# Investigation FFF FY 13-06 

# Abbott Volunteer Fire Department Bruceville-Eddy Volunteer Fire Department Dallas Fire-Rescue Department Mertens Volunteer Fire Department Navarro Mills Volunteer Fire Department West Volunteer Fire Department

West, Texas April 17, 2013 S T A T E

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# Firefighter Fatality InvestigationInvestigation Number FFF FY 13-06 1 

# The subsequent investigation of this incident provides valuable information to the fire service by examining the lessons learned, to prevent future loss of life and property.Investigation Number FFF FY 13-06 2 

# Table of Contents

Acknowledgements 3 Executive Summary 4

Introduction 8 West Volunteer Fire Department 11 Building Structure and Systems 13 Fire Investigation 21 Fireground Operations and Tactics 24 Personal Protective Equipment 35 Findings and Recommendations 37

Appendix 1: The HMEx Assistant Chemical Classification 52

Appendix 2: Best Practices for the Storage of Ammonium Nitrate 53Investigation Number FFF FY 13-06 3 

# Acknowledgements

The following Texas Fire Chiefs conducted the review of th e operations and tactics and provided recommendations. We commend these individuals for their commitment to the review of this incident in the pursuit of firefighter safety:

Chief Steve Bass, City of Grapevine, Texas: Group Leader Chief Jimmy Chew, City of Stephenville, Texas

Chief Brian Crawford, City of Plano, Texas Chief Danny Kistner, City of McKinney, Texas Chief Les Stephens, City of San Marcos, Texas

Technical advice provided by: Martin T. Gresho, PE, FP2FIRE

The Texas State Fire Marshal wishes to th ank the following entities for their coopera tion and assistance in the investigation o f this incident:

West Volunteer Fire Department City of West Police Department Office of the Governor Texas Department of Insurance Texas Department of Public Safety Texas Parks and Wildlife Texas A&M Forest Service U. S. Bureau of Alcohol, Toba cco, Firearms and Explosives McLennan County Sheriff’s Office McLennan County Office of Emergency Management Texas Commission on Fire Protection Texas A&M Engineering and Extension Service East Texas Medical Center National Institute for Occupational Safety and Health And the many responders to the incidentInvestigation Number FFF FY 13-06 4 

# Executive Summary

On April 17, 2013, the West Volu nteer Fire Department re sponded to the report of a structure fire at the West Fertilizer Plant in the City of West, Texas. The fire depa rtment arrived to a heavily in volved structure fire and mu tual aid was requested. West Emergency Medical Services (EMS) responded along with studen ts attending an Emergency Me dical Technician-Basic (EMT) class at the West EMS building. The West EMS facility is located a few blocks west of the fertilizer plant. Students included members representing variou s area fire departments.

The fire involved the seed and fertilizer building known as the Bulk Processing Plant. Pallets with bags of seed and fertilizer
were stored and sold from the north end of the building known as the seed room. The pl ant’s bulk materials were stored in large wood lined bins with varying am ounts of the multiple products used in the lo cal farming community. These bulk products lined the west side of the building. A larger st orage bin containing ammonium nitrate pellets was located in a central area of the no rth end. The bulk chemicals were mixed at the plant according to ea ch customer’s specifications and then distributed to customers from a loading dock and conveyor chute on the east side of the building. Chemic als included ammonium nitrate, potash, ammonium sulfate, diammonium sulfate, and KMAG – a mixture of potassium, magnesium, and sulfur . Storage tanks of liquid chemicals including liquefied anhydrous ammonia, a corrosive, flammable, and water reactive gas (stored under pressure as a liquid),
were located near the south end of the structure.

The fire department response included an attack to the interior of the build ing by directing water streams through the east sid e rolling door from two 11⁄2 inch hose lines. Responders called for an evacuation of the nursing home and park west of the plant and mutual aid was requested. As the building became more in volved the roof collapsed and an explosion occurred. The blast killed ten firefighters, two civilians responding to assist, and th ree civilians in the residential area west of the plant. Sev eral more responding firefighters suffered debilitat ing or near-fatal injuries. The blast created a 90-foot-w ide and 10-foot-deep crater, and damaged or destroyed 500 structures in a 37-block area including three sc hools, the West EMS building, a nursing home, an apartment complex, and many single-family homes. Civilian injuries totaled more th an 200. Initial loss estimates reached $100 million. Pieces of debris from the plant we re photographed as fa r away as 2.5 miles. The explos ion registered a 2.1 on the Rich

ter scale for earthquakes. The subsequent in vestigation of this incident provides valu able information to the fire service by e xamining the lessons learned, to preven t future loss of life and property.Investigation Number FFF FY 13-06 5 West Volunteer Fire Department (VFD) is a volunteer fire department and does not fall under the jurisdiction of the TCFP and is not required to abide by the rules and standards of the TCFP.

The final analysis of this incident does not suggest the firefi ghters who lost their lives, or any surviving members of the Wes t VFD, failed to perform their duties as they had been trained, or as expected , by their organization.

This report is intended to honor the sacrifice made by these firefighters and all the first responders while protecting their c ommunity so that others may not perish.



## Jerry Dane Chapman Abbott Volunteer Fire Department

Cyrus Reed Abbott Volunteer Fire Department

Kevin S a nders Br uceville-Eddy Volunteer Fire DepartmentInvestigation Number FFF FY 13-06 6 

## Captain Kenneth Harris Dallas Fire-Rescue Department

Morris Bridges West Volunteer Fire Department Perry Calvin Mertens Volunteer Fire Department and Navarro Mills Volunteer Fire Department

Cody Dragoo West Volunteer Fire DepartmentInvestigation Number FFF FY 13-06 7 

## Joseph Pustejovsky West Volunteer Fire Department

Douglas Snokhous West Volunteer Fire Department

Robert Snokhous West Volunteer Fire Department

Two civilians on the fire scene died in th e blast. Jimmy Matus, manage r of a local fire apparatus manufacturing company, responded to the scene to assist the fire department with the oper ation of the fire truck. Willia m Uptmor, Jr., responded to eva cuate livestock at a property located east of the plant.

The Dallas County Medical Examiner’s Offi ce performed the autopsies and determined the deaths a result of blunt force and blast injuries.Investigation Number FFF FY 13-06 8 

# Introduction

On April 17, 2013, the State Fire Marshal’ s Office (SFMO) received notification from the State Operations Center of multiple firefighter fatalities at a fire and explos ion incident in the north-central Texas commu nity of West. The fire at the West Fert ilizer Plant was reported at approximatel y 7:29 p.m. The explosion occurr ed at approximately 7:51 p.m.

The State Fire Marshal’s Office commenced the firefighter fatalit y investigation under the author ity of Texas Government Code
Section 417.0075.

If a firefighter dies in the line of duty or if the firefighter’s death occurs in co nnection with an on-duty incident in this s tate, the state fire marshal shall investigate the circumstances surrounding the death of the firefigh ter, including any factors that may have contributed to the death of the firefighter.

In conducting an investigation under this section, the state fire marshal has the same powers as those granted to the state fir e marshal under Section 417.007. The state fire mars hal will coordinate the investigat ive efforts of local government officials and may enlist establis hed fire service organizations and private entities to assi st in the investigation.

The investigation began on April 17, 2013, with a response to the in cident site for an initial assessment and survey. The SFMO team members responded to the incident location to assess the damages and determine the equipment and personnel numbers needed to investigate the incide nt. Several agencies had already responded to the site to assist the City of West, the McLennan County Office of Emergency Mana gement, and the McLennan County Sheriff’s Office with several tasks including: to locate and care for victims, control and extinguish fires, evacuate nearby residents, and mi tigate continuing haza rds. Subsequent activities over the next few days in cluded the mitigation of hazards presented by the chemicals st ored at the fertilizer plant, inclu ding anhydrous ammonia and the recovery of victims.

The State Fire Marshal’s Office notified the Bureau of Alcohol, Tobacco, Firearms and Explos ives (ATF) and requested assistance from the ATF National Response Team (ATF-NRT) to assist in the investigation of the incident.

The State Fire Marshal’s Office requested assistance from the Texas Fire Chiefs Asso ciation to provide personnel to review the operations and tactics utilized by the West Volunteer Fire Depart ment and other agencies for the response to the fire. The fire chiefs of five Texas fire departments responded to assist in the evaluation of the response and tactics utilized: Chief Steve B ass,Investigation Number FFF FY 13-06 9 City of Grapevine, Texas - Grou p Leader; Chief Jimmy Chew, City of Stephenville, Texas; Chief Br ian Crawford, City of Plano, Texas; Chief Danny Kistner, City of McKinney, Texas; and Chief Les Ste phens, City of San Marcos, Texas.

The Texas Department of Public Safety (DPS) and the Texas Pa rks and Wildlife Department (TPWD) provided scene security and assisted in the investigation. DPS is responsible for the Texas Department of Emergency Management, providing the Incident Management System support. The DPS Criminal Investig ation Division conducted intervie ws and provided background information. The Texas Highway Patrol provided traffic co ntrol, scene security and in itial emergency management.

The Texas Commission on Environmental Quality assisted in the mitigation of the remaining hazards and air monitoring of the
site.

The National Institute for Occupational Safe ty and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program was notified. NIOSH responded with a team to conduct an independent investigati on of the incident to determine contributing factors in the firefighter deaths. The goal of the NIOSH investig ation is to provide information to the fire service nationally to prevent firefighter injuries and deaths.

The Texas Commission on Fire Protection (TCFP) assisted in the evaluation of the pers onal protective equipment used by the West VFD to determine if there were any contributing factors to the injuries sustained by the firefighters.

The SFMO and ATF were the lead investigating agencies and coordinated investigative effort s of the on-scene personnel.

The investigation of the incident involved more than 230 personne l representing over 30 local, st ate, and federal agencies. The initial investigation and site examination continued for 31 days after the fire and ex plosion. All agencies operated under a un ified
command structure as recommended in the National Incident Ma nagement System (NIMS). This allowed for the sharing of investigative responsibilities according to each agency’s statutory authority.

Recommendations to prevent injuries and redu ce risks for fire departments include:

 Develop standard operating pr ocedures/guidelines to train and educate members on firefighting and emergency scene strategies and tactics for high-hazard occupancies.

 Develop pre-incident plans by visiting the commercial and high-risk properti es within the response jurisdiction.

 Utilize risk management systems on all emergency responses to determine when to employ alternative tactics.

 Incorporate incident management systems into every emergency incident, training exercise an d basic operational process of the fire department to provide appropriate command and control for conducting operations.Investigation Number FFF FY 13-06 10  Implement a strategic incident action plan (IAP) for all emergency operations through a coordinated application of appropriate emergency scene tactics for the presented dangers.

 Ensure that an incident safety officer (ISO), a person who is independent fr om the incident commander, is appointed and effectively utilized at every incide nt that would require an ISO.

