Critical Coordination!

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This account is provided by a reader. Chief Goldfeder's comments follow.

Our tower ladder company (quint) was dispatched to assist a neighboring community for a working building fire. The call came in after midnight and our on-duty crew of four responded with our battalion chief. I was the officer of the rig. While responding, information was relayed to us (from one of our off-duty officers who was at the scene in an unofficial capacity) that the fire was in a building approximately 100 years old, 50 feet wide in the front and rear with 80-foot sides. There was a restaurant on the main floor, apartments on the second floor and an open cockloft.

The fire was advancing and first-due units had been there for 11/2 hours prior to our dispatch. We were advised that the fire was extending into the cockloft and the roof needed to be ventilated. Our assignment was to lay our five-inch supply line to an engine in the rear as we approached and get to the roof and ventilate it.

On arrival, we could see the rear with considerable fire that appeared to be on the first floor, extending to the second floor and cockloft. We dropped the supply line to the engine in the rear of the structure and turned to the scene. The front of the structure had two large picture windows on both sides of the entrance and three windows on the second floor. The second-floor windows were not taken out yet and a positive-pressure ventilation (PPV) fan was blowing into the front entrance door.

While the crew set the tower ladder in place and gathered tools, I reported to the command post. There, the off-duty officer from our department (observing the fire in no official capacity) stated that the roof needed venting and firefighters were on the second floor, further stating the fire was getting into the cockloft. I never made contact with the incident commander.

As I returned to the truck, I brought our crew around the front entrance, shut down the PPV fan and took one firefighter to the roof with a chain saw, a circular saw with a multipurpose blade and axes. We reached the roof and found it in good condition. It was at this point that the mistakes started to happen.

As we got onto the roof, I thought to myself that I should put my mask on and advised the firefighter with me to do the same. My reasoning was that if we fell through, we would want to have them on. We donned our masks and started to find the place to cut. Remember, this was a mutual aid run and radio communications were not well coordinated. The department we assisted had a different frequency than we did, but communications were being relayed by the off-duty officer who was at the command post.

We went to the location in the back of the building where we had seen the fire on arrival. The fire was contained to that area and crews on the first floor had their 21/2-inch lines into the fire, while the second-floor crew had an 13/4-inch line. Smoke was coming over the rear (east) edge and obscuring our view. We backed off the edge and went to the center to find the "spongy area" without success. I then made the decision to just get something open for the guys on the inside. We started to make our cuts in the center of the building. We found the roof joists and it became just a vent job from there. By this time, other firefighters were making it to the roof, including the turntable operator.

At this point, the off-duty officer was calling me on the radio. I approached the front of the structure to make contact with him visually as well as by radio. He asked if we could reach the front windows of the second floor and take them out. I did this with a long pike pole. While I was doing this, the other firefighters were finishing the cutting and more air bottles were being brought up to us.

As I finished venting the front windows, my low-air alarm was sounding, so I returned to the area were the hole was being cut. A firefighter who was standing there didn't have his mask on and was unable to help. (This was the person who was supposed to be on the turntable.) Other firefighters came to me and stated that the hole was cut, but the decking had to be removed. Their low-air alarms were going off and they were returning to get fresh packs. I switched packs with one of the firefighters who, at this point, was physically unable to help any longer and I returned to the location of the ventilation hole.

By this time, the wind had shifted and was blowing the smoke from side C to side A, in the direction in which I was going. I put the pike pole down to scan the roof and feel for the opening. I just missed the hole and down I went - right into the hole.

In the blink of an eye, I went from walking to lying face down. I felt a sharp pain in my left shoulder and instant numbness in my fingertips. I remembered yelling out in pain, feeling tremendous heat on the front of my body and thinking this will hurt when I stop falling. But then I realized I had stopped falling. All this took place in the matter of seconds - the pain, the thoughts, everything.

