As reported in parts one and two of this column in the July and August issues, on Feb. 24, 2012, the Prince George’s County, MD, Fire/Emergency Medical Services Department (PGFD) was dispatched to an arson fire in a single-family house at which seven firefighters were injured. Given the severity of the injuries and the magnitude of the event, an investigative team was ordered by Fire Chief Marc S. Bashoor, in accordance with the department’s General Order 08-18: Safety Investigation Team (SIT). This series of columns provides an overview of the fire and the process used to determine what went wrong – and how those issues can be avoided in the future.
Additionally, the Prince George’s County Fire/EMS Office of the Fire Marshal investigated the fire. Assisted by the Prince George’s County Police Department and special agents from the federal Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), the Fire Marshal’s Office determined the fire was incendiary in nature. At the time of this writing, this case remains as an open active criminal investigation.
This month’s concluding installment focuses on recommendations resulting from the safety and operational investigation report
The following is a color-coded list of recommendations resulting from the SIT’s report. This list is an excellent “check list” for ANY fire department to review and compare to its operations. The compilation of the SIT recommendations is grouped by priority type where red is immediate (life safety and firefighter survival), yellow is for short-term recommendations (relatively easy to implement) and green is for long-term recommendations (may require significant planning including fiscal impacts). In addition to being separated by priority type, these recommendations are listed in order of appearance in this report and the numbering should not be misconstrued as an indicator of further importance.
RED RECOMMENDATIONS
1. The department must develop a new training program to better qualify personnel to function in areas of responsibilities particularly in the areas of command, control, and accountability on the fireground.
2. Basement fire tactics must be revised to reflect current best practices. This should include the importance of getting water on the fire as quickly as possible and not placing personnel unnecessarily above the fire, or in its flow path.
4. Incorporate a 360-degree survey and the evaluation of environmental conditions as part of the strategic and tactical plan development into future revisions of the General Orders:
• The first-arriving officer must make every practical and reasonable effort to complete a 360-degree survey prior to making entry.
• Emphasize the importance of continuous situational reporting from critical units, divisions, and groups.
15. Modify General Order 06-01 to include a procedure for emergency evacuations during fireground operations:
• Develop policies that require the incident commander to ensure a personnel accountability report (PAR) is completed when incident conditions change.
• Develop a standardized Mayday quick reference guide to be used by all command officers. The quick-reference guide must detail steps to be taken when a Mayday occurs. These quick reference guides should be carried on every command vehicle.
19. All personnel shall review triage procedures for handling multiple-casualty incidents (MCIs) and the various roles required to mitigate an MCI.
20. The department should consider placing additional EMS supervisors in service in the northern and southern areas of the county to allow for shorter response times and greater geographical coverage. Multiple EMS duty officers would allow supervision of the various divisions within the EMS group, such as treatment area and transportation area.
26. Establish a work group to review and define pertinent and vital airable information and when it must be delivered to responding units. This may be accomplished via mobile data computers when available.
29. General Order 03-13: Emergency Identifier Activation Procedure and General Order 06-14: Mayday Procedures need to be reviewed and tenants of both policies need to be combined. Additionally, revise the General Orders to include an automatic dispatch of an additional assignment for any Mayday transmission.
31. Ensure that the Fire/EMS Department Communications Manual for the 700/800 MHz radio system is completed and it details all functions and operations of the system.
34. Update Subtitle 11 to include up-to-date training certifications and standards.
36. Develop and implement an officer development training program for career and volunteer personnel who are non-officer certified so that they may act as unit officers. At a minimum, these programs should address:
• Risk-benefit analysis
• Strategy and tactics
• Building construction
• Fire spread and extension (e.g., exterior fires with interior extension)
• Crew integrity
• Crew resource and situational awareness management
• The Incident Command System (ICS), particularly expansion of the command structure
• Command-level decision-making and practices (e.g., escalating incidents, high-risk/low-frequency events)
37. Require Mayday training for all operational personnel that is taught in compliance with the General Orders and includes an annual refresher training component.
41. Develop and deliver a training program to all personnel that provides instruction on wearing all personal protective equipment (PPE) properly and emphasizes the importance of wearing only department-approved items that are National Fire Protection Association (NFPA) compliant.
45. Check all self-contained breathing apparatus (SCBA) cylinder valves Department-wide to ensure that the cylinder hand wheel lock nut is not turned in on the stem eliminating the designed safety feature that prevents the cylinder from being accidentally turned off.
YELLOW RECOMMENDATIONS
3. Develop and implement a formal process to disseminate adverse weather advisories/alerts to ensure all personnel are aware of changing conditions to aid during initial on-scene size-up.
