Fire Fighter = Fatality Investigation Report F2007-18| CDC/NIOSH

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3D"NIOSH

Nine Career Fire Fighters Die in Rapid Fire Progression at = Commercial=20 Furniture Showroom =96 South Carolina

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SUMMARY

On June 18, 2007, nine career fire fighters (all males, ages 27 =96 = 56) died=20 when they became disoriented and ran out of air in rapidly deteriorating = conditions inside a burning commercial furniture showroom and warehouse=20 facility. The first arriving engine company found a rapidly growing fire = at the=20 enclosed loading dock connecting the showroom to the warehouse. The = Assistant=20 Chief entered the main showroom entrance at the front of the structure = but did=20 not find any signs of fire or smoke in the main showroom.

Incident Scene
(Photo courtesy of = Alexander=20 Fox, Associated Press.)

He observed fire inside the structure when a door connecting the rear = of the=20 right showroom addition to the loading dock was opened. Within minutes, = the fire=20 rapidly spread into and above the main showroom, the right showroom = addition,=20 and the warehouse. The burning furniture quickly generated a huge amount = of=20 toxic and highly flammable gases along with soot and products of = incomplete=20 combustion that added to the fuel load. The fire overwhelmed the = interior attack=20 and the interior crews became disoriented when thick black smoke filled = the=20 showrooms from ceiling to floor. The interior fire fighters realized = they were=20 in trouble and began to radio for assistance as the heat intensified. = One fire=20 fighter activated the emergency button on his radio. The front showroom = windows=20 were knocked out and fire fighters, including a crew from a mutual-aid=20 department, were sent inside to search for the missing fire fighters. = Soon=20 after, the flammable mixture of combustion by-products ignited, and fire = raced=20 through the main showroom. Interior fire fighters were caught in the = rapid fire=20 progression and nine fire fighters from the first-responding fire = department=20 died. At least nine other fire fighters, including two mutual-aid fire = fighters,=20 barely escaped serious injury.

NIOSH investigators concluded that, to minimize the risk of similar=20 occurrences, fire departments should:

develop, implement and enforce written standard operating = procedures=20 (SOPs) for an occupational safety and health program in accordance = with NFPA=20 1500
develop, implement, and enforce a written Incident Management = System to be=20 followed at all emergency incident operations
develop, implement, and enforce written SOPs that identify = incident=20 management training standards and requirements for members expected to = serve=20 in command roles
ensure that the Incident Commander is clearly identified as the = only=20 individual with overall authority and responsibility for management of = all=20 activities at an incident
ensure that the Incident Commander conducts an initial size-up and = risk=20 assessment of the incident scene before beginning interior fire = fighting=20 operations
train fire fighters to communicate interior conditions to the = Incident=20 Commander as soon as possible and to provide regular updates
ensure that the Incident Commander establishes a stationary = command post,=20 maintains the role of director of fireground operations, and does not = become=20 involved in fire-fighting efforts
ensure the early implementation of division / group command into = the=20 Incident Command System
ensure that the Incident Commander continuously evaluates the risk = versus=20 gain when determining whether the fire suppression operation will be = offensive=20 or defensive
ensure that the Incident Commander maintains close accountability = for all=20 personnel operating on the fireground
ensure that a separate Incident Safety Officer, independent from = the=20 Incident Commander, is appointed at each structure fire
ensure that crew integrity is maintained during fire suppression=20 operations
ensure that a rapid intervention crew (RIC) / rapid intervention = team=20 (RIT) is established and available to immediately respond to emergency = rescue=20 incidents
ensure that adequate numbers of staff are available to immediately = respond=20 to emergency incidents
ensure that ventilation to release heat and smoke is closely = coordinated=20 with interior fire suppression operations
conduct pre-incident planning inspections of buildings within = their=20 jurisdictions to facilitate development of safe fireground strategies = and=20 tactics
consider establishing and enforcing standardized resource = deployment=20 approaches and utilize dispatch entities to move resources to fill = service=20 gaps
develop and coordinate pre-incident planning protocols with mutual = aid=20 departments
ensure that any offensive attack is conducted using adequate fire = streams=20 based on characteristics of the structure and fuel load = present
ensure that an adequate water supply is established and = maintained
consider using exit locators such as high intensity floodlights or = flashing strobe lights to guide lost or disoriented fire fighters to = the=20 exit
ensure that Mayday transmissions are received and prioritized by = the=20 Incident Commander
train fire fighters on actions to take if they become trapped or=20 disoriented inside a burning structure
ensure that all fire fighters and line officers receive = fundamental and=20 annual refresher training according to NFPA 1001 and NFPA 1021
implement joint training on response protocols with mutual aid=20 departments
ensure apparatus operators are properly trained and familiar with = their=20 apparatus
protect stretched hose lines from vehicular traffic and work with = law=20 enforcement or other appropriate agencies to provide traffic = control
ensure that fire fighters wear a full array of turnout clothing = and=20 personal protective equipment appropriate for the assigned task while=20 participating in fire suppression and overhaul activities
ensure that fire fighters are trained in air management techniques = to=20 ensure they receive the maximum benefit from their self-contained = breathing=20 apparatus (SCBA)
develop, implement and enforce written SOPS to ensure that SCBA = cylinders=20 are fully charged and ready for use
use thermal imaging cameras (TICs) during the initial size-up and = search=20 phases of a fire
develop, implement and enforce written SOPs and provide fire = fighters with=20 training on the hazards of truss construction
establish a system to facilitate the reporting of unsafe = conditions or=20 code violations to the appropriate authorities
ensure that fire fighters and emergency responders are provided = with=20 effective incident rehabilitation
provide fire fighters with station / work uniforms (e.g., pants = and=20 shirts) that are compliant with NFPA 1975 and ensure the use and = proper care=20 of these garments.

Additionally, federal and state occupational safety and health=20 administrations should:

consider developing additional regulations to improve the safety = of fire=20 fighters, including adopting National Fire Protection Association = (NFPA)=20 consensus standards.

Additionally, manufacturers, equipment designers, and researchers = should:

continue to develop and refine durable, easy-to-use radio systems = to=20 enhance verbal and radio communication in conjunction with properly = worn=20 SCBA
conduct research into refining existing and developing new = technology to=20 track the movement of fire fighters inside = structures.

Additionally, code setting organizations and municipalities = should:

require the use of sprinkler systems in commercial structures, = especially=20 ones having high fuel loads and other unique life-safety hazards, and=20 establish retroactive requirements for the installation of fire = sprinkler=20 systems when additions to commercial buildings increase the fire and = life=20 safety hazards
require the use of automatic ventilation systems in large = commercial=20 structures, especially ones having high fuel loads and other unique=20 life-safety hazards.

Additionally, municipalities and local authorities having = jurisdiction=20 should:

coordinate the collection of building information and the sharing = of=20 information between building authorities and fire departments
consider establishing one central dispatch center to coordinate = and=20 communicate activities involving units from multiple = jurisdictions
ensure that fire departments responding to mutual aid incidents = are=20 equipped with mobile and portable communications equipment that are = capable of=20 handling the volume of radio traffic and allow communications among = all=20 responding companies within their jurisdiction.

INTRODUCTION

On June 18, 2007, nine male career fire fighters (the victims), aged = 27 to=20 56, died when they became disoriented in rapidly deteriorating = conditions inside=20 a burning commercial furniture showroom and warehouse facility. At least = seven=20 other municipal fire fighters and two mutual aid fire fighters barely = escaped=20 serious injury.

The National Institute for Occupational Safety and Health (NIOSH), = Division=20 of Safety Research, Fire Fighter Fatality Investigation and Prevention = Program,=20 learned of the incident on June 19, 2007 through the national news = media. On=20 June 19, 2007, the U.S. Fire Administration (USFA) notified NIOSH of the = fatalities. That same day, a Safety Engineer and a General Engineer from = NIOSH=20 traveled to South Carolina to initiate an investigation of the incident. = The=20 NIOSH investigators traveled to the incident site and met with = representatives=20 of the Bureau of Alcohol, Tobacco and Firearms (ATF), National Institute = of=20 Standards and Technology (NIST), South Carolina State Law Enforcement = Division=20 (SLED), and South Carolina Occupational Safety and Health Administration = (SC-OSHA). The NIOSH investigators were on-site June 20-22, and the = NIOSH=20 General Engineer returned June 24th to work with representatives of NIST = to=20 collect data related to the structure=92s construction^a=20 for the NIOSH investigation and for a comprehensive fire reconstruction = model.=20 Note: The NIST Building and Fire Research Laboratory is developing a = computerized fire model to aid in reconstructing the events of the fire. = When=20 completed, this model will be available at the NIST website:=20 http://www.bfrl.nist.gov/.

^a The fire completely destroyed the = structure and=20 the sheet metal roof was removed at the direction of ATF before NIOSH = and NIST=20 were allowed access to the structure. Consequently, detailed information = on the=20 construction was not available and NIOSH and NIST frequently relied on=20 photographs of the structure after the fire.

On July 9, 2007, three NIOSH investigators (Safety Engineer, General=20 Engineer, and Safety and Occupational Health Specialist), along with=20 representatives of NIST, returned to South Carolina. Meetings were = conducted=20 with the Fire Chief; Assistant Chief; the city=92s Director, Safety = Management=20 Division; and the city=92s Workers=92 Compensation administrator.

During the weeks of July 9-13, July 16-20, and August 27-31, 2007, = interviews=20 were conducted with officers and fire fighters who were on-duty and = dispatched=20 to the incident scene, as well as fire fighters who were off-duty and = came to=20 the scene to offer assistance. Fire fighters from two mutual aid = departments=20 were also interviewed during these times. NIST representatives = participated in=20 many of the NIOSH interviews to collect information for their = computerized fire=20 model.

During the course of the ensuing investigation, the NIOSH = investigators met=20 with chief officers and fire fighters from the initial responding = department,=20 two local mutual aid departments, NIST staff, the county coroner, the = county=20 emergency response dispatch center staff, city building inspectors, city = water=20 system officials, representatives of the International Association of = Fire=20 Fighters (IAFF) labor union, U.S. Fire Administration staff, ATF, and=20 representatives of the city=92s Fire Review Team (FRT).

NIOSH investigators reviewed some departmental standard operating=20 procedures,^b=20 the victims=92 training records, chief officers=92 training records, and = floor plans=20 and photographs of the structure. Photographs were obtained from a = number of=20 sources including NIOSH, NIST, the city police department, the FRT and = national=20 media.^c=20 NIOSH investigators visited the city=92s fire training academy, met with = the=20 training officer, and reviewed the training schedule (see = Appendix=20 I). The department=92s maintenance and repair facility (for in-house = maintenance and repair of fire apparatus, equipment, and self-contained=20 breathing apparatus (SCBA)) was visited and maintenance records were = reviewed.=20 An independent inspection report for one of the apparatus involved in = the=20 incident, that had been contracted for by the city, was reviewed (see = Appendix=20 II). The city=92s fire and police dispatch center was visited as = well as the=20 dispatch center for the first responding mutual aid department. Other = sources of=20 information used in this investigation include state and federal OSHA=20 regulations, NFPA standards, fire department pre-plan information (see = Appendix=20 III), coroner=92s reports, copies of the fireground radio = transmissions=20 provided by the city legal department, a transcript of the dispatch = audio=20 records provided by the FRT, and the FRT Phase I and Phase II = reports.^1,2=20

^b NIOSH investigators reviewed two = Standard=20 Operating Procedures (SOPs) provided to NIOSH: =93Standard Operating = Procedures=20 Engine Company 2=94 (undated) and =93Fire Department Policies and = Procedures Manual=94=20 dated July 25, 2005. The city reported that there were additional SOPs = in place=20 at the time of the incident.

