# Two Career Lieutenants Killed and Two Career Fire Fighters Injured Following a Flashover at an Assembly Hall Fire—Texas/Recommendations

​Recommendations Recommendation #1: Fire departments should use risk management principles at all structure fires.
Discussion: While it is recognized that firefighting is an inherently hazardous occupation, risk management principles established by the fire service are based on the philosophy that greater risks will be assumed when there are lives to be saved and the level of acceptable risk to fire fighters is much lower when only property is at stake. Interior offensive firefighting or fast-attack operations can increase the risk of traumatic injury and death to fire fighters from structural collapse, a flashover, and potential asphyxiation. When it is confirmed that there are no lives to save, the IC must then decide what risks they are willing to expose their personnel to based on risk-versus-gain. ​
Established risk management principles suggest that more caution should be exercised in abandoned, vacant, and unoccupied structures and in situations where there is no clear evidence indicating that people are trapped inside a structure and can be saved. In this incident, no vehicles were observed within the parking lot for the structure, the time was late evening, and all doors were secured. From this information, a determination may have been made that the structure was unoccupied.
The IC, with input from the assigned ISO and/or division/group supervisors, is responsible for evaluating conditions at a structure fire and determining safe tactics for fighting the fire. To accomplish this, the IC should use a standardized strategic decision-making model. First, the IC should size up the critical fireground factors.3 Before ordering an offensive attack, the IC must make a determination that offensive (interior) operations may be conducted without exceeding a reasonable degree of risk to fire fighters and must be prepared to discontinue the offensive attack if the risk evaluation changes during the firefighting operation. A full range of factors must be considered in making the risk evaluation, including but not limited to the following:
* Presence of occupants in the building
* A realistic evaluation of occupant survivability and rescue potential
* Size, construction, and use of the building
* Age and condition of the building
* Nature and value of building contents
* Location and extent of the fire within the building
* Adjacent exposures (structures)
* Fire involvement or compromise of the building’s structural components
* Residential or commercial structure
* Delayed discovery/reporting and its effect on burn time and structural stability
* Considerations of fire loading and fire behavior
* A realistic evaluation of the ability to execute a successful offensive fire attack with the resources that are available.
These fireground factors must be weighed against the risk management plan. Fire fighters are routinely exposed to certain known and predictable risks while conducting operations that are directed toward saving property. The IC is responsible for recognizing and evaluating those risks and determining whether the level of risk is acceptable or unacceptable. However, risks taken to save property should always be less than those to save lives. Risks to fire fighters versus gains in saving lives and property must always be considered when deciding whether to use an offensive or defensive attack. The IC should routinely evaluate and re-evaluate conditions and radio progress reports in reaching objectives to dispatch and on scene fire fighters. This process allows the IC to determine whether to continue or revise the strategy and attack plans. Failure to revise an inappropriate or outdated attack strategy is likely to result in an elevated risk of death or injury to fire fighters.
NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, section 4.2, provides detailed information regarding the risk management plan. Incident demands on the modern fireground, unlike those of the past, require ICs and commanding officers to have increased technical ​knowledge of building construction with a heightened sensitivity to fire behavior, a focus on operational structural stability, and considerations related to occupancy risk versus the occupancy type. Strategies and tactics must be based on occupancy risk, not occupancy type, and must orchestrate sufficient staffing, fire flow, and tactical patience in a manner that identifies with the fire profiling and the predictability of the occupancy profile and accounts for presumptive fire behavior.6 The firstarriving officer, as well as the IC, must make an informed judgment before and ongoing as to what is at risk—people or property. This judgment will determine the risk profile for the incident. Many fire fighters stand by the notion that all incidents are “people” events until proven otherwise. Historically, the fire service has a poor history of changing risk-taking strategies based upon the people/property issue.
Arriving officers and incident commanders need to consider all information gathered during their initial risk assessment when determining their incident action plan (IAP).
Recommendation #2: Fire departments should ensure that incident commanders and fire fighters understand the influence strategy and tactics (e.g., fireground ventilation) may have on fire behavior and fire fighter safety and consider whether traditional firefighting tactics are appropriate.
Discussion: Ventilation is the systematic removal of heated air, smoke, and fire gases from a burning building and replacing them with cooler air. The two types of ventilation are vertical and horizontal. During vertical ventilation the natural convection of the heated gases creates upward currents, which draw the fire and heat in the direction of the vertical opening. Horizontal ventilation allows for heat, smoke, and gases to escape by means of a doorway or window but is highly influenced by the location and extent of the fire, and special caution should be taken if the fire is in the attic or above a ceiling.
Ventilation may begin as early as opening a door to a structure that is on fire. For this reason ventilation should be closely coordinated with hoseline placement and offensive fire suppression tactics. Close coordination means the hoseline is in place and ready to operate, so that when ventilation occurs, the hoseline can overcome the likely increase in combustion. In other words, if air is added without the addition of water, then the fire gets larger and fire fighter safety decreases.
Properly coordinated ventilation can decrease the rate the fire spreads, increase visibility, and lower the potential for flashover or backdraft. Proper ventilation reduces the threat of flashover by removing heat before combustibles in a room or an enclosed area reach their ignition temperatures. Proper ventilation can reduce the risk of a backdraft by reducing the potential for superheated fire gases and smoke to accumulate in an enclosed area. Properly ventilating a structure fire will reduce the tendency for rising heat, smoke, and fire gases, trapped by the roof or ceiling, to accumulate, bank down, and spread laterally to other areas within the structure. The ventilation opening may produce a chimney effect, causing air movement from within a structure toward the opening. These air movements help facilitate the venting of smoke, hot gases, and products of combustion but may also cause the fire to grow in intensity and may endanger fire fighters who are between the fire and the ventilation opening.
