The term “perfect storm” has been around for years. It describes an event where a low-frequency combination of circumstances or actions can drastically impact a situation.
You may also be familiar with the “Swiss cheese” model of accident causation, which is used in risk analysis and management circles. In my version of it, things that are predictable eventually come together to create a bad result. The event is often followed by someone saying, “I knew this could happen.” When we look at firefighter close calls and line-of-duty deaths, in a large majority of cases, the Swiss cheese model serves as a reliable tool in determining why and how things went wrong—things that were very often predictable.
It may be easy for some to ignore things that go wrong at “that other” fire department; however, the goal must be to look at our fire department to determine if what happened to them can happen to us. That is and has always been the intent of this column. Rest assured, it is rarely just one specific “thing” that results in a mayday, injury or worse; rather, it is usually a culmination of several events, circumstances and behaviors that lead to something going terribly wrong.
Mutual-aid partners: Oxford and Auburn
Earlier this year, Oxford, MA, firefighters responded to a fire in a mixed-use building with a commercial hair-styling business on the first floor and apartments above—a fire that ultimately resulted in a mayday and close call for two mutual-aid firefighters.
I intentionally mention that the firefighters were mutual aid because now more than ever, departments are relying on mutual aid and automatic aid due to staffing issues in full-time, part-time, call and volunteer-served communities. It’s vital to understand that if you are going to assist or ask for assistance on a regular basis, the departments must have common policy, guidelines, standards and operational goals as well as compatible equipment, from radios to hose couplings and so much more. It is incumbent upon fire chiefs, commissioners and other leaders to focus on the needs of those needing help (the callers and the victims) and those helping (the firefighters) vs. personal attitudes, likes, dislikes and irrelevant territorial interests.
The Oxford Fire-EMS Department serves a 26-square-mile primarily residential community with a population of approximately 13,500. Its membership consists of 14 full-time firefighters and approximately 20 on-call firefighters and EMS providers. Oxford Fire-EMS operates four engines, two forestry trucks, one tower ladder, one heavy rescue, two paramedic-level ambulances, one paramedic response unit, one marine unit and one MCI unit, responding to approximately 2,300 fire- and EMS-related runs annually.
The mutual aid Auburn, MA, Fire-Rescue Department provides fire, rescue and EMS in 16.4 square miles, covering a population of 16,474, which increases to 50,000 during the day. Department members respond from two fire stations that house three engines, one tower ladder, one heavy rescue, one rescue pumper, one brush truck and three ambulances. The department consists of 35 full-time members and eight paid on-call firefighters, answering approximately 3,500 runs annually.
Incident overview
On Jan. 2, at 0202 hrs, Oxford Fire Dispatch received a report of a fire in a mixed-use building in Oxford. Oxford Police units were dispatched at 0204 hrs, and fire units were dispatched on a second alarm (per run card for confirmed structure fire) at 0205 hrs.
The first Oxford police cruiser arrived on scene at 0206 hrs and confirmed an active structure fire. Police officers reported at 0207 hrs that occupants were trapped on the second floor; shortly thereafter, reports indicated that occupants were out of the building.
Support Staff Kyle Gibbons, the first fire staff on scene at 0206 hrs, gave a brief size-up. Oxford Engine 2, with crew of three, was en route at 0211 hrs. Engine 2 crew requested an update at 0211 hrs to which Oxford dispatch reported heavy fire on Division 1 with fire showing from the windows and that all occupants were out of the building. Gibbons requested a third alarm at 0212 hrs and repeated the request at 0213 hrs.
Oxford Engine 2 was first fire unit on scene at 0215 hrs. Gibbons notified the crew on a face-to-face that police officers on scene reported that they believed all occupants to be out of the building. This was the last time this information was provided to any fire personnel on scene.
Oxford Firefighter-EMT Ruess Lambert then attempted a transmission but later discovered that his portable antenna was broken.
Oxford Firefighter-EMT Lambert and Firefighter-Paramedic Dennis Fitzgibbons stretched a line to the A-side door of the salon. Firefighter-EMT Jeffrey Morris was the pump operator. Prior to entering the structure, the crew requested that Gibbons monitor the radios and get resources via the run card until a fire officer arrived on scene.