^c Some photographs used in this NIOSH = report have=20 been altered to remove names, faces and other identifiers.

NIOSH contracted with a leading expert in personal protective = clothing to=20 evaluate the clothing and personal protective equipment worn by the = victims (see = Appendix=20 IV). This evaluation took place on August 29, 2007. The evaluation = site and=20 handling of the evidence materials was coordinated with the assistance = of the=20 county coroner=92s office and the city police department. The PPE = evaluation was=20 witnessed by representatives of NIOSH, NIST, the FRT, the county = coroner=92s=20 office, the city police department, and the state fire marshal=92s = office.

The lead NIOSH investigator participated in a meeting convened by the = U.S.=20 Fire Administration on September 20, 2007 to discuss the status of = ongoing=20 investigations and share information not of a confidential nature. This = meeting=20 consisted of representatives of the U.S. Fire Administration, ATF, the = FRT, the=20 county coroner, NIST and NIOSH. The lead NIOSH investigator participated = in a=20 similar meeting convened by the FRT on December 18, 2007. This meeting = consisted=20 of representatives of the FRT, ATF, the county coroner, NIST, and NIOSH. =

Safety and Health Regulations=20

South Carolina is one of 26 states and territories which administers = its own=20 occupational safety and health program through an agreement with the = U.S.=20 Department of Labor, Occupational Safety and Health Administration = (OSHA). The=20 South Carolina Occupational Safety and Health Administration (SC-OSHA) = has=20 jurisdiction over private and public sector employers and employees = within the=20 state. The state occupational safety and health act requires employers = to=20 provide their employees with a safe and healthy worksite which is free = of=20 hazards which may cause injuries and illnesses to workers. South = Carolina has=20 adopted the federal OSHA Standards verbatim, with a few = exceptions.³⁼=20 Most notably, South Carolina OSHA has revised the federal OSHA = Respiratory=20 Protection Standard paragraph 1910.134(g)(4)(ii), commonly known in the = fire=20 service as the =93two in =96 two out=94 rule, to allow fire fighters to = enter=20 immediately-dangerous-to-life-or-health (IDLH) atmospheres with only one = fire=20 fighter located outside the IDLH atmosphere until additional fire = fighters=20 arrive, provided certain conditions are met.

Following the fatal fire, SC-OSHA cited the fire department for = several=20 alleged violations and assessed penalties.⁴⁼=20 The fire department and city contested these findings and SC-OSHA and = the city=20 reached a settlement in which the fire department was cited for two = violations,=20 an inadequate fire department incident command system and failure to = ensure use=20 of personal protective equipment by some fire fighters at the = incident.⁵⁼=20 SC-OSHA also cited the furniture store employer for locked exit doors, = fire=20 doors not operating properly, and not implementing an emergency action = plan at=20 the store.⁴⁼

Fire Department

At the time of the incident, the career fire department was an = ISO^d=20 Class I rated department with 19 fire companies located throughout the = city. The=20 fire department serves a population of approximately 106,000 in a = geographic=20 area of about 91 square miles. In June 2007 the fire department = consisted of=20 approximately 240 uniformed fire fighters and fire officers. The = department=20 operated 16 engine companies and 3 ladder truck companies at 14 stations = in the=20 city. Each apparatus was staffed with four fire fighters but routinely = operated=20 with three fire fighters per apparatus (a captain, engineer, and fire = fighter),=20 depending on the staffing available each shift. The standard work shift = was 24=20 hours on-duty and 48 hours off-duty, with fire fighters assigned to one = of three=20 rotating shifts. Each shift was supervised by an Assistant Chief. On the = day of=20 the incident, the department had 61 fire fighters, 4 Battalion Chiefs = and an=20 Assistant Chief working on-duty. Note: At the time of the incident, = the fire=20 department did not have a safety officer position and a safety officer = was not=20 designated at the incident. Since then, the fire department has hired a=20 full-time permanent safety officer.

^d ISO is an independent commercial = enterprise which=20 helps customers identify and mitigate risk. ISO can provide communities = with=20 information on fire protection, water systems, other critical = infrastructure,=20 building codes, and natural and man-made catastrophes. Virtually all = U.S.=20 insurers of homes and business properties use ISO=92s Public Protection=20 Classifications (PPC) to calculate premiums. In general, the price of = fire=20 insurance in a community with a good PPC is substantially lower than in = a=20 community with a poor PPC, assuming all factors are equal. ISO=92s PPC = program=20 evaluates communities according to a uniform set of criteria known as = the Fire=20 Suppression Rating Schedule (FSRS). The FSRS has three main parts =96 = fire alarm=20 and communications (10%), the fire department (50%), and water supply = (40%). The=20 FSRS references nationally recognized standards developed by the = National Fire=20 Protection Association (NFPA) and the American Water Works Association. = Rated=20 fire departments are classified 1 through 10 with Class 1 being the best = rating=20 a fire department can receive. More information about ISO and their = Fire=20 Suppression Rating Schedule can be found at the website=20 http://www.isogov.com/about/.

The fire department utilized the 911 dispatch center operated by the=20 municipal police department (PD). The local county also maintains an = emergency=20 communications / dispatch center and provides communications for two = small fire=20 departments. Some mutual aid fire departments within the county maintain = their=20 own dispatch centers.

The first mutual aid department to respond to the scene was a career=20 department that employs 60 fire fighters and officers. It maintains four = stations and serves a population of approximately 24,000 residents in an = area of=20 approximately 30 square miles. Jurisdictional boundaries between this = mutual aid=20 department and the municipal department were intermingled. Adjoining = properties=20 in the same block could be in different jurisdictions. This led to = incidents=20 where a department would be the first to arrive at a working fire = outside its=20 jurisdiction.

The second mutual aid department to respond to the scene was a = combination=20 department with 44 fire fighters that serves a rural population of = 14,000.

Training

In South Carolina, it is up to the local fire chief to decide what = level of=20 training is required for fire department personnel to obtain in order to = meet=20 SC-OSHA training requirements. At the time of the incident, this = municipal fire=20 department required fire fighters to receive basic training to at least = Fire=20 Fighter I certification from the South Carolina Fire Academy or some = other=20 source. While the South Carolina Fire Academy is accredited by the = International=20 Fire Service Accreditation Congress to provide a number of NFPA level = courses,=20 at the time of the incident, the fire department recognized training = from=20 sources other than the South Carolina Fire Academy as meeting their = basic=20 certification requirements. Note: Basic fire fighter certification = required=20 by the fire department at the time of the incident did not meet NFPA = 1001,=20 Standard for Firefighter Professional Qualifications. ⁶⁼

Once hired, the recruits were assigned to the department=92s training = center=20 for 10 days of hands-on training after which the new fire fighters were = assigned=20 to companies throughout the city. The department=92s training focused on = equipment=20 use, SCBA use, ladder drills, hydrant hookup, hose lays, hose pulls, = rescue=20 drills, and live-burn exercises (see training schedule =96 Appen= dix I=20 ). A training officer supervised the recruit training and oversaw = the=20 department=92s training program. Individual companies normally trained = from 0930=20 to 1130 hours each day with each company=92s captain responsible for the = training.=20 Training on hydrant location and hook-up was done once per month. Driver = /=20 operator training was mainly on-the-job hands-on training. Individual = fire=20 fighters could request to receive driver / operator training. The = request would=20 then be reviewed and approved through the department=92s chain of = command.

Training records provided by the city for the nine victims consisted = of=20 verification of the weekly in-station training, certificates indicating = training=20 on subjects such as National Incident Management System (NIMS), weapons = of mass=20 destruction (WMD) and emergency medical services =96 medical first = responder. SCBA=20 facepiece fit test records were also provided. Training records for the = chief=20 officers were provided, consisting mainly of copies of National Incident = Management System (NIMS) training certificates.

Victims

Note: Throughout this = report, the=20 9 victims are identified by the order in which they were located at the = scene,=20 identified by the County Coroner, removed from the structure and = transported.=20 The following table provides information on each victim.

Victims Rank, Apparatus, Age, and Year(s) of Experience =
Victims (Order = located)	Rank	Apparatus	Age	Experience (yrs)
1	Engineer	Engine 19	37	9
2	Fire fighter	Engine 19	56	32
3	Fire fighter	Engine 16	46	2
4	Assistant Engineer	Ladder 5	27	1.5
5	Captain	Engine 16	49	29
6	Captain	Engine 19	48	30
7	Acting Captain	Ladder 5	40	12.5
8	Captain	Engine 15	34	11.5
9	Fire fighter	Ladder 5	27	4

Equipment and Personnel

The municipal = fire=20 department initially responded to the alarm with 3 apparatus and 9 fire = fighters=20 including Engine 11 (E-11 acting captain, acting engineer and fire = fighter),=20 Engine 10 (E-10 captain, acting engineer and fire fighter), Ladder 5 ( = L-5=20 acting captain, engineer (assistant engineer), and fire fighter), a = battalion=20 chief (BC-4) and an Assistant Chief (AC). Note: Fire department = procedures=20 stated that where structures were 5 stories or less in height, the first = alarm=20 assignment would be 2 engines, 1 ladder truck, and a Battalion Chief. = For=20 structures over 5 stories in height, the first alarm assignment would be = 3=20 engines, 1 ladder truck, a Battalion Chief and the Assistant Chief. Once = on-scene, the Incident Commander could request additional resources as = deemed=20 necessary. Procedures also stated that a confirmed report of =93smoke = showing=94=20 would automatically send an additional engine. When a ranking officer = arrived=20 on-scene, that officer automatically became Incident Commander. =

Engine 16 (E-16 captain, engineer, and fire fighter) was dispatched = after=20 BC-4 (the initial Incident Commander (IC)) radioed dispatch to confirm = smoke was=20 showing at the incident site as per department procedures. E-16 was = designated=20 as the third-due engine responding to all structure fires in the western = district (where the incident occurred) if not assigned on the = initial=20 dispatch. Chief Officers requested Engine 15 (E-15), Engine 12 (E-12), = Engine 19=20 (E-19), Engine 6 (E-6), Engine 3 (E-3), Engine 13 (E-13), Engine 9 = (E-9), and=20 Ladder 4 (L-4) as the incident escalated. Additional responders included = the=20 Battalion Chief from the neighboring district (BC-5) and the Battalion = Chief of=20 training (BC-T). A large number of off-duty officers and fire fighters = also=20 responded to the incident scene. Some of the off-duty fire fighters = responded=20 with turnout gear, others did not.

Only the units directly involved in the operations preceding the = fatal event=20 are discussed in this report. The activities of the additional mutual = aid=20 departments that were dispatched after the structure collapsed are not = addressed=20 by this report.

Timeline=20

Note: This timeline is provided to set out, to the extent = possible, the=20 sequence of events as the fire departments responded. The times are = approximate=20 and were obtained from review of the dispatch audio records, witness = interviews,=20 photographs of the scene and other available information. In some cases = the=20 times may be rounded to the nearest minute, and some events may not have = been=20 included. The timeline is not intended, nor should it be used, as a = formal=20 record of events.