Fire development in a compartment may be described in several stages, although the boundaries between these stages may not be clearly defined. The incipient stage starts with ignition, followed by growth, fully developed, and decay stages. The available fuel largely controls the growth of the fire ​during the early stages. This is known as a fuel-controlled fire, and ventilation during this time may initially slow the spread of the fire as smoke, hot gases, and products of incomplete combustion are removed. As noted above, increased ventilation can also cause the fire to grow in intensity as additional air is introduced. Effective application of water during this time can suppress the fire, but if the fire is not quickly knocked down, it may continue to grow.
If the fire grows until the compartment approaches a fully developed state, the fire is likely to become ventilation controlled. Further fire growth is limited by the available air supply as the fire consumes the oxygen in the compartment. Ventilating the compartment at this point will allow a fresh air supply with oxygen to support combustion, which may accelerate the fire growth, resulting in an increased heat-release rate. If coordinated fire suppression activities do not quickly decrease the heat-release rate, ventilation-induced flashover can occur. Considering that most fires beyond the incipient stage are or will quickly become ventilation-controlled, increasing ventilation is likely to be one of the most significant factors in changing fire behavior and can result in rapidly accelerating the fire.
Underwriters Laboratories (UL) Fire Research Division has recently conducted research that suggests traditional firefighting tactics should be reconsidered and suggests a more innovative fire attack tactic is more effective in making the fireground safer for fire fighters and occupants. For over 250 years, traditional tactics used by the American fire service to mitigate and control hazards of fire have worked—and these tactics have been passed down from individual fire fighter experiences through the generations. However, structure fires have decreased by 53% over the past 30 years, which in turn has limited the opportunities for today’s fire service to gain necessary experience to understand the increasingly complex fires they are now up against.
UL experiments showed that applying water into a burning room through an exterior door or window before making an interior attack will lower temperatures within the structure and cool the unburned fuel, thereby increasing the potential survival time for building occupants and providing safer conditions for fire fighters to enter. Additionally, UL experiments demonstrated that the traditional practice of increasing ventilation to a ventilation-limited structure fire by opening doors, clearing windows, or cutting the roof increased fire hazards and the potential for a rapid transition to flashover.
Units arriving at this incident observed fire coming from the roof at the A/B corner. The truck company "popped" the door located at the A/B corner on the B-side and observed heavy fire in this area but did not have a hoseline to attack the fire. Victim #1 and his probationary fire fighter advanced a hoseline through the bingo hall to this same area to attack the fire from the inside. They had not pulled any ceiling tiles and did not have a thermal imager to see if the fire was advancing above them. Additionally, PPV fans were placed at the front door on A-side, which allowed better visibility within the vestibule but in turn pushed fresh air into the structure. A better strategy may have been to attack the fire through the B-side door in a defensive manner, committing to an interior attack only when confirmed lives were at risk, or the conditions improved sufficiently to make such actions low-risk. ​
Recommendation #3: Fire departments should ensure that an established incident management system on a fireground is appropriate and effective as it relates to that specific incident.
Discussion: Most incidents are considered routine and involve a small commitment of resources (highfrequency/low-risk events), while fewer incidents involve large structures, large commitments of resources, and complex situations (low-frequency/high-risk events). An incident management system is intended to provide a standard approach to the management of emergency incidents. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program and NFPA 1561 Standard on Emergency Services Incident Management System both state an incident management system shall be utilized at all emergency incidents. Most often, this system is commonly known as, or referred to as, the Incident Command System, or ICS. The many different and complex situations encountered by fire fighters require a considerable amount of judgment in the application of ICS. The primary objective is always to manage the incident. The IC should be able to apply ICS in a manner that supports effective and efficient management of the incident. The use of ICS should not create additional challenges for the IC, but rather provide a systems approach to ensuring a successful outcome of the incident.
NFPA 1561, Chapter 3.3.30 defines an incident management system as "A system that defines the roles and responsibilities to be assumed by responders and the standard operating procedures to be used in the management and direction of emergency incidents and other functions." Chapter 4.1 states, "The incident management system shall provide structure and coordination to the management of emergency incident operations to provide for the safety and health of emergency services organization responders and other persons involved in those activities." Chapter 4.2.1 states, "The incident management system shall integrate risk management into the regular functions of incident command."
The incident management system covers more than just fireground operations. The incident management system must ensure for command/control and fire fighter safety, which includes situational evaluation, strategy and the IAP, personnel accountability, risk assessment and continuous evaluation, communications, rapid intervention teams, roles and responsibilities of the incident safety officer, and interoperability between multiple agencies (e.g., mutual aid departments, law enforcement, emergency medical services, state and federal government agencies and officials) and surrounding jurisdictions (i.e., automatic aid or mutual aid responders).