I tried to lift myself out of the hole, but the pain in my shoulder was tremendous. The heat was intensifying and I knew I had to do something. I then realized that I was lying on the roof joists (luckily, they were not burnt through). I rolled to the right (my left shoulder was the one injured) and onto a stable area of the roof. I was scared, nervous, in pain and disoriented. I moved toward the west and, as I crawled out of the hole to the front of the building, other firefighters came to assist me up. This is the first time anyone knew I was in trouble - I couldn't get to my radio and I was in the hole for only 15-20 seconds. I got onto the bucket of our tower ladder and turned to find flames about 10-15 feet in the air issuing from the vent hole I had been trapped in.

At this point, we all made it down and the roof sector was terminated. The building was a total loss and one other firefighter suffered a minor leg injury. I was taken to the hospital treated, evaluated and released with a lacerated bicep tendon, superficial wounds to my knees and left elbow, and an obvious case of "I can't believe I'm still alive!"

Here are what I feel were the mistakes that were made and explain what I learned from this fire:

Building construction. The first mistake was made while we were responding. I didn't consider the type of construction we were dealing with. It was type III ordinary construction. Frank Brannigan refers to it in his book Building Construction for the Fire Service as "Main Street USA." The report that the building had been on fire for 11/2 hours should have sent alarms off in my head. Ordinary construction has a considerable amount of combustible voids and given the time frame of the fire involvement and the type of construction, we were approaching (if we had not already passed) the point when defensive positions should have been taken.

Masking up. I put my mask on "just in case I fall through the roof." I shake my head at this thought now. That protection is there not only for the worse-case scenario, but for smoky conditions as well.

The PPV fan. I am a supporter of positive-pressure ventilation, but only in the right environment. It has been my experience that the fire must be under control before a PPV fan can be deployed. This fire was far from being under control. Not only did the fire have a considerable amount of fuel, but now it may have had more of the supply of oxygen it needed.

Radio communications. We have over a dozen channels on our radios and a plethora of agencies that use them - police, other fire departments, our own tactical channels, etc. I should have found the right radio channel before ever committing to the roof sector. This is an embarrassing mistake and I am ashamed that I made it. Not only was the channel an issue, but also all commands were coming secondhand when I should have been in communication with the incident commander.

Freelancing. The tower operator came up the ladder and on the roof. Nobody was on the turntable or at the controls in the bucket. The what-ifs in this case are too many to write. If you are on the turntable, stay there! Fire could cut off the firefighters and the ladder would need to be repositioned, or tools may need to be lifted to the firefighters.

More bottles to the roof. You don't go to the roof and camp out. Get up there, get the job done and get down. Above the fire is the most dangerous place to be on the fireground. If you need more air, then you must sit for a minute. Air bottles last from 30 minutes to one hour under nonstressful conditions. Under stressful conditions the time is cut in half. Retired FDNY Deputy Chief Vincent Dunn writes about the dangers of overhaul and salvage in his book Safety and Survival on the Fireground. He states, "Exhausted and overexerted firefighters make poor judgment decisions on the fireground." Also, I took the fresh air bottle from the firefighter who was unable to help. I should have followed the advice above and gotten my own bottle. After all, the roof was open, and all I was going to do was finish pulling decking to increase the size of the hole.

These comments are based on Chief Goldfeder's observations and communication with the writer:

Since the writer did such an excellent detailed and honest job on this reported "Close Call," I will join him in his continued comments below with a few independent observations and closing thoughts. As in all "Close Calls" submissions, we genuinely appreciate the frankness and effort in sharing information so others can learn.

The writer: "When we were notified that the building was around a century old and the fire had been burning for 11/2 hours, I should have considered the extent of the fire, the fact that fire was in hidden voids and the structural elements were being attacked."

Goldfeder: A building that has been burning for that period of time REQUIRES us to think! The most critical issue here is structural stability and the risk/benefit of placing firefighters in or on the structure. In this case, two firefighters were hurt and the building was a total loss anyway - was it worth it? Not at all. First time you've heard that happen? Nope.

The writer: "I should have considered going right to a defensive attack and putting the deck guns in the windows of the second floor."