The response, listed in order of arrival (time approximate) and = events,=20 include:

1907 hours=20: Dispatch for possible fire behind furniture store
1909 hours=20: BC-4, E-10, E-11, L-5 enroute=20; BC-4 confirms smoke showing while enroute=20; E-10, L-5, E-16 acknowledge hearing BC-4 confirm fire=20; AC enroute=20
1910 hours=20: E-16 enroute as third-due engine=20; E-15 relocates to western district=20; BC-4 arrives on scene and reports trash fire at side of building.=20; BC-4 radios for E-10 to come down side of building=20
1911 hours=20: Assistant Chief (AC) on scene=20; E-10 and E-11 on scene=20
1912 hours=20: AC radios for E-16 to come inside building when they arrive = on-scene.=20; (Showroom clear with no fire/smoke showing)=20; Ladder 5 on scene=20; Fire Chief (enroute) radios E-15 to relocate to Station 11=20; AC radios dispatch to send Engine 12=20; BC-4 radios Car 2 and says he knows fire is inside building=20; Engine 12 dispatched to scene
1913 hours=20: BC-4 radios E-12 that he needs E-12 to lay a supply line to E-10=20; E-11 acting captain radios =93I need an 1 =BD=94 inside this = building=94=20; (Door connecting showroom to loading dock was opened by AC showing = heavy=20 fire in loading dock)=20; AC radios E-15 to =93come on=94=20; AC radios E-15 and says to bring 1 =BD=94 hose line inside to = right rear of=20 building=20; E-6 begins relocating to the west side
1914 hours=20: AC radios BC-4 and says fire is inside the rear of the building = and moving=20 towards the showroom=20; AC radios dispatch to send E-6=20; E-6 dispatched to scene=20; Fire Chief radios dispatch to send E-19 and have E-6 relocate to = Station=20 11
1915 hours=20: AC radios E-16 to bring 2 =BD=94 hose line in front door=20; E-16 radios AC to confirm assignment=20; E-16 on-scene
1916 hours=20: L-5 engineer and L-5 fire fighter both radio E-11 to charge line = (1 =BD=94=20 line pulled by L-5 / E-11 crews)=20; E-19 enroute=20; L-5 again requests E-11 to charge hose line=20; Fire Chief on scene
1917 hours=20: E-12 on scene - assigned to lay supply line to E-10=20; E-15 on scene
1919 hours=20: Fire Chief radios E-6 and tells them to come to scene and come in = front=20 door=20; E-6 responds they are enroute=20; Fire Chief radios dispatch to call the power company=20; E-16 captain radios =93charge that 2 =BD=94
1920 hours=20: E-11 engineer radios the E-11 acting captain to see if he wants = the 2 =BD=94=20 hose line charged.=20; AC replies =93not until the supply line is charged=94=20; E-19 on scene=20; E-12 radios E-10 =85 =93water coming 10=94=20; E-12 engineer radios dispatch that the police department is needed = because=20 cars are running over hoses. Dispatch replies that the police = department is=20 enroute
1921 hours=20: AC radios E-16 engineer - =9316, what about that supply line?=94 = E-16 engineer=20 replies he is looking for a hydrant.=20; E-6 on scene
1922 hours=20: E-11 engineer radios E-16 that tank water is down to half-full=20; E-16 engineer replies he is looking for hydrant
1924 hours (see = Photo=20 #1)=20: Battalion Chief 5 (BC-5) on scene=20; Fire Chief radios E-12 to boost water pressure on supply line by = 50 pounds=20; E-12 acknowledges=20; AC radios.. =93We need that 2 =BD=94 (referring to 2 =BD=94 = hoseline off E-11)=20; E-3 is relocated to Station 16/19=20; Mutual aid department # 1 on-scene
1925 hours=20: E-10 radios that tank water is down to one-quarter full=20; Fire Chief radios E-12 to boost supply water pressure to E-10 by = 50 more=20 pounds=20; E-12 acknowledges=20; Mutual aid department # 1 radios the fire department with no = response
1926 hours=20: E-16 engineer radios that =93water coming=94=20; Dispatch radios Fire Chief and informs him that dispatch has = received a=20 phone call from a civilian saying he is trapped at the rear of the = building=20; Fire Chief acknowledges
1927 hours=20: Inaudible radio traffic =96 possibly =93lost inside=94 or = =93trapped inside=94=20; Fire Chief radios AC and says that the warehouse door has been = opened and=20 a 2 =BD=94 hose line is in operation. Fire Chief also asks about the = rescue=20 attempt of the trapped civilian and tells AC to do what he can do.=20; Dispatch radios AC to inform him that the trapped civilian is = banging on=20 exterior wall with a hammer
1928 hours=20: AC radios for E-11 and gets no response. Note: This may be = when the AC=20 is looking for fire fighters to assist with rescue of the civilian and = mutual=20 aid fire fighters are pressed into action.
1929 hours=20: Broken radio traffic of fire fighter in distress asking =93which = way out=94=20 then =93everyone out=94
1930 hours (see = Photo #=20 2)=20: E-11 radios that 2 =BD=94 hose line is charged=20; Several different fire fighters in distress radio =93need some = help out,=94=20 =93need help getting out,=94 also =93lost connection with the hose=94=20; AC radios Fire Chief that they are attempting to free civilian = trapped in=20 warehouse
1931 hours =96 1934 hours (see = Photo=20 #3)=20: More broken radio traffic from fire fighters in distress=20; L-5 repositioned to D-side by off-duty fire fighters=20; Fire Chief asks for E-3 to come to scene and lay supply line to = L-5=20; BC-5 reports civilian is out of building=20; E-16 engineer radios dispatch that police department is needed to = prevent=20 traffic from running over supply line.=20; FF calls Mayday=20; Fire Chief asks AC =93is everyone out?=94 AC responds the civilian = is out=20; Fire Chief radios AC to make sure his people are accounted for.=20; E-15 FF exits building (out of air) =96 reports he didn=92t call = the Mayday=20; Fire Chief radios =93who called Mayday=94=20; Fire Chief radios =93=85we need to vacate the building=94=20; Dispatch tells Fire Chief that the L-5 engineer emergency button = (on=20 radio) has been activated=20; Fire Chief radios for E-15 captain with no response=20; E-15 FF changes air cylinder and goes back inside
1935 hours =96 1936 hours (see = Photos #=20 4, # 5, and # 6)=20: Front windows knocked out=20; E-6 crew (captain, engineer, and FF) along with E-15 engineer and = FF exit=20 showroom=20; Fire Chief orders mutual aid crew to search for missing fire = fighters=20; Fire Chief continues to radio for E-15 captain and crew with no = response=20; Fire Chief instructs everyone else to stay off radio=20; Conditions at front of showroom change dramatically =96 turbulent = thick dark=20 smoke rolls out windows
1937 hours=20: Fire Chief continues to radio for E-15 captain and crew with no = response=20; E-13 is dispatched to scene=20; E-7 relocates to Station 13=20; Fire rolls out windows at front of showroom
1938 hours (see = Photos # 7=20 and # 8)=20: Mutual aid crew exits building=20; Fire Chief continues to radio for E-15 captain and crew with no = response=20; Fire Chief radios for everyone to abandon the building=20; Training Chief (BC-T) radios for E-15 captain=20; BC-T radios E-16 engineer to boost water supply pressure to E-11. =
1939 hours=20: AC radios E-16 to =93give me some more water=94=20; BC-T also radios E-16 for more water pressure=20; E-16 engineer acknowledges and water pressure is boosted to 200 = psi
1940 hours=20: E-3 on scene=20; Mutual Aid Department # 2 enroute to lay water supply line to L-5 =
1942 hours=20: BC-T continues to radio for E-15 captain (no response)=20; Fire Chief radios that no one is to go inside=20; E-13 on scene
1943 hours=20: Fire Chief asks if everyone is out of front=20; BC-T radios E-16 engineer that he needs more water pressure. = Engineer=20 responds that the entire hose bed has been stretched out plus two = sections of=20 3=94 hose. Additional radio communications about civilian vehicle = traffic=20 driving over the supply line.=20; BC-T radios E-16 engineer and says =93I need all you can give = me!=94
1944 hours=20: AC radios dispatch to call the city water department to increase = water=20 pressure in the area.=20; Fire Chief radios for E-15 captain=20; E-3 engineer radios that water is coming (water supply established = to L-5)=20

Additional crews continued to arrive on-scene and = contributed to the=20 fire suppression efforts. Engine 13 began laying a supply line to L-5 at = 1947=20 hours. The Fire Chief radioed dispatch to send Ladder 4 to the scene at = 1948=20 hours. The Fire Chief radioed dispatch and requested that the Mayor be = notified=20 at 1950 hours. A portion of the roof over the right side of the showroom = collapsed causing the front fa=E7ade to begin collapsing at 1951 hours.=20 Eventually, almost the entire roof over the main showroom and the right = side=20 addition collapsed. Ladder 4 was put into operation in the front parking = lot at=20 approximately 2005 hours. The fire was brought under control after 2200 = hours.=20 Recovery operations continued until after 0400 hours the next morning.=20

Personal Protective Equipment

The fire = department issued each fire fighter a full set of black turnout gear and = station=20 uniforms when they were hired and sent to the recruit training class. = The=20 department issued helmets, hoods, gloves, and boots. The Chief Officers=20 (Battalion Chief rank and higher) wore a set of brown turnout gear from = a=20 different manufacturer. At the time of the incident, each fire fighter = was=20 allowed to purchase and wear his own turnout gear, or bring their gear = from=20 other departments they served in, if they desired, so long as it met the = requirements of the department.

Following the incident, the personal protective equipment (PPE =96 = turnout=20 clothing, SCBA, radio, hand tools, etc) worn by each of the nine victims = was=20 secured by the city police department. On August 29, 2007, the PPE was = examined=20 in detail by a personal protective clothing expert contracted by NIOSH. = The PPE=20 was examined, documented and photographed through a systematic process. = The=20 county coroner=92s office coordinated the PPE examination at the request = of NIOSH.=20 Representatives of NIOSH, NIST, the FRT, the county coroner=92s office, = the city=20 police department, and the state fire marshal=92s office were present = during the=20 examination. Each victim=92s PPE was severely damaged by fire and heat = exposure=20 due to the length of time it took to locate and recover the victims. The = evaluation indicated melting of polyester station uniforms (non-NFPA = 1975⁷⁼=20 compliant) in the areas where the turnout clothing was degraded by the = fire=20 exposure. The PPE examination also identified examples where turnout = gear was=20 not being properly worn such as turnout coat collars not fully extended = upward=20 and helmet ear flaps not deployed. A summary of the complete PPE = inspection is=20 contained in Appen= dix=20 IV. A copy of the complete PPE inspection report is available upon = request=20 from the NIOSH Fire Fighter Fatality Investigation and Prevention = Program.

The city fire and police departments utilized a type-2 trunked radio = system=20 (computer-aided) that automatically assigned radio frequencies as needed = to=20 different =93talk groups.=94 Each apparatus riding position was assigned = a radio so=20 that each on-duty fire fighter had access to a radio. Each radio = contained an=20 emergency notification button that, when activated, would send a signal = to the=20 dispatch center with the radio=92s identity. On the day of the incident, = radios=20 were available, but at least one fire fighter did not carry his assigned = radio.=20 The county in which this incident occurred maintained its own dispatch = center=20 for emergency medical services (EMS) and the smaller outlying volunteer = fire=20 departments. Some smaller fire departments operated as public service = districts=20 (PSDs) and operated their own dispatch centers. Thus not all fire = departments=20 who were on scene could communicate directly with the city fire = department due=20 to the multiple radio systems in place.

