5. FACTOR: From the onset of operations, the Incident Management System (IMS) was not properly expanded as the incident progressed. Given the scale of this incident, the span of control quickly became too large for the IC to effectively manage and additional functions were not delegated to subordinates. Critical tasks such as safety and accountability were not effectively implemented.
REMEDY: N.J.A.C. 5:75 mandates that all fire departments utilize an IMS. It is a modular system, which allows the IC to apply only those elements that are necessary at a particular incident, and allows elements to be activated or deactivated as incidents escalate or decline. Fire departments are required to adopt written plans, or Standard Operating Guidelines (SOG’s) based on the IMS, to address different types of incidents. The NJ Division of Fire Safety distributed suggested SOGs upon adoption of this regulation and they continue to be available to all fire departments.
6. FACTOR: The GCFD did not assign a dedicated safety officer (SO) to observe operations and terminate potentially unsafe actions.
REMEDY: IMS regulations under N.J.A.C. 5:75 mandate the use of safety officers (SO’s) at all incidents. An SO is required to observe operations on the fire scene, identify next steps and order the correction of safety hazards to personnel. Given the scope of this incident, the IC should have assigned at least one SO.
7. FACTOR: The GCFD did not designate accountability officers to monitor each area of entry into the structure. Nor was a Personal Accountability Report (PAR) or roll sheet utilized to track personnel and monitor their functions. Therefore, the concept of accountability of personnel location, function, and time failed.
REMEDY: Although not enforceable at the time of this incident, the regulations for the NJ Personal Accountability System (NJPAS) under N.J.A.C 5:75 now require that fire departments utilize an accountability system. This system includes the designation of accountability officers and the use of PAR’s / roll calls, all within the framework of the IMS that is required to be utilized at all incidents. The NJ Division of Fire Safety is in the process of finalizing suggested SOGs and will distribute them to all fire departments when complete.
8. FACTOR: Although firefighters Sylvester and Stewart were equipped with Personal Alert Safety System (PASS) devices, they did not activate them prior to entering the structure. It should be further noted that their PASS devices were not automated; they had to be manually activated by the user. Firefighter West was not equipped with a PASS device.
REMEDY: PASS devices must be provided, used, and maintained in accordance with PEOSH regulations under N.J.A.C. 12:100-10 et seq. Although many departments still rely on PASS devices that must be activated manually, – devices that are acceptable by PEOSH regulations – they are not ideal because the firefighter must remember to activate the PASS device. For this reason, fire departments should strongly consider upgrading their SCBA to those employing automatic activating PASS devices.
9. FACTOR: The GCFD did not specifically designate the required personnel for the rescue of distressed firefighters through the establishment of Rapid Intervention Teams (RIT) or Firefighter Assist and Search Teams (FAST). Consequently, when the building collapsed, there was not a properly equipped team in place for immediate rescue operations.
REMEDY: IMS regulations under N.J.A.C. 5:75 require that fire departments utilize RIT or FAST to rescue distressed firefighters when operating in a hazardous atmosphere. The IC should request a RIT or FAST as soon as possible after dispatch to allow the team to arrive quickly.
10. FACTOR: Not all fire departments operating on the fire ground were communicating on the same radio frequency, which resulted in communication failures. Although, the Camden Fire Department (CFD) did have the capability to communicate on the GCFD “Fire 5” frequency they chose not to.