One of the most critical components of this system is the development and implementation of an IAP. For the fire service, the IAP is communicated verbally a majority of times. The IAP is based on the resources immediately available and those responding. The goal is determined in accordance with the incident priority from which a strategy must emerge; tactical objectives aimed at meeting the strategy are determined, and specific assignments made. A personnel accountability system should be established as assignments are made. The important point is that the overall IC communicates the IAP to tactical- and task-level supervisors. ​
During this incident, this fire department responded to a high-risk/low-frequency incident in which they were faced with a nonsprinklered 7,400 square foot assembly hall versus the routine room-and-contents residential fire. This fire had vented through the roof, which was observed by cellular 9-1-1 callers before the first emergency unit ever arrived on scene. ICs and front line officers need to take this information into account and be aware that the fire may be free-burning—potentially above an interior operation—as it was in this incident. In addition, the assessment indicated that there likely were no civilian lives in jeopardy from this fire. All officers arriving at this incident performed a walk-around of the structure, giving them a better feel for the structure. This walk-around should empower the officers to express their thoughts on the structure and potential strategies and tactics before ever committing their personnel to an interior attack, especially when only property loss is at risk. Today’s fire departments need to consider that performing the same strategies and tactics on every fire may make the fireground personnel complacent and not allow for situational awareness and an assessment of risk.
Recommendation #4: Fire departments should ensure that a complete situational size-up is conducted on all structure fires.
Discussion: Among the most important duties of the first officer on the scene is conducting an initial 360-degree situational size-up of the incident and transmitting this information to units on the fireground or responding to the incident. NFPA 1561, 8.9.1.1 states the incident commander shall conduct an initial and ongoing situational assessment of the incident.14 In order to accomplish this, the first officer on scene needs to have the requisite knowledge of the elements of a proper size-up.15 A proper size-up begins from the moment the alarm is received, and it continues until the fire is brought under control either offensively or defensively. The size-up should include an evaluation of factors such as the following:
* Location and volume of the fire
* Required fire flow
* Building construction
* Commercial versus residential structure
* Water supply
* Initial arriving engine laying in from a hydrant versus waiting for another engine to supply them upon their arrival.
* Length of time the fire has been burning, recognizing burn time may have affected structural stability
* Conditions on arrival
* Occupancy
* Fuel load
* Presence of combustible or hazardous materials
* Exposures
* Roof and wall loads
* Time of day
* Available staffing on scene or en route ​
* Weather conditions
* A realistic evaluation of the ability to conduct an offensive attack with available resources.
Even before ICs take command of an incident, they will be faced with having to determine which critical tasks must be performed (simultaneously or as required) to bring the incident under control, and whether they can delegate these tasks before becoming overwhelmed. ICs may need to consider assigning an individual to be an aide or operations sector leader so that critical tasks can be delegated, carried through, and effectively supervised. ICs will use current knowledge and previous experience to formulate a plan for arriving apparatus and personnel. When the IC arrives, as much information as possible must be ascertained to determine whether the IAP will still work. The IC may be faced with several priorities, such as an entrapped civilian, an incident of a scale larger than previously determined, and the fire environment itself, which are additionally part of the initial situational size-up. Items such as these will constantly change as the incident progresses until it is brought under control. ICs should be willing to prioritize and change their strategy and plan based on these assessments. Most importantly, the initial size-up provides a starting point for all fireground operations, especially when deciding on how to safely control and extinguish the fire.
During this incident, all arriving officers performed a 360-degree walk-around of the structure. The IC did not perform a walk-around. A decision was made to stretch a hoseline interiorly, find the seat of the fire, and extinguish it. ICs should consider factors such as whether civilian lives are at stake, size and type of the building, fire progression, fire behavior and extension, available man power, and ventilation tactics before placing fire fighters interiorly.
Fire departments should be aware of the International Association of Fire Chiefs' (IAFC) Rules of Engagement (ROE) of Structural Firefighting. These guidelines recommend that ICs conduct or obtain a 360-degree situational incident size-up, determine the occupant survival profile, and conduct an initial risk assessment.
Recommendation #5: Fire departments should ensure that crew integrity is properly maintained by face-to-face contact or radio contact when operating in an immediately dangerous to life and health (IDLH) atmosphere.
Discussion: When an engine company enters a structure, the members must remain in contact by visual (eye-to-eye contact), verbal (by radio or by face-to-face), or direct (by touch) contact. NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 8.5.5 states, "Crew members operating in a hazardous area shall be in communication with each other through visual, audible, or physical means or safety guide rope, in order to coordinate their activities," 8.5.4 states, "Members operating in hazardous areas at emergency incidents shall operate in crews of two or more. Additionally, NFPA 1500 8.5.6 states, “Crew members shall be in proximity to each other to provide assistance in case of an emergency."
The International Association of Fire Chiefs, Safety, Health, and Survival Section has redefined the Rules of Engagement for Structural Firefighting. One of its objectives is to ensure that fire fighters always enter a burning building as a team of two or more members and no fire fighter is allowed to be ​alone at any time while entering, operating in, or exiting a building. A critical element for fire fighter survival is crew integrity. Crew integrity means fire fighters stay together as a team of two or more. They must enter a structure together and remain together at all times while in the interior, and all members come out together. Crew integrity starts with the company officer ensuring that all members of the company understand their riding assignment, have the proper PPE, and have the proper tools and equipment. Upon arrival at the incident, the company is given a task to perform by the IC. The company officer communicates to the members of the company what their assignment is and how they will accomplish their assignment. To ensure that crew integrity is maintained, all the members of a company should enter a hazardous environment together and leave together. If one member has to leave, the whole company leaves.