 Establish a hazardous materials program and actively train me mbers on the tactics to use when an incident involving hazardous materials occurs.

 Install approved fire protection systems in hazardous buildings in accordance with National Fire Protection Association (NFPA) Standards.

 Ammonium nitrate shall be separated by fi re barrier walls of not less than 1-hour fire resistance or located in a separate building as required by NFPA 400, Hazardous Materials Code, 2013 Edition

.

 Local jurisdictions should adopt and enforce a fire prevention code. Codes prescribe minimum requirements necessary to
establish a reasonable level of fire and lif e-safety and property protection from the hazards created by fi re, explosion, and dangerous conditions.

 Existing structures that do not meet the requirements of NFPA 400, 2013 Edition , should be retroactively provided with several key features to assure adequa te public and fire fighter safety.

 Develop written policies and have procedures in place to restrict members from part icipating in departme nt activities while
under the influence of alcohol or drugs.Investigation Number FFF FY 13-06 11 

# West Volunteer Fire Department

The City of West is located in north-cen tral Texas in McLennan County, approxim ately 70 miles south of Dallas and 20 miles north of Waco. The city was esta blished in 1892. The West Volunteer Fire Depa rtment was established in 1894 and was located at the city hall until 2003, when a new facility was built. The depart ment serves an area of approx imately 54 squa re miles. The 2010 census indicated that over 2800 pe ople live in the city limits.

The department listed 31 members on the roster and uses a pager system for incident notification. There are sirens placed throughout the city for notification to the department members and the city residents. Apparatus included:

 (F6) White Brush Truck: 1991 Ford F700 with a 750-gallon tank, 200 feet of 11⁄2 inch hose cross lay, two 1-inch whip lines, and a 1-inch booster reel

 (F7) Red Tender: 1997 GMC K5500 2000 gallon Te nder with a 1-inch booster reel hose

 (F8) Engine 1: 1997 Spartan Quality with a 1500 g.p.m. Hale pump; 750-gallon tank; 1000 feet of 4-inch hose; three 200 feet, 11⁄2 inch hose cross la ys; and 150 feet of 11⁄2 inch quick attack bumper line

 (F9) Engine 2: 2004 Ford F750 XL Super Duty with a 1500 g.p. m. Darley Pump; 1000 gallon tank; 1000 feet of 4-inch hose; two 200-feet, 11⁄2 inch hose cross lays; and one 50-foot, 13⁄4 inch quick attack bumper hose

 (F10) Red Brush Truck: 2010 Ford F550 with a 150 g.p.m. pump , 400-gallon tank, 200 feet of 11⁄2 inch hose, and a 1-inch booster line.

Three West VFD trucks were destroyed in the explosion. The West VFD was left with the 1997 Spartan Quality Engine 1 and the 2010 red brush truck. Several area depart ments volunteered time and equipment to work at the department to respond to calls as the department recovered.

During 2011, West VFD responded to 118 emergency calls including 55 fire calls. Th ere were 3 structure fire incidents, 2 vehicl e fires, and 50 “other fire” incidents including brush fires, grass fires, miscellaneous fires and false alarms.

During 2012, West VFD responded to 104 emergency incidents, of wh ich 73 were fire related. The 73 fire-related incidents were 18 structure fires, 12 vehicle fires and 43 classified as “other fire” calls involving grass fire s, miscellaneous fires, and fa lse alarms.Investigation Number FFF FY 13-06 12 During the first three months of 2013, West VFD responded to 2 structure fires, 1 au to fire, and 5 miscellaneous fire calls.

Applicants for membership in th e West VFD must be 21 years old. Membership is dependent on a vote by the fire department members. The West VFD conducts two scheduled meetings per month that members must attend unless excused by the fire chief. One meeting is to conduc t fire department business and the other meeting is for traini ng. Members missing more than two training classes per year are required to present a valid ex cuse. New members accepted by th e department mu st pass a background check before participating in any training. The fire de partment does not have any minimum training requirements.

The fire department received an upgraded rating from the Insurance Services Organization (ISO) 1 , moving from a rating of 7 to a rating of 5. In the ISO rating system, Class 1 represents exemplary fire protection, and Class 10 indicates that the area' s firesuppression program do es not meet ISO's minimum criteria.

The City of West’s water system is supplie d by a 12-inch supply line from the City of Waco at a pump station 11 miles south of the City of West. The pump station supplies 700 gallons per minute with a storage capacity of 167,000 gallons. Household water pressure was normally 48-50 PS I. Water pressure on the morning of April 18 , 2013, was measured below 20 PSI because of damaged water lines. As a result, a water bo il announcement was required. City main water lines are mostly 8-inch cast iron. Ap

proximately 25 percent of the city main lines had been replaced wi th 8-inch PVC. The 8-inch wate r mains reduce to 6 inches at fire hydrants. Hydrants in the city have a steamer connection th at requires an adaptor. Engine One and Engine Two each have 2 adaptors on board. Mutual aid responders arriving post blast, connected to the 21⁄2 inch hose connections, as they were not equipped with a steame r connection adaptor.

Two wells supplying water in the city are out of service. Well 1, supplying 250,000 gall ons in capacity, has been out of servic e for approximately 7 years. Well 2, which supplied 250,000 gallons, was taken out of service in January 2013 fo r “rehab.” The aboveground water tower has a storage capacity of 150,000 gallons. Post-blast fire depart ment response nearly drained the system, according to the Director of the City of West Water Department.

1 ISO is an independent commercial enterprise which helps customer s identify and mitigate risk. ISO can provide communities with information on fire protection, water systems, other critical infrastructure, building codes, and natural and man-made catastrophes. I SO’s Public Protection Criteria program evaluates communities according to a uniform set of criteria known as the Fire Suppression Rating Sche dule (FSRS). http://www.isogov.com/about/

.Investigation Number FFF FY 13-06 13 

# Building Structure and Systems

Neither the City of West nor McLennan County have adopted a fire code or building co des. There is not a designated fire marshal on staff in either jurisdiction w ho conducts fire safety inspections.

National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 Edition , is adopted by the State Fire Marshal’s Office, and is the applicable standard for fire and lif e safety inspections in the absence of an adopted fire code wi thin unincorporated areas of a county by an applicable authority. There was no requirement or request for the State Fire Marshal’s Office to inspect this facility prior to this incident.

In preparing this report, the National Fire Protection Association ( NFPA) 1, Fire Code, 2012 Edition, was referenced as a guide for evaluating the building’s fire safety fe atures. Similar provisions can be found in the International Fire Code as well.

History The structure was originally built in 1962, with several subsequent additions, up to the 1980s. It was reported that at the tim e the facility was originally constructe d it essentially existed alone in what was a rural farming area, and the neighborhood slowly
evolved around the fertilizer facility over many years.

The fertilizer plant proper ty is located alongside a railroad line that runs north/south. A short spur extends from the main li ne into the fertilizer plant property to facilitat e delivery of raw materials by rail car.

The fertilizer pro cessing building was located approx imately 230 yards from We st Intermediate School and 400 yards from West High School. An apartment complex and nu rsing home facility we re located approximately 175 ya rds and 250 yards respectively to the west of the fertilizer building. Sing le-family homes surrounded the plant property with the largest number of homes to t he west and south. Two single-familyhomes were located across the roadway on the east side of the plant entrance and one singlefamily home was adjacent to the north end of the plant property.

According to the McLennan County Appraisa l District database, Adair Grain, DBA We st Fertilizer, was located on a portion of property that was outside the ju risdictional boundarie s of the incorporated Ci ty of West, within McLennan County, and whichInvestigation Number FFF FY 13-06 14 contained the fertilizer storage bu ilding. West Fe rtilizer Company also occupi ed property on a contiguous lot that was located within the city limits of West.

Structure The West Fertilizer Plant bulk proce ssing building had an estimated floor area of 12,000 square feet. Most of th e building was one story in height with the exception of the vertical storage bins (one of which was for ammoniumnitrate) and associated conveyor and elevator equipment, which were multiple stories in height. The building construction wa s classified as Type-V 000
wood frame with no fire resistance rati ng for supporting structural members,
in accordance with NFPA 220, Standard on Building Construction . The internal structural elements were mostly exposed to the interior without a finished covering. Various materials we re used for the exterior covering, including tin sheathing, wood siding and possibly some fiberglass materials.
The structure was built on a reinforced concrete slab foundation under a combination roof consisting of asphaltshingles, asphalt roll-roofing materials or corrugated sheet metal.

The north end of the building was an ar ea referred to as the “seed room” where several hundred 50-pound bags of seed stacked on pallets were stored. The pallets were placed adjacent to the vertical ammonium nitrate (AN) bin. The pallets were separate d from the AN bin by a wood frame
wall. Several hundre d 50-pound bags of 36 percent dry zinc were stored in the seed room along with other general farm and ranch hardware.

Building Service The building utility services were all electr ic. No natural gas or propane gas was prov ided to the buildings. The main power su pply to the facility was loca ted at, and attached to, the northeast portion of th e fertilizer structure.

Building Contents and Operations Ammonium nitrate with 34 percent total nitrog en content, also referred to as 34-0-0 (with 97 percent pure ammonium nitrate), was stored in bulk granular form in an open system consisting of a vertical bin constructed of wood walls approximately 24 feet high.

The bin contained an estimated 20-30 tons of ammonium nitrate. An ai r conditioner was installed to maintain low humidity levels and reduce “shrinkage loss” and caki ng of the ammonium nitrate product in th e vertical bin. Investigators determined through interviews of the employees that the air co nditioner was not in use the day of the incident.

West Fertilizer showing the city limits, the processing building (red circle), and railroad tracks Inside city limits Outside city limits

R A I L R O A D

T R A C K S 

# NInvestigation Number FFF FY 13-06 15 Ammonium nitrate was also stored in two smaller bins located along the west wall of the building. Separation from adjoining storage bins was accomplished by 10 foot hi gh wood framing and plywood walls. Only one of the smaller bins contained ammonium nitrate on the day of the incident, estimated at 20-30 tons . The remaining bins stored potash, ammonium sulfate, diammonium sulfate, and KMAG – a mixture of potassium, magnesium, and sulfur. A second vertical storage bin was present in the building, but it had been abandoned years before.

The basic operation of the facility was to “c ustom blend” fertilizer to the customer’s desired formula. The finished product wa s loaded into applicator vehicles for delivery to the specified location. The blending and delivery machinery was located under a n awning on the east side of the building. View of the building from the northeast

East side of the processing building where the mixing and delivery of chemicals occurredInvestigation Number FFF FY 13-06 16 Using the classification methods defined in National Fire Protection Association 400 , Ammonium Nitrate 34 percent is classified as a solid class 3 oxidizer and an unstable reactive class 3 detonable.

