A Close Call & an LODD—the Aftermath

Billy Goldfeder reflects on the May 2017 incident in which San Antonio Firefighter Scott Deem was killed and Firefighter Brad Phipps was injured.

Interior of Spartan Box Gym, post fire. Location where Firefighter Deem was located.
Interior of Spartan Box Gym, post fire. Location where Firefighter Deem was located.
Photo from Texas State Fire Marshal's Office Report/DSFM Lt. B. Fine

Thousands of firefighters have experienced close calls and too many have died in the line of duty, and each of these fallen brothers and sisters is honored at the National Fallen Firefighters Memorial in Emmitsburg, MD. Between the beautiful funerals, the honorable memorials and other events that are conducted so that we never forget their sacrifice, the one most important thing that we can do for us—the firefighters—is to learn the facts of what happened at “that” event so that we never repeat what is determined to be avoidable. I genuinely believe there is nothing more important than honoring by learning. 

Among several issues you will learn about related to the incident we cover this month, crew integrity and freelancing were contributing factors that lead to a tragic outcome for the San Antonio Fire Department (SAFD). The issue of fireground discipline continues to challenge departments throughout North America each and every day.  

The fire and mayday

On May 18, 2017, the SAFD responded to a fire in a strip mall on Ingram Road. Responding companies encountered heavy smoke and fire conditions upon arrival, and a second alarm was requested.  

Collapse of storage area in strip mall.Collapse of storage area in strip mall.Photo from Texas State Fire Marshal's Office Report/Deputy State Fire Marshal Sgt. H. MahlmannFirefighters Scott Deem and Brad Phipps were ordered to conduct search-and-rescue operations in The Spartan Box gym. They entered the gym and immediately began a right-hand search of the structure. As they were conducting their search, conditions began to deteriorate rapidly. During this time, the rapid progression of the wind-driven fire, as well the decisions made to continue the search into the building away from a handline, led to Deem and Phipps positioning themselves in an area of the structure that made their exiting the building unattainable.  

A mayday was sounded, and the incident commander (IC) was unable to make radio contact with Deem. Rapid-intervention teams (RITs) were immediately sent in to conduct search and rescue, but they were unable to find him. During the fire spread and rapidly deteriorating conditions, Deem and Phipps had become separated. This led to the RIT being able to locate Phipps, but not Deem, and then making continued entries to attempt to locate Deem, all while conditions continued to decline at an extremely rapid pace.  

The IC was forced to makes a critical decision—abandon the search for Deem due to extreme fire conditions (to avoid additional members becoming victims). The gut-wrenching decision to discontinue these efforts was one no IC would ever want to have to make. But this decision no doubt protected the lives of the firefighters who would have continued to search for Deem at their own risk. Once conditions were brought under control, and the main body of the fire knocked down, crews re-entered the structure and were able to remove Deem’s body. 

Phipps was severely injured. He continues to show amazing courage while recovering from his injuries and has undergone over two dozen surgeries for burn excision and skin grafts along with extensive physical therapy.  

LODD fire and investigation

As members of the SAFD mourned their heavy loss and began the healing process, both physically and emotionally, a thorough fire investigation was launched. The SAFD Arson Bureau—in close coordination with the San Antonio Police Department, the Bexar County Fire Marshal’s Office, the State Fire Marshal’s Office, the FBI, and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)—worked diligently to determine the origin and cause of the fire.   After an extensive investigation, the fire was ruled an arson fire. A suspect was identified, brought in for questioning and subsequently confessed to starting the fire. The suspect was booked into the Bexar County Jail on multiple felony counts related to the fire. 

NIOSH released its report of the Ingram Square Fire that took Deem’s life, and the SAFD concurs with the recommendations.

This isn't just for SAFD. EVERY fire chief, fire officer and firefighter must take the time and consider the question, “Could this happen at MY fire department?” before rushing to judgment—or before rushing to your next fire. Use the following information as a checklist or template to determine the risk factors at your department. Specifically, think about your last working fire: Have any of the following concerns occurred on your scenes, by your members or even your officers?