Goldfeder: Deck guns? Master streams? We talk about them, but rarely use (or train with) them - until the fire FORCES us to use them! A few thoughts that readers should consider: How fast can you deploy a master stream? What size/type nozzle is on the master stream? Will the "top-mounted" master stream on your pumper even reach the building or is the apparatus "command" or "high-top" cab blocking it? How safely and quickly can the master stream be removed from the top? What about considering tailboard-mounted "quick-deploy" master streams? This is a good time for all of us to check out how quick and safely these rarely used streams can be deployed and placed into operation.

The writer: "I should have communicated with the chief of operations and announced intentions so he could get crews out and have everyone accounted for. I should have disregarded the off-duty officer's orders and gone straight to the chief of operations. It is his fire and he runs it. Freelancing is freelancing. I should have had the right channel on our radios to communicate with him. I should have gotten the information on the location of the interior crews and location of the fire from the incident commander."

Goldfeder: "Communication" is so much more than your mother-in-law yelling at you. Only recently are we starting to figure out that fireground communication is important. Unfortunately, some systems have become so complicated that it only adds to the problems. Manufacturers and politicians please listen: We need powerful, simple-to-use (under fireground, not police, public works, or parks and recreation department conditions) and reliable fire service radio communication systems ... but that's for another article at another time.

Interoperability? That's a new buzzword, and it includes radio communication, but note that in this case the mutual aid departments did have common frequencies - it was "interoperable," they just didn't coordinate the use of radios when they arrived on the scene. The writer stated, "Remember, this was a mutual aid run and radio communications were not well coordinated. The department we assisted had a different frequency than we did, but communications were being relayed by the off-duty officer who was at the command post."

Responding on mutual aid requires pre-planning, which is also what interoperability is all about. We can't expect to run mutual aid (or automatic aid) with other fire departments and not know what channels to operate on, not know their standard operating procedures (SOPs), not know their hose connections and not know their ... anything! This requires planning BEFORE the tones go off. It should be noted that these two departments did use the same frequencies - they could have talked to each other - but the channel assignments to be used were not planned or coordinated. That is the responsibility of the incident commander as well as the officer of the crew before anyone goes inside.

The writer: "A building of this age could have been altered, even in the cockloft, and our cutting efforts could have failed. By the time we realized where we needed to be, our saw blade could have been dull and useless."

Goldfeder: The length of time that the fire has been burning, where it was and where it is going, plus construction/related alterations, plus current conditions are but a few indications of the predictable outcome. Almost anything burning and not declared "under control" for 11/2 hours is a problem with predictable outcomes.

The writer: "The turntable operator should have never left that area and I should have never, ever, have taken someone else's breathing apparatus."

Goldfeder: The operator must be able to reposition the stick in the event of a problem, either from the turntable or the bucket. You also stated, "I switched packs with one of the firefighters who, at this point, was physically unable to help any longer and I returned to the location of the ventilation hole." When an airpack runs out, it's time for you and those who went in with you to get out of the hazardous area, get rehabbed and get new bottles, if directed to. The roof is rarely the place to do that, unless you are involved in a rare life-saving action such as a member trapped, which was not the case at this point. As far as the member who was "physically unable to help any longer," if that member is unable to continue working, odds are the entire crew should be rehabbed or replaced.

The writer: "That night ended with no more injuries or casualties. I was transported, treated and released that evening. One of our chiefs took me back to the fire station, assisted me with the paperwork and made the call to my wife to take me home for the balance of the shift. My wife came and picked me up and we were well taken care of by our 'fire family.' For this, I am grateful. I got in the car with my pregnant wife and my little son and we went home. I looked at my wife and I have seen her look so great many times - the day we got married, when she had our first child - but on this night, this night was the best I have ever seen her. This is the purpose of this submission to 'Close Calls,' to show each other our mistakes, learn from them and let us go home to our families."