It is the responsibility of every fire fighter to stay connected with crew members at all times. All fire fighters must maintain the unity of command by operating at all times under the direction of the IC, division/group supervisor, or their company officer. The ultimate responsibility for crew integrity and ensuring no members get separated or lost rests with the company officer. While operating in a hazard zone they must maintain constant contact with their assigned members by visual observation, voice, or touch. They must ensure they stay together as a company or crew. If any of these elements are not adhered to, crew integrity is lost and fire fighters are placed at great risk.
NFPA 1500, 8.4.4 – 8.4.6 states:
* The incident commander shall maintain an awareness of the location and function of all companies or crews at the scene of the incident.
* Officers assigned the responsibility for a specific tactical level management component at an incident shall directly supervise and account for the companies and/or crews operating in their specific area of responsibility.
* Company officers shall maintain an ongoing awareness of the location and condition of all company members.
If a fire fighter becomes separated and cannot immediately get reconnected with his/her crew, the fire fighter must attempt to communicate via portable radio with the company officer. If reconnection is not accomplished after three radio attempts or reconnection does not take place within one minute, a mayday should be declared. If conditions are rapidly deteriorating, the mayday must be declared immediately. As part of a mayday declaration, the fire fighter must next activate the radio’s emergency alert button (where provided), followed by manually turning on the PASS alarm. Similarly, if the company officer or the fire fighter’s partner recognizes they have a separated member, they must immediately attempt to locate the member by using their radio or by voice. If contact is not established after three attempts or within one minute, a Mayday must be declared immediately.
During this incident, Victim #1 and his probationary fire fighter somehow became separated after leaving together. The probationary fire fighter was unaware that Victim #1 was having trouble in exiting until after he heard a radio transmission over the radio. By this time, the two were out of reach and contact from each other. Victim #1 immediately began radioing for assistance and alerted others by depressing his emergency button on his hand-held radio. ​
Recommendation #6: Fire departments should ensure that fire fighters are properly trained in "out of air" and "low air" SCBA emergencies and SCBA repetitive-skills training.
Discussion: Repetitive-skills training on an SCBA is a vital necessity for fire fighters working in an immediately dangerous to life and health (IDLH) atmosphere. Repetitive-skills training can increase the ability to operate SCBA functions and controls in a high-anxiety moment or an emergency. Many times, these skills must be performed with gloved hands, limited vision, and reduced ability to hear commands or information from other fire fighters or fire officers. Repetitive-skills training allows fire fighters to engage buttons such as the don/doff button, bypass, cylinder wheel or main line valve, and buddy breathing connection in training conditions that are non-IDLH. This helps build the fire fighters muscle memory skills so their hands will be able to activate the controls with gloves on and the operation will be a second-nature response.
Fire fighters need to be trained to use their equipment and the repetitive-skills training reinforces the muscle memory to properly activate the correct controls. Overcoming out-of-air emergencies is an important goal of repetitive-skills training. Fire fighters also need to understand the psychological and physiological effects of the extreme level of stress encountered when they run low on air, become lost, disoriented, injured, or become trapped during rapid fire progression. Most fire training curricula does not include discussion of the psychological and physiological effects of extreme stress, such as encountered in an imminently life-threatening situation, nor do they address key survival skills necessary for effective response. Understanding the psychology and physiology involved is an essential step in developing appropriate responses to life-threatening situations. Reaction to the extreme stress of a life-threatening situation, such as being trapped, can result in sensory distortions and decreased cognitive processing capability. In the book Stress and Performance in Diving the author notes that while all training is important, "we know that under conditions of stress, particularly when rapid problem-solving is crucial, over-learning responses is essential. The properly trained individual should have learned coping behavior so well that responses become virtually automatic requiring less stop and think performance." Fire fighters should never hesitate to declare a mayday. There is a very narrow window of survivability in a burning, highly toxic building. Any delay declaring a mayday reduces the chance for a successful rescue.
Air management is the responsibility of the fire fighters using the SCBA as well as those commanding the incident. Fire departments and fire fighters need to understand what it means to manage their SCBA air (especially with a 1,200 liter bottle), the importance of leaving an IDLH environment prior to a low air alarm sounding, and the need to treat low-air alarms as an emergency or mayday situation to promote immediate planned actions.
In this incident, several fire fighters on the fire ground expended their air supply simultaneously which may have led to fire attack positions not being manned. The International Association of Fire Chiefs, Safety, Health, and Survival Section Rules of Engagement for Structural Firefighting states all fire fighters should maintain continuous awareness of their air supply, situation, location and fire conditions. Fire departments should also consider retiring 1,200 liter volume SCBA bottles and replace with 1,800 liter volume bottles or higher. Additional information on what should be evaluated ​when looking at one’s ability to use an SCBA and air management can be found in NFPA 1404 Standard for Fire Service Respiratory Protection Training.
Fire fighters must frequently check their air supply while in a structure. Major benchmarks include prior to entering the structure, labor demanding tasks (e.g., pulling ceiling/charged hoselines, ascending stairs), before/after entering an interior room to search, and before entering large open spaces or long corridors.
