Close Calls: The Start of Many Bad Endings

Working on the roof is an essential task. In July 2020, I wrote about a firefighter who went through the roof of a commercial building (firehouse.com/21140213). Later, when I learned about a mayday that involved the Tulare, CA, Fire Department (TFD), I was struck by the similarities of the two incidents.

My sincere thanks to TFD Fire Chief Luis Nevarez, Division Chief David Rossman, and all of the TFD officers and members who operated at the fire. Their appreciation for the importance of sharing their incident makes for all of us to be better firefighters and officers.

Account from Chief David Rossman

Units were dispatched to a reported commercial structure fire at approximately 12:50 a.m. on July 5, 2020. On arrival, only a small orange glow and light smoke on the D side of the structure was visible from what appeared to be the exterior of the roof of a metal warehouse. (I couldn’t see actual fire because of a parapet wall on the A side.) I had a feeling that this was going to be accumulated leaves that caught fire from an aerial firework. This drew me into a relaxed/complacent state of mind and led me to not call for a working fire assignment.

I radioed in my on-scene report and established command. I noticed that the structure was behind a locked chain link gate, so I drove to the street north of the lot to see what our access options were. Seeing that the gate was the only way into the property, I drove back to the A side then made a U-turn to situate the rear of my vehicle to see the greatest amount of the building while staying out of the way of the engines.

I radioed an update to dispatch (and all incoming units, because they still would have been on our command channel). I readvised the fire’s location and that it appeared to be on the exterior of the roof. Because of the on-scene conditions and lack of any smoke coming from the inside of the building, I told dispatch to “hold off on a working fire assignment.” (A working fire assignment would have gotten me a safety officer, police for traffic control, a Code 2 ALS ambulance for standby, a V-Fire channel for emergency operations, and the gas and electric companies.) I advised the first-arriving engine that they would have to use bolt cutters on the gate.

Engine 261 was the first engine on scene and was staffed with an acting captain, an acting engineer and a firefighter/paramedic. The chain on the gate was cut, and I directed them to deploy a 200-foot, 1¾-inch wye line to the A/D corner (the fire was along the D side roof line edge). I also directed them to throw a 24-foot ground ladder for roof access.

I assigned Engine 62 (a captain, an engineer and a firefighter/paramedic) to go to the roof to see what we had. The initial ladder at the A/D corner was in place but wasn’t raised because of concerns about overhead electrical service. A second 24-foot ground ladder was deployed to the A/B corner (B side).

Engine 63 (a captain, an engineer and a firefighter/paramedic) arrived. I met with the captain face-to-face and assigned them to force entry to conduct a quick search.

Truck 61 (a captain and an engineer) was the last unit to arrive because of the delay in personnel movement over to it. Truck 61 was staged just south of the gate in the lot. I didn’t believe that there was a need to set it up for the little fire that showed. Truck 61’s crew was assigned via face-to-face as two out.

After all assignments were made, I began my 360-degree size-up. As I walked clockwise toward the C side, I ran into the engineer of Engine 62. I tasked him with securing the utilities, because I saw that exterior lights still were on.

The mayday

Just as I was making it to the B/C corner, the captain of Engine 62 declared a mayday on our TAC channel. An off-duty captain who heard the initial dispatch responded to the scene with our fire marshal, who heard the mayday. I stopped my 360 and hurriedly walked back to my command vehicle, announcing “All personnel operating on the fireground hold all radio traffic. We have a firefighter who’s declared a mayday,” and then, “Firefighter with the mayday go ahead.”

The captain of Engine 62 advised that he was uninjured and that he just needed help getting out. I then made a blanket radio assignment to get personnel to the roof to assist him. In the moment, I didn’t think to assign any particular crew (particularly my two-out crew).

When I made it back to my command vehicle, I radioed dispatch. When they responded, I told them that we were working a mayday with a firefighter that fell through the roof, and we were working to get him out. I asked them to page a safety officer and to notify the fire chief.

Engine 261’s firefighter/paramedic was the first one at the captain’s side. When the firefighter/paramedic got there, she was standing on a purlin, holding on to the captain’s right SCBA shoulder strap. Her foot slipped off and broke through the skylight panel. She lost her balance and dropped into a sitting position, straddling the purlin with one leg on each side. The captain was able to grab her leg and support them both. Remarkably, the captain was able to maintain his composure and to relay to Engine 261’s acting captain (who now was at the side of the captain and of the firefighter) the need to remain in a safe spot away from the edge of the hole. With help, the captain was able to “roll” out of the hole onto the metal roof panels.

The captain radioed to me that he was freed and that he was “OK.” I pulled all of them off of the roof and had the captain report to the street to confirm that he was uninjured. As he came to the command post, I radioed dispatch to advise them that the mayday was finished, that we got him off of the roof and that he was uninjured. Hearing that we had a working mayday, our dispatchers took the initiative to assign a Code 3 ALS ambulance to the scene. They asked whether I wanted them to continue in, which I did.

After the mayday was finished, I had a brief discussion with the off-duty captain who was on scene. He suggested that I bring the truck in to set up on the A side, so we didn’t have to send anyone across the entire roof again. I agreed that it was a good idea and ordered the operation. While that took place, I had a third 24-foot ground ladder thrown on the C side. We needed personnel on the roof to check the fire and overhaul, and I wanted a usable ladder closer to the operation. The fire partially was knocked down using the deployed 1¾-inch wye line from the ground. It took about five minutes for the truck to set up, because there was some miscommunication regarding my intentions: I wanted the ladder set up for personnel to get onto the roof; instead, it was set up as an aerial waterway. 

