Close Calls: “Mayday! Mayday! Mayday!” … But No Answer — Part 2

Sept. 1, 2017
Billy Goldfeder and personnel from Oxford Fire-EMS share key takeaways from a mayday incident in Oxford, MA.

In January 2017, Oxford, MA, firefighters responded to a fire that ultimately resulted in a mayday call and close call for two mutual-aid firefighters—Auburn Engine 1 Lt. Justin Brigham and Firefighter-Paramedic Scott Davis. Thirty seconds after Brigham and Davis evacuated the structure, the room flashed over. Fortunately, they were not injured. 

We reviewed the incident details last month; this month we’ll review several concerns, comments and suggested resolutions, as provided by Oxford Fire-EMS, as well as additional observations from myself. 

Concern 1: Dispatch time

The dispatch log shows a time of 0202 hrs for call received and a time of 0205 hrs for fire department dispatch. This resulted in a 3-minute delay in dispatching the fire department by Oxford Fire Dispatch. 
 
Comments: The 9-1-1 call recording is 2 minutes, 9 seconds long with multiple questions being asked by the dispatcher prior to the dispatch of fire resources. However, a cruiser is heard being dispatched to confirm the report of the fire during the 9-1-1 recording. A 3-minute delay is significant in the resulting fire conditions encountered by crews. According to an NFPA video, fire grows 16 times in 3 minutes. 

Suggested resolution: The dispatcher had enough information to dispatch the fire department but did not do so until she hung up from the 9-1-1 call. The dispatcher could have toned out the fire department and simulcast transmission to both fire and police. Additional dispatcher training is required. The town should also consider increasing the number of dispatchers on duty. An additional dispatcher would have been able to do this while the primary dispatcher continued to obtain information. 

From Chief Goldfeder: Call-handling and processing time has been the culprit of many delayed incidents. While it may be easy to “blame” dispatchers, it almost always comes down to policies, procedures and training. If dispatchers are not trained in fire operations and don’t understand the critical difference that seconds can make, then the problem isn’t theirs. In so many cases, three questions—Where is the fire? What is on fire? What is your phone number?—are enough to get the tones sent and fire departments alerted. Many departments now use technology, such as Locution Systems, which enables the call-taker to initiate the dispatch using keyboard automation, saving precious time. 


Concern 2: Communication of cleared building

The police officer’s report of occupants out of the building was not passed on by the Oxford Engine 2 crew or repeated to Command by Dispatch.
 
Comments: It should be noted that Dispatch did not relay the information to the Oxford Engine 2 crew upon their en route transmission. The crew asked for an update at which time a very concise update was provided by the dispatcher.
 
Suggested resolution: A trained, experienced fire officer should be added to the group. Training is needed for the Engine 2 crew. Dispatcher training helps provide important updates to the initial crew en route and when command is taken.

From Chief Goldfeder: “Keep no secrets” is a phrase I like to use when working with dispatchers. If dispatch knows it, fire units should know it. After all, a simple statement that may not seem important to a dispatcher may be critical to those operating on scene. Communication is clearly a two-way street, and units on scene must also be trained as to what constitutes an important transmission.


Concern 3: Long on-air time

The Oxford Fire on-duty crew had a 6-minute on-air time from the time of dispatch. 
 
Comments: A review of the radio transmissions and the dispatch log shows 6 minutes from the tone to the apparatus being en route. During the investigation, it was determined that the crew in the apparatus chose to wait a couple minutes for additional staffing. At this point, they are only aware of it being a commercial business that would not be occupied. No update on occupants or building use had been provided to them. The crew felt that only two firefighters entering the fire was unsafe and decided to wait for additional staff to arrive. After waiting for what they report to be approximately 2 minutes, they responded but had to wait for the re-tone of the second alarm to be completed before being able to use the radio to transmit an en route notification. At the time that they called en route, they were already off the apron. A 6-minute delay, combined with the 3-minute delay in dispatching, resulted in a total of 9 minutes for the deteriorating conditions to worsen.
 
Suggested resolution: 
Per department policy, two firefighters are required before apparatus can respond. The Engine 2 crew should have responded with the three firefighters on board. The crew needs to be trained in department polices and what tactical decisions were available to them with a crew of three. Again, a trained, experienced fire officer needs to be added to the group. An officer would have been able to make proper decisions on response, and run the incident while preparing to enter the structure. Mutual-aid agencies should not be filling the role of incident commander. 

From Chief Goldfeder: Don’t leave response policies to someone who has to make a call “in the moment.” Develop these policies based upon standards, conditions and known risks in the community—and then train on them!