These classifications are confirmed by the Hazardous Material Expert Assistant (HMEX) version 4.0.0 software output (See HMEX categorization output chart in Append ix, page 55) which is commonly used to classify hazardous material in the categories used by the International Fire Codes, which are the same as those in NFPA 400 for this material.

 3.3.61.10* Unstable (Reactive) Material. A material that, in the pure state or as comme rcially produced, will vigorously polymerize, decompose or condense, become self-reactive , or otherwise undergo a violent chemical ch ange under conditions of shock, pressure , or temperature.

 3.3.61.10.3* Class 3 Unstable (Reactive). Materials that in themselves are capable of detonation or explos ive decomposition or explosive reaction, but that require a strong init iating source or that must be heated under confinement before initiation.

 3.3.72* Oxidizer. Any solid or liquid material that readily yi elds oxygen or other oxidiz ing gas or that readily reacts to promote or initiate combustion of combustible materials and that can, under some circumstances, undergo a vigorous self-sustained decomposition due to contamination or heat exposure.

 3.3.72.3 Class 3. An oxidizer that causes a severe increase in the burning rate of combustible material s with which it comes into contact or a solid oxidizer classified as Class 3 when tested in accordance with the test protocol set forth in G.1.

Exemplar Material Safety Data Sheets for ammonium nitrate reference the material as “unstable” under high temperature and when exposed to fire and incompatible materials or confinement. 2

2 Obtained from the MSDS Sheet for material suppl ied to West Fertilizer from CF Industries: HAZARDS IDENTIFICATION EMERGENCY OVERVIEW Strong oxidizer. Contact with combustible material will in crease fire hazard. May undergo detonation if heated under confinement causing pressur e buildup or if subjected to strong shocks. Solid AN when sensitized or during decomposition may become unstable and/or explosive. When AN is h eated to decomposition it may produce vapors which contai n nitrogen oxides (NOX). AN is an oxidizer and as such may increase the flammability an d/or explosiveness of other substances. Use water to control fires involving AN, if water is compatible with burning material. AN itself is non-flammable. AN can cause irr itation to eyes and skin and may be an inhalation discomfort in confined locations. NFPA Hazard Classification Health Hazard (Blue)....................... 1 Flammability (Red)......................... 0 Reactivity (Yellow).......................... 3 Other ...........................................OXInvestigation Number FFF FY 13-06 17 Fire Prevention Code Features Fire prevention code compliance is generally determined by locally adop ted codes and ordinances established by the municipality as the authority having jurisdiction within the community. Howeve r, the City of West does not have an adopted fire code or personnel that conduct fire and life safety inspections within th eir jurisdiction. Planning and z oning ordinances are determine d by the local authority having jurisdiction.

In preparing this report, the National Fire Protection Association (NFPA) 1, Fire Code, 2012 Edition , was referenced as a guide for evaluating the building fire safety fe atures. Similar provisions can be found in the International Fire Code as well. In utilizing this reference document, the incide nt building is initially classified as st orage occupancy. Th e primary hazardous m aterial is 97 percent pure ammonium nitrate (34-0-0) which is classi fied according to its physical hazards as a Class 3 unstable r eactive detonable (UR3D) and Class 3 oxidizer as described above. The base maximum allowable quantity for a UR3D solid is 5 pounds per NFPA 1 Chapter 60, Hazardous Materials , Table 60.4.2.1.1.3. Because this MAQ was exceeded, the building was classified as a high-hazard protection le vel 1 occupancy, per the same table. NFPA 1 Chapter 74, Ammonium Nitrate, requires NFPA 400 to be utilized for ammonium ni trate containing more than 60 percent ammonium nitrate.

The following requirements are from NFPA 400:

 5.3.3.1 and 11.1.5 Construction Type. Per building code (IBC), type V-B (or V-000 per NFPA 220) is not allowed. Minimum permissible construction type is V-B or (V111 per NFPA 220 ) where structural members are provided with a fire resistance rating.

 6.2.1.1.3 and 6.2.1.11 Fire Alarm. Waterflow alarms shal l be monitored.

 6.2.2.2 Detached Building Required. Buildings shall be used for no other purpose (than storage of ammonium nitrate).

 11.2.6 Automatic Fire Sprinklers. Automatic fire sprinklers are required.

 11.2.6.2.1 Portable Fire Extinguishers. Portable extinguishers shall be provided th roughout the storage area and in the loading and unloading areas in accordance with the fire prevention code adopted by the jurisdiction and NFPA 10, Standard for Portable Fire Extinguishers

.

 11.2.12.1 Separation. Ammonium nitrate shall be separated by fire barrier walls of not less than 1-hour fire resistance or located in a separate buil ding from the storage of any of the following: (1) Organic chemicals, acids, or other corrosive materials (2) Compressed flammable gasesInvestigation Number FFF FY 13-06 18 (3) Flammable and combustible materials, solids or liquids (4) Other contaminating substanc es, including the following: (a) Wood chips (b) Organic materials (c) Chlorides (d) Phosphorus (e) Finely divided metals (f) Charcoals (g) Diesel fuels and oils

 11.2.12.1.1 Walls shall extend from the floor to the und erside of the roof above. In lieu of fire barrier walls, ammoni um nitrate shall be permitted to be separated from the materials by a space of at least 30 ft (9.1 m) or more, as required by the AH J, and sills or curbs shall be provided to prevent mixing during fire conditions.

 11.2.12.2 Incompatible Materials. Flammable liquids, such as gasoline, kerosene, solvents, and ligh t fuel oils, shall not be stored on the premises, unless the f ollowing criteria

are met: (1) The storage conforms to NFPA 30, Flammable and Combustible Liquids Code

. (2) Walls and sills or curbs are provided in accordance with 11.2.12.1.1 through 11.2.12.1.3

. 11.2.12.2 . LP gas shall not be stored on the pr emises, unless such storage conforms to NFPA 58, Liquefied Petroleum Gas Code

.

 11.3 Indoor Storage. Storage Conditions/Arrangement. Storage arrangement shall be in accordance with 11.3.2.1 through 11.3.2.3.

 11.3.2.1 Containers. Bags and containers used for ammonium nitrate shall comply with the specifications an d standards established by the U.S. Depart ment of Transportation (DOT).

 11.3.2.2 Piles of Bags, Drums, or Other Containers. Containers of solid ammonium ni trate shall not be placed into storage when the temperature of the ammonium nitrate exceeds 130° F (54.4° C). Bags of ammonium nitrate shall not be st ored within 30 in. (762 mm) of the walls an d partitions of the storage building. Piles shall comply with the following dimensions: (1) The height of piles shall not exceed 20 ft (6.1 m). (2) The width of piles shall not exceed 20 ft (6.1 m). (3) The length of piles shall not exceed 50 ft (15.2 m), unless otherwise permitted by NFPA 400 11.3.2.2.3(4). (4) Where the building is of noncombust ible construction, or is protected by auto matic sprinklers, the length of piles shall not be limited.Investigation Number FFF FY 13-06 19 In no case shall the ammonium ni trate be stacked closer than 3 ft (0.9 m) belo w the roof or its supporting overhead structure. Aisles shall be provided to separate piles by a clear space of not less than 3 ft (0.9 m) in width, with at least one service o r main aisle in the storage area not less than 4 ft (1.2 m) in width.

 11.3.2.3.3 Piles of Bulk Solid Storage. Warehouses shall have ventilation, or be ca pable of ventilation in case of fire, that will, in the event of a fire, prevent theexplosive decomposition of ammonium nitrate. Buildings shall be ventilated so as to pr event confinement of decomposition gases. Bulk storage structures shall not exceed a height of 40 ft (12.2 m). Where bulk storage structures are constructe d of noncombustible material and faciliti es for fighting a roof fire are provided, the height of the storage building shall only be limited by the building constructi on type as specified in the building code adopted by the juris diction.

 11.3.2.3.4 Compartments. Bins shall be clean and free of materials that can contaminate ammonium nitrate. Due to the corrosive and reactive properties of ammonium nitrate, and to avoid contam ination, galvanized iron, copper, lead, an d zinc shall not be used in bin construction, except where such bins are protected against impregnati on by ammonium nitrate. Aluminum bins, and wooden bins prot ected against impregnation by ammoni um nitrate, shall be permitted. The warehouse shall be permitted to be su bdivided into any desired number of ammonium nitrate storage compartments or bins. The partitions dividing the ammonium nitrate storage from the st orage of other products that would contaminate the ammonium nit rate shall be constructed to prevent the ammonium nitrate from becoming contaminated. The ammonium nitrate storage bins or piles shall be clearly identified by signs reading AMMONIUM NITRATE with letters at least 2 in. (50.8 mm) high. Piles or bins shall be sized and arranged so that all material in the pile is able to be moved out in order to minimize possibl e caking of the
stored ammonium nitrate. The height or depth of piles shall be limi ted by the pressure-setting tendency of the product; however, in no case shall the am monium nitrate be piled higher at any point than 3 ft (0.9 m) below the roof or its su pporting and overhead structure. Ammonium nitrate shall not be placed into storage when the temperature of the prod uct exceeds 130°F (54.4°C). Dynamite, other explosives, and blasting agents shall not be used to break up or loosen caked ammonium nitrate.

 11.3.3 Floors. All flooring in storage and handling areas shall be without open drains , traps, tunnels, pits, or po ckets into which any molten ammonium nitrate is able to flow and be confined in the event of fire.Investigation Number FFF FY 13-06 20 Uniform Building Code (UBC) 1961 The code of record used when the building was originally constructed is not known but UBC 1961 was available and commonly
used at the time.

Per UBC 1961 , the building would have been classified as an F-2 occu pancy. The basic allowable he ight and area provisions based on the occupancy and construction type were met (6,000 square fe et base with 33 1/3 percen t increase to 8,000 square feet for fire zone 3 (rural – no conflagration hazard) and a 100 percent area increase to 16,000 square feet for frontage). The ~12,000 square feet structure would have co mplied. There was not a requir ement in place for sprinklers at the time. Fire code provisions were not reviewed because the first edition of NFPA 1, Uniform Fire Code, was not published until 1971.Investigation Number FFF FY 13-06 21 

# Fire Investigation

The following information is provided by the SFMO and the ATF investigation teams.

The fire and subsequent explosi on on April 17, 2013, at the West Fe rtilizer Plant in West, Texas, was investigated by the SFMO, ATF and other local, state and federal law enforcement agencies in accordance with the statutory authority of Texas and federal laws. The majority of the scene investigat ion was completed in the 31 days following April 17, 2013; however, investigators remained on the ground and assigned to the area of the scene for a total of 38 days.

A unified command system between the SFMO and ATF was establis hed at the onset of the invest igation. The SFMO received control of the scene from McClennan County’s incident commander. Although exigent circumstances existed at the time of the incident and for a period of time following the incident, the SFMO obtained two evidentiary search warrants to conduct the origin-and-cause inve stigation. The SFMO, in conjunction with the ATF, had control of the scene. The final report regarding the origin-and-cause investigation, although not complete at this time, has been a joint effort between the SFMO and ATF.