Rather than reposition the aerial ladder again, I asked the acting captain and the firefighter if they were comfortable going back on the roof, which they both were. We used the aerial to apply water onto several loose 2 x 4-inch pieces of lumber and an accumulation of dry leaves. After a few minutes of water application, the two members on the roof made their way to the lumber and flipped all of the boards. They backed away, so the aerial could apply water again.

The resounding theme of the tailboard meeting after this run was communication. There was a lot of confusion about who was assigned to what task, because command made some of the assignments face-to-face. The confusion regarding assignments worsened during the mayday.

I have to own a lot of what went wrong on this incident. I allowed what I observed upon arrival to draw me in to an almost nonurgent state of mind. I knew that I had a truck responding to this incident, but I chose to stage it instead of to move it into position. I also didn’t call a working fire assignment.

I believe that once the mayday was called, we went into free-for-all. I ordered crews to the roof to assist the captain, but I didn’t specify that I wanted my two-out team to report. Engine 62’s firefighter still was footing the ladder when the mayday was announced, so the next two closest members were the acting captain and the firefighter from Engine 261, who immediately went to the roof to help with the rescue.

When I ordered the truck to move to set up to get personnel to the roof, there was a miscommunication/misunderstanding of my intentions. Rather than stop the action and redirect the crews, I allowed the action to proceed, adapting the operation to fit the situation.

I believe that some things went well during the mayday.

The captain who was in distress remained very calm, which translated into me being calm. I believe that it was during the mayday that we had the clearest, calmest radio traffic during the entire incident.

The mayday was resolved within five minutes of it being declared. Following the incident, I didn’t release any of the crews until we completed a tailboard discussion about what took place. Also, prior to releasing Engine 62, I made face-to-face contact with the captain who called the mayday and asked him directly whether he would like me to have someone come in so he could process what happened. He appreciated it but wanted to stay on shift.

I believe that the only way to get better is to own your mistakes and then to learn from them.

During the mayday, I was unable to see what was going on because of where I parked. I couldn’t see the scramble that took place and, just as we read all of the time, all other operations essentially stopped. At one point during the mayday, orders were given by someone other than the incident commander (IC) via face-to-face communications, and a 14-foot roof ladder was ordered to be placed below the captain to support him. He was rescued before the ladder was placed; furthermore, the ladder wasn’t tall enough to reach the purlins, which essentially would have wasted valuable time.

Had this been a working fire, particularly if there was fire under the captain, it would have been imperative to continue suppression efforts for the safety and protection of the member who was in distress. That said, I now see how easy it is for our men and women to direct their focus on a fellow firefighter who is in trouble. As the IC, it is so important to pull everyone back, launch your rescue crew and keep other operations going.

Several members who were on scene reported that they either didn’t hear the mayday transmission or that it came across very scratchy.

Observations from Chief Luis Nevarez

After the incident, Nevarez emailed his department to tell members that he ran across the Firehouse.com article, “Close Calls: On a Treacherous Path.” He noted how the article reports on an incident that was very similar to the one that the TFD encountered.

The article read so familiar, he wrote, including the fact that the chief of the department who was involved in that close call hit upon the same comments that Nevarez made during the debriefing of TFD’s incident, such as better preplanning during company inspections and situational awareness during the duration of COVID-19 (excessive overtime, minimum staffing, etc.). Nevarez reported that the TFD Training Committee is working to revise roof operations policy in regard to both residential and commercial structures.

Thanks to the quick thinking of two TFD members, Nevarez added, the captain was rescued perhaps 3–4 minutes before he would have fallen to the ground. The captain did a great job of keeping his composure and calling out his mayday.

Comments from Chief Goldfeder

Although I have responded to my share of working fires, few went perfectly. That doesn’t mean that most didn’t go well. In any case, it’s been rare that, if given the chance, I wouldn’t do something a little differently (applying it next time), with the goal to be better. It never stops—and shouldn’t.

Getting too comfortable in an unconfirmed, unverified and not fully investigated incident is something every one of us experienced. As my partner at FirefighterCloseCalls.com, Gordon Graham, reminds us all, low-frequency/high-risk events can jam us up. The challenge is to prepare and to act as we trained and per what policy directs us to do. For example, if policy and training state that if you see fire or smoke, you transmit a “working fire dispatch,” then do that.

As a young firefighter, I remember being struck by the “downplaying” that I observed from bosses at a fire. Attitudes of “If I need more help, I’ll call for it then” and “This doesn’t look like much” have been the start of many bad endings.

Don’t allow the prehistoric thinking of “hold off until you need it” to get into your head. After all, once you and your crew determine exactly what the problem is, your “working fire dispatch” assignment always can be turned around. However, if what appears to be minor turns into something major, that extra help is on the way—or already there.

Worried about the risk that other apparatus that respond might be put in? Make sure that they have good training and drive carefully. Worried about “bothering” other companies that might not be needed? Bother them. If getting called and not being needed is a problem for them, they are in the wrong profession.

Essentially, do at least all that is minimally expected and never hesitate to go above and beyond by doing more, calling for more, etc., until you don’t have to. Do so even on what might appear to be among the most basic of runs. Treat your emergency as what it might become.