have to go through what its members went through.
All we have to do now is to pay attention to what they have to say – and to aggressively apply their lessons learned – as opposed to allowing history to repeat itself.
William Goldfeder will present “Scared Straight on the Fireground” at Firehouse Expo 2004 in Baltimore, July 13-18.William Goldfeder, EFO, a Firehouse® contributing editor, is a 31-year veteran of the fire service. He is a battalion 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 and 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 website www.FirefighterCloseCalls.com. Goldfeder may be contacted at [email protected]. Steve Meyer, a Firehouse® contributing editor, has been a member of the Garrison, IA, Volunteer Fire Department for 22 years, serving as chief since 1985. He is past president of the Iowa Fire Chiefs Association. Meyer is a graduate of the National Fire Academy’s Executive Fire Officer Program, and is a contract instructor for leadership and administration with the NFA. In 1998, he was presented the State of Iowa Firefighter of the Year award.