5. Develop a department-wide training program that focuses on understanding fire behavior, fire flow paths and how to “read” interior and exterior smoke conditions to identify the location and predicted spread of a fire.
8. In an effort to ensure all fireground activities are coordinated and prevent freelancing, the department should consider modifying General Order 06-01 to control the deployment of units on a fireground; e.g., first engine and special service operate and the remaining units stage until directed by command.
9. The department should strictly prohibit any personnel from responding to the scene in their personally owned vehicle.
10. Develop and implement formal, system-wide policies, procedures and training related to “two-in/two-out” rule compliance. Such policies and procedures should address the following:
• Identify what unit is to assume/assign the “two-in/two-out” responsibilities
• Require verbalization of “two-in/two-out” compliance over the tactical radio channel
• Require the “two-out” crew to accept that assignment over the tactical radio channel
• Ensure the adherence of the “two-out” regulations of the second-due engine until the arrival and establishment of the rapid intervention crew (RIC)
• Identify the specific criteria required in order to deviate from this policy
• Review and modify all current General Orders to ensure there is no conflict with the newly established policy
11. Revise the General Order to ensure the RIC assignment changes from the third-due special service to an earlier-arriving unit.
12. A simple and standardized command check list or guide should be placed in the front seat area of every piece of apparatus within the county for easy, “at-a-glance” use.
21. Develop a formal callback procedure/activation plan for the Critical Incident Stress Debriefing (CISD) Team and inform/educate all command officers on this procedure.
22. The department needs to adequately staff the CISD Team and should use the latest findings and suggestions available from the National Fallen Firefighters Foundation (NFFF) as a template. This service should be available to the department at all times.
23. The department needs to develop and implement a comprehensive Behavioral Health Program with adequate professional behavioral health staff to support all personnel.
24. The department needs to provide a comprehensive in-station refresher training on the behavioral health services that are available to all career and volunteer personnel.
25. Consider utilizing community clergy to assist in providing CISD services to members and families in cases of firefighter injuries and deaths. This would increase the team size and increase the involvement of the department with the community.
27. Evaluate the current working fire dispatch policy and consider adding additional units. Consideration should be given to adding a large-diameter-hose company, an additional rescue squad, an additional truck company and additional chief officers.
28. Consider establishing a command talk group between the command post and communications to provide direct communications, requests for additional resources and provide incident updates without interfering with critical transmissions on the tactical talk group.
30. Develop a policy that requires a task force or greater assignment to respond on a different talk group from the tactical talk group.
33. Develop a General Order outlining how the firefighter’s portable radio is to be carried during firefighting operations to provide the maximum thermal protection for the radio and enhanced firefighter safety.
44. Standardize the labeling and painting of SCBA and SCBA cylinders department-wide.
GREEN RECOMMENDATIONS
6. Amend the General Orders to require incident commanders to prioritize and announce critical information, including strategy (defensive/offensive operations) that will impact incident outcomes and tactics, as a part of the initial size-up report. This should also include classroom and hands-on command, control, and accountability training.
7. Consider adopting guidelines of the International Association of Arson Investigators (IAAI)/U.S. Fire Administration (USFA) “Vacant and Abandoned Building Project/Toolbox.”
13. ONE standardized county-wide tactical command sheet/board must be used in any multi-unit response to ensure command and control of incident operations.
14. The department should consider the use of chiefs’ aides. This position would most likely be a captain or lieutenant so that there is a form of mentoring associated with this assignment. This can further enhance the development of the line officer into the role of a chief officer.
16: Develop and implement system-wide policies and procedures related to personnel accountability utilizing the passport system. Such policies should address the following:
• Requiring personnel verify the passport and unit roster as quickly as possible after arriving for duty.
• Requiring personnel to drop their passports off at a predetermined location, immediately after arriving on the scene of an incident.
• Standardize the location of unit rosters and passports.
17. Develop a structured transition and implementation plan to achieve standardization of apparatus and equipment. The structured transition and implementation plan must include a process for the removal of non-standardized apparatus and equipment from the system’s inventory. Consideration should be given to:
• Standard hoselines (supply and attack lines)
• Standard complement of nozzles (nozzle types, standardized pressure and gpm flow, etc.)
• Standard hose load configurations
• Standardize appliances to be used (i.e., four-way hydrant valves, blitz nozzles)
18. Develop a system-wide plan that shall identify the deployment and distribution of all apparatus. This plan should be routinely evaluated for optimal strategic placement of apparatus and consider emerging technologies.
32. Work with the radio manufacturer to develop an extension microphone cable that is better protected from the effects of high heat.
35. Develop and implement a centralized, standardized system-wide record-keeping system for all training-related records, for both career and volunteer personnel.