Auburn Engine 1 arrived at 0218 hrs per automatic mutual-aid agreement. Auburn Fire Lt. Justin Brigham assumed command at the request of Gibbons, and Lt. Brigham took command at 0223 hrs.
At 0219 hrs, the Oxford Engine 2 crew entered the structure on the first floor to attempt to extinguish the heavy fire in the salon area. Auburn Engine 1 crew stretched a line to the C side of the building to begin a primary search of the residential areas. Oxford Fire Captain John Belanger arrived on scene and had a face-to-face with Lt. Brigham before assuming command at 0225 hrs.
At 0228 hrs, the Auburn Engine 1 crew reported that they were entering the C side of the structure with a hoseline. Lt. Brigham knew the hoseline used to search the C-side apartment would not reach the D-side apartment door, so he split his crew of four and sent two members—Firefighters Kim O’Brien and Skylar Stafford—to pull an additional hoseline to be deployed on the D-side hill. Command was made aware of this tactical decision via radio transmission.
Lt. Brigham decided to enter the D-side apartment to conduct a primary search with his partner, Firefighter-Paramedic Scott Davis, prior to the second hoseline being in place. He was aware of the advancing fire conditions and building construction prior to entering the D-side apartment.
Oxford Engine 1 with Firefighter Bryan Givner arrived on scene and was directed to connect a supply line to Oxford Engine 2. At this time, Oxford Engine 2 was providing water to both the interior crews. Auburn Engine 3 was then requested to tie into the hydrant directly across from Old Depot Road, on the southbound side of Route 12.
A 4-inch diameter line was put in place from the hydrant across Route 12 to Oxford Engine 2, providing a continuous water source to that engine. Oxford Engine 1 was instructed to disconnect its feeder line connection to Oxford Engine 2, and then instructed to connect to the hydrant south of the fire at 592 Main St. Firefighter Givner hand-dragged the 4-inch diameter hose to the hydrant to provide a continuous water source to Oxford Engine 1. Two additional 1¾-inch handlines were deployed and charged from Oxford Engine 1.
While searching for occupants, Lt. Brigham and Firefighter-Paramedic Davis realized conditions were becoming untenable. First, they felt their gloves sticking to the linoleum tiles, then they started to feel the plastic on their SCBA masks break down, and then the next room over had just flashed. Further, the layout of the apartment, coupled with low-visibility conditions, caused the two firefighters to become disoriented. They quickly realized it was time to get out, and spent approximately two minutes making passes along the walls trying to locate the door through which they entered.
Mayday transmitted
At 0238 hrs (more than 30 minutes into the fire), Auburn Engine 1 called a mayday on District 7 Fire Orange Repeater. Lt. Brigham did not realize it was being transmitted on that frequency. The mayday was not heard by Captain Belanger or Oxford Fire Dispatch because the frequency was not in use or being monitored. The District 7 Fire Orange repeater frequency is reserved for movement of District 7 assets during large incidents and is not intended to be used as a fireground frequency, and therefore would not have been normally monitored by command or dispatch.
At 0239 hrs, Auburn Engine 1 repeats the mayday call on the District 7 Fire Orange Repeater frequency. This mayday is heard by South County Regional Dispatch as well as mutual-aid agencies covering Oxford Fire Headquarters. South County Regional Dispatch called the Oxford Dispatch to confirm that the mayday was heard.
Lt. Mike Gonyor of the Dudley Fire Department contacted Oxford Fire Dispatch over the Oxford fire radio frequency to confirm that the mayday was heard. Oxford Fire Dispatch also contacted Captain Belanger to notify him of the mayday at 0240 hrs.
Captain Belanger was originally notified of the mayday by local cameraman Paul Shea, who was scanning all local frequencies while on scene taking photos of the incident. The mayday was confirmed to Captain Belanger by Oxford Fire Alarm just after he received the report from Shea.
Lt. Brigham and Firefighter-Paramedic Davis were eventually able to break a window to escape the apartment and jumped onto the roof of the salon. Fortunately, they were not injured.
Thirty seconds after self-rescuing, the room flashed.
Captain Belanger cleared the mayday at 0241 hrs, reporting that Auburn Engine 1 crew had self-extricated. The crew's bailout through a Division 2 window onto the roof of the salon on the A side of the structure was witnessed by the other half of Lt. Brigham's crew, and they reported this to Captain Belanger.