Contributing factors and recommendations

Following is a summary of contributing factors and the 19 recommendations from the final NIOSH report and the Texas State Fire Marshal’s Office. Read through this list not focused as much on the question, “What happened with San Antonio that evening?” but rather “How would my department respond and operate under the same circumstances?” 

Contributing factors:

•      Arson fire

•       No sprinkler system in commercial structure 

•       Winds blowing from side Charlie to side Alpha 

•       Zero visibility and cluttered floor space impeding hoseline advancement 

•       Freelancing tactics (ladder company searching for fire beyond protection of hose stream) 

•       Crew integrity not maintained 

•       Uncoordinated ventilation (rear door opened at side Charlie)


Recommendation 1: Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational procedures by developing or updating standard operating procedures (SOPs), conducting live-fire training, and revising fireground tactics, including wind-driven fires.  

Recommendation 2: State, local and municipal governments, building owners, and authorities having jurisdiction (AHJs) should consider requiring the use of sprinkler systems in commercial structures. 

Recommendation 3: Fire departments should define fireground strategy and tactics for an occupancy that are based upon the organization’s SOPs. ICs should base the strategy and tactics on the community risk assessment, building occupancy, pre-incident planning, critical building information system, staffing and available resources. 

Recommendation 4: Fire departments should develop and implement SOPs, training programs and tactics for wind-driven fires.

Recommendation 5: Fire departments should ensure all fireground ventilation is coordinated with firefighting operations. 

Recommendation 6: Fire departments should ensure that RIT or rapid-intervention crew (RIC) resources are dedicated, assigned and in place before interior firefighting operations begin and throughout an incident so that they can immediately respond to emergency situations. 

Recommendation 7: Fire departments should train firefighters on the principles of situational awareness. 

Recommendation 8: Fire departments should ensure that crew integrity is properly maintained by visual (eye to eye), direct (touch) or verbal (voice or radio) contact at all times when operating in an immediately dangerous to life and health (IDLH) atmosphere.  

Recommendation 9: Fire departments should ensure that an initial risk assessment is performed and continuous risk assessment is accomplished throughout the incident and the strategy and tactics match the conditions encountered.  

Recommendation 10: Fire departments should ensure critical benchmarks are communicated to the IC on a regular basis. 

Recommendation 11: Fire departments should consider periodic training on the transfer of Command. 

Recommendation 12: Fire departments should conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics. 

Recommendation 13: Fire departments should ensure that mayday training programs are developed and implemented so that firefighters are adequately prepared to call a mayday.  

Recommendation 14: Fire departments should provide all firefighters with radios and train them on their proper use. 

Recommendation 15: Fire departments should ensure that firefighters are trained to understand the influence of building design and construction on fire behavior and growth and the needed tactics for safe firefighting operations. 

Recommendation 16: Fire departments should ensure that firefighters are trained and proficient on following hoselines outside as a means for egress and self-rescue. 

Recommendation 17: Fire departments should ensure that firefighters are trained to report search findings as soon as the search is completed, and if the search team does not have the protection of a hoseline, immediately exit to a safe area. 

Recommendation 18: Fire departments should train and empower all firefighters to report unsafe conditions to Incident Command. 

Recommendation 19: Fire departments should consider using search lines when conducting primary and secondary searches in large or smoke-filled areas. 


SAFD actions taken

The SAFD has already made several critical operational changes in response to the 19 recommendations:

·       Review of NIST videos on fire behavior, fire travel paths and effects of ventilation occurred department-wide at the company level (July 2017).

·       Department developed a Firefighting Policies Manual available on SharePoint (April 2018).

·       Incumbent training class on fire behavior based on research from NIST and UL has been taught to all fire personnel (45 percent complete as of June 2018).

·       SAFD enforces the 2015 International Fire Code (IFC) as adopted by the City Council. 