In this incident, Victim #1 asked his probationary fire fighter to check his remote pressure gauge for him to see how much air he had remaining. According to information provided to NIOSH from the lieutenant coming off shift, there might have been an issue with Victim #1’s HUD. After determining how much air he had left, approximately ¼ or 25%, Victim #1 made the decision for him and his probationary fire fighter to exit the building. Victim #1 became separated from his probationary fire fighter and then had difficulty in following the hoseline to the exit. The remaining air in his bottle was not sufficient for Victim #1 to attempt to follow the hoseline out before becoming disoriented. Victim #1 most likely suffered an SCBA out-of-air emergency and may have been out of air when the RIT found him. It is not known whether he removed his own facepiece but it was not on when he was brought out of the structure.
Recommendation #7: Fire departments should use thermal imagers (TIs) during firefighting operations.
Discussion: Thermal imagers, (TI), also known as a thermal imaging camera or "TIC", provide a technology with potential to enhance fire fighter safety and improve the ability to perform tasks such as size-up, search and rescue, fire attack, and ventilation. TIs should be used in a timely manner, fire fighters should be properly trained in the use of a thermal imager and be aware of their limitations. The application of thermal imaging on the fireground may help fire departments accomplish their primary mission, which is saving lives. This mission can be accomplished in many ways. First and foremost, in near zero visibility conditions, primary searches may be completed quickly and with an added degree of safety. The use of thermal imaging technology may also be invaluable when a fire department is confronted with larger floor areas or unusual floor plans. Searching for trapped civilians is part of a fire department’s primary mission. At times, the search may be for a member who has become separated from the company or crew. TIs may also provide a method for fire fighters to track and locate other fire fighters in very limited visibility conditions. The TI may provide invaluable assistance in locating a missing member of the company or crew. This process can enhance fire fighter accountability before an issue arises.
At a structure fire, the TI may help identify the location of the fire or the extent of fire involvement prior to fire fighters being deployed into a structure. Knowing the location and extension of the fire may help fire fighters determine the best approach to attack the fire. The TI may provide additional information for a crew(s) making the fire attack that they would not previously have due to poor visibility and building construction. Using this information, fire fighters may be able to locate the fire ​more quickly and may also ensure that the water application is effective. One of the most important aspects of the TI is that when used properly and understood it may provide the potential to detect a fire that is isolated or hidden within parts of a structure. While the use of a TI is important, research by UL has shown that there are significant limitations in the ability of these devices to detect temperature differences behind structural materials, such as the exterior finish of a building or outside compartment linings (i.e., walls, ceilings, and floors). It is important that fire fighters understand these limitations.
Of all the operations in which the TI can improve a fire fighter’s efforts, search and rescue has been impacted the most. Fire fighters using thermal imagers can see the room, which enables them to quickly navigate and identify victims. Without a TI, fire fighters search burning buildings by crawling through smoke to try and locate possible victims. From a ventilation perspective, fire fighters can use the TI to identify areas of heat accumulation, possible ventilation points, and significant building construction features. This helps ensure proper and effective ventilation and fire attack that successfully removes smoke and heat from a building.
In this incident, thermal imagers were not used by initial engine companies searching for the seat of the fire. A TI was used by RIT when initially entering the structure to locate Victim #1.
Recommendation #8: Fire departments should conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics.
Discussion: NFPA 1620 Standard for Pre-incident Planning states, "The purpose of this document shall be to develop pre-incident plans to assist responding personnel in effectively managing emergencies for the protection of occupants, responding personnel, property, and the environment." A pre-incident plan identifies deviations from normal operations and can be complex and formal or simply a notation about a particular problem, such as the presence of flammable liquids, explosive hazards, lack of hydrants, modifications to structural building components, or structural damage from a previous fire.
Building characteristics including type (or more importantly risk) of construction, materials used, occupancy, fuel load, roof and floor design, and unusual or distinguishing characteristics should be recorded, shared with other departments who provide mutual aid, and, if possible, entered into the dispatcher’s computer so that the information is readily available if an incident is reported at the noted address. NFPA 1021, 4.5.2, states "Identify construction, alarm, detection, and suppression features that contribute to or prevent the spread of fire, heat, and smoke throughout the building or from one building to another." These pre-incident plans can help determine safety hazards within or around a structure, length of response times, and locations of closest hydrants. Since many fire departments have tens/hundreds of thousands of structures within their jurisdiction, it is a challenge to establish an effective preplanning system. Priority should be given to structures that have elevated or unusual fire hazards, have high occupancy loads (e.g., schools, malls, hospitals, meeting halls), represent a high-risk and low-frequency type incident, and have life safety considerations. ​
According to the fire department, this structure had a pre-plan but it was outdated and not available the night of the incident.
Recommendation #9: Fire departments and dispatch centers should ensure that emergency traffic over a radio, such as a Mayday, is effectively monitored, receiving the highest priority during an incident.
Discussion: NFPA 1221 Standard for the Installation, Maintenance, and Use of Emergency Services Communications Systems recommends the communication center have the ability to monitor tactical fireground radio traffic. Fireground communications can become very hectic and confusing when a fire fighter is in distress, becomes lost, or is trapped. Fire departments and dispatch centers must be able to effectively monitor radio transmissions (e.g., maydays) while on the fireground and within a dispatch center. A mayday procedure can outline the fireground response plan and duties of fire fighters, officers, the dispatch center, and the IC. Procedures can include establishing separate radio channels for fireground operations, search and rescue operations, and/or water supply. Fire departments and dispatch centers should understand and be trained on what should happen and what individuals’ roles are in the event of a mayday or emergency button activation. This will help reduce any confusion during the mayday.