Apparatus and Equipment Maintenance =

The fire=20 department operated a maintenance and repair facility at one of the = stations,=20 where in-house maintenance was performed on all fire apparatus, = equipment and=20 SCBA. Annual pump flow testing was conducted and recorded. During the = NIOSH=20 investigation, interviewed fire fighters reported a number of recurring=20 maintenance problems on apparatus and power equipment to the NIOSH=20 investigators.

During the NIOSH investigation, fire fighters reported during = interviews that=20 Engine 11 (E-11) required specific procedures to engage the pump. When=20 interviewed by NIOSH investigators, the maintenance supervisor reported = that=20 E-11 had a hydraulic transmission and a non-electric pump, and and if = the engine=20 was not throttled to full throttle before the pump was engaged, the pump = would=20 not discharge at full capacity. The city reported that there were no = records or=20 reports of operational issues with E-11 prior to this event, and that = daily=20 equipment checks were performed. In December 2008, the city contracted = with a=20 nationally recognized company to conduct independent testing and = evaluation of=20 E-11. The city indicated that no changes had been made to Engine 11 = since the=20 fire. A copy of the December 16, 2008 inspection report was provided to = NIOSH=20 for review (Appen= dix=20 II). The results of this testing and evaluation indicated that = Engine 11 was=20 generally in good acceptable working order with 3 maintenance findings = that were=20 corrected during the inspection, and 8 findings needing corrective = action. In=20 addition, the report highlighted findings of the Engine 11 pump = inspection. The=20 report reads, =93When shifting the [pump] lever downward from top = position, proper=20 operation calls for a pause in center (neutral) position momentarily = before=20 bringing the lever to the complete downward position. Failure to pause = at the=20 center (neutral) position can cause a long excessive delay in engaging = of pump.=20 There is an expected delay even in proper operation of this pump. Please = check=20 with manufacturer for exact acceptable delay time line.=94

During the NIOSH investigation, fire fighters reported to NIOSH = investigators=20 that the fire department=92s procedure was to refill cylinders when the = pressure=20 dropped to 1500 psi which is well below the required 90% level found in = the OSHA=20 Respirator Standard⁸⁼=20 and NFPA 1852⁹⁼=20 (1500 psi is 68% of full cylinder pressure or 2216 psi). NIOSH = investigators=20 examined a small number of SCBA cylinders in service on city fire = apparatus and=20 did find some with cylinder pressures below 2000 psi.

Structure

The structure involved in = this=20 incident was a one-story, commercial furniture showroom and warehouse = facility=20 totaling over 51,500 square feet that incorporated mixed-construction = types. The=20 structure was non-sprinklered. The facility had been renovated and = expanded a=20 number of times over the past 15 years. The original structure was = constructed=20 in the 1960=92s as a 17,500 square foot grocery store with concrete = block walls=20 and lightweight metal bar joists (metal roof trusses) supporting the = roof to=20 create an open floor plan. After being converted to a furniture retail = store,=20 the original structure was expanded by adding a 6,970 square foot = addition on=20 the right side (D-side) in 1994 and a 7,020 square foot addition to the = left=20 (B-side) in 1995. Both additions were attached to the original exterior = walls=20 and consisted of steel beams supporting the walls and roof. To provide = access=20 between the original structure and the two additions, the exterior walls = on the=20 B and D sides of the original structure were each penetrated in 3 = locations to=20 form six 8=92 X 8=92 openings that were equipped with metal roll-up fire = doors.=20 These fire doors were equipped with fusible links designed to = automatically=20 close the doors in the event of a fire. In 1996, a 15,600 square foot = warehouse=20 was added to the rear of the main showroom. The main showroom and the = warehouse=20 were connected by an enclosed wood-framed loading dock of approximately = 2,250=20 square feet. Double metal doors connected the rear of the right-side = addition to=20 the loading dock area. These metal doors swung outward (opened into the = loading=20 dock). Additional access to the loading dock area was available from the = rear of=20 the original structure. (See = Diagram=20 1)

At the time of the incident, the showroom included painted = sheet-metal siding=20 on the B and D side exterior walls with a combination of sheet metal and = concrete block in the rear (C-side) and a front masonry and block = fa=E7ade (at the=20 A-side). The roof over the main showroom (original structure) was = constructed of=20 sheet-metal roof decking covered by foam insulation and a weather = membrane. Both=20 right and left showroom additions included roofs constructed of sheet = metal roof=20 decking over fiber glass insulation. The fire caused extensive damage to = the=20 roof structure, making an analysis of the roof construction difficult. =

The warehouse was a free-standing, clear-span structure with = sheet-metal=20 walls and roof. Both structures contained concrete floors. The main = showroom=20 measured 9 feet from the floor to a suspended drop ceiling and = approximately 14=20 feet to the roof, creating almost 5 feet of void space above the = suspended=20 ceiling. The warehouse measured 29 feet from the floor to the roof. The=20 warehouse contained rows of metal storage shelving that contained a = variety of=20 furniture items including couches, chairs, mattresses, etc. (see = Photo 9=20 showing storage racks in warehouse).

The roofs over the main showroom, the showroom additions on both the = B and D=20 sides of the structure, and the warehouse contained limited penetrations = (ventilation ductwork, utilities, etc.). Thus there were limited = openings for=20 smoke and hot gases to escape naturally in the event of a fire.

According to city building officials, the property was annexed into = the city=20 in 1990. The original structure and the 3 additions were considered as 4 = separate structures for code enforcement purposes. Separate permits were = issued=20 for the construction of the left and right side additions and the = warehouse.=20 City building officials indicated to NIOSH investigators that after the = fire,=20 the furniture store property was determined to be =93non-code = compliant=94 (not in=20 compliance with applicable codes). Work had been performed on the = loading dock=20 area and the maintenance shop without permits between 1996 and 2005. = Other code=20 violations included the accumulation of trash outside the loading dock, = large=20 quantities of flammable liquids, solvents, and thinners in the loading = dock=20 area, and storage of furniture and flammable materials in non-permitted = areas.=20

At the time of the incident, city ordinances required commercial = structures=20 over 15,000 square feet to be equipped with a sprinkler system. The = original=20 structure was grandfathered (exempt from this requirement) while the = left and=20 right additions (at the B and D-sides) did not meet the threshold = requirement.=20 Thus, since the store was considered as 4 separate structures, the = facility had=20 been exempt from sprinkler system requirements.

The structure had been inspected by the fire department on a number = of=20 occasions. In 1987, fire inspection duties were transferred from the = fire=20 department to the city with the last documented fire code inspection by = the city=20 in 1998. The fire department continued to perform periodic pre-plan = inspections.=20 A building pre-plan form obtained from the fire department dated April = 26, 2006=20 noted that store contents were =93household furniture and office = equipment=94 and=20 that the rear warehouse contained racks approximately 30 feet high (see = Appendix=20 III). The pre-plan form did not mention the large volume of = furniture and=20 flammable materials (fuel load) contained in the structure. It was = reported to=20 NIOSH investigators by fire fighters during interviews that trash from = the=20 furniture business, including packing materials, cardboard, broken = furniture and=20 other flammable materials, were routinely stored against the building = near the=20 loading dock on the west (D) side of the structure (see = Diagram=20 2).

Weather

At the time of the incident, = the=20 temperature was approximately 86 degrees Fahrenheit (F) with a dew point = of 72=20 degrees F and a relative humidity of 63 percent. The sky was partly = cloudy with=20 light winds blowing from the south up to 11 miles per hour.¹⁰=20

INVESTIGATION

The furniture store fire on June 18, 2007, was originally dispatched = as a=20 possible fire behind a commercial retail furniture store. The initial = Incident=20 Commander radioed dispatch that the fire was a =93bunch of trash = free-burning=20 against the side of the structure.=94 The fire very rapidly grew into an = incident=20 of major proportions. (A computerized fire model will be available in = the future=20 from NIST at=20 http://www.bfrl.nist.gov/).

Summary of Initial Sequence of Events

On June 18, 2007, at approximately 1907 hours, the fire department = was=20 dispatched to a possible fire behind a large commercial retail furniture = store.=20 Two engines (Engine 11 and Engine 10), one ladder truck (Ladder 5), and = the=20 Battalion Chief (BC-4) were dispatched per department procedures. The = on-duty=20 Assistant Chief (AC) was at Station 11 and responded to the scene. While = enroute, BC-4 observed heavy dark smoke rising into the air and radioed = dispatch=20 that smoke was coming from the direction of the store. Per department=20 procedures, this initiated the response of the third-due engine (Engine = 16) to=20 the scene.

BC-4 arrived on scene driving east to west, pulled past the store and = drove=20 down the alley to the loading dock located on the D-side of the = structure. BC-4=20 observed fire burning from ground level to over the roofline outside of = the=20 covered loading dock. Note: The covered loading dock connects the = front=20 showroom area to the rear 15,600-square foot warehouse facility. = BC-4=20 radioed dispatch that the fire was a =93bunch of trash free-burning = against the=20 side of the structure.=94 The dispatcher asked the responding units if = they heard=20 BC-4=92s report on the fire conditions. E-10, L-5, and E-16 = acknowledged.=20

When the AC arrived on-scene, he parked in the parking lot in = front of=20 the main showroom right addition. The AC and BC-4 briefly discussed = their=20 observations and directed Engine 10 to back down the alley to the = loading dock=20 area. The AC entered the store through the main entrance located in the = center=20 of the front of the structure (A-side). The AC walked down the center of = the=20 showroom to the rear (in the original structure) then went back outside. = He did=20 not observe any smoke or fire in the main showroom. BC-4 drove his car = to the=20 front of the showroom and observed the AC coming out of the showroom=92s = main=20 entrance. The AC remained at the front of the store while BC-4 returned = to the=20 D-side. Note: Departmental policy was that the highest ranking = officer=20 on-scene was the Incident Commander. Incident Command (IC) was never = formally=20 announced at this incident.

While the E-11 crew looked for a hydrant to establish water supply, = the AC=20 and the E-11 acting captain re-entered the main showroom. The AC radioed = E-16 to=20 come inside the front door when they arrived on scene. E-16 = acknowledged. Ladder=20 5 (L-5) arrived on-scene at 1912 hours and pulled into the parking lot = in front=20 of the furniture store, facing east. BC-4 radioed the AC and informed = him that=20 the fire was now inside the structure. The AC radioed Dispatch and = requested=20 that Engine 12 (E-12) be sent to the scene. The Fire Chief advised the=20 dispatcher to relocate Engine 15 (E-15) to Station 11. BC-4 radioed E-12 = and=20 instructed them to lay a supply line to E-10. E-12 acknowledged.

The Assistant Chief detected fire when he opened a door connecting = the rear=20 of the right showroom addition to the loading dock area. The E-11 acting = captain=20 radioed that he needed a 1 =BD=94 hand line inside the building. When = E-15 radioed=20 that they had relocated to the west-side, the AC instructed E-15 to come = to the=20 scene. The AC also instructed E-15 to bring a 1 =BD=94 hand line inside = to the rear=20 right-side of the structure. The AC radioed that the fire was inside the = rear of=20 the structure and was moving towards the showroom.