There are several schools of thought regarding who should be in command in “small town” settings. Clearly, when the officer arrives, they take command. But that should be for a brief period because the system ensures that a chief is on the way. The problem is that when the company officer takes command with no chiefs turning out, that person is really no longer a company officer; they are the IC. They cannot be both. Either they have initial command, as a chief is on the way, or they assume command for the duration, and the crew operates without an interior officer, which can create other challenges. 

Every department should know who is on call as the duty command officer and they should be responding directly to the scene with radios, tactical works sheets, etc., to command the incident. This doesn't require a $100,000 command vehicle; a staff car works fine.  

In some areas, the role of duty officer is shared among various departments in an automatic mutual-aid setting. Regardless of whose jurisdiction the fire is in, Command is provided by the first-arriving chief. But to be clear, that isn't done without clear policies and training. But it is possible, it does work well, and it is a great solution for departments with limited resources.

 
Concern 4: Limited response

Oxford Engine 1 responded with only one firefighter.

Comments:
Firefighter Bryan Givner was alone on Oxford Engine 1. He had to perform multiple tasks that require at least three staff to complete safely and efficiently. Oxford Fire Department policy requires at least two firefighters on the apparatus before it can respond to an incident, unless directed to do otherwise by an officer. The water supply was needed to ensure the safety of the interior crew, which is why the decision was made for Oxford Engine 1 to respond with only one firefighter.
 
Suggested resolution: An increase of on-duty staffing for Oxford Fire Department is needed. NFPA 1710 states that fire apparatus should be staffed with four trained firefighters before responding. It further states that 15 firefighters should be dispatched on the initial alarm for residential structure fires. 
 
Review of Oxford Fire-EMS run cards should be conducted in order to increase responding mutual aid earlier in the run card structure.

From Chief Goldfeder: While community leaders can determine what level of staffing they want (and/or can afford), it is incumbent upon fire leadership to make it clear what a fire department can (and cannot) do based upon the resources provided.  

The model is relatively simple: If your goal is to establish water, pump three hoselines (1¾ inch), force entry, conduct searches, get water on the fire, remove victims, vent the structure, have at least two command officers—all standard requirements at a fire (in an average 1,500-square-foot dwelling, for example)—you can calculate that well ahead of the fire. 

Career, volunteer, call, whatever, we must know how many firefighters we need and how many we will get when the bell rings. What is your department protecting? What are the dwelling sizes? What about multi-family or commercial structures?


Concern 5: Mayday on wrong frequency

The mayday was called on District 7 Fire Orange Repeater, not on the Oxford Fire frequency. 

Comments: An investigation of the radio used by Lt. Brigham found that all buttons were locked out, as recently programmed. Lt. Brigham was heard transmitting on the Oxford Fire frequency prior to entering the structure. Auburn Fire has concluded that during the search, the knob was knocked off frequency.

Suggested resolution: The District 7 Fire Orange Repeater should be removed from the Auburn Fire Departments portable template.

From Chief Goldfeder: The more time goes on, the more complicated it seems that fireground communications equipment has become. Radio manufacturers, however, can configure equipment that makes them easier to use. Bigger knobs, loud audio channel identification and virtually any configuration you would like allows organizations to set up the radios to be simple and easy to use in the worst of conditions. We drill on ladders, hose and other tactics; drilling on radio usage and related operations helps prepare us for “that” day.


Concern 6: Communication problem

Oxford Firefighter/EMT Ruess Lambert was initially unable to communicate with Fire Dispatch and other arriving apparatus. 
 
Comments: It was determined during the investigation that Lambert was issued a Vertex 900V. This is one of the original batch of radios purchased with a grant in 2001. His radio was found to be on the right frequency, but the antenna was broken internally. The use of 16-year-old radios for life safety purposes is unacceptable. The department budget only allows for the replacement of two to three radios per year. As new radios are purchased, they are issued to career staff by seniority. Lambert was still in possession of an older radio, awaiting funds for replacement. 

Further, Lambert's portable was used previously on his shift without incident. Radio repair believes it was damaged during the initial minutes of the fire incident. It had been previously evaluated for intermittent “vague” issues, with nothing found. It was determined that the system-wide issue of repeater placements that often affect communications was most likely to blame. The point: A radio tested at the beginning of the shift and used on other calls still failed.
 
Suggested resolution: The radio has been removed from service and radio repair contacted. Funds should be allocated to replace all the radios older than 5 years.

From Chief Goldfeder: Oxford Fire always had radios in assigned seat positions, but due to the aging radios, at the time of the fire, they had to leave two in each apparatus and then assign radios to each interior firefighter. The radio in question was tested that morning and used on previous calls that day. It failed on that call specifically.