The term mayday is the international distress signal. Fire fighters must act promptly when they become lost, disoriented, injured, low on air, or trapped. They should announce, "Mayday-Mayday-Mayday" over the radio and manually activate their PASS device. A transmission of the mayday situation should be followed by the last known location of the fire fighter and, if able, the individual’s identifier. A crew member who suspects a fire fighter(s) is in trouble or missing should quickly try to communicate with the fire fighter(s) via radio and, if unsuccessful, initiate a mayday providing relevant information.
An emergency radio transmission reporting a mayday is the highest priority transmission that may occur at any incident and should receive precedence from dispatch, the IC, and other units operating at the incident. When this emergency traffic is initiated, all other radio traffic should stop to clear the channel and allow the message to be heard. Mayday transmissions must always be acknowledged and immediate action taken. The IC must either personally handle the situation or designate another officer to do so. Part of handling a mayday is to communicate with the fire fighter(s) in distress and with other fire fighters or officers involved. The sooner the IC is notified and a RIT is activated, the greater the chance of the fire fighter being rescued. If there is any question that a mayday may have been transmitted and heard by someone (not all), priority should be given in verifying if it were a mayday transmission. The IC should be made aware of this immediately, so that he can attempt to contact the individual who potentially transmitted the mayday or contact dispatch to verify the transmission. A possible mayday transmission should never be overlooked. Additionally, fireground communications should immediately be transferred to an additional tactical channel so that the mayday or emergency activation can have a dedicated channel so that RIT operations or communications with a distressed fire fighter can be managed. ​
Fire departments should be aware of the International Association of Fire Chiefs' (IAFC) Rules of Engagement (ROE) of Structural Firefighting. These guidelines recommend that fire fighters constantly monitor fireground communications for critical radio reports and declare a mayday as soon as they are in danger. Although not addressed by the IAFC ROE, ICs and dispatch centers should also be constantly monitoring fireground communications for critical radio reports. The value of a dispatch center monitoring fireground channels cannot be understated. Quite often, due to normal fireground activities, it is possible for the IC to miss a critical radio transmission. The dispatch center, in a different environment than the fireground and with a dispatcher dedicated to the incident, may be able to hear that transmission, potentially making a measurable difference in the outcome of the incident.
During this incident, Victim #1 did not declare a mayday but did radio the IC that he needed assistance and he did activate the emergency button on his hand-held radio, alerting all listening of his emergency. However, he was unable to reset it, which may have caused communication problems at times on the fireground between responders on this channel. Dispatch or the IC should request an additional tactical channel when a fire fighter issues a mayday or is in trouble to handle the fireground operations.
Also, the IAFF Fire Ground Survival program which is available to all fire departments was developed to ensure that training for mayday prevention and mayday operations is consistent between all fire fighters, company officers, and chief officers.
Recommendation #10: Fire departments should ensure that Mayday training program(s) are developed and implemented so that they adequately prepare fire fighters to call a Mayday.
Discussion: The first and foremost priority for fire fighter safety is not getting oneself into a situation that could potentially cause injury or death. The fire fighter must maintain situational awareness at all times while operating on the fireground. Knowledge and skill training on how to prevent a mayday situation and how to call a mayday should begin and be mastered before a fire fighter engages in fireground activities or other immediately dangerous to life and health environments. Beginner firefighter training programs should include training on such topics as air management; familiarity with an SCBA, a radio, or PPE; crew integrity; reading smoke, fire dynamics, and fire behavior; entanglement hazards; building construction; and signs of pending structural collapse. Fire fighters must be able to recognize when they find themselves in a questionable position (dangerous or not) and be trained on procedures for when and how a mayday should be called. A fire fighter’s knowledge, skill, and ability to declare a mayday must be at the mastery level of performance. This performance level should be maintained throughout their career through training offered more frequently than annually.
Fire departments must understand that each fire fighter may have a different interpretation of what is life-threatening. The ability of a fire fighter to call a mayday is a complicated behavior that includes the affective, cognitive, and psychomotor domains of learning and performance. Any delay in calling a mayday reduces the chance of survival and increases the risk to other fire fighters trying to rescue the downed fire fighter. This incident illustrates the need for fire fighters to be given specific mayday procedures for determining when a mayday must be called. ​
No rules are established for determining when a mayday must be called, and mayday training is not included in the NFPA standard for fire fighter qualifications. It is up to the authority having jurisdiction to train members for emergency operations and to develop rules and performance standards for a fire fighter to call a mayday. The National Fire Academy (NFA) has two courses addressing the fire fighter mayday doctrine: Q133 Firefighter Safety, Calling the Mayday, a 2-hour program covering the cognitive and affective learning domain of the fire fighter Mayday doctrine; and H134 Calling the Mayday: Hands-on Training, an 8-hour course covering the psychomotor learning domain of the fire fighter Mayday doctrine. These courses are based on the military methodology used to develop and teach ejection doctrine to fighter pilots. A training CD is available to fire departments free of charge from the U.S. Fire Administration Publications Office. The NFA Mayday courses present specific mayday parameters or rules for determining when a fire fighter must call a mayday. The courses may help fire departments in developing and teaching mayday procedures for fire fighters. Also, NFPA 1001 Standard for Fire Fighter Professional Qualifications, includes job performance requirements related to the fire fighter calling for assistance (such as a mayday situation).
The IAFF Fire Ground Survival program is another resource fire departments can use and was developed to ensure that training for mayday prevention and mayday operations are consistent between all fire fighters, company officers, and chief officers.