The E-11 acting captain went outside and met the L-5 crew pulling a 1 = =BD=94 hand=20 line off E-11. The AC radioed dispatch and requested that Engine 6 (E-6) = be sent=20 to the scene. E-6 was dispatched at 1914 hours. The Fire Chief (enroute) = radioed=20 dispatch to change the assignment to have Engine 19 dispatched to the = scene and=20 have E-6 relocate to Station 11. E-16 radioed the AC to ask if they were = to go=20 to the rear of the building. The AC instructed E-16 to come to the front = door=20 and bring a 2 =BD=94 hand line inside. The Fire Chief arrived on-scene = at 1916=20 hours. Note: Beginning at approximately 1916 hours, the L-5 engineer = is=20 heard over the radio asking for the 1 =BD=94 hose line from E-11 to be = charged.=20 Diagram= 2=20 shows the location of Engine 10 and Engine 11 in relation to the = structure and=20 how the attack lines were deployed during offensive operations.

A mutual aid department noticed heavy black smoke in the area and=20 self-dispatched to the scene. The fire had already spread to the = warehouse when=20 the mutual aid department arrived on-scene. After some discussion with = the Fire=20 Chief, the mutual aid department was assigned to the rear of the = warehouse=20 (C-side) to begin fire suppression.

The burning furniture quickly generated large volumes of smoke, toxic = gases=20 and soot that added to the fuel load. At approximately 1926 hours, a = store=20 employee called the city=92s 911 Dispatch center and reported that he = was trapped=20 inside the back of the building. Note: The employee was actually = working=20 near the front of the warehouse opposite the covered loading dock (see = Diagram=20 3.) The employee stated he was banging on the exterior wall = with a=20 hammer. The dispatcher told the employee to continue banging on the wall = and to=20 stay calm and stay as low to the floor as he could. The dispatcher = radioed the=20 Fire Chief and informed him of the situation. This information was also = relayed=20 to the city police dispatcher and a police officer on-scene verbally = informed=20 some fire fighters of the situation. The city Assistant Fire Chief and a = Battalion Chief (BC-5) quickly instructed a crew of four fire fighters = from the=20 mutual aid department to initiate the rescue attempt on the B-side of = the=20 warehouse. This crew quickly located the point where the trapped = civilian was=20 banging on the exterior wall. They were able to cut through the exterior = wall=20 (metal siding) using a Haligan bar and axe. The fire fighters were able = to=20 safely extricate the civilian at approximately 1933 hours. The civilian = employee=20 rescue was announced over the radio. The mutual aid fire fighters = assisted the=20 employee to the front parking lot where he was checked by EMTs.

As the civilian was being rescued, the fire was extending into the = main=20 showroom. The fire quickly outgrew the available suppression water = supply. The=20 interior fire attack crews could not contain the spread of the fire. = Note:=20 At this point, three hose lines were inside the main showroom =96 the = initial 1=BD=20 inch hose line, a 2=BD inch hose line and a 1 inch booster line. All = three hose=20 lines were pulled off Engine 11 which was being supplied by Engine 16 = through a=20 single 2 =BD inch supply line approximately 1,850 feet long. Water = supply from=20 Engine 16 to Engine 11 was established at approximately 1926 hours. = The=20 interior crews from Engine 11, Ladder 5, Engine 16, Engine 15, Engine = 19, and=20 Engine 6 became disoriented as the heat rapidly intensified and = visibility=20 dropped to zero as the thick black smoke filled the showroom from = ceiling to=20 floor. The interior fire fighters realized they were in trouble and = began to=20 radio for assistance. At least one Mayday was called. Another fire = fighter=20 radioed that he had lost contact with the hose line and needed help. One = fire=20 fighter activated the emergency button on his radio.

Note: During this incident fire fighters experienced intermittent = radio=20 communication problems and interruptions. Audio transcripts of the = fireground=20 channel recorded multiple instances where fire fighters inside the = structure=20 (including some of the victims) transmitted over the radio but the = transmissions=20 were not heard or not understood. The first recorded transmission of a = fire=20 fighter requesting assistance occurred at approximately 1927 hours and=20 transmissions requesting =93we need help,=94 =93lost connection with the = hose,=94 and=20 =93Mayday=94 continued until at least 1934 hours. The first =93Mayday=94 = was recorded at=20 approximately 1932 hours. The first recorded transmissions indicating = chief=20 officers were aware of the fire fighters calling for assistance was at=20 approximately 1933 hours.

The Engine 6 crew and three fire fighters from E-15 were able to find = the=20 front door and exit the showroom. The front showroom windows were = knocked out to=20 improve visibility. Fire fighters, including two fire fighters from the = mutual=20 aid crew who extricated the trapped civilian, were sent inside to search = for the=20 missing fire fighters at approximately 1936 hours. The two mutual aid = fire=20 fighters made brief contact with two disoriented fire fighters just as = the=20 flammable mixture of gases and combustion by-products in the showroom = ignited,=20 filling the showroom with flames. The two mutual aid fire fighters lost = contact=20 with the two disoriented fire fighters and were driven outside by the = intense=20 heat and flames (see = Photo=20 7). One of the rescuers received second degree burns on his face, = neck,=20 hands, and arms. An off-duty Battalion Chief and the Engine 6 engineer = also=20 entered the structure for a rescue attempt. They also were driven out by = the=20 rapid fire spread.

While fire fighters were known to be trapped inside, the number and = their=20 identities were not known. Interior fire fighters were caught in the = rapid fire=20 progression and nine fire fighters from the first-responding fire = department=20 were killed.

The operational details of each responding apparatus company are = listed=20 below. Per department procedures, chief officers requested additional = apparatus=20 as the need was identified.

Engine 10=20

The E-10 crew (consisting of a captain, engineer, and fire fighter) = was=20 in-transit returning to quarters when the fire dispatch came in. The = crew could=20 see smoke billowing from the incident scene as they pulled onto the = highway and=20 they heard BC-4 report over the radio a trash fire on the side of the = structure.=20 Note: E-10 and Ladder 5 are quartered at the same station. The fire = fighters=20 on E-10 and L-5 had switched positions so that another fire fighter = could train=20 on pumping E-10.

The AC and BC-4 were already on-scene when Engine 10 arrived. The AC = directed=20 E-10 to back down the alley parallel to the D-side of the store toward = the=20 loading dock. The crew observed smoke and flames inside the loading dock = area=20 and coming out an exhaust fan in the D-side wall. The E-10 captain = pulled a=20 booster line (1=94 red hose) and knocked down the outside trash fire = while the=20 E-10 fire fighter pulled a 1 =BD=94 pre-connected hand line to the = loading dock.=20 BC-4 returned to the loading dock after meeting with the AC and observed = fire=20 burning inside the structure so he radioed dispatch to report that the = fire was=20 now inside the building. The E-10 captain decided to use the 1 =BD=94 = hand line for=20 the interior attack. The E-10 engineer charged the 1 =BD=94 hand line = from the=20 engine=92s tank-water supply. Fire was readily visible inside the = loading dock=20 area as the E-10 fire fighter and captain advanced the hoseline inside = the=20 loading dock about 20 to 25 feet. At their furthest point of entry, the = E-10=20 crew could just see the door connecting the enclosed loading dock to the = showroom right-side addition. This area became fully involved in flames = as the=20 E-10 crew directed water onto the fire. The 60 gallons per minute (gpm) = flow=20 from their 1 =BD=94 handline was insufficient to control the fire. = According to the=20 fire fighters interviewed by NIOSH, the flames appeared to float in the = air and=20 burned floor to ceiling. The water didn=92t appear to have any effect on = the fire=20 so the crew started to retreat. Note: The E-10 crew told NIOSH = investigators=20 that the water pattern produced by their fog nozzle just pushed the = flames=20 around the room as they attempted to extinguish the fire. After the = fire, at=20 least 28 one-gallon cans of extremely flammable solvents were found = inside the=20 loading dock suggesting that at some point a vapor fire was burning = inside the=20 loading dock. As they were backing out, the hose either burst or = was burned=20 through by the fire. Water spraying from the ruptured hose aided the = fire=20 fighters (improved visibility and provided a protective water curtain) = in=20 locating the door and moving outside.

The E-10 engineer pulled some sections of 2 =BD=94 supply line from = E-10 out to=20 the street to meet E-12 which had been assigned to provide a water = supply line.=20 When the E-10 attack crew exited the loading dock, they asked fire = fighters from=20 Engine 12 (E-12), just arriving on-scene, to repair the damaged 1 =BD=94 = hand line.=20 The E-10 captain and fire fighter got the 1=94 booster line that they = had=20 previously pulled off E-10 and advanced the booster line to the loading = dock=20 door. The booster line did not have any effect on the fire so they = backed the=20 line out, switched back to the 1 =BD=94 hand line (that had been = repaired by the=20 E-12 crew) and moved back inside the loading dock. By this time the Fire = Chief=20 was on scene. The Fire Chief came to the loading dock and yelled inside = to tell=20 the E-10 captain not to advance any further. A few seconds later, the = Fire Chief=20 ordered the E-10 crew to back outside and operate from the doorway. = Note:=20 The E-10 crew was inside the loading dock 3 times for a total of = approximately=20 15 minutes. BC-4 observed that the fire had extended into the = warehouse.=20 BC-4 returned to the front of the building and asked the manager if he = had keys=20 for the warehouse at the rear of the loading dock. The manager said = =93no,=94 so=20 BC-4 returned to the loading dock and directed the E-12 crew and = off-duty fire=20 fighters who had responded to the scene to cut through the warehouse=92s = roll-up=20 door with a power saw. The crews experienced trouble with getting the = saw to run=20 properly and used axes and Haligan bars to open the warehouse doors. = BC-4 also=20 directed the E-10 crew to assist with opening up the warehouse. BC-4 = then=20 directed the E-10 crew to get a 2 =BD=94 hand line with a stack-tipped = nozzle from=20 E-10 and pull it to the warehouse door. By this time, the warehouse was = becoming=20 well involved. A second 2 =BD=94 hose line was later pulled from E-10 = and put into=20 operation.

BC-4 was able to look inside the warehouse and he observed a large = amount of=20 fire inside. BC-4 went back to the front of the building and directed 2 = off-duty=20 fire fighters to move Ladder 5 to the D-side and set it up for aerial = water pipe=20 operation. BC-4 also met with an off-duty captain and asked him to take = over=20 getting L-5 set up for operation. Note: This off-duty captain is = also an=20 Assistant Chief at a neighboring mutual aid fire department located = about 20=20 miles away. A crew from the mutual aid department responded and the = captain used=20 this mutual aid crew to assist with establishing water supply to L-5 by=20 supplying it with tank water and then stretching supply lines to Engine = 12. Per=20 department procedures, off-duty fire fighters are allowed to respond to = working=20 fires and become involved in fire suppression activities. Off-duty fire = fighters=20 are supposed to check in with the IC, give the IC their ID card or = driver=92s=20 license, and get an assignment. The civilian owner of a small = yellow frame=20 building located next to the D-side of the furniture warehouse advised = BC-4 that=20 his building was full of vehicles, gasoline, oil, and other flammables = (see = Diagram #=20 2). BC-4 talked to the deputy chief of the first mutual aid = department about=20 the building and asked him to get a hand line to protect the yellow = building.=20 Once L-5 was put into operation at approximately 1944 hours, it also was = used to=20 protect this building.

