HEATHER CASEY
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AP Photo/Phoenix Fire Department

Phoenix Firefighter Bret Tarver.
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The death of Phoenix Firefighter Bret Tarver was an accident, and
not the result of any safety deficiencies within the fire
department, according to a report issued by the Arizona Division of
Occupational Safety and Health.
Tarver died March 14 after running out of air inside a burning
supermarket. An autopsy showed that his cause of death was carbon
monoxide inhalation.
Because of the carbon monoxide, "He was lost, incoherent,
disoriented, and couldn't follow instructions," said Bruce Hanna,
one of the investigators and writers of the report.
"People were trying to get him out and it just didn't work."
The investigator said there were no policies violated during the
fighting of the fire. Tarver's SCBA was working correctly, and his
fitness records were up to date and showed him to be in good health.
Hanna said he isn't sure exactly what went wrong. According to his
interviews, Tarver notified his captain that he needed to leave and
the crew of four started to exit together.
Some kind of collision happened at that point and knocked the
firefighters off the hose line. "I don't know if two guys collided -
it's kind of unclear," Hanna said.
Hanna said the disturbance could not have been caused by a collapse
in the building, because the structure didn't give way until the
firefighters exited some time later.
In the following confusion, Tarver and his partner became lost
together and moved around a lot in the building. The partner told
Hanna that the two thought they knew the way out, but eventually
became separated.
"It was quite a fire," Hanna said. There was zero visibility, debris
on the floor covered the hose line, and there was no sprinkler
system.
The partner was found and rescued, but Tarver was a challenge
because he was a big guy and was too disoriented to cooperate, Hanna
said.
"They had him three or four times," Hanna said. "They had him on a
hose line at one point and he got up and he disappeared.
I don't know what else you could do to get the guy out."
Tarver was found in a food preparation area under a bench used to
prepare meat. The firefighter probably thought this was the exit
because both areas had sections of long plastic strips, Hanna said.
Hanna said his agency does not issue recommendations, as NIOSH will
in its report on the incident. However, one investigator did suggest
in the report that thermal imaging cameras might have helped
firefighters find the heavy structural fire overhead sooner, and
caused them to move out sooner.
Hanna said the fire department is already trying to improve the
safety of its procedures.
Deputy Fire Chief Bob Khan said it's too soon to discuss any
potential changes in the department.
However, he said they are examining their technology, command
procedures, tactics and strategies, and will process any proposals
through several committees.
The implementation of any changes should begin within the next six months.
"To a certain extent we set the bar for command procedures and
wellness issues, but that doesn't mean you stop trying to make it
better," Khan said.
"This is something that we're all looking at, and we're going to make
the fire ground as safe as possible for firefighters."