Tactical Errors, Lack of Policies Cited in LODD of St. Mary's County, MD, Firefighter

"There were several obvious signs visible during the initial size-up that should have indicated that an offensive fire attack was going to be ineffective. Significant involvement of lower floors in a Type V private dwelling, where there is also significant involvement of upper floors and attic spaces, should be an obvious sign that fire has already occupied the void spaces, spread to the open areas..."

Those were among the observations made by fire service officers who delved into operations at a 2023 house fire in Leonardtown, MD, where Patuxent Naval Air Station Firefighter Brice Trossbach died after falling into the basement.

Strategic and tactical errors were made, they concluded in a report released Thursday by the Leonardtown Volunteer Fire Department. 

Firefighters involved in the incident told the investigating group that they were attacking the fire from the porch when someone kept urging for them to go inside. 

“Get in and put the fire out, or I will do it for you,” a firefighter can be heard shouting.

Within about 30 seconds after entering the house, a firefighter saw the upper floor collapse, followed by the first floor, which sent Trossbach into the basement. Due to falling debris, they were unable to get him out of the basement.

They saw him attempting to hold himself up between the floor joists for a moment before falling through the floor and into the basement. Trossbach was never heard from.

After the two firefighters who were inside with Trossbach were out of the house, they and others sprayed water into the hole where their colleague had fallen. They did not declare a mayday, the reported showed.

That call came from an officer who went to check operations at the front of the house.

Several firefighters ran to join the search for their colleague at that point.

Trossbach was located, buried motionless in debris about two hours after the mayday was declared. He was pronounced dead at a local hospital.

The investigative team noted: "The majority of recommendations in any LODD report can be linked back to acts, omissions and violations of standing policy/procedure. The same could be said for this report; however, alarmingly, there are very few, if any, policies and procedures to point to."

They added that some departments in the county "selfishly refuse to participate in the process of formulating such documents. The Committee has deduced this to be the biggest liability to the firefighters, the county, and its residents if left unaddressed."

They recommend: "St. Mary’s County should immediately address the autonomous operational authorities that exist within the fire system in favor of some form of governance system that has full authority to propagate, codify, and enforce policies and procedures that impact Fire/EMS operations. Volunteer corporations should be able to maintain their independence when it relates to corporate matters; however, when it impacts emergency operations, there must be movement towards a one-standard, one-system, one-team approach. This is the only way to ensure that the residents of the county receive the same level of response regardless of where they live."

They added that people without firefighting expertise or experience should not be involved in developing the operational policies. 

The investigators also wrote about the importance of a thorough 360-degree investigation at every incident. 

"While there are many benefits of conducting the 360, the primary focus must be on determining the absence or presence of a basement and confirming if there is smoke or fire present. Operating above an unknown, unrecognized, and/or unchecked (hoseline in place) basement fire is perhaps the highest risk activity that firefighters engage in."

No interior operations should begin before the 360 is completed. Among their suggestions:

• A requirement that when the first arriving officer cannot complete the 360, they must assign that task to a specific company, before units enter the structure.  
• Verbal statement of the number of floors in the rear.
• Verbal statement of exterior entrance locations.
• Verbal confirmation of the absence or presence of a basement.
• Verbal statement of conditions evident in the basement, i.e., fire or smoke.  

The report read: 

"Throughout the Deer Wood Park Drive incident, there were numerous occasions where crew integrity was violated. Fire officers who are charged with ensuring crew integrity either initiated these violations or observed them and did nothing about them. 
 
For unknown reasons, Engine 132’s Acting Captain made a purposeful decision to assign the two firefighters whom he was personally responsible for to advance Engine 132’s hose line through a front porch window, onto the first floor, while he decided to attach himself to Engine 11’s crew. To be clear, the Committee was unable to determine if there was any overwhelming reason for him to make that decision.

There was certainly nothing obvious that came up during interviews or in the review of the fireground video. Absent something unknown to the Committee, this was a poor decision at best. The fire officer has no greater obligation than the safety and welfare of those assigned under their leadership. 
 
Throughout fire suppression efforts and the RIT operations, there were numerous instances of firefighters operating independently without their officers, as well as officers abandoning their crew, leaving subordinates who they were responsible for operating alone inside and outside of the IDLH. Firefighters operate in the most complex, dangerous, and time-deficient environments; our response system is the most effective when supported by strong policies, operational organization, communications, and teamwork. In the absence of consistent implementation of one or more of these tenets, individuals will begin to take matters into their own hands.

Observation: Although there is no video or photographs that show the Deer Wood Park Drive structure at the exact time that Chief 1 arrived and completed his 360, there were video and photographs that show the structure one to two minutes later. It was obvious to the committee members that this was a well-advanced fire that already involved 80 percent of the structure, with obvious signs that the structural integrity was significantly compromised, before the first application of water. This is not the 'opinion' of the committee; it’s a fact-based assessment from the committee's more than 165 combined years of firefighting experience.  
 
Video of the operations from the start through the point of collapse shows severe window and door racking, alligatoring of the wood siding, internal wall studs (visible because the drywall had completely deteriorated) that had burned through, and a sagging roof and second floor.   
 
Throughout the interview process, the committee was astonished at the number of firefighters who were on the scene, offering their assessment that this was a 'bread and butter fire' or that 'this was a two-line fire.' More insidious was the fact that many of those same individuals had little to no actual firefighting experience. It is worth stating that there were also several experienced firefighters (career firefighters in larger more busier fire departments) who opined that this was a glaringly obvious defensive fire once they viewed all sides of the structure. 
  
There are numerous explainable reasons for the contradiction in observation, most of which could be categorized as 'cognitive bias.' Most came from those with little to no real experience who simply regurgitate phrases and slogans they hear from those they look up to in an attempt to sound like a seasoned firefighter. 

Much of it also came from people who mistakenly think they are more knowledgeable, experienced, and competent than they really are, and worst yet, many of those same people are unable to see just how incompetent they are. This is in no way intended to disparage anyone. These are legitimate cognitive biases that are a liability to fire officers and the safety of the people they lead. This type of company officer exists in every fire department 
in the country, not just in St. Mary’s County."