Engine 11=20

The Engine 11 (E-11) crew (acting captain, acting engineer, and fire = fighter)=20 was in quarters at Station 11 and the engine was being washed when the = fire=20 dispatch was initiated. The AC and BC-4 were also at station 11. E-11 = was the=20 first due engine but Engine 10 was in the vicinity and arrived on-scene = first.=20 While enroute to the scene, the E-11 crew heard BC-4 radio that smoke = was coming=20 from the location of the furniture store. The original fire dispatch = stated that=20 the fire was at the rear, so E-11 turned left off the highway onto a = side street=20 and drove behind the building. The AC radioed for E-11 to come back to = the front=20 of the store and pull into the second entrance to the parking lot. E-11 = circled=20 around and turned right into the parking lot in front of the store just = as E-10=20 backed down the alley on the D side. E-11 got on scene at 1911 hours = just before=20 BC-4 radioed that the fire was inside the structure. The acting captain = on E-11=20 directed the E-11 acting engineer and fire fighter to lay a supply line = to E-10.=20 The E-11 fire fighter (suction man) started walking down the street = looking for=20 a hydrant. The E-11 fire fighter returned to E-11 before making a = hydrant=20 connection when Ladder 5 (L-5) arrived on-scene. The E-11 acting = engineer was=20 directed by the L-5 acting captain to reposition E-11 near the front = door facing=20 northeast.

The E-11 acting captain entered the main showroom doors and walked = down the=20 center aisle to the rear of the main showroom. The showroom was clear = with no=20 smoke visible inside. The AC had preceded the E-11 acting captain inside = the=20 showroom and the two walked into the right addition and walked to the = rear of=20 the right showroom addition. They both observed a small wisp of light = smoke=20 visible at ceiling level in this area. They were not immediately alarmed = by this=20 smoke and the AC opened the double door leading to the loading dock. = They=20 reported seeing lots of fire and smoke beyond the door. The AC attempted = to pull=20 the door shut but he could not shut the door due to the air rushing from = the=20 showroom toward the fire. The E-11 acting captain helped pull the door = shut and=20 the AC told the acting captain to get a 1 =BD=94 hand line.

At 1913 hours, the E-11 acting captain radioed that he =93needed an=20 inch-and-a-half inside the building.=94 The E-11 acting captain then = went outside=20 and met the acting captain from Ladder 5 (L-5) pulling a 1 =BD=94 = preconnected hand=20 line off E-11. They both pulled the 1 =BD=94 pre-connected hand line = through the=20 center doors and down the center aisle. The hand line just reached the = rear of=20 the center showroom. The E-11 acting captain told the L-5 acting captain = he was=20 going to go outside to add in another section of hose. The E-11 acting = captain=20 added 5 more sections of 1 =BD=94 hose (the second pre-connected hose = line on E-11)=20 and dragged it inside. The L-5 acting captain and L-5 fire fighter were = at the=20 nozzle at this time. The L-5 crew pulled the nozzle toward the rear of = the right=20 side addition (the line was still not charged at this point). The E-11 = fire=20 fighter entered the main showroom flaking more slack in the hose line. = The E-11=20 acting captain asked him to go find out why they did not yet have water = pressure=20 on the 1 =BD=94 hose.

After waiting a short time for water pressure, the E-11 acting = captain went=20 outside to find out why they still didn=92t have water pressure. The = E-11 acting=20 captain and engineer were able to get the pump in operation by cycling = the=20 engine transmission to get the pump in gear. Note: Fire fighters = interviewed=20 by NIOSH stated that E-11 required specific procedures to engage the = pump; an=20 independent inspection of the apparatus confirmed these findings. On the = day of=20 the incident, the E-11 engineer was serving as the acting captain so = E-11 was=20 driven and operated by a fire fighter less experienced in its operation. =

The E-11 acting captain then re-entered the structure. He had to don = his=20 facepiece and go on air because gray-colored smoke was starting to = accumulate in=20 the center of the showroom. Fire was still not visible in the showroom = at this=20 point.

The Engine 16 (E-16) captain and fire fighter entered the showroom = with a 2=20 =BD=94 hose line that was uncharged at this point. The E-11 acting = captain told the=20 E-16 captain he would go find out why the 2 =BD=94 hose line was still = uncharged. As=20 he started to exit the showroom, the inside conditions changed very = rapidly. The=20 smoke turned very thick and grayish black. The E-11 acting captain had = to find=20 the 1 =BD=94 hose and follow it outside. E-11 was still without a water = supply at=20 this point. After talking with the E-11 acting engineer about the water = supply=20 situation, the E-11 acting captain walked around to the loading dock = area to=20 look for the E-11 fire fighter.

While at the D-side, BC-4 asked the E-11 acting captain to help with = setting=20 up a 2 =BD=94 hose line to the warehouse. Note: This 2 =BD=94 hose = line was pulled=20 from E-10. The E-11 acting captain was just stepping up to the = warehouse=20 door when the Fire Chief ordered everyone out of the warehouse. The E-11 = acting=20 captain observed that the other fire fighters in this area had things = under=20 control so he went back to the A-side. When the E-11 acting captain = returned to=20 the front, fire was blowing out the front windows. He heard the Fire = Chief give=20 an order to evacuate. The E-11 acting captain got into the E-11 cab and = sounded=20 the airhorn 3 times for an evacuation signal.

Ladder=20 5

Ladder 5 (L-5) was the third apparatus to arrive on-scene and = initially=20 positioned in the parking lot in front of the furniture store just west = of E-11.=20 The L-5 crew included an acting captain (Victim # 7), an assistant = engineer=20 (Victim # 4) and a fire fighter (Victim # 9 - who had switched = assignments with=20 the E-10 fire fighter). Note: This fire department typically = dispatches=20 ladder trucks as extra manpower, and not for ventilation activities. The = ladder=20 trucks do not have their own pumps and must be supplied by an engine in = order to=20 flow a master stream.

The L-5 acting captain directed the E-11 acting engineer to = reposition E-11=20 near the front door of the main showroom. It is assumed that the L-5 = acting=20 captain heard the E-11 acting captain radio for a hand line inside the = structure=20 so the L-5 crew started to pull a 1 =BD=94 preconnected hand line off of = E-11. When=20 the L-5 crew took this hand line inside, they met the E-11 acting = captain coming=20 outside to get a hose line. The L-5 crew took the 1 =BD=94 hose line to = the rear of=20 the right-side addition (after the E-11 acting captain added additional = sections=20 to the hose line) and after some delay in getting water, advanced into = the=20 loading dock through the double doors connecting the showroom to the = loading=20 dock. This was the last confirmed location of the L-5 crew.

Between approximately 1932 and 1934 hours, L-5 was repositioned from = the=20 front of the showroom to the D-side by off-duty fire fighters who had = responded=20 to the scene. Fire fighters from a mutual aid department along with = off-duty=20 fire fighters worked to establish water supply to L-5. Engine 3 arrived = on scene=20 at approximately 1940 hours and also worked to get a water supply = established to=20 L-5. Water supply was established at approximately 1944=20 hours.

Engine 16

At the time of the incident, Engine 16 (E-16) was designated as the = 3rd due=20 engine on all confirmed structure fires in the department=92s western = district if=20 not assigned on the initial dispatch. Note: NIOSH investigators were = told=20 that the 3rd due engine is designated as the =93Safety Team=94 and = should have been=20 held on stand-by at the scene. However, the crew was instructed to = engage in=20 fire suppression activities before they arrived on-scene.

The crew was in quarters when the fire dispatch was initiated. The = E-16 crew=20 consisted of a captain (Victim # 5), an engineer, and a fire fighter = (Victim #=20 3). E-16 started to move toward the scene when BC-4 reported smoke in = the area.=20 At approximately 1915 hours, the AC radioed E-16 to bring a 2 =BD=94 = hose line in=20 the front door. E-16 arrived on scene driving west to east. The E-16 = captain and=20 fire fighter dismounted the engine and went to talk to the AC. They took = a 2 =BD=94=20 hose line with a stacked-tip nozzle (uncharged) into the main showroom = and=20 advanced it to the double doors leading to the loading dock and met up = with the=20 acting captain from E-11. This was the last confirmed location of the = E-16 crew.=20

The E-16 engineer was instructed to lay a supply line for E-11 so he = drove=20 east on the highway toward where a hydrant had been previously located. = This=20 hydrant had been removed in 2004 because it had received damage from = heavy truck=20 traffic in the immediate area. He continued east to the next hydrant = located=20 approximately 1,200 feet away. Note: 1,850 feet of a single 2 =BD=94 = supply line=20 was stretched from E-11 to the hydrant. The E-16 engineer reported = hearing=20 the radio traffic about the civilian worker being trapped in the rear of = the=20 building just as he was pulling up to the hydrant. (see = Diagram #=20 2)

At approximately 1919 hours, the E-16 captain radioed to charge the 2 = =BD=94=20 hoseline (inside the building). The E-11 engineer radioed the E-11 = acting=20 captain to ask if he wanted the 2 =BD=94 hoseline charged. The AC = responded to not=20 charge the 2 =BD=94 hoseline until the supply line from E-16 to E-11 was = charged.=20 Note: Water supply from E-16 to E-11 was not yet established at this = point.=20 Water supply from E-16 to E-11 was established at approximately 1926 = hours.=20 After the hose was stretched out, traffic on the highway began to = drive=20 over the supply line from E-16 to E-11. The E-16 engineer radioed = dispatch that=20 the city police were needed for traffic control. As crews attempted to = battle=20 the escalating fire, water supply became an issue. Later, during the = time period=20 from 1937 hours to 1941 hours, chief officers in front of the showroom=20 repeatedly called the E-16 engineer to boost water pressure to E-11 as = the fire=20 escalated out of control. At approximately 1941 hours, the E-16 engineer = was=20 instructed to switch to another radio channel to clear up the main = channel for=20 rescue purposes.

Engine 12

The Engine 12 (E-12) crew, consisting of an acting captain, assistant = engineer, and two fire fighters were in quarters at the time of the = initial=20 dispatch. At approximately 1912 hours, the AC radioed dispatch to send = E-12 to=20 the scene. While enroute, BC-4 radioed E-12 and instructed them to lay a = supply=20 line down the alley on the D-side of the building to E-10. Engine 12=20 acknowledged this assignment. The Fire Chief also radioed the same = instructions.=20

Engine 12 arrived on-scene at approximately 1917 hours and hooked up = a 2 =BD=94=20 supply line to E-10, then drove across the highway and down a side = street to a=20 hydrant, laying out 15 sections of supply line. The E-12 engineer hooked = up to=20 the hydrant and operated the pumps supplying E-10 throughout the = incident. Water=20 supply to E-10 was established at approximately 1920 hours. The E-12 = acting=20 captain and fire fighters assisted the E-10 crew by repairing the 1 = =BD=94 hoseline=20 that had burst, then forced open the walk-thru door at the front of the=20 warehouse and advanced a 2 =BD=94 hoseline inside the warehouse about 10 = feet before=20 being ordered to withdraw. The 2 =BD=94 hoseline was then operated = through the=20 doorway into the warehouse. The fire was reported to be burning so hot = that the=20 water immediately turned to steam and did little good in suppressing the = fire.=20

Note: The E-12 crew reported that while forcing open the = warehouse door,=20 they experienced problems with a gasoline powered saw that had the wrong = type of=20 blade (for cutting plywood, not metal). Crews had to use axes to cut = through the=20 metal siding. The E-12 crew also cut holes in the metal siding = along the=20 D-side walls for ventilation and to direct water streams inside the = building (see = Photo=20 10).