View of the site prior to scene excavation and examinationInvestigation Number FFF FY 13-06 22 Throughout the initial 31 days, investigator s conducted over 200 intervie ws, searched for evidence in a 37-block area, and exca

vated the entire 14 acres of the fertilizer facility, docu menting, measuring, and securing hundreds of pieces of evidence. Additionally, reconstruction, to the extent possi ble, was completed. After more than 20, 000 personnel hours were worked by more than 100 investigators from the SFMO and ATF, and prior to th e final press briefing on May 16, 2013, several possible causes of the fire were eliminated; however, multiple potential causes could not be eliminated. As a result, at the time of publication o f this firefighter fatality investigati on report, the investigation is on-going, “open” and the cause of the fire at the West Fertiliz er facility remains undetermined.

Despite the cause of the initial fire being undetermined, the SFMO and ATF continue to scientifically test and investigate fact ors and circumstances surrounding the cause of the fire. Forensic testing has alread y occurred, and will continue, at the ATF Fire Research Laboratory in Maryland. Upon comp letion of the testing and in vestigation, a formal repor t will be prepared by the
ATF.

View of the scene during the examination and reconstruction Crater outline marked in green

Bulk storage bins AN Bin Seed Room

Approximate building outlineInvestigation Number FFF FY 13-06 23 Comparison photos of the reconstruction and pre-blast photos of the processing building Seed storage room

AN Bin

Bulk product storage binsInvestigation Number FFF FY 13-06 24 

# Fireground Operations and Tactics

The following information is provided by th e SFMO investigation teams. The following sequence of events was developed from radi o transmissions, photographs, video, firefighter statements and witness informatio n. Those events with known tim es are identified. Events withou t known times are approximated in the sequence of the events based on firefigh ter statements regarding their actions and/or observations.

Weather at the time of the fire wa s partly cloudy with winds from the east-southeast at 5-10 mph. Google Earth view showing streets, schools, apartments, nursing home, and the EMS building 

### Hydrant

High School EMS

Nursing Home

Intermediate School

Apartments

Park

West Fertilizer 

# NInvestigation Number FFF FY 13-06 25 19:29:19 The McLennan County Sheriff’s Office received a 911 call reporting a fire at the We st Fertilizer Plant. The
West Fertilizer Plant was located at 1471 Jerry Mashek Drive in West, Te xas. The caller was located in the park, west of the plant, across the railroad tracks.

19:31:44 West PD Officer Michael Irving (West PD 209)was on patrol on Haven Street, near the public basketball courts, west of the We st Fertilizer Plant, and smelled wood burnin g. As he drove through the area and saw several kids playing basketball, one young man approached the patrol ca r and pointed toward the fertilizer plant and said, “Smoke is coming from the tall building of the fertilizer plant.” Officer Irving reported to Dispatch on the radio and stated "Kick out West Fire. One of the mills at the West Fertilizer Plant is on fire; heavy smoke coming out of the roof.”

19:32:28 West VFD was dispatched and the disp atcher stated "a fire ca ll at West Fertilizer Plan t, they have a fire out there, again.” And the dispatcher repeated the informati on. “Again” was routinely used by dispatch to indicate a repeat of the information.

The elapsed time from the receipt of the initial 911 call to the dispatch of West VF D was three minutes and nine seconds.

C.J. Gillaspie, Douglas Snokhous, and Cody Dragoo exited the Exxon St ation and looking north could see the “billowing white smoke coming from the plant.” Cody Dragoo, who oversaw the opera tions of the bulk processing building at the West Fertilizer Company, responded direct ly to the scene in his personal vehicle. Captain Gillaspie and Doug Snokhou s responded, in separate personal vehicles, to th e West Fire Station.

West PD Officer Irving knew the building on fire contained fertilizer. After notifying Dispatch of his initial observations, Ir ving turned on his emergency lights and continued north through th e residential neighborhood on St illmeadow Drive, east on Grady Calvery Drive and back south on Jerry Mashek Drive toward the plant’s north entrance. From inside his patrol car, he observed “thick” smoke coming out of the north end of the building. He positioned his car on Jerry Mashek Drive and exited his vehicle. From this vantage point he could see orange -red flames coming through the wall above the lower level roof at the north end of the building. He did not notice any smoke or flames below the lower level roof. While outside his patrol car he notified Dispat ch
that there was a structure fire with visible flames at the fertilizer plant.

19:34:13 West Fire was notified by Dispatch: “PD on scene advises one of the mills is on fire.”

19:35.33 West PD 209 called for contact number s for the fertilizer plant. He was gi ven numbers for two individuals.

19:36:44 West Fire was notified by Dispatch that West PD can see flames “coming out.”Investigation Number FFF FY 13-06 26 19:37:03 Engine 1, driven by Firefighter Jo ey Pustejovsky, Jr., and staffed by Captain Bob Snokhous and Firefighter Morris Bridges, reported en route follo wed by Engine 2 driven by Captain C.J. Gillaspie and staffed by Firefighter Eddie Hykel.

As he approached the s cene from the south, Firefighter Pu stejovsky radioed West PD 209 and asked him to block traffic. The two vehicles passed each other on Jerry Mashek Drive.

Realizing the kids playing basketball needed to be evacuated, West PD 209 continue d south on Jerry Mashek Drive, west on Spring Street, and back north on Haven Str eet toward the park area. Without stopping or exiting his vehicle, he utilized his PA system to tell the kids to get back. At the same time, he observed heavy smoke coming from the “bell tower” of the fertilizer plant. He then retraced his earlier clockwise rout e back to the north end of Jerry Mashek Drive.

The white brush truck, driven by Captain Do ug Snokhous; the water tender, driven by Fire Chief George Nors Sr.; and later, the red brush truck driven by Pat Grimm wi th Firefighter Stevie Vanek were en route to the West Fertilizer Plant.

Passerby view of the east side of the building, approximate time 7:38 p.m. (Photo by Macik)Investigation Number FFF FY 13-06 27 19:39:18 Engine 1 arrived on scene “with flam es” and asked Engine 2 to hook to a hydrant. Engine 1 pulled one 11⁄2 inch hand line from the bumper and one 11⁄2 inch cross- lay hand line and began to attack the fire from outside through a sliding door located on the east side of the structure near the north end. The door was reportedly closed and locked when the plant was closed, as a normal course of business.

At an unknown time, the white brush truck, driven by Captain Douglas Snokhous, arri ved at the north end of the plant and positioned the truck at the northwest corner of the office building under electric service lines, northeast of the bulk processin g plant. Captain Snokhous deployed atleast one 11⁄2 inch hand line.

West PD 209 stopped briefly at the north end of Jerry Mashek Drive to block traffic and observed a red fire engine that he believes was Engine 2 at the intersection of Jerry Mashek Drive and Spring Street. He then enlisted the resident of a nearby home to use his personal vehicle to block traffic on the north end of Jerry Mashek Drive.

West VFD Firefighter Kirk Wines first noticed the structure fire as he exited his shop at his residence. He had heard the initi al page but was unable to understand the mess age. He remained in his shop until he heard radio traffic asking for assistance block

ing traffic at the high school. Firefighte r Wines left his shop and saw West VFD fi refighters Kevin Maler and David Maler. David Maler was also a McLennan County Constable. Firefighter Wines informed the brothers ofthe fire and the three responded to the fire in separate personal vehicles. Passerby view of Engine 1 position at east side of building, approximate time 7:40 p.m. (Photo by Campbell)Investigation Number FFF FY 13-06 28 Engine 2, driven by Captain Gillaspie, arrived at the intersec tion of Jerry Mashek Drive and Sp ring Street, approximately 1600 feet south of the plant entrance, and dropped a 4-inch hose supply line. Firefighter Hykel helped to lay out the 1000 feet of 4

- inch hose for connection. Captain Gillaspie was aware that the 1000 feet of hose would not be sufficient to reach the fire buil ding. He planned to forward lay all of the supply line off of Engine 2 and revers e lay the 4-inch hose off Engine 1 to complete the lay before returning to the hydrant to charge the line.

West PD 209 relocated his patrol vehicle to the south intersection of Jerry Mashek Dr ive and Spring Street, facing Pustejovsky Lane, in order to block Jerry Mashek Drive. Once he arrived ther e, he realized Engine 2, whic h he had observed from the other end of Jerry Mashek Drive, wa s no longer at that location.

After deploying all 1000 feet of 4-inch hose supply line from Engi ne 2, Firefighter Hykel stayed at the end of the 1000 feet of hose supply line as Captain Gillaspie drove to the location of Engine 1 and parked behi nd it. Captain Gillaspie ordered the Engine 1 crew to disconnect the bu mper hose line as he threw the cross-lay hose line on top of the truck. Captain Gillaspie intended to finish laying the supply line in a reverse lay back to Firefighter Hykel’s location and then use Engine 1 at the hydr ant. Engine 2 was turned over to the cr ews that were operating Engine 1. The white brush truck was positioned under the electric service lines in this area before moving back (Insurer photo)Investigation Number FFF FY 13-06 29 19:40:16 McLennan County Sheriff’s Office c ontacted Dispatch by 911 and relaye d a message to request mutual aid
from the Abbott VFD.

West Assistant Fire Chief Emanue l Mitchell arrived in his personal vehicle and pa rked on Jerry Mashek Drive and walked to the plant to meet with Captain Cody Dragoo. Chief Mitchell did not report that he was on scene. West VFD Captain Cody Dragoo and West PD Officer Irving were already on scene. Dragoo stated the seed room wa s on fire. Mitchell did not formally assume
command.

19:41:50 Assistant Chief Mitchell called McLennan County Sh eriff’s Office Dispatch by phone and requested Lacy Lakeview to bring a ladder truck.

West VFD Firefighter David Maler arrived on scene in his personal vehicle from the south. Firefighter Maler said that he drove past the southeast entrance of the plant and parked his pickup across the northeast entrance to discourage civilians from enter

ing. Firefighter Kevin Maler arrived at the same time as David Maler and told David that he would drive to the West Fire Statio n and pick up their turn out gear.

Before Firefighter Kevin Maler left the area he received a phone call from Brian Rene gar. Renegar is a former West VFD firefighter and former West Fertilizer Plant empl oyee. Renegar advised that th ey needed to evacuate the plant to at least a quarter

mile distance because of the risk of explosion.

View of the site from the northeast (Photo by Wright)Investigation Number FFF FY 13-06 30 Firefighter David Maler left his vehicle at the northeast entrance and walked toward the fire. Firefighter Maler walked to the white brush truck parked between the offi ce building and a large, round storage elev ator. Firefighter Maler told Captain Doug
Snokhous to move the white brush truck be cause it was beneath power lines. The pow er lines had already fallen at one end where they connected to the north side of the bulk processi ng building. Captain Doug Snokhous moved the white brush truck back toward the east as Firefighter Maler assisted by pulling the hose line back with the truck. Firefighter Maler told investigators the hoses were easy to move and seemed like they had not be en charged with water. Firefighter Maler then walked along the east side of the office building to the south en d where he could assist the other firefighters.

