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The National Fire Protection Association's (NFPA) Fire Investigations Department released their summary of the December, 1999 house fire in Keokuk, Iowa in which three firefighters and three children died.
Not having a chance to completely size up the incident upon arrival was the most significant factor leading to the firefighter deaths, according to Senior Fire Investigator Robert Duval. If the depth of the fire had been know immediately, different decisions might have been made, Duval said.
NFPA documents some of the most significant fires and incidents throughout the world. The objective of this investigation is to determine what lessons can be learned from these incidents.
Courtesy Ed Vinson, www.keokuk.com
A view of the rear of the apartment house
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The lesson of this day, according to investigator Duval, is if there had been functioning smoke detectors in the house, the factors that contributed to the tragedy probably would have been nonexistent.
On Dec. 22, a fire was reported in a house in Keokuk. Four firefighters with two pieces of equipment arrived on the scene and began dropping hose from a hydrant a block away. One firefighter stayed at the hydrant. Two were setting up the apparatus. Assistant Chief Dave McNally rushed into the house attempting a search and rescue operation.
When Chief Mark Wessel arrived, he ordered the two firefighters with the apparatus into the house to assist McNally. Wessel then made an immediate trip to the hospital with the second rescued victim. When he returned, there was no further communication with the firefighters in the house.
As the fire was knocked back, arriving firefighters were able to search the house and the three firefighters and remaining child were found. All had perished.
On the basis of the fire investigation and analysis, the NFPA determined that the following significant factors might have contributed to the deaths of the three Keokuk fire fighters:
- Lack of a proper building/incident size-up (Risk vs. Benefit Analysis).
- Lack of an established Incident Management System.
- Lack of an Accountability System.
- Insufficient resources (such as personnel and equipment) to mount interior fire suppression and rescue activities.
- Absence of an established Rapid Intervention Crew (RIC) and a lack of a standard operating procedure requiring a RIC.
The NFPA determined that the significant factor that likely contributed to the deaths of the three children, thus the three firefighters:
- Lack of functioning smoke detectors within the apartment to provide early warning of a fire.
Risk vs Benefit Analysis: Assistant Fire Chief Dave McNally faced a situation where decisions needed to be made instantaneously. A mother was screaming for her children inside the burning house. He saw smoke but was not aware of the extent of the blaze, visible from other sides of the house. Without the luxury of time to determine the scale of the incident, his decision was to focus on the immediate need, an internal rescue effort.
Duval believes this may have been a leading factor in the tragedy. "Any human being with a pulse would have done what he did," Duval said. But McNally did not know how far along the fire had gotten without the opportunity to view the building from all sides. Perhaps, Duval believes, this would have led McNally to make a different decision about entering a building in much worse condition then he understood. "We will never know," Duval said. "Multiply the normal anxiety of arriving at this fire by 10,000% and you might know what he was facing."
Incident Management System: The opportunity to create an incident management system (IMS) began with Fire Chief Wessel when he arrived at the fire with the firefighter he picked up at the hospital. But that opportunity vanished when he moved to the door of the house and someone handed him a child victim. With no other support having arrived, the Chief had no alternative but to travel in a police car to the hospital with the victim. At that point, the IMS broke down.
It was during that transport period that Duval believes the firefighters died. "No one knew where the firefighters were in the building," he said. "There was no system in place."
Accountability System: This follows closely on the problem with the lack of an IMS. McNalley was the only one with a radio, Duval said. But it did not matter since there was no one to communicate with and he was busy with the search and rescue. The audiotapes provide no recordings from the dead firefighters.
Insufficient Resources: According to Duval, this is a very obvious factor in the incident. Four firefighters arrived on the scene with two pieces of apparatus. One stayed with the hydrant for hookup a block from the fire. Two were setting up the apparatus. That left one to face the burning building and do all the other functions necessary.
The size of the department at the time, 18 members and the chief, meant their first form of aid was callbacks. The procedure was to call off-duty firefighters and get them to respond. Duval was not critical of this plan as opposed to calling for mutual aid from a neighboring town. The nearest department, he said, would not have arrived sooner then the callbacks. Most of the Keokuk department reached the scene and they brought the fire under control.
The on-duty firefighters were finishing with an MVA when the fire call came out and the normally available five firefighters were four when one went to the hospital with the MVA victims. Also, the ambulance crew could not respond immediately to the fire.
The four initially on the scene were not enough to handle many of the important functions at this fire, Duval said.