Later in the incident, additional supply lines were stretched to E-12 = so that=20 E-12 could pump to E-11 and L-5 and L-4. Chief Officers radioed E-12 to = boost=20 the water pressure to E-10 at least 3 times during the incident. The = E-12=20 engineer also radioed dispatch to have the city police department stop = traffic=20 on the highway from running over the supply lines.

Engine = 15

The Engine 15 crew was in quarters when the first alarm crews were=20 dispatched. The E-15 crew consisted of a captain (Victim # 8), engineer, = and two=20 fire fighters. One of the E-15 fire fighters ( fire fighter # 2) was = newly hired=20 and was responding to his first working structure fire with the = department. Per=20 department procedures, E-15 began to relocate from downtown to the west = side.=20 The E-15 crew reported that smoke was visible from a couple of miles = away as=20 they relocated so they began running hot (Code 3 - lights and sirens = on). At=20 approximately 1912 hours, the Fire Chief radioed dispatch to have Engine = 15=20 relocate to Station 11. Almost immediately, the AC radioed for E-15 to = come to=20 the scene. Then the AC radioed E-15 to bring a 1 =BD=94 hose line to the = right rear=20 of the building.

Engine 15 arrived on-scene at approximately 1917 hours just as Engine = 16=20 began dropping a supply line for Engine 11. The E-15 captain instructed = the E-15=20 engineer to get dressed to go inside the building. Note: During the = NIOSH=20 interviews, numerous fire fighters reported that most fire fighters = responding=20 after the first alarm would be expected to enter a structure fire for = additional=20 interior support. Coordinated ventilation and ladder truck operations = reportedly=20 were seldom initiated.

The E-15 captain and two fire fighters donned their SCBA and = proceeded to=20 Engine 11. One fire fighter took a pike pole and Haligan bar while the = other=20 fire fighter took an axe. They briefly talked with the E-11 engineer. = They=20 observed two hose lines going through the front entrance and followed = the hose=20 lines (one 1 =BD=94 and one 2 =BD=94) inside. Visibility at the front of = showroom was=20 still good at this time and the crew did not go on air until they were = about 10=20 feet inside the door. As the E-15 crew advanced further, the visibility=20 decreased. They were aware of other crews working to their right. The = E-15=20 captain discussed with his crew that he wanted to work a hose line to = the center=20 and left rear of the main showroom to cut the fire off from spreading in = that=20 direction (contain fire to the right rear corner). The E-15 captain = instructed=20 fire fighter # 2 to go outside and get a hose line.

Fire fighter # 2 went outside and pulled a booster line (1=94 red = hose) as far=20 as he could down the center walkway through the main showroom. By this = point,=20 the visibility had decreased to where it was difficult to distinguish = other fire=20 fighters moving nearby. Fire fighter # 2 moved as far as he could and = then began=20 to flow water from the booster line toward a red glow overhead. He ran = low on=20 air and followed the hoseline toward the front entrance. Once outside he = changed=20 his air cylinder, then followed the hoseline back inside. He heard = airhorns=20 sounding (evacuation signal)and followed the hoseline back outside.

The E15 engineer donned his PPE and went to the front door where he = assisted=20 fire fighter # 2 in pulling the booster line through the front door. The = E15=20 engineer advanced inside the showroom about 10 feet where he encountered = thick=20 black smoke from ceiling to floor. He could see a red glow at the rear = of the=20 showroom but no distinct flames. He ran low on air and went outside and = changed=20 his SCBA cylinder then re-entered the main showroom. It was noticeably = hotter=20 inside the showroom as the E15 engineer entered the second time. The = engineer=20 heard three airhorn blasts then heard radio traffic about evacuating the = building so he followed the hose line outside.

After the E-15 captain (Victim # 8) and fire fighter # 1 moved deeper = into=20 the showroom, the E-15 captain instructed fire fighter # 1 to go get = another=20 hose line. Note: This was the last confirmed location of the E-15=20 captain. Fire fighter # 1 found a charged booster hose and dragged = this=20 hose as far as he could in the direction of where he had last seen the = E-15=20 captain. Fire fighter # 1 did not encounter the E-15 captain or his = other crew=20 members when he returned to the rear of the showroom. Fire fighter # 1 = opened=20 the hose line nozzle a couple of times but couldn=92t see much fire. = Fire fighter=20 # 1 noticed that it was starting to get really hot and the thickening = smoke was=20 reducing visibility to near zero. His low air alarm began to go off so = he=20 started to follow the hose line outside. He came to a point where the = hose line=20 ran underneath furniture and he couldn=92t follow the hose line any = further so he=20 jumped over the furniture. Once on the other side of the furniture, he = searched=20 for the hose line but could not locate it. As he searched for hose = lines, he saw=20 the bright flashing light of a PASS device and moved toward the light. = He=20 encountered the engineer from Engine 6 who was looking for his crew. The = E-6=20 engineer guided the E-15 fire fighter to the front of the showroom and = when they=20 got close enough to the front entrance to hear the sound of Engine 11 = running=20 outside, the E-15 fire fighter bolted through the door (shortly after = 1931=20 hours). The E-15 fire fighter went to Engine 11 and asked the E-11 = engineer to=20 switch out his SCBA cylinder. At approximately 1934 hours, while = changing his=20 cylinder, the E-15 fire fighter was asked if he had radioed a Mayday and = he=20 reported that he had not.

While changing cylinders, the E-15 fire fighter heard that fire = fighters were=20 missing inside the building. Note: During the timeframe of = approximately=20 1935 to 1936 hours, fire fighters outside the main entrance knocked out = the=20 showroom windows to improve visibility inside the building. After = changing=20 cylinders, he followed the hose lines back inside the main showroom to = search=20 for his crew. He advanced about 50 feet into the showroom and = encountered=20 intense heat and could see fire burning everywhere around him. He met = the E-6=20 crew (captain, engineer, and fire fighter) following the hoseline to = exit the=20 showroom. The E-6 engineer told the E-15 fire fighter he couldn=92t go = any further=20 and he needed to get out. These four fire fighters exited the showroom = with the=20 E-15 fire fighter jumping through a showroom window to the right of the = doorway.=20 The E-15 engineer and fire fighter # 2 also exited the main entrance at=20 approximately the same time. The E-15 captain did not exit the building. =

Engine 19

The Engine 19 crew was in quarters when the fire dispatch was = initiated. The=20 Engine 19 crew consisted of a captain (Victim # 6), engineer (Victim # = 1), and=20 one fire fighter (Victim # 2). Engine 6 had just been dispatched to the = scene=20 when, at approximately 1914 hours, the Fire Chief radioed dispatch to = send=20 Engine 19 to the scene and to have Engine 6 relocate to Station 11.

Engine 19 arrived on scene at approximately 1920 hours and parked in = the=20 middle of the highway in front of the furniture store. The E-19 crew = entered the=20 main showroom through the front entrance. There are few details about = their=20 activities after this point.

Engine 6 =

The Engine 6 crew, consisting of a captain, engineer, and one fire = fighter=20 were in quarters when they heard the initial fire dispatch. Engine 6 is = the=20 second engine to relocate to the western district per fire department=20 procedures. At approximately 1914 hours, the AC radioed dispatch to send = Engine=20 6 to the scene. When Engine 6 was dispatched, the Fire Chief radioed for = Engine=20 6 to relocate to Station 11 and for Engine 19 to come to the scene. At=20 approximately 1919 hours, the Fire Chief radioed for Engine 6 to come to = the=20 scene and to come in the front door. Engine 6 was already enroute = (relocating to=20 the west side) and acknowledged that they were enroute.

Engine 6 arrived on scene at approximately 1921 hours. The E-6 = captain and=20 E-6 fire fighter went to the front door and donned their SCBA masks. = They=20 followed the 1 =BD=94 hose line into the building. The E-6 captain = observed light=20 smoke coming out the front door and also at the connection of the main = showroom=20 and the right side addition (exterior wall). Visibility was initially = about 5 to=20 10 feet but visibility was reduced as they advanced into the showroom = interior.=20 There was little heat and the E-6 captain and fire fighter were able to = walk=20 into the showroom standing upright as they followed the hose line to the = rear of=20 the main showroom then into the right side addition. The E-6 engineer = entered=20 the showroom a couple of minutes later after donning his turnout gear, = SCBA, and=20 grabbing a pike pole from E-6. He reported the smoke at the front of the = showroom was intensifying and beginning to bank down. He followed the 1 = =BD=94 hose=20 line to the rear of the main showroom. A booster line reached only to = the right=20 rear side of the main showroom. He could hear other fire fighters = talking in the=20 direction the 1 =BD=94 hose line was running (into the right addition) = and began=20 opening up sheetrock walls and pushing up ceiling tiles to look for fire = extension.

The E-6 captain and fire fighter met other crews near the double = doors to the=20 loading dock. The other fire fighters stated they were going to get = another hose=20 line so the E-6 captain worked the nozzle of the 1 =BD=94 hand line for=20 approximately 5-6 minutes while the E-6 fire fighter attempted to pull = slack in=20 the line so they could advance closer to the fire in the loading dock = area. The=20 water pressure on the 1=BD=94 hose line fluctuated and at one point = water pressure=20 dropped to near zero. The E-6 captain attempted to radio outside to ask = what=20 happened to the water pressure but the on-off button on his radio had = broken off=20 during his entry so he couldn=92t turn on his radio. The E-6 crew = noticed that the=20 interior conditions suddenly deteriorated very rapidly with visibility=20 decreasing and in less than 30 seconds, the heat became unbearable.

As the E-6 engineer was opening the walls and ceiling at the rear of = the main=20 showroom, three or four unidentified fire fighters approached him and=20 frantically stated that they were running out of air and couldn=92t find = the way=20 outside. The E-6 engineer heard their low-air alarms sounding as they = bumped=20 into him then pulled away from him and disappeared into the smoke. This = happened=20 in a matter of seconds. During the short contact with the other fire = fighters,=20 the E-6 engineer was turned around several times and became separated = from the=20 hoseline. He moved in short circles until he found the hose line and = began=20 following it. Almost immediately, the E-6 engineer encountered another = fire=20 fighter (later identified as the E-15 fire fighter # 1) who also stated = he was=20 out of air and couldn=92t find his way outside. The E-6 engineer led the = E-15 fire=20 fighter along the hose line (at one point having to reverse directions) = until=20 they got within a few feet of the front door. They could hear the sound = of=20 Engine 11 running outside and the E-15 fire fighter ran outside, = followed by the=20 E-6 engineer. After checking on the condition of the E-15 fire fighter, = the E-6=20 engineer re-entered the main showroom.

As the E-6 fire fighter was pulling slack in the 1 =BD=94 hose line, = another fire=20 fighter, searching for the way out, ran into him and momentarily knocked = him off=20 the hose line. As the E-6 fire fighter regained the hose and stood up, = water=20 pressure in the hose was lost. At this point, the heat began to = intensify and=20 the E-6 fire fighter decided it was time to retreat. At the same time, = he began=20 hearing radio traffic of the Mayday followed by attempts by the Fire = Chief and=20 the dispatcher to identify who was calling Mayday and who had activated = their=20 emergency button.