These are reminders that radios play a critical mandatory role in today’s fire operations for ALL fire departments. Departments must ensure that all equipment is checked regularly, all parts work, and they are ready for emergency service based upon what the manufacturer and related NFPA standards recommend.

Concern 7: No charged hoseline

Auburn Engine 1 crew entered the building without a charged hoseline, and this was not transmitted to Command.
 
Comments: Lt. Brigham made an educated decision to enter the structure to search for victims without a charged hose. This is not an uncommon practice; however, the situation should have been relayed to Command. Additionally, had he and his crew been aware that all occupants were accounted for, they would not have made entry under such conditions. The charged hoseline could have been used to help the crew out of the room they were trapped in and/or to cool the room.
 
Suggested resolutions: Lt. Brigham is aware that he could have been clearer with making the IC aware that they were entering the structure without a charged hoseline. However, this investigation has determined that the decision to make entry to complete a search was appropriate with the information known at the time.

From Chief Goldfeder: Firefighting is a risky business. In this case, the officer had good information and indications that the building was occupied and, yes, communication would have helped minimize the risk he took in going in. But that information was not relayed, so he went with what he had.

As far as an uncharged hoseline, that is a huge risk. In the past, heroic firefighters have lost their lives and victims due to not having a charged hoseline; on the other hand, lives have been saved by firefighters operating without a charged line. Especially in today's fire environment, the need for a charged hoseline is among resources that are paramount. Going in without a charged line is like a cop entering a “bad guy zone” without a gun: It may work out, but history tells us it likely will not.


Concern 8: No safety officer assigned

There was not a designated safety officer assigned on this incident.
 
Comments: The presence of an assigned safety officer could have assisted with ensuring that hoselines were in place, recognizing flashover conditions, and relaying staffing and equipment needs. Department policy, NFPA and National Incident Management System (NIMS) require that the safety officer position be filled at every event. At the time of the mayday, there was not enough staff to fill any of the necessary NIMS roles.
 
Suggested resolutions:
An increase of on-duty staffing for Oxford Fire Department is needed.
 

From Chief Goldfeder: Old, out-of-date equipment is an obvious problem that is outlined above. Regardless of that fact, be it old radios, old apparatus or old firefighters, make sure they are checked regularly, all parts work and they are ready for emergency service. A broken antenna should have been identified and could have been rectified. There also may be a value in assigning radios to riding positions on the apparatus vs. individuals until every member can be issued a reliable radio.  

How does your department compare?

  • What are the policies and fire service training provided to your communications/dispatch personnel? How often are they re-trained or drilled? 
  • What are the “communicating” policies and procedures that minimize important information being missed on your fireground?
  • How do you know what your first-alarm staffing is? What is your history on staffing turnout, especially in volunteer and call scenarios? Based on that, what is your department realistically expected to do and able to do in the first 5 minutes? What does the public expect?
  • What is your required size-up report?
  • Who takes initial command? What are their qualifications? Is every member trained in taking the initial command role? 
  • What determines occupied or unoccupied in your organization? What’s the related training?
  • What are your water supply procedures? From supply to handlines or master streams, how quickly can your first-alarm response get water on the fire? 
  • What are your mayday policy and procedures? What is expected to happen when a mayday is transmitted? What are the various fireground roles? Radio procedures? What do the dispatchers do? What resources are automatically sent to the scene? Do you have enough staffing if a mayday happened in the first 5 minutes?
  • Is a RIT/RIC due on every reported structural fire? What are their qualifications, resources and staffing? 
  • How often are your portable radios checked for operation and ability? How are they set up in the case of a mayday? What do all the buttons, switches and knobs do?
  • Are your elected officials aware of what your department can and may not be able to realistically do? Do they have all the facts?
  • Is the fire department leadership running the department realistically or are they making unattainable assumptions and promises?

Final thoughts

Fire departments are like an insurance policy: You get back what you put into it … and hope you never need it. Risk management is an important part of the equation, and taking time well before an incident to carefully determine what is realistically needed, based upon best practices and standards, can pay off many times over. Looking at the community that is being protected and comparing it to the best possible fire services for that community—while spending (and maximizing) available tax dollars prudently—provides those calling 9-1-1 with the best possible outcome.  

Our sincere thanks to Fire Chief Sheri Bemis of the Oxford Fire-EMS Department along with Fire Chief Steve Coleman of the Auburn Fire Department, with special thanks to all the Auburn, Oxford and other mutual-aid partners for their cooperation in sharing this close call. 

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