·       The department has been proactive in drafting ordinances to promote the installation of fire sprinkler systems. The 2018 IFC and amendments went into effect on Oct. 1, 2018. 

·       Complex commercial projects are tracked by the Developmental Services Department with a list being periodically updated and sent to SAFD (January 2018).

·       Tactical worksheet was revised to include documentation of weather and occupancy type (December 2017).

·       SAFD risk management philosophy has been reviewed and stressed department-wide (June 2017).

·       Department-wide training was held on “Size-Up, Fireground Factors, and Risk Management and Survivability Profile” (March 2018).

·       Department-wide training was held on “Reading Smoke and Penciling Smoke” (May 2018). 

·       The Extremely Dangerous Structure SOP has been researched, with best practices updated, and reviewed on all shifts at the company level (June 2017 and January 2018).

·       Extremely Dangerous Structure and Mayday/Rapid Intervention Team training has begun. 

·       Department-wide re-stressing of the “Order Model,” a standing SOP that sets groundwork for on-scene communications, specifically an order is given and that order is repeated back to the IC (March 2018).

·       Wind direction, wind speed and temperature are being announced by Communications at the time of dispatch and are now included in the incident’s dispatch notes (November 2017).

·       Department-wide ventilation training has been completed (November 2017).

·       Battalion- and company-level mayday training is ongoing department-wide (80 percent complete).

·       RIT and mayday procedures have been reviewed on all shifts at company level (June and August 2017).

·       A mayday checklist has been incorporated into the SAFD Tactical Worksheets (December 2017).

·       SAFD developed the Scott Deem Incumbent Training Firefighter Center though the repurposing of the Cherry Street Warehouse, with focus on crew integrity and communications (June 2018).

·       SAFD added an incumbent training division chief position to work with firefighters in the field on the completion of SAFD Future Actions from this document (October 2018/ongoing).

·       SAFD is looking at current software and exploring alternative software that could be used to permanently house the thousands of completed Pre-Fire Plans to make the retrieval of them easier during a fire (60 percent complete).

·       Tactical worksheet was revised to include documentation of the transfer of command at incidents (December 2017).

·       All battalion chiefs and fire shift commanders have completed Blue Card Training, which emphasizes transfer of command (August 2018).

·       SAFD continues to conduct Pre-Incident Planning within the city. Emphasis has been made to utilize Pre-Incident Plans if available on scene (November 2017).

·       The Community Risk Assessment and Standards of Cover document has been presented to the Public Safety Committee, and highlights high hazard occupancies in the city (August 2018).

·       SAFD reviewed and updated its RIT Policy (June 2018).

·       A mayday training prop has been created using a repurposed trucking trailer at the Fire Training Academy. Training for all firefighters has been provided (May 2018).

·       All personnel are equipped with a radio and trained in its use. 

·       SAFD held training on the Command Mode portion of the Incident Management System SOP to include development of a training system, such as Blue Card Training (September 2018). 

·       Blue Card training has allowed SAFD to expand on communications training at the command level, with focus on mayday (October 2018).

·       SAFD has on-duty safety officers who are dispatched to working fires to ensure the safety of operations during an incident. 

·       SAFD completed department-wide training on the search and rescue prop located at Fire Station #45.


SAFD future actions

The SAFD is currently working to implement the following changes in response to the 19 recommendations:

·       Training on wind-driven fires, defined as the potential to cause a dramatic and sudden increase in fire, heat and smoke conditions (January 2019).

·       Redefining fireground terminology and benchmarks (December 2018).

·       Training of proper usage of positive-pressure ventilation (PPV) operations specifically for residential, commercial and high-rise (January 2019).

·       Improvements anticipated with new Accountability System reinstituted (September 2018 and ongoing).

·       System-wide revamp of the Pre-Plan Program (January 2019).

·       Evaluation of technological improvements related to radio system upgrades, changes to the SCBA system, and radio holsters for more effective use of the system.