Dallas Fire-Rescue Captain Kenneth Harris arrive d on scene and talked with Firefighter David Maler, Captain Dragoo, and Assistant Chief Mitchell. After Harris introdu ced himself as a Dallas firefighter he asked if he could offer some advice. When he was told to do so, Harris stated he believed the building was a lost cause and should be “written off.” Harris told Dragoo and Mitchell to concentrate on flowing water on the anhydrous amm onia tanks south of the building, once a water supply was established.

Firefighter Maler turned to Captain Dragoo, and asked what kind of dangerous items were in the building that they needed to contend with. Captain Dragoo stated there was a large amount of ammonium nitrate in the building but “it could never get hot enough for it to go off.”

During interviews, Assistant Chief Mitche ll recalled asking Captain Dragoo where the fertilizer was located. Dragoo replied tha t the fertilizer and chemicals were far enough away from the fire to not be of concern. Dragoo stated the fire would not get to that point. Mitchell recalled su ggesting and saying out loud that they “needed to go.” However, Mitchell did not give an order to withdraw. Mitchell recalled making a mental note th at he had never witnessed a fire burn that fast.

Firefighter David Maler stated that he saw Engine 2 reposition from the east side of the bulk pr ocessing building. He stated th at he heard gears grinding while th e truck was moved. Engine 2 was positioned facing to the north, southwest of the office building.

The 2000

- gallo n water tender driven by Fire Chief Geo rge Nors, Sr., arri ved and parked on the roadwa y near the east entrance.
Chief Nors di d not report his arrival. He got out of the water tender as Brian Rena gar drove by. Renegar stopped briefly and told Chief Nors that he should get every one out, that it’s “gonna blow.” Chief No rs did not take command. Chief Nors approached Captain Dragoo and told him what Renegar had said abou t leaving because of the risk of explosion. Dragoo said he didn’t think an explosion would happen. Chief Nors turned and walked back toward the water tender. Chief Nors did not give
an order to withdraw.

Engine 1, now driven by Captain Gillaspie , who had intended to reverse lay the 4-in ch hose supply line to the point where the initial 1000 feet of 4-inch hose supply line from Engine 2 ended, drove to the hydrant but forgot to reverse lay the 4-inch sup ply hose. Gillaspie positioned Engine 1 at the hydrant located on Jerry Mashek Drive near the intersection with Spring Street, faci ng north toward the West Fertilizer Plant. West VFD Firefighter Ma rty Marak was there an d connected to the hy drant even though the supply line was not finished.Investigation Number FFF FY 13-06 31 West Emergency Medical Services Paramedic Coil Conaway overhear d radio traffic requesting mutual aid from Abbott Fire Department. Conaway and EMT April Conaway were on duty assigned to Medic 2 at the West EMS building located in the residential neighborhood west of the fertilizer plant.

19:45:50 West EMS Medic 2 notified East Texas Medical Center of their response to the fire. An EMT class was in progress at the time of the call with students that in cluded area fire department firefighters. EMT student Kevin Sanders, a firefighter from th e Bruceville-Eddy Volunteer Fire Depart ment, was assigned to Medic 2 as part of the EMT class ride-out requirements for the cour se and responded to the fire scene aboard Medic 2.

Abbott Volunteer Fire Department firefighters Jerry Chapman and Cyrus Reed, and Mertens/Navarro Mills Volunteer Fire Department Firefighter Perry Calvin were students in the EMT cl ass at the West EMS building when the call for mutual aid was transmitted. All three firefighters responde d to the fire scene in personal vehicles.

19:47:00 Medic 2 arrived on scene and parked near the scale house, located approximately 600 feet southeast of the bulk processing building.

Paramedic Conaway contacted West VFD Assistant
Chief Emmanuel Mitchell. Conaway, suspecting chemical involvement and toxic smoke,asked Mitchell if any evacuations had begun. Mitchell
indicated that no evacuations had been ordered. Conawayradioed Dispatch and instructed them to call the West EMS building and have the remaining students respondand begin evacuating a nursing home.

Kevin Sanders left Medic 2 and walked toward the structure fire . Conaway tried to prevent Sanders from leaving the unit but
was unsuccessful.

Firefighters Chapman, Reed, and Calvin arrived in their persona l vehicles. They parked southeast of the plant and walked past Medic 2 toward Engine 2. Conaway stated that he recalled one of the firefighters wearing turn out gear. View from the north at approximate time 7:48 p.m. (Photo by Bajer)Investigation Number FFF FY 13-06 32 West VFD Firefighter Robbie Payne arrived on scene and observed several unidentifi ed firefighters and a civilian, Jimmy Matus, an employee of Westex. Westex manufactures fire apparatus. It was not unusual for Matus to res pond to fire scenes with West VFD to assist in the operation of the apparatus. Firefighter Payn e stated he remembered seeing other firefighters on the scene and thought they were spraying water but later said he was not certain of that. Payne stated that he was on scene for less than one minute before the explosion occurred. From his vantage point on the east side of the office building, he wasn’t able to observe all of the activities taking place.

View from the southeast at approximate time 7:50 p.m. (Photo by Nathan Nors)Investigation Number FFF FY 13-06 33 View of the plume of smoke after the explosion (Photo by Kapavik)

19:50:24 Assistant Chief Emanuel Mitchell called back to Mc Lennan County Sheriff’s Office Dispatch via cell phone and asked, “Did you notify Abbott Fire and Lacey Lakeview Fire and tell them to keep coming?”

The explosion occurred at approximately 7:51 p.m.

Captain Gillaspie and Firefighter Marak were in the process of making the connection from the hydrant to Engine 1 when the explosion occurred.Investigation Number FFF FY 13-06 34 Approximate positions of apparatus at time of explosion F9 Engine 2 F6 White Brush Truck

F7 2000 gallon Tender

1000 feet 4” Supply Line Medic 2 AmbulanceInvestigation Number FFF FY 13-06 35 

# Personal Protective Equipment

The Texas Commission on Fire Protection (TCF P) conducted an evaluation of the firefigh ters’ personal protective equipment for performance of and compliance with TCFP rules. Examination of the Personal Protective Equipment (PPE) u sed in this incident may provide important information related to the incident. The following are excerpts of the TCFP evaluation report.

The examination of the PPE and the investigation of the incident revealed that the PPE worn by the responding personnel did
not affect the outcome of the incident and was not a contributing factor in the deaths of the firefighters.

TCFP compliance officers Lamar Ford and Bob Manley traveled to th e city of West, Texas, to assi st the SFMO with the investigation of the firefighter fatalities that occurred on April 17, 2013.

West Volunteer Fire Department (VFD) is a volunteer fire department and does not fall under the jurisdiction of the TCFP and is not required to abide by the rules and standards of the TCFP.

In the interview with the West fire chief, the following information was requested:

 PPE records (annual inspections)

 Self contained breathing apparatus (SCBA) records (annual flow test)

 Records of the last hydrostatic test (air cylinders)

 Standard operating procedures (SOPs) required in Chapter 435 of the Texas Administrative Code

 Training or CE records, for each of the fallen, be tween May 31, 2012, and May 31, 2013, or since employment began

These five items are part of the biennial inspection process for paid, regulated fi re departments in the state of Texas.

The West VFD fire chief explained that there were no PPE or SCBA records available and it was not the usual practice of West
VFD to have the annual PPE inspection or the SC BA flow test done.Investigation Number FFF FY 13-06 36 The department had purchased some new cylinders within the last year when it was discovered some cylinders were out of date during the refill process.

There are no records of hydros tatic test dates on file.

The West VFD does not have any written stan dard operating procedures or guidelines.

Available training records were provided by each department. Records included the State Firemen’s and Fire Marshals’ Association (SFFMA) training objectives report for each victim belonging to the West VFD or copies of certificates of training attended.Investigation Number FFF FY 13-06 37 

# Findings and Recommendations

These recommendations are based upon nationally recognized cons ensus standards and safety practices for the fire service. Volun teer fire departments in Texas and all firefighting personnel should know and understand nationally recognized consensus standards. Fire departments sho uld create and maintain SOGs and SOPs to ensure effective, efficie nt, and safe firefighting /training operations.
This portion of the document contains the most significant lessons learned and best-practice recommendations of the SFMO Firefighter Fatality Investigation Task Forc e. This report is intended to focus atte ntion on the points that could have the gre atest impact on preventing similar and future firefighter fatalities. Th e purpose of the recommendations portion of this document is to provide fire departments with a reference that will enable them to proactivel y plan for and engage fu ture and similar emergency events to maximize the chances for a successful and safe outcome.

The West Fertilizer Company was a high-risk commercial business th at presented specific risks to the health and safety of firefighters. The fire risk factors that were found in this occupancy also presented risk s to the employees, customers, neighbors, and the surrounding community.

Fire Department Operations The lack of adherence to nationally recognized consensus standa rds and safety practices for the fire department exposed firefighters to excessive risks and failed to re move them from a critically dangerous situation. The strategy and tactics utilized by the West Volunteer Fire Department were not appropriate for the rapidly developing and extremely volatile situation, and exposed the firefighters to extreme risks.

The predominant factors identified in the analysis of fire department operation s included the following:

(1) There was no incident command system and senior ranking members did not perform supervisory roles.
(2) The essential duties of an incide nt commander were not performed.

(3) The emergency scene operation was conducted in an unst ructured and uncoordinated manner, without overall direction and without adequate supervision.Investigation Number FFF FY 13-06 38 The West VFD was not trained or equipped to conduct an operation of this complexity , involving a large commercial occupancy
filled with hazardous materials th at possessed explosive properties . Firefighters were committed to attacking a fire that was s ignificantly beyond the extinguishment stage, with few resources and a limited water supply. The vo lume of fire could not be controlled by the limited flow that would have been available from the small hose lines that were deploy ed. The West Fertilizer Company fire required a drastically different combination of strate gy and tactics than those expected or acceptable for fightin g a residential fire. However, the application of water during extinguishment attempts wa s not a contributing factor to the explosion.

Residential fire attack approaches are high ly effective in controlling a large percenta ge of most structur e fires and were like ly effective in controlling a large percentage of the fires the West VFD had encountered over the years. Howe ver, for a large and complicated commercial occupancy, alternative firefighting strategies must be cons idered early and reassessed continuously throughout the incident.

Firefighting is not an exact science, and through post-incident an alysis of most emergency incide nts, it is not unusual that a number of performance problems are identified . The final analysis of this incident does not suggest the firefighters who lost their lives, or any surviving members of the West VFD, failed to perform their duties as they had been trained, or as expected, by their organization.