38. Develop a department-wide policy that requires personnel to wear 100%-cotton garments under uniforms. This should include verbiage that prohibits the wearing of synthetic “moisture wicking” fitness apparel at any time while on duty. Combined with properly worn PPE, this will provide better protection from thermal injury.
39: Provide and require that all newly acquired uniforms comply with NFPA 1975, Standard on Station/Work Uniforms for Emergency Services.
40. A department-wide policy should be implemented to ensure that personnel are provided a “matching” ensemble of coat and pants from the same manufacturer.
42. Develop and maintain a centralized database to track the issuance, inspection and maintenance of all PPE items. This information database should include (but not limited to) the manufacturer, manufacture date, serial numbers, model, size, last cleaning date and other pertinent information.
43. Revise General Order 10-03: Cleaning, Repair, Replacement and Alteration of Personal Protective Equipment to require an annual advanced inspection as outlined in NFPA 1851, Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Firefighting and Proximity Firefighting.
46. Ensure all filters in the primary and secondary pressure reducers are changed when flow tested. If a third-party contractor is used, this must be specified in the contract.
Assessing the incident
These comments are by Fire Chief Randy Kuenzli of the Bladensburg Volunteer Fire Department, PGFD Fire/EMS Station 809:
I can honestly say, in no uncertain terms, this clearly can and does happen to you. I have read the trade articles on these and many other kinds of incidents for many years and often thought “It won’t happen to us” and I could probably list a million reasons, in my mind, why. Then reality strikes, of course when least expected. It hits you upside the head like a 50 lb. sledge when it involves your own personnel.
I wasn’t as prepared as I should have been; however, through years of reading articles and reports such as this one, I knew what I needed to do; for my members, their families and the rest of my personnel. These articles and reports are important for every firefighter to read, more importantly they are a must for every chief or command officer. As a fire chief, your personnel come first and foremost. DO NOT ignore the things you think won’t happen or put off the things you don’t want to deal with because you doubt you’ll ever need to.
I learned a phrase as a young firefighter, years ago, that has stuck with me my entire career. It has never run through my mind as much as it did that night and since, to this day been proven so true. It is a phrase we must live by and apply as much as possible, to the development of and actions taken in mitigating our calls for service. “If it is predictable; it is preventable!” by Gordon Graham; 1980.
As the chief of our all-volunteer fire and EMS Station 809, answering over 6,000 fire/EMS calls per year, operating within one of the greatest and most unique combination systems in our nation, I recognized the need for some immediate change. These changes, where possible at the station level, began implementation within weeks of this incident. I welcomed the investigation of the incident, knowing very well it would fully open my personnel and our station to scrutiny. We accept the recommendations of the team and look forward to reviewing and input of the pending changes as they are developed.
On behalf of all of my personnel, we are thankful for the continued support of Kevin, Ethan and our entire station. We will continue to strive at providing the best professional service to our customers.
These comments are by Chief Goldfeder:
This fire could have easily ended up with a line-of-duty death or deaths; thankfully, due to quick thinking when the interior conditions turned bad, it did not. It should be noted that while much of this could have been avoided, regardless of that, when the conditions did turn, Firefighter Sorrell’s quick actions led to the rapid removal of Fire Sergeant O’Toole, likely saving his life.
Fire chiefs have options before, during and after fires. The most effective are often what we do (to prepare and plan) before the next fire. Sizing-up refers to determining what the situation is-and determining your plan of action, and insuring you have the resources to do what you want-quickly. Size-up refers to NOT ONLY when we arrive at a fire, but well before we are dispatched to a fire, so we can predict what we may encounter, what we want to do-and what resources are needed. BEFORE THE FIRE.
PGFD Fire Chief Marc S. Bashoor, along with the SIT Team, have “sized-up” this incident so we can all learn what went well, what didn’t go well – and what can be done so it does not happen again.
Albert Einstein defined “insanity” as doing the same thing over and over again and expecting different results. We in the fire service, over the past several years, have improved on our ability to learn from others. Unfortunately, in some areas where firefighter deaths and related close calls have occurred, the results are ignored by the leadership – and, predictably, those outcomes will probably happen again. Fortunately, in this case, Chief Bashoor and the career and volunteer members of the PGFD have provided us with a very frank, factual and “step-by-step” prioritized report so that we can ensure that our departments do not repeat what they went through. This series of columns, with its color-coded priority documents, is of great value in determining if “that” can happen “here.” It has been made clear by Chief Bashoor that the PGFD is going to use this report to facilitate change – and the actions toward those changes are currently underway.
We all have a chance to use this information as well, without experiencing what they did. This three-part series and the investigation report provides us with some excellent “insanity-prevention” tools.
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