Closing Thoughts

Does this fire sound familiar to you? Sure. Unfortunately, this kind of situation happens a lot - "Close Calls" that almost ended up with tragic results. We have ALL been there. Sadly, some go further than just a "Close Call." The firefighters were lucky this time. How will the "roll of the dice" go at your next run? Vital "positive outcome ingredients" such as communication coordination, adequate staffing, rapid transmission of additional alarms, accountability, mutual aid training, and strict command and control are not always present. Aggressive focus before and during "the mission" by those in charge can turn that around.

Let's take a look:

  • Delayed response for mutual aid/multi-alarm companies. When you have a reported fire, have enough qualified help coming quickly to make a difference, and simultaneously accomplish the essential, basic firefighting tasks in a short time. If the building burns down after a slow or delayed response with poor or inadequate staffing, isn't that an indicator of a problem? The first-responding fire department and its incident commander are responsible for getting firefighters and equipment there quickly. A system that automatically dispatches the appropriate resources through pre-planning based on what you are responding to is even better.

  • The "truck company" was used for water supply before taking on the task of truck work, causing a delay. I like quints in some situations, but if you have a commercial building fire, decide what role the quint is going to take on and give it that task. In this case, if another supply line was needed, why not have an additional engine or quint company handle that and let the truck do what it was called on to do initially.

  • When you arrive on a scene, be sure of the command structure and know who is qualified or authorized to give you orders - and who isn't. Unfortunately, this isn't always easy, especially on mutual aid runs. In this case, the truck company officer arrived and took orders from an off-duty fire officer (from his own department) who was observing the fire, but not in a command role. If you "buff" a fire and have no command role, don't give orders. A simple yet strict, regularly practiced and disciplined use of the incident command system (involving the battalion chief) would have made this problem go away.

  • Positive pressure ventilation. I fully agree with this officer's decision to shut the fan down, but it should have been done in coordination with command. We cannot freelance decisions on the fireground. A quick call to command recommending that the fan be shut down would have solved the problem, but just shutting it down adds to the "I do what I wanna do" situation on the fireground. There was fire on all floors and in the cockloft, so a lone PPV fan was doing nothing productive at this point and may actually have contributed to the spread of the fire. Like any tool, PPV must be used when deemed appropriate by a trained and experienced incident commander.

  • The writer stated, "Remember, this was a mutual aid run and radio communications were not well coordinated. The department we assisted had a different frequency than we did, but communications were being relayed by the off-duty officer who was at the command post." All of this could have been avoided by planning ahead and training and drilling on the system used.

  • Have enough trained personnel standing by to replace firefighters whose bottles run out or who need to head to rehab, or to perform additional tasks. Don't wait until you may need them; act as if you will need them right now and have them at the scene, ready. We have said it before, but it is always worth repeating: It takes trained firefighters, and plenty of them, arriving sooner (vs. later) to accomplish the basic tasks at a structural fire. That is, if you want to deliver the best and true "customer service" to the public - and to the firefighters who are operating.

  • Sector officers "observing" are there to assist command with decision making. In this case, the roof officer was "working" the ventilation of the fire, so he couldn't see the big picture. Another set of eyes and ears on the roof (a sector officer or, at this fire, possibly the battalion chief) may have avoided some of the above-mentioned problems. Sector officers help the incident commander and others by providing the information needed to make safe and successful decisions.

Readers are asked to share their accounts of incidents in which firefighters found themselves in dangerous or life-threatening situations, with the intention of sharing the information and learning from one another to reduce injuries and deaths. These accounts, in the firefighters' own words, can help others avoid similar "close calls." We thank those firefighters who are willing to share their stories. We invite readers to share their experiences. We will not identify any individuals, departments or communities. Our only intention is to provide educational information and prevent future tragedies. We thank Contributing Editor William Goldfeder for compiling these reports. You may send your reports to him at chgold151@aol.com.


William Goldfeder, a Firehouse® contributing editor, is a 30-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 fire officer since 1982 and has served on numerous IAFC and NFPA committees, recently completing his sixth year as a 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 a writer, speaker and instructor on fire service operational issues.

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