The analysis does, however, indicate a systemic deficiency in th e training and preparation of th e West VFD to adequately prepare for the incident they encountere d at the West Fert ilizer Company fire.

Had best practices been followed, the situation that occu rred in West, Texas, on April 17, 2 013, could have been prevented. The findings and recommendations listed below are re-statements of lessons that have been identified in previous investigations of firefighter fatalities, and recommendations that have been wide ly adopted as standard practices within the fire service.

Finding 1: Standard Operating Procedures The initial responding fire department di d not have standard operating procedures (SOPs) or standard operating guidelines (SOGs) for emergency operations.

Recommendation: Specific SOPs/SOGs should be developed, and members trai ned and educated regarding firefighting and emergency scene strategies and tactics for responding to high-hazard or high-risk occupancies.

References:
Texas Commission on Fire Protection Standards Manual, Chapter 435, Section 435.15, Part (a): The fire department shall develop, maintain and use standard operating procedure for fire protection personnel operating at emergency incident s.

Command and Control of Fires and Emergencies (Dunn) , Fire Engineering Books Publishing, page 63 : Standard operating procedures. A standard operating procedure provides accountability and control. It is a general plan of who does what and where. It lets companies know where they should be operating and what they should be doing.Investigation Number FFF FY 13-06 39 Finding 2: Pre-fire Planning There was no pre-fire or pre-incident plan of this facility.

Recommendation: Fire departments should visit and pre-inci dent plan responses to comm ercial structures in thei r jurisdiction. It is imperative that high-risk occupancies containing hazardous materials are identified and appropriate emergency response strategies and tactics are developed through pre-plan docu ments and SOP directives. High-hazard and high-risk occupancies containing heavy fire loads and hazardous materials should be well defined and all members made aware of their potential dangers. This w ill better prepare th em for the hazards which may be foun d in the event of a fire and also provide them with insight as to when it is pr udent to attack a fire or evacuate the area.

References: Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 43: Establishing SOPs is the first step in the size-up. Pre-incid ent planning is step two. After SOPs are developed, individual properties should be examined for specific hazards and characteri stics. Pre-incident plans are a natural extension of SOPs.

NFPA 1620, 2010 ed., Chapter 8, Paragraph 8.1: The pre-incident plan shall identify an d document any spe cial hazards recognized by the authority having jurisdiction that present extraordin ary life safety challenges, operations challenges, or other challenges to emergency responders.

NFPA 1620, 2010 ed., Annex, Paragraph A.4.4.1: The pre-incident plan should be the fo undation for making decisions during an emergency situation and provide important da ta that will assist the incident commander in developing appropriate strategies and tactics for managing the incident.

NFPA 1620, 2010 ed., Annex, Paragraph A.4.4.2: The pre-incident plan should help respon ding personnel identify critical factors that will affect the ultimate outcome of the incident, including personnel safety.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 50: (Regarding
which structures shou ld be pre-planned) If there is a high hazard (including firefighter safety issues), a particularly difficult extinguishment problem, or high-value property, then there is a need to prepare a pre-incident plan.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 285: Industrial Occupancies: Recognizing hazards and equipment li mitations is paramount during an industri al fire. In the large industrial building or complex, pre-incident planning is critical to fire fighter safety and ef ficient operations.Investigation Number FFF FY 13-06 40 Finding 3: Incident Management The West Fertilizer Company incident clearly demonstrates the critical importance of establishing a comprehensive incident management system (IMS) to provide command, control, and coordi nation of emergency operations. Fire department officers failed to provide supervision of subord inate members, implement an IMS, establish an incident command post, and properly identify an incident commande r (IC). The absence of command and control and the failure to create and communicate an incident action plan resu lted in an uncoordinated and unmanaged fire ground operation.

Recommendation: An IMS should be fully incorporated into the basic operatio nal processes of all fire depa rtments and routinely applied to every emergency incident and training exercise to prov ide the appropriate structure fo r conducting operations. An easily visible, stationary command post sh ould be established at the beginning of an incident and be staffed by a wellinformed commander. Having an esta blished command post will give incoming units a reporting position and lend itself to better organization. The comm ander should use every means available to gather information about the conditions on the fire ground before tactical decisions are made. The applic ation of IMS is critically important in situations that involve complex problems and excepti onally hazardous circumstan ces. Key concepts of incident management that must be fully integrated into the ope rations of fire de partments include: (1) Establish an IC, performing a standard se t of functions within a well-defined system. (2) Determine an overall strategy for the inci dent, based upon an a ppropriate size-up. (3) Delegate authority and responsib ility to subordinate officers with pr edefined roles within a standard

structure. (4) Ensure that the IC, whether indi vidually or, as a unified command, has overall authority and responsibility for management of all activities at an incident. (5) Establish a fixed command post in a safe location that allows the IC to view the overall incident scene. (6) Ensure that the IC conducts an initial size-up and risk assessment of the incide nt scene before beginning firefighting operations. (7) The IC should re-evaluate the situation continuous ly, based on observation, r econnaissance, information gathering, effective communications and situational awareness.

References: NFPA 1021, Fire Officer Professional Qualif ications, 4.6: Emergency Service Delivery. This duty involves supervising emergency operations, conducting pre-incident planning, and deployin g assigned resources in accor dance with local emergency pla ns and according to the following pe rformance requirements:
4.6.1 – Develop an initial action plan, given the size-up info rmation for the incident ... 4.6.1(A) – Requisite Knowledge. Elements of a size-up, standard operating proced ures for emergency operations, and fire behavior. 4.6.1(B ) – Requisite Skills. The ability to analyze emergency scene conditions; to activate the local emergenc y plan, including localized evacuation procedures ...
4.6.2 – Implement an action plan at an emergency operation, given assigned resources, type of incident, and a preliminary plan ... 4.6.2(A) – Requisite Knowledge. Standard operating proc edures, resources available for the mitigati on of fire and other emergency incident s, an incident management system, scene safe ty, and a personnel accountability system.

.Investigation Number FFF FY 13-06 41 4.6.2(B) – Requisite Skills. The ability to implement an incident management system , to communicate orally, to manage scene safety, and to supervise and account for assigned personnel under emergency conditions.

NFPA 1026, Incident Management Pe rsonnel Professional Qualifications

. 4.1.1.1 – General Knowledge Requireme nts. The importance of command presence to an IC ... knowledge of the Incident Command System (ICS) ...
4.1.1.2 – Prioritizing tasks so as to accomplish th e most critical first, making effective decisions in an environment with a large numbe r of unknowns ... anticipating hazards, taking action in a proa ctive manner to ensure responder safety and health ...
4.2.1 – Assume initial command of an incident ... so that the incident cond itions are accurately assessed, the safety of all responders i s ensured, a detailed size-up report is tran smitted, an appropriate initial Incident Action Plan (IAP) is developed ... and the person assuming command and his or her location is identified.

NFPA 1500 as referenced by Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 107: An incident management system must be used at all scen es. The IC maintains command and control of all operating forces within a common strategy based on situational analysis. The situational analysis must be ongoing with changes in strateg y consistent with the changing situation. Inexperienced members must be directly supervised by more experienced members.

NFPA 1561, Chapter 5, Section 5.3.3: The incident management system shall clearly identify who is in overall command at the scene for the duration of the incident. NFPA 1561, 5.3.7.1: Following the initial stages of the incident, the incident commander shall es tablish a stationary command post. A stationary command post should be established to plan, organize, and account for all aspects of the operation. NFPA 1561, 5.3.7.2: In establishing a command post, the Incident Commander shall ensure the following: (1) The command post is located in or tied to a vehicle to establish presence and visibility. (2) The command post includes radio capability to monitor and communicate with the assigned tactical, command, and designated emergency traffic cha nnels for that incident. (3) The location of the command post is communicated to the communications center. (4) The Incident Commander, or his or her de signee, is present at the command post. (5) The command post shall be located in the cold zone of an incident. NFPA 1561, 5.3.8: The Incident Commander shall continually co nduct a thorough situation evaluation. NFPA 1561, 5.3.17: The Incident Commander shall evaluate the risk to responders with respect to purpose and potential results of their
actions in each situation. NFPA 1561, 5.3.18: In situations where the risk to emergenc y service responders is excessive, activities shall be limited to defensive operations.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 58: The effectiveness of the operation must constantly be evaluated. The IC continually evaluates the sa fety and effectiveness of the standard operation and determines whether a nonstandard attack would be more effective.Investigation Number FFF FY 13-06 42 Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 58: (Organization and coordination); the first arriving company begins the pr ocess by organizing the initial attack and communicating orders to incoming
units.

Fire Command, The Essentials of Local IMS (Brunacini), Chapter 1, The Command Post: ... the stand-command position for the incident commander is a stationary one, located outside the hazard zone ... It should be situated in a standard and predictable location that affords the IC a good view of the scene an d the surrounding area. To a major extent, command effectiveness (or ineffectiveness) is directly connected to regular command positioning, and the entire command system revolv ing around the rapid establishment of a stationary, remote IC operating in a stand command post.

Command and Control of Fires and Emergencies (Dunn), Fire Engineer ing Books Publishing, page 63:Command Post. Set up a command post at every fire, and direct the operation from this location.

Additional references used in formulating the recommendations in this finding: IFSTA (2008) Essentials of Fire Fighting, (5th Edition), Chapter 1, page 39, Fire Protection Publications, Oklahoma Stat e University.

U.S. Department of Homeland Security - Federal Emergency Management Agency Incident Command Systems; http://www.fema.gov/emergen cy/nims/ICSpopup.htm#item5

.

Finding 4: Strategy and Tactics
4A. The fire department did not approach this fire as a commercial structure with hazardous materials, but rather initiated residential structural fi refighting practices, with which they were familiar.
4B. Fire department officers did not determ ine an appropriate firefighting strategy (e.g., offensive, de fensive, including evacuation) or coordinated tactical plan , which are key factors in controlling and mitigating fire incidents and protecting firefighters.
4C. There was no appearance of an appropria te firefighting strategy based on (1) an accurate size-up of the incident. (2) a realistic evaluation of the available resources. (3) the capabilities of fire crews respond ing to an operation of this scale. (4) the application of risk management principles, such as those found in the International Association of Fire Chiefs Rules of Engagement : (a) Determine the occupant survival profile. (b) Do not risk your life (or your firefighters) for lives or property that cannot be saved. (c) Extend limited risk to protect savable property. (d) Extend vigilant and measured risk to protect and rescue savable lives. (e) Abandon your position and retreat before deteriorating conditions can harm you. (f) If you do not have the resources to safely suppor t and protect firefighters, seriously consider a defensive strategy.Investigation Number FFF FY 13-06 43 Recommendation: A strategic incident action plan (IAP) for all emergency opera tions should be implemented by the IC through a coordinated application of appropriate emergency scene tactics for the presented dangers (e.g., high-risk, commercial structure, hazardous material, fire, etc.). Th e incident commander should determine and coordinate the necessary resources to execute the action plan safely and effectively, based init ially on an effective and accurate scene size-up and through a definitive strategy and tactic to mitigate dangers while keepin g firefighters as safe as possible. The effectiveness of an incident action plan must be closely monitored and continuous ly re-evaluated to ensure thatit is meeting the IC’s expectations. If the attack is not effective and/or conditions ch ange in a manner that shifts the risk management balance, the IC must re-evaluate the strategy, adjust the tactics and, if necessary, change the incide nt action plan, up to and including, evacuation of the incident scene.