Rapid Intervention Crew: This goes back to the lack of department resources. Having such a unit would have made a difference, Duval said.
Of all the elements in place leading to the results of the fire, the one item not in place, a smoke detector, probably was the most significant factor leading to the deadly results, according to Duval. The mother would have been aware sooner of the fire. The children would have been out on the lawn of the house, alive. "McNalley would not have been faced with the dilemma he had," he said.
"The smoke detector is what it all boiled down to," Duval said. "We have a long line of cases where the lack of a smoke detector was the cause of a tragedy like this. It would have been a kitchen fire, nothing more," he said.
For information on obtaining the full report, go to the web site www.nfpa.org or call 617 984-7445
At the time of posting of this report, the Keokuk Fire Department had not had an opportunity to review the report or comment on it.
The incident in greater detail:
At approximately 8:24 a.m. on Wednesday, December 22, 1999, a fire was reported in a multifamily dwelling in Keokuk, Iowa. Several neighbors phoned the Keokuk 911 center to report smoke coming from a residence, and that a woman was outside screaming that there were children inside
At the time the fire was reported, the on-duty force from the Keokuk Fire Department (an assistant chief, a lieutenant and three firefighters) was completing operations at a motor vehicle accident two miles northwest of the fire scene. Both units at the accident (Rescue 3 and Aerial 2) responded from the accident scene.
One member of the on-duty force of five firefighters was assisting the EMS crew on the ambulance and was en route to the Keokuk hospital at the time of the report of the house fire.
The chief became aware of the incident as he entered his office at the fire station. He responded from the station and went to the hospital to get the other fire fighter.
Upon arrival at 8:28 a.m. the units found heavy smoke showing from the building. A water supply was established from a hydrant one-block southwest of the scene. Rescue 3 laid a supply line from the hydrant while the lieutenant stayed at the hydrant to connect the line and activate the hydrant. Aerial 2 continued to the scene.
The assistant chief requested six firefighters be called back to duty as he arrived at the house in Aerial 2. As the two truck operators set up the apparatus, the assistant chief reportedly spoke to the female resident. She said three of her children were still inside and that she tried but could not get them out. She got out from a second floor window with her 4 year old son with the help of neighbors. The Assistant chief finished donning his protective clothing including SCBA and entered the right side apartment door.
The chief arrived not long after the assistant entered the building and ordered the apparatus operators into the building to assist with the search of the children. Shortly thereafter, a firefighter passed a 22 month old male out the front door to a police officer, who began CPR. The officer with the infant was taken to a police car and transported to the hospital six blocks west of the scene. An unresponsive 22-month old female was then passed out the door to the fire chief. With no EMS units yet there, the chief took the infant to the hospital in another police car with a police captain driving. The fire chief conducted CPR during the one-minute ride to the emergency room. He quickly handed the infant over to the staff and returned to the fire scene.
In the meantime, the firefighter that arrived with the chief stretched a hoseline to the front door and returned to don her SCBA. When the hoseline was charged, she noticed that the hoseline had burned through while at the entrance to the apartment. She reported that the first level of the apartment was engulfed in flames visible from her vantagepoint at Aerial 2.
The location and condition of the firefighters and the remaining child in the burning apartment was not known. The burned length of hose was removed, and the nozzle reconnected to the line as it was charged again. The firefighter played a hose stream into the apartment. She was only able to advance six to eight feet into the apartment before being driven back by the intense heat.
The first two of the "call-back" firefighters arrived in Engine 6 (reserve unit). They were teamed with the lieutenant that was at the hydrant and had now walked the one block to the scene. The three were ordered to search the adjoining apartment for a resident that supposedly was still inside. The search was completed with nothing found. (The occupant was at a local restaurant.)
Efforts continued to contact the three firefighters that were in the apartment. As additional callback firefighters arrived in Aerial1, they were ordered to search for the missing firefighters in the original fire apartment. As the fire was knocked back and a search could begin, firefighters quickly found one firefighter in the first floor room to the right of the main entrance corridor. He had perished.
The assistant chief's body was then found at the top of the stairs, not far from the body of the remaining child, a seven-year-old girl. The third firefighter was found in the master bedroom to the right of the top of the stairs. All had perished.
The remaining fire was extinguished at approximately 1:30 p.m. Overhaul was conducted until 3:30 p.m. and at that point units were placed back in service.
Related
NFPA: Smoke Detector, Manpower Contributed to Keokuk Tragedy