Training and experience on the part of Lt. Brigham (who has since been promoted to captain) and Firefighter-Paramedic Davis ensured that they recognized the flashover conditions and were able to find their way out of the situation. Lt. Brigham’s facepiece was compromised but did not fail. The mask performed as designed.
From Captain Brigham
I have often heard the saying, “Let no man’s ghost ever say his training let him down.” I guess we are living proof of that. The first thing the chief asked me about the morning after that fire was what part training played in our experience. After a momentary pause, I answered: “I think training put us in the situation and training also got us out.”
Yes, it’s true that in those 90 seconds after that first mayday call went out, we remained composed and together. Yes, it’s true that we communicated well and knew without hesitation our deteriorating conditions. Yes, it’s true that we have spent countless hours crawling around abandoned buildings and on the apparatus floor practicing for this very moment. And yes, it’s true that we didn’t do everything perfectly. But it’s also true that our training gave us the confidence and the mental capacity, the physical ability and fortitude to enable our actions. We consider ourselves intelligently aggressive, well trained and experienced. That’s what our training gives us. That training gives us the courage to do the things we do every day. That’s what put us there that early morning and that’s what saved our lives.
Vince Lombardi once said, “Perfection is not attainable, but if we chase perfection, we can catch outstanding.” I know that is what we try to do every day: chase perfection—for ourselves, for the people we serve and for our families waiting for us to walk through the door in the morning. We can’t ever stop trying to get better.
When I look back on that night, and I often do, I am reminded of how great the people around me are. How we motivate each other every day to bring a better game than the shift before. You are only as good as the people with you. So help the people around you exceed their own expectations daily.
Company officers have asked me about my experience that night. There are so many things that run through my head, so many things I want to say. However, the thing I put the most focus on is preparation. In that room, at the moment, there was no time for a plan. The plan for that minute and a half began a long time ago, in a fire station far away, when I put my helmet and jacket on for the first time and participated in my first training.
Next month
In the next installment of Close Calls, we’ll review several concerns, comments and suggested resolutions related to this incident, as provided by the Oxford Chief Sheri Bemis, as well as additional analysis from myself.
Our sincere thanks to Fire Chief Sheri Bemis of the Oxford Fire-EMS Department along with Fire Chief Steve Coleman of the Auburn Fire Department, with special thanks to all the Auburn, Oxford and other mutual-aid partners for their cooperation in sharing this close call.
Sidebar: How Does This Mayday Compare?
After the incident, Captain Justin Brigham, who called the mayday in this Close Call, reviewed how the incident details compared to other maydays, as reported through Project Mayday. Funded through Command Emergency Response Training (CERT), as well as Don and Bev Abbott, Project Mayday compiles user-submitted information about maydays at http://projectmayday.net.
The text in black below shows the more frequent responses from the Project Mayday data. The text in red shows the information for this Close Call.
Age of those involved in mayday event
Project Mayday: 32–40
Close Call: Lt. Brigham: 40; Firefighter-Paramedic Davis: 32
Time of mayday event
Project Mayday: Between 0000 and 0300 hrs
Close Call: 0200 hrs
Reporting crew
Project Mayday: First-arriving crew (54%)–First companies (78%)
Close Call: First companies
Top reason for mayday
Project Mayday: Lost/disoriented firefighter
Close Call: Lost/disoriented firefighter
Additional comparison data
48% of maydays happen to crews that do not have the protection of a hoseline.
Close Call: No hoseline in place
50% maydays had no 360; 78% had an incomplete 360
Close Call: 360 was complete by Brigham
67% had a mobile, non-fixed Command
Close Call: Non-fixed Command
71% had a company officer as Command
Close Call: Company officer was in Command
40% on the wrong channel
Close Call: On the wrong channel when mayday was transmitted
60% had difficulties because of radio traffic
Close Call: Radio difficulty experienced
41% of incident commanders using accountability board/worksheet
Close Call: Separate accountability
More than 80% never train using Fire Alarm
Close Call: No Fire Alarm training
36% occur with RIT on scene
Close Call: RIT on scene
30% of crews thought about calling long before they did
Close Call: Called at appropriate time
22% self-rescued; 25% rescued by member of own crew; 30% rescued by crew inside the structure; 10% rescued by RIT
Close Call: Self-rescued