References: NFPA 1021, Fire Officer Professional Qualifications
4.6.1 Develop an initial action plan, given th e size-up information for the incident ... 4.6.1(A) Requisite Knowledge. Elements of a size -up, standard operating procedures for em ergency operations, and fire behavior. 4.6.1(B ) Requisite Knowledge. The ability to analyze emergency scene cond itions; to activate the local em ergency plan, including localiz ed evacuation procedures ...

4.6.2 Requisite Knowledge. Implement an action pl an at emergency operations, given assigned resources, type of incident, and a prelim inary plan ... 4.6.2(A) Requisite Knowledge. Standard operating proc edures, resources available for the mitigati on of fire and other emergency incident s, an incident management system, scene safe ty, and a personnel accountability system. 4.6.2(B) Requisite Skills. The ability to implement an incident management system, to comm unicate orally, to manage scene safety, and to supervise and account for assigned pe rsonnel under emergency conditions.

NFPA 1026, Incident Management Pers onnel Professional Qualifications 4.2.2 (A) Requisite Knowledge: Applicable strategies and tactics for variou s types of incidents, safety fa ctors and considerations for in cident operations, and variables and conditions that affect incident outcomes. 4.2.2(B) Requisite Knowledge: Performing a size-up and interpreting incident information for th e purpose of verifying the effectiveness, applicability, and safety of the size-up.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 53: Once on scene, the IC will add to what is known through personal observation, comm unication with fire companies an d building personnel, and reconn aissance. Once the on-scene information is processed, the IC must quickly evaluate the action th at is taking place and the conditions of the building.

NFPA 1143, Annex, Paragraph A 5.4.2: The safety and welfare of personnel are the firs t and foremost considerations in all incident operations and decisions.Investigation Number FFF FY 13-06 44 Texas Commission on Fire Protection Standards Manual, Chapter 435, Section 435.15, Part b, Paragraphs 1
and 2: (1) specify an adequate number of personnel to safely conduct emergency scene operations;
(2) limit operations to those that can be sa fely performed by personnel at the scene ...

Fireground Support Operations 1st Edition, IFSTA, Chap ter 10, Fundamentals of Firefighting Skills, NFPA/ IAFC, 2004, Chapter 2: Fire departments should require crews to perform a comp lete scene size-up before beginning operations. A thorough size-up will provide a good base for deciding tactics and op erations. It provides the IC an d on-scene personnel with a gen eral understanding of fire conditions, building cons truction, and other sp ecial considerations.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 217: Attacking a fire with anything less than a water supply from a so urce of water that is capable of supplyin g flow requirements over an extended period of time is a gamble. Attack pumper tactics (operating with water from the atta ck pumper) work well in many situations, especially fighting a small dwelling. However, relying solely on water fr om the apparatus water tank can be dangerous.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 284: Storage Occupancies: The risk of fast moving fire or explosion may be high within the storage occupancy ... Fighting a fire in a large commercial building is more challenging tactically than attacking a fire inside a small residential building.

Structural Firefighting Strategies and Tactics, 2 nd

Edition, NFPA (Kalene and Sanders), pg. 285: Industrial Occupancies: Recognizing hazards and equipment limitations is paramount during an industrial fire. In the large industrial building or complex, preincident planning is critical to firefighter safety and efficient operations. The number of hazards and the potential for harm dictate that special tactics be developed for each large manufactu ring storage property within a jurisdiction.

Finding 5: Firefighter Safety and Accountability Firefighting operations were not conducted in a manner that incorporated national and industry recognized safety standards and practices.
5A. The safety and welfare of fire depart ment personnel were not the first and foremost considerations in incident operations and decisions.
5B. An incident safety o fficer was not appointed.
5C. A firefighter accountabilit y system was not utilized.
5D. Personnel operating within the IDLH environment did not utilize full appropria te PPE including SCBA.
5E. Nationally recognized firefighter risk ma nagement principles were not applied.

Recommendation: (1) The safety and welfare of fire depa rtment personnel should be the first an d foremost considerations in incident operations and decisions.Investigation Number FFF FY 13-06 45 (2) Fire departments should designate a safety officer at all working incidents. Fire depart ments should ensure that the incident safety officer (ISO ) position, independent from the incident commander, is appointed and effectively utilized at every structure fire, meeting the requirements within NFPA 1521, Standard for Fire Department Safety Officer . The incident safety officer or assistant safety officer(s) shall have the authority to immediately
correct situations that create an imminent hazard to personnel. (3) All firefighters must be empowered to stop unsafe practices. (4) Fire departments must implement an d utilize an accountability system to track all members working within the
IDLH area. (5) Fire departments, through the assigned IC, must main tain accountability for all pe rsonnel operating on the emergency scene. (6) Fire departments must ensure that all firefighters wear incident appropriate personal protective equipment (PPE), including SCBA appropriate for the assigned task while participating in fi re suppression activities. (7) Risk management principles with re gards to safety rules of engagement sh all be applied to fire suppression and emergency scene activities.

References : Finding 5A NFPA 1143, Annex Section 5.4.2: The safety and welfare of personnel are the first and foremost considerations in all incident operations and decisions.

NFPA 1561, 2008 ed., Chapter 5, Paragraph 5.10.1.5: Supervisory personnel shall ensure that the safety and health of all responders is the primary consideration.

Finding 5B NFPA 1521, 2008 ed., Chapter 3, Paragraph 3.3.44.2 defines the Incident Safety Officer (ISO) as: A member of the command staff responsible for monitoring and assessing safe ty hazards or unsafe situations and for developing measures f or ensuring personnel safety.

NFPA 1561, 2008 ed., Chapter 5, Paragraph 5.9.6.6.3 : The major responsibilities of the safety officer, which shall apply to any in cident, are as follows: (4) Exercise emergency authority to stop and prevent unsafe acts.

Finding 5C
Texas Commission on Fire Protection Standards Manual, Chapter 435, Section 435.13, Part b, Paragraph 3 & 4, and Part d: The accountability system shall (3) require that all fire protec tion personnel operating at an emergency incident to actively pa rticipate in the personnel accountability system; and, (4) require that the incident commander be responsible for the overall personnel accountability system for the incident; (d) th e personnel accountability system shall meet the minimum standards required by the NFPA 1561, Standar d on Fire Department Incident Management System.Investigation Number FFF FY 13-06 46 NFPA 1561, Chapter 4, Resource Accountability
4.5.1: The Emergency Services Organization (ESO ) shall develop and routinely use a syst em to maintain accountability for all resources assigned to the incident with special emphasis on the accountab ility of personnel. This system shall also provide a process for the rapid a ccounting of all personnel at the incident scene. All supervisors shall maintain a constant awareness of the pos ition and function of all personnel assigned to operate under their supervision. This awar eness shall serve as the basic means of accountability that shall be required for operational safety.

Finding 5D NFPA 1500, 7.1.2: Protective clothing and protective equipment shall be used whenever th e member is exposed or potentially exposed to the hazards for which it is provided.

IFSTA, Essentials of Fire Fighting, (5th Edition), Ch.5 , pg.167: When operating at any emergency scene, firefighters must wear protective clothing and equipment suitable to that incident.

Finding 5E NFPA 1561, 2008 ed., Chapter 4
4.2.1: The incident commander shall integrate risk manageme nt into the regular func tions of incident command.
4.2.2: The risk management plan shall meet the requirements of Chapter 4 of NFPA 1500.
NFPA 1500, 2013 ed., Chapter 8
8.3.1* The incident commander shall integrat e risk management into the regu lar functions of incident command.
8.3.2* The concept of risk management shall be utilized on the basis of the following principles: (1) Activities that present a significant risk to the safety of members shall be limite d to situations where there is a potenti al to save endangered lives. (2) Activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of members, and
actions shall be taken to reduce or avoid these risks. (3) No risk to the safety of members shall be acceptable when there is no possibility to save lives or property. (4) In situations where the risk to fire department members is excessive, activities shall be limited to defensive operations.

Additional references used in formulating the recommendations in this finding: Everyone Goes Home, 16 Firefighter Life Safety Initiatives

. The full 16 Life Safety Initiatives can be
found at http://www.lifesafetyinitiat ives.com/initiatives.html

.

Participate in the “Courage to be Safe” (CTBS) program that emphasizes th e message “Everyone Goes
Home.” Information on the CTBS program is available online at http://www.everyonegoeshome.com

.Investigation Number FFF FY 13-06 47 Texas Administrative Code Chapter 435.25, www.tcfp.texas.gov “(a) In an effort to improve firefighter safety in the State of Texas, all regulated entities wi ll ensure that the National Fal len Firefighters Foundation's "Courage to be Safe So Everyone Goes Home" program be completed as part of the continuing education required for certified fire protection personnel by December 1, 2015. Individuals wi ll be credited with four hours of cont inuing education credit for completing this program. (b) All regulated fire protection personnel must complete the Nati onal Fallen Firefighte rs Foundation's "Courage to be Safe So Everyone Goes Home" program prior to December 1, 2015.”

“Effective January 1 st , 2012, the SFFMA Certification Pr ogram for volunteer department s requires completion of the Everyone Goes Home - “Courage to be Safe” course for any new applications submitted after January 1, 2012.” www.sffma.org

NFPA 1720, 4.5.1.3 : The incident commander shall ensure that a personnel accountability system is immediately utilized to rapidly account for a ll personnel at the incident scene.

Finding 6: Training The State of Texas has not adopted minimum training standa rds for volunteer fire depart ments; however, all fire department members must be properly trained and qualified to perform their assigned duti es. Members who are authorized to work in high-level assignments (rank) must be tr ained and evaluated in performing those duties. All membersmust be periodically re-evaluated to ensure that they are capable of performing their assigned duties safely and effectively.