·       Creation of Professional Standards Division Chief needed. SAFD is currently addressing the resistance to change by stressing the awareness of personal accountability and enforcing progressive discipline more vigorously. This position would better manage the focus of creating and sustaining a new cultural paradigm.

·       Evaluation and updates to the department’s Incident Management Policy to include standardizing of necessary benchmarks (January 2019).

·       Examination of software that will enable the creation and storage of pre-incident plans (July 2019).

·       Evaluation of new radio system for countywide use. 


Enhanced Training

SAFD developed the Scott Deem Incumbent Training Firefighter Center though the repurposing of the Cherry Street Warehouse.SAFD developed the Scott Deem Incumbent Training Firefighter Center though the repurposing of the Cherry Street Warehouse.Photo courtesy SAFDAs noted, the SAFD recently added the Incumbent Training Officer position that is responsible for enhancing their training program for the nearly 1,100 firefighters assigned to the fire suppression division. SAFD firefighters are currently mandated by the Texas Commission on Fire Protection to complete a total of 21,960 hours of training each year (20 hours per firefighter). With the addition of the Incumbent Training Officer, the SAFD is now conducting well over 15,000 hours of training, in addition to the required minimum hours, each year. Adding to the facilities and props that are already part of their state-of-the-art training facility, the SAFD has recently opened the Scott Deem Training Center. This new facility is being used to conduct various scenarios, including a firefighter mayday, within a 2,400-square-foot structure that can be fully reshaped to replicate various building types. With the addition of the Incumbent Training Officer and the Scott Deem Center, the SAFD vows to learn and grow from the tragic events of May 18, 2017, doing so while forever honoring the memory of Firefighter Deem. 

Final thoughts

There were a total of 93 LODDs across the nation in 2017; five of those were in Texas. The most devastating for San Antonio was, of course, the loss of brother Deem. Like most departments that have experienced an LODD, for the SAFD, the findings are difficult to accept, but they are accurate and fair. 

By the very nature of their numerous daily successes, the SAFD is a highly respected, high-performing and intensely trained agency. However, on May 18, 2017, the SAFD was rocked to its very core with the loss of Deem. There are few things worse than what the entire membership of the SAFD has been through, including those on the scene that evening and even those who were not—it impacts them all. 

As stated to the entire SAFD membership by Chief Charles Hood, "I want to assure every member of this department that our response to this report will be prompt and thorough. The SAFD will do everything within its power, and will take every measure necessary, to protect the lives of the men and women of this great department. To do anything less would be a dishonor to the legacy of Firefighter Scott Deem. His wife and children deserve our greatest effort to ensure this type of tragedy never happens again.” 

Unfortunately, not all departments that have suffered LODDs take a critical look at their operations to determine what can be done different and how they can work to minimize such events from happening again. A recent fire in another part of the country left a firefighter dead in a completely avoidable scenario. By nature of both a state report and a NIOSH investigation, companies ignored Command’s orders, firefighters freelanced, there was no scene control or accountability, radios were not compatible with a common fireground channel and many other issues. Then, quite frankly, to make it worse, the findings were blasted by that department’s leadership … and by all accounts, the same behaviors continue at that agency today. A real shame.

The SAFD leadership and members have taken a completely different attitude. The SAFD is an extremely active metropolitan department. From 2015 to 2017, the SAFD responded to 541,543 incidents, 1,045,290 unit responses and 3,285 structure fires, and by all accounts, experience huge successes.

But then May 18 happened.

May 18 hasn’t changed the good that the SAFD members do each and every day by any means, but it has allowed them to make an intentional and aggressive decision to continue improving by training, becoming even more disciplined, and considering technology and operational changes, all to honor the life of Deem, the ongoing recovery of Phipps, their families, and the emotional recovery of every SAFD member. 

That’s the genuine way to honor their lost brother—by using measurable and proven actions to underline their heartfelt words and emotions.


Our sincere thanks to Chief Charles Hood and the entire membership of the SAFD for sharing the facts and what actions can be taken by all of us so we don't experience what they did in May 2017.

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