Following this incident, the fire department implemented a "Mayday" mode of operation which focuses on enhancing SOPs to ensure critical tasks are accomplished.
Recommendation #11: Fire departments should ensure that policies and procedures for proper inspection, use, and maintenance of self-contained breathing apparatus (SCBA) are enforced to ensure they function properly when needed.
Discussion: NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus for Emergency Services and NFPA 1852 Standard on Selection, Care, and Maintenance of Open-Circuit Self-Contained Breathing Apparatus speak directly to the maintenance and use of self-contained breathing apparatus. Daily, weekly, and or monthly inspections of a SCBA needs to be documented to include items like air bottle and remote pressure gauge readings, general state of SCBA components and facepiece, PASS device actuation, and regulator flow test and hydrostatic tests. A documented inspection can catch minor issues before they result in a SCBA malfunction or failure. Additionally, annual maintenance, testing, and repairs require an individual to receive specialized training from factory-certified technicians and to perform required tasks as outlined by the manufacturer. This requires special tools, equipment, and knowledge to take apart the components of a SCBA. A fire department should consider adopting a policy that states all SCBA are thoroughly inspected prior to each shift and after each use.
Prior to the incident, Victim #1 was advised by the lieutenant coming off shift that the HUD on the officer's SCBA was not functioning. It is believed that Victim #1 used this same SCBA during the incident. Victim #1's HUD wasn't working so he was not able to determine how much air was remaining in his SCBA bottle. When Victim #1 asked his probationary fire fighter to look at his ​remote pressure gauge it was discovered that Victim #1 was only at ¼ of his bottle, or about 25% of air remaining. This proved not to be enough air for Victim #1 to follow the hoseline out before getting separated and disorientated. Over 15 minutes passed after he made his final transmission and he was brought out of the structure.
Recommendation #12: Fire departments should ensure that appropriate staffing levels are available on scene to accomplish fireground tasks and be available for unexpected emergencies.
Discussion: Adequate resources are needed at incident scenes to ensure incident stabilization and fire fighter safety and health. Prior to any response, a department should pre-plan the tasks that may be performed at any structural fire. From determining the required fire flow, to stretching hoselines, forcing entry, search, rescue, extinguishment and much more—fire departments should consider what the staffing need will have to be in order to simultaneously perform these tasks. Additionally, the planning for the first alarm assignment needs to include additional unassigned fire fighters to be on scene, staged and ready to assist with fireground operations in the event of an emergency or to allow for fire fighter rehab. An IC must recognize the limits of their desired action plan based on available resources to fight a fire.
NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments identifies the minimum resources for an effective firefighting force to perform critical tasks. These tasks include establishing water supply, deploying an initial attack line, ventilating, performing search and rescue, and establishing a RIT. NFPA 1710 recommends that the minimum staffing levels for an engine company to perform effective and efficient fire suppression tasks is four. However, NFPA 1710 also recommends that large jurisdictions with tactical hazards, high hazard occupancies, high incident frequencies, or other pertinent factors, should staff companies with a minimum of five or six on-duty members.
In addition, a study released by the National Institute for Standards and Technology (NIST), Report on Residential Fireground Field Experiments, concluded that a three-person crew started and completed a primary search and rescue 25% faster than a two-person crew and that a four or five-person crew started and completed a primary search and rescue 6% faster than a three-person crew. In this incident, the fire department responded with three-person engine crews and a three-person truck company.
Recommendation #13: Fire departments should ensure that incident commanders are provided chief’s aides to help manage information and communication.
Discussion: A chief's aide, staff assistant, or field incident technician (FIT) is a position designed to assist an IC with various operational duties during emergency incidents. The chief's aide is an ​essential element for effective incident management and for a successful outcome of the incident. The importance of having a chief's aide assigned to a battalion chief is to insure that the tasks associated with incident management can be initiated even before arrival on scene. The benefit of having a chief's aide is that the battalion chief can focus on radio communications, initiate the development of the strategy and tactics for the incident, and began to develop an incident action plan. The battalion chief is able to focus on the critical incident management tasks versus trying to operate the vehicle and locate the incident scene under emergency response conditions. If a chief's aide is not provided for a battalion chief, the tasks are delayed until a fire fighter or fire officer is appointed to this position. At an emergency incident, the staff assistant can assist with key functions, such as managing the tactical worksheet; maintaining personnel accountability of all members operating at the incident (resource status and situation status); monitoring radio communications on dispatch, command, and fireground channels; control information flow by computer, fax, or telephone; and access reference material and pre-incident plans.
The personnel accountability system is a vital component of the fire fighter safety process. The system is designed to account and track personnel as they perform their fireground tasks. In the event of an emergency or mayday, the personnel accountability system must be able to provide the rapid accounting of all responders at the incident. This is one of the chief's aide's essential responsibilities.
Another important chief's aide function is the role of a driver in addition to their role as part of the command team. Chief officers are required to respond quickly to emergency incidents. In their response, they have to be fully aware of heavy traffic conditions, construction detours, traffic signals, and other conditions. More importantly, the chief officer must also monitor and comprehend radio traffic to assess which companies are responding, develop a strategy for the incident based upon input from first-arriving officers, and develop and communicate an incident action plan that defines the strategy of the incident. A chief's aide can assist the battalion chief or chief officer in processing information without distraction and complete the necessary tasks en route to the scene.