Recommendation: (1) Fire departments must establish re alistic training and educational require ments for all positions and ranks and a promotional process that ensures that ranking members demonstrate a progre ssive knowledge, skill, and ability to perform their assigned duties an d responsibilities according to their position in the organization. (2) Fire department companies should be trained and periodically evaluated in performing a range of standard company functions within a system of standard operating procedures. (3) Fire department members must be trained to recognize hazardous conditions and situations, such as construction types and unusual and hazardous fire loads, and react appropriately. (4) Fire department company and command o fficers should be trained at an increasi ng level of firefigh ting strategy and tactics, including the application of ope rational risk management principles. (5) Simulation exercises should be conducted to provide ex perience in managing unusual, complex, and challenging
situations. (6) Ensure that all firefighters and line officers receive fundamental and annual refr esher training according to NFPA
1001 and NFPA 1021

. (7) Implement joint training on response protocols with mutual aid departments. (8) Fire departments should develop standard operating guidelines and co nduct appropriate training involving those critical findings as noted in this document and specific to incident command, strategy and tactics, and firefighter safety as listed in the reference sections of each respective area.Investigation Number FFF FY 13-06 48 References:
NFPA 1500 5.1.2: The fire department shall provide traini ng, education, and professional deve lopment for all department members commensurate with the duties and function s that they are expected to perform.
NFPA 1500 5.1.6: The fire department shall provide all memb ers with training and education on th e fire department’s written procedures.

Finding 7: Fire Prevention, Code Enforcement, and Risk Mitigation The fire department had no authority or regulat ory governance over material storage or building (fire) preventative
measures in this incident.

The following recommendations are imperative to list for fire department awareness purposes and the future safety of firefighters.

Recommendation: (1) A properly installed and maintained fi re sprinkler system might have controlle d the fire. Measures that mandate or provide incentives to install automatic sprinklers or support alternative fire protection measures should be adopted as public policy. (2) Mitigation programs to reduce or eliminate excessive risk levels sh ould be encouraged and supported. (3) It is government’s responsibility to ensure that adopted fire and safety co des are adequately enforced through systematic inspections. (4) Fire departments should be trained to recognize fire hazards and code violations and should have a specific responsibility to take appropria te corrective measures.

Reference: NFPA 400, Hazardous Materials Code, 2013 Edition, Chapter 11: The requirements of this chapter shall apply to the storage, use, and handling of ammonium nitrat e when the amount of solid or liquid ammoni um nitrate exceeds the MAQ as set forth in Chapter 5

.

Finding 8: Adopt and Enforce a Fire Prevention Code There was no fire prevention code adopted by the local jurisdic tion. Currently, the regulatory landscape for fire prevention is inconsistent from jurisdiction to jurisdiction. In municipalities where there is no adopted fire prevention code, one should be adopted. Regarding coun ties, Texas Local Government Code 233. 061 only allows counties with a population of 250,000 or more, or those counties adjacent to a county with a 250,000 or more population, to adopt a fire
code.

Recommendation: The local jurisdictions should adopt a fi re prevention code. The Texas Legislature should consider allowing all counties to adopt a fire code.Investigation Number FFF FY 13-06 49 There are two nationally accepted model fire codes in the US: the International Fire Code (IFC) and NFPA 1, Fire
Code. Both adequately address egress as well and either is acceptable.

Regardless of which model fire prevention code is used, particular emphasis s hould be placed on the administrative requirements of Chapter 1 of either document. Chapter 1 describes the accepted minimum requirements for effective
administration and enforcement of a fire prevention code.

Adopting a fire prevention code resolves the majority of re gulatory applicability questions for fire prevention. Both
model fire codes reference lower tier codes and standards (many of which are NFPA documents) by edition, so there are never questions about which codes and/or st andards and editions thereof are applicable.

References: 2012 IFC, Preface, p. vii: Effective Use of the International Fire Code
The International Fire Code (IFC) addresses fire prevention, fire protection, life safety and safe storage and use of hazardous materials in new and existing buildings, facilities and processes. The IFCprovides a total approach of controlling hazards in all buildings and sites, regard less of the hazard being indoors or outdoors.

The IFC is a design document. For example, before one constructs a bu ilding, the site must be provided with an adequate water supply for fire-fighting opera tions and a means of building access for emergency responders in the event of a medical emergency, fire or natural or technological di saster. Depending on the build ing’s occupancy and uses, the
IFC regulates the various hazards that ma y be housed within the building, includ ing refrigeration sy stems, application of flammable finishes, fueling of motor vehicles, high-pile d combustible storage and the storage and use of hazardous
materials. The IFC sets forth minimum requirements for these and other hazards and contains requirements for maintaining the life safety of building occu pants, the protection of em ergency responders, and to limit the damage to a building and its contents as the resu lt of a fire, explosion or unauthor ized hazardous material discharge.

2012 NFPA 1, Fire Code 1.2* Purpose. The purpose of this Code is to prescrib e minimum requirements necessary to establ ish a reasonable level of fire and life safety and property protection from the hazards cr eated by fire, explosion, and dangerous conditions. 1.3 Application.
1.3.1 This Code shall apply to both new and existing conditions.Investigation Number FFF FY 13-06 50 Finding 9: Establish a Consistent Hazardous Materials Program per Fire Code Requirements There was no adopted hazardous materials prog ram adopted by the lo cal jurisdiction.

Recommendation: Above all, the incident at West was a ha zardous materials incident. While it occurred in an industrial setting, simply applying common industrial firefighting tactics would not have been successful. Industrial firefighting tactics can be successful in occupancies with high-cha llenge commodities (such as a warehouse wi th high-rack storage, tire storage, most industrial processes, etc.) but to be successful at a facility such as West Fe rtilizer, such an approach must be dovetailed with an effective hazardous materi als program. A program to address hazardous materials is integral to and required by the model fire prevention code s (see Finding 7) and might have prev ented the explosion and fatalities at
West Fertilizer.

Hazardous materials present un ique fire hazards and have the capability to have a much broa der impact on surrounding areas than fires that do not involve them. Ammonium nitrate can display both the accelerated burning characteristics of an oxidizer and the explosive characteristics of an un stable reactive. Both of these, as well as the characteristics of all other hazardous materials, are addressed by the hazardous material pr ovisions of a fire prevention code. Effectively implementing such a program requires expertise and resources that may exceed those available in some jurisdictions. Regardless, the level of safety expected by the public requires such a program. In cases where expertise and capability to implement and enforce a hazardous material program does not exist with in a jurisdiction, a qualified agency should develop an d provide the service.

References: IFC, 2012 edition , Chapters 1 and 50 with particular emphasis on §§105 Permits , 105.6.20 Hazardous Materials , and Chapter 50, Hazardous Materials

.

Finding 10: Develop a Policy to Address Existing Structures Existing structures that do not meet the requirements of NFPA 400, 2013 edition , should be retroactively provided with several key features to assure adequate public and firefighter safety.

The following elements for existing ammonium nitrate buildings should be considered and have been proposed to the
NFPA 400 Committee as revisions for the 2016 edition: Require retrofit within a reasonable timefr ame of the following protective measures:

(1) Install automatic sprinklers per NFPA 400, 2013 edition

. (2) Install a fire alarm system for the entire bu ilding with a fire sprinkler system flow switch. (3) Install a community evacuation siren automatically ac tivated by the water flow switch for storage amounts greater than 1000 pounds. (4) Develop a detailed Emergency Response Plan and Evac uation Plan for the area within 1 mile of the building.Investigation Number FFF FY 13-06 51 Finding 11: Alcohol and substance abuse The autopsy results of three of the res ponders to this incident indicated levels of alcohol and/or drugs. There was no evidence to suggest that the use of alcohol or drugs by these responders contributed to the explosion and the resulting
fatalities.

Recommendation: All fire and/or emergency service agencies/organizations sh ould develop written policies an d have procedures in place to restrict members from responding to emergency scen es while under the influence of alcohol or drugs.

Reference: International Association of Fire Chiefs (IAFC) Guide to Model Policies & Procedures for Emergency Vehicle Safety, pg. 16, Alcohol and Substance Abuse. Fire department members are not permitte d to be on duty, to respond to emergenc y incidents, to drive or operate fire department vehicles, nor to perform any other duty-related functions while under the influence of alcohol or drugs. Fire department members shall not perform any duty-relat ed functions for a minimum of eight hours following the consumption of any alcoholic be verages. A longer period wait ing period may be required to ensure that the individual is free of impairment. A blood alcohol concentration of 0.02 percent or higher , while on duty, shall create the presumption that the member is under the influence of alcohol.Investigation Number FFF FY 13-06 52 

# Appendix 1: The HMEx Assistant Chemical ClassificationInvestigation Number FFF FY 13-06 53 

# Appendix 2: Best Practices for the Storage of Ammonium Nitrate

References Related to Best Practices : Storage of Ammonium Nitrate Please check with your local jurisdiction ha ving authority to determine whether there is a local fire code or other regulatory code that must be utilized related to storage of ammonium nitrate. De pending on the regulations adopted, the best practices listed below may be mandatory.

Additional information is available on the State Fire Marshal’s Office website at http://www.tdi.texas. gov/fire/fman.html

.

On August 30, 2013, the United States Oc cupational Safety and Health Administrati on; Bureau of Alcohol, Tobacco, Firearms and Explosives; and the U. S. Environmental Protection Agency provided the following: Chemical Advisory: Safe Storage, Handlin g, and Management of Ammonium Nitrate http://www.epa.gov/osweroe1 /docs/chem/AN_advisory.pdf

Occupational Safety and Health Administration (OSHA) OSHA Standard 1910.109(i)(4 ) also defines additional requirements for storag e of ammonium nitrate. The following are some, but not all the requirements: 1910.109(i)(5)(i)(a ) :

“Ammonium nitrate shall be in a sepa rate building or shall be separated by approved type firewalls of not less than 1-hour fire-resistance rating fr om storage of organic chemicals, acid s, or other corrosive materials ... ”

1910.109(i)(5)(i)(b): “In lieu of separation walls, ammoni um nitrate may be separated from the materials referred to in paragraph (a) of this section by a space of at least 30 feet.”

1910.109(i)(6)(i): “Electrical installations shall confor m to the requirements of subpart S of this part, for ordinary locations. They shall be designed to minimize damage from corrosion.”

1910.109(i)(7)(ii)(a): “Water supplies and fire hydrants shall be availabl e in accordance with recognized good practices.”

The U.S. Senate Committee on Environment and Public Work s held a hearing on June 27, 2013, in Washington, D.C., and various experts from the Chemical Safety Board, Department of Homeland Security, Texas A&M University,Investigation Number FFF FY 13-06 54 and others all agreed with Chairperson Boxer that fire mu st be prevented from reaching bulk storage of ammonium
nitrate. Some recommendations included:

 Storage of ammonium nitrate in non-combusti ble storage facilities or at least have a one-hour fire barrie r separating a storage bin of ammonium nitrate fr om other adjacent products.

 Fire sprinkler system suitable for a corrosive atmosphere.

 Third-party inspection of these fa cilities should be in pl ace (e.g., insurance companies insu ring these facilities, safety institutes, etc.)

Note: This is not an all-inclusive list of best practices related to storage of ammoni um nitrate, but is pr ovided to provide hi ghlights from three resources to facilitate further research by th e property manager and/or owner.