Departments should consider the aide to be an individual who has the experience and authority to conduct the required tasks. Other potential functions for the chief's aide include serving as group or division supervisor, training position to facilitate officer development, and non-emergency functions that are vital to the daily operations of the department (e.g., daily staffing and leave management).
In this incident, the IC was managing arriving units from the automatic aid department and current operations on the fireground when Victim #1 gave his distress call. The IC juggled the RIT operations, deteriorating fire conditions, and fireground operations. A chief's aide would have been valuable in managing the tactical worksheet; maintaining personnel accountability of all members operating at the incident; and monitoring radio communications on the multiple channels. ​
Recommendation #14: Fire departments should ensure that backup hoselines are deployed, staffed, and appropriately utilized to protect the means of egress for interior operating crews.
Discussion: A backup hoseline is known as the “safety line” for the interior suppression crew. The primary responsibility of the backup hoseline is to protect interior fire suppression crews if they become overrun with fire, have a failure with the primary hoseline or appliance, and protect a fire fighter’s egress point(s). A backup hoseline should be advanced through the same entry point as the primary attack line(s) and should not be advanced past the primary suppression crew. Additionally, the staffed backup line should not crowd the fire suppression crew. The backup line should not be used as the primary attack line for a fire in another area or for exposure control. The backup hoseline crew and suppression crews need to stay in constant communication so that each hoseline is advanced appropriately.
During this incident, a second hoseline was initially advanced into the structure by E2 to support the E1 crew. When it was determined that the E1 crew was fine, the E2 crew repositioned the second hoseline for suppression support from the vestibule into the dance hall. At this point, both hoselines were now being used for primary suppression in two different locations and the crews and the primary egress point were not protected by a backup hoseline.
Recommendation #15: State and local government should adopt and enforce requirements for sprinkler protection in all commercial buildings.
Discussion: Fire development beyond the incipient stage is one of the greatest hazards that fire fighters are exposed to. This exposure and risk to fire fighters can be dramatically reduced when fires are controlled or extinguished by automatic sprinkler systems. NFPA statistics show that most fires in sprinklered buildings are controlled prior to fire department arrival by the activation of one or two sprinkler heads. The presence of automatic fire sprinklers also reduces the exposure risk to fire fighters in rescue situations by allowing the safe egress of building occupants before the fire department arrives on scene. Finally, by controlling fire development, the exposure to hazards such as building collapse and overhaul operations are greatly reduced, if not eliminated. In this incident, having a sprinkler system possibly could have contained the fire to the room of origin and prevented extension of the fire to the ceiling. Containing or extinguishing the fire would have significantly reduced the risk to all emergency responders and likely would have prevented these injuries and fatalities.
* ↑ 2. NIOSH [2010]. NIOSH alert: preventing deaths and injuries of fire fighters using risk management principles at structure fires. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No.2010-153 [http://www.cdc.gov/niosh/docs/2010-153/]. Date accessed: April 2014.
* ↑ 4. Grorud LJ [2009]. Written comment to NIOSH Docket # 141. March.
* ↑ 3. Phoenix Fire Department [2009]. Written comment to NIOSH Docket # 141. March 9.
* ↑ 5. NFPA [2013]. NFPA 1500 standard on fire department occupational safety and health program. 2013 ed. Quincy, MA: National Fire Protection Association.
* ↑ 7. Dodson D [2005]. The art of first-due. Fire Eng March:135 – 141.
* ↑ 8. IFSTA [2008]. Essentials of fire fighting. 5th ed. Stillwater, OK: Oklahoma State University, College of Engineering, Architecture, and Technology, Fire Protection Publications, International Fire Service Training Association.
* ↑ 9. Kerber, S [2010]. Impact of ventilation on fire behavior in legacy and contemporary residential construction. Northbrook, IL: Underwriters Laboratories. http://www.ul.com/global/eng/pages/offerings/industries/buildingmaterials/fire/fireresearch/ventilation/]. Date accessed: April 2014.
* ↑ 10. UL [2013]. Innovating fire attack tactics. Northbrook, IL: Underwriters Laboratories [http://www.ul.com/global/documents/newscience/article/firesafety/NS_FS_Article_Fire_Attack_Tactics.pdf]. Date accessed: April 2014.
* ↑ 11. Kerber S, Sendelbach TE [2013].What research tells us about the modern fireground. Firefighter Nation June. [http://www.firefighternation.com/article/strategy-and-tactics/what-research-tells-us-about-modern-fireground]. Date accessed: April 2014.
* ↑ 12. Fahy R [2010]. U.S. fire service fatalities in structure fires, 1977 – 2009. National Fire Protection Association, June.[http://paramountalarm.info/2010-NFPA-US-Fatalities-InStructures.pdf]. Date accessed: April 2014.
* ↑ 13. Kerber S [2012]. Examination of the impact of ventilation and exterior suppression tactics on residential fires. Northbrook, IL: Underwriters Laboratories. Gaithersburg, MD: National Institute Standards and Technology. New York, NY: Fire Department of the City of New York. July 2012.
* ↑ 14. NFPA [2014]. NFPA 1561 standard on emergency services incident management system. 2014 ed. Quincy, MA: National Fire Protection Association.
* ↑ 16. IAFC [2009]. Rules of engagement for structural firefighting, increasing firefighter survival. [Draft]. Fairfax, VA: International Association of Fire Chiefs, Safety, Health and Survival Section.
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