As the heat rapidly intensified, the E-6 captain began following the = hoseline=20 outside. His low air alarm started to sound and he burned his hands = feeling for=20 the hose line. His facepiece began to pull down onto his face as he = exhausted=20 his remaining air supply. He encountered the E-6 fire fighter who told = the E-6=20 captain he had the hose line and they began moving toward the front of = the=20 building. By this time, the E-6 captain was almost completely out of air = and he=20 bolted toward the front of the building. The E-6 engineer was following = the=20 hoseline back into the showroom looking for his crew and encountered the = E-6=20 captain who was now out of air and becoming disoriented. The engineer = grabbed=20 his captain and guided him toward the front door until they could hear = the sound=20 of Engine 11 running outside. They made their way outside followed = seconds later=20 by the E-6 fire fighter and the E-15 fire fighter # 1. The front = showroom=20 windows were just being knocked out when the E-6 crew exited the = showroom (see = Photo=20 4).

Engine 9

The Engine 9 (E-9) crew, consisting of a captain, engineer, and fire = fighter=20 were in quarters at Station 9 when they heard the fire dispatch. The = crew=20 monitored the fireground radio traffic and knew that a serious situation = was=20 developing. They heard the Fire Chief calling for additional resources = and=20 Engine 9 was dispatched to relocate to Station 10 and arrived at 1946 = hours. At=20 1951 hours, E-9 was directed to drive past the incident site and stretch = a 2 =BD=94=20 supply line from the hydrant west of the site back to the site to Engine = 13 to=20 supply Ladder 4 before it arrived. After stretching the supply line, the = E-9=20 crew worked on the D-side of the structure supporting fire suppression=20 activities.

Engine 13

The Engine 13 (E-13) crew consisting of a captain, engineer, and fire = fighter=20 were in quarters when they heard the fire dispatch. E-13 was dispatched = to the=20 scene at approximately 1937 hours and arrived on-scene at 1942 hours. = The E-13=20 crew worked to help establish water supply to Ladder 5 by stretching a 2 = =BD=94=20 supply line from E-12 to L-5. The E-13 crew then assisted with fire = suppression=20 activities.

Engine 3

The Engine 3 (E-3) crew consisting of a captain, engineer and fire = fighter=20 was out of service at a special event several miles outside of the city = when=20 they heard radio traffic about the fire. When they heard the incident = was a=20 confirmed structure fire, they began moving back to the city. At = approximately=20 1924 hours, E-3 was directed to relocate to cover Station 16/19. At=20 approximately 1931 hours, the Fire Chief called dispatch and requested = the next=20 closest engine company. E-3 was still enroute to Station 16/19 so the = Fire Chief=20 requested that E-3 come to the scene and lay a supply line to Ladder 5. = At=20 approximately the same time, L-5 was repositioned from in front of the = structure=20 to the D-side by off-duty fire fighters who had arrived at the scene. =

E-3 arrived on-scene at 1940 hours. The E-3 suction man (fire = fighter) took=20 their 5=94 adaptor to connect to the hydrant, but E-19 (driven by the = acting=20 captain of E-11) arrived at the hydrant first. E-3 stretched a 2 1/2=94 = supply=20 line from E-19 (the next hydrant west of the structure) to L-5 and water = supply=20 was established at 1944 hours. After establishing water supply, the E-3 = engineer=20 stayed at the engine and the rest of the E-3 crew worked on the D-side = of the=20 structure operating a 2 =BD=94 hand line. Fire fighters cut holes into = the sheet=20 metal siding and at one point, the E-3 fire fighter and an off-duty fire = fighter=20 attempted to advance a hoseline inside the showroom by crawling under = the metal=20 shelving located along the D-side wall. They were only able to advance 5 = or 6=20 feet and had to withdraw because of the intense fire and heat inside the = burning=20 showroom.

Ladder 4

The Ladder 4 crew consisting of an acting captain, engineer, and fire = fighter=20 were in-quarters at the time of the initial dispatch. The crew monitored = the=20 radio traffic and knew things were escalating. The Fire Chief radioed = dispatch=20 at approximately 1948 hours and requested that Ladder 4 be dispatched to = the=20 scene. At approximately 1952 hours, the Fire Chief radioed dispatch and=20 requested Engine 9 be sent from Station 10 to lay supply line for L-4. =

Ladder 4 was on scene at approximately 1956 hours and BC-4 directed = the crew=20 on where to position in the front parking lot. Portions of the showroom = roof had=20 already collapsed when L-4 got set up. Engine 19 began supplying water = to L-4 at=20 approximately 2002 hours through one 2 =BD=94 supply line. At = approximately 2006=20 hours, L-4 radioed the Fire Chief and requested another supply line be = set up to=20 L-4 so that both nozzles on the bucket could be put into operation. The = mutual=20 aid department laid a 4=94 supply hose to L-4. L-4 initially operated = with 300 gpm=20 flowing through one nozzle. L-4 operated at 750 gpm when the second = supply line=20 was set up.

Mutual Aid

Jurisdictional boundaries separating the municipal fire department = from=20 surrounding fire departments were irregular and often intermingled. As=20 commercial areas were annexed into the city, jurisdictional boundaries = often=20 split blocks. For example, the furniture store involved in this incident = was=20 within the city=92s jurisdiction. Residential structures directly behind = the=20 furniture store property that were within the same block were in the=20 jurisdiction of a mutual aid fire department that operates as a public = service=20 district (PSD). This mutual aid fire department had 60 fire fighters = operating=20 from 4 stations and served a population of approximately 24,000 in an = area of=20 approximately 30 square miles. Note: This fire department operated = its own=20 dispatch system. This fire department routinely used positive = pressure fans=20 for ventilation purposes and routinely deployed thermal imaging cameras = at=20 structure fires.

Two crews from the mutual aid department were in close vicinity to = the=20 incident scene for a special event and noticed heavy smoke. The acting = battalion=20 chief (BC) for the mutual aid department (who was at the special event = with the=20 crews) radioed his dispatch and said the mutual aid crews were going to = the=20 scene. The dispatcher reported that the municipal fire department was = already on=20 scene. The acting battalion chief (BC), Engine 2 (E-2) with a crew = consisting of=20 an acting captain and an engineer / fire fighter, and Rescue 1 (R1) with = a crew=20 of an engineer and a fire fighter, proceeded to the scene and arrived at = approximately 1924 hours. The BC radioed dispatch that they were = on-scene and=20 also requested that Engine 1 (E-1) be dispatched.

The BC immediately went to the D-side of the furniture showroom and = talked=20 with the city Fire Chief. The BC informed the Fire Chief he had two = crews on=20 scene and another crew on the way. The BC also offered the use of their = thermal=20 imaging camera and their large diameter (4=94) supply hose (LDH). = According to the=20 acting battalion chief, the city Fire Chief initially told him that the = mutual=20 aid department=92s assistance would not be needed. The BC asked the Fire = Chief if=20 he wanted the mutual aid department to cover the rear of the warehouse = and the=20 Fire Chief said =93yes.=94

At approximately 1925 hours, the BC directed E-1 to drive down the = street at=20 the rear of the warehouse and set up operations there. The BC also = radioed=20 dispatch to send Truck 1 (T-1). E-1 arrived on scene at approximately = 1926 hours=20 with a captain, engineer, and two fire fighters. E-1 connected to a = hydrant=20 located just east of the warehouse. The E-1 captain and fire fighters = advanced a=20 1 =BE=94 preconnected hand line inside the warehouse through a door = located on the=20 B-side at the rear near the B-C corner at approximately 1930 hours.

Engine 2 (E-2) and Rescue 1 (R-1) parked in the middle of the highway = in=20 front of the main showroom. The two crews (two fire fighters on each = apparatus)=20 donned their turnout gear and proceeded to the D-side of the showroom to = join up=20 with their BC when a city police officer stopped them and said a male = employee=20 was trapped in the rear of the structure and had telephoned 911 for = assistance.=20 They proceeded to the front of the showroom and were directed by the = city AC and=20 BC-5 to assist them in rescuing the trapped employee. They radioed their = dispatch at approximately 1928 hours that the city fire department = wanted them=20 to assist in rescuing the employee, then proceeded around the B-side of = the=20 showroom to the rear after knocking a lock off a wooden gate at the B-C = corner=20 to gain access (see = Diagram=20 3).

The fire fighters located the area where the employee was banging on = the=20 exterior wall. The fire fighters used a Haligan bar and axes to cut = through the=20 metal siding and opened a hole large enough for the employee to crawl = through.=20 The mutual aid department=92s dispatch was notified at approximately = 1931 hours=20 that the employee had been rescued. The fire fighters assisted the = employee to=20 the front parking lot to receive medical attention. Note: The = Assistant=20 Chief of the municipal fire department radioed for an ambulance after = the=20 employee was extricated. Dispatch reported an ambulance was already in = route.=20

The fire fighters returned to the front entrance and observed heavy = black=20 smoke filling the showroom and pushing out the door, but no visible = fire. They=20 observed city fire fighters yelling about fire fighters missing inside = the=20 structure. They reported hearing orders for the front showroom windows = to be=20 knocked out to improve visibility inside the showroom. The E-2 acting = captain=20 and R-1 engineer knocked out the windows to the right of the doorway = while the=20 city BC-5 knocked out the windows to the left of the doorway. The fire = fighters=20 noted that air rushed inside the showroom after the windows were knocked = out.=20 The E-2 acting captain cut his hand (requiring time off) while knocking = out the=20 windows. The E-6 and E-15 fire fighters (from the city department) = exited the=20 building at approximately 1935 hours while the windows were being = knocked out.=20 Some of the city fire fighters were completely out of air. At = approximately 1936=20 hours, the Fire Chief instructed the mutual aid fire fighters to go = inside and=20 search for the missing city fire fighters. Two city fire fighters (an = off-duty=20 battalion chief and the E-6 engineer) also entered the showroom. The R-1 = engineer and the E-2 fire fighter teamed up and followed the hoselines = inside=20 the front door a short distance. They encountered two fire fighters who = were in=20 distress. One was down on his hands and knees screaming for help and = also=20 attempting to drag the other fire fighter. The R-1 engineer attempted to = assist=20 the fire fighters while the E-2 fire fighter guided them back to the = hose line.=20 The showroom erupted in flames and the heat knocked the fire fighters to = the=20 floor, causing them to become separated. Both rescue teams were forced = to=20 evacuate. The E-2 fire fighter found the door first and assisted the R-1 = engineer outside at approximately 1938 hours. They both reported hearing = PASS=20 devices going off inside the structure. The R-1 engineer received second = degree=20 burns to his face, hands, and arm.

The R-1 engineer reported that other fire fighters were just inside = the door=20 so another rescue attempt was made. An off-duty captain from the mutual = aid=20 department, along with city fire fighters, attempted to advance a 2 = =BD=94 hose line=20 back inside the door, but their progress was quickly halted by the = intense heat=20 and fire and they were forced to retreat. At 1938 hours, the city Fire = Chief=20 radioed for everyone to stay outside and to abandon the building. One = last=20 attempt to enter the front entrance (by the off-duty battalion chief and = the E-6=20 engineer) was stopped at the doorway by the intense fire and heat.

At approximately 1935 hours, the mutual aid BC requested that Engine = 7 (E-7)=20 be dispatched and come to the rear (C-side) of the warehouse with E-1. = At=20 approximately 1943 hours, the mutual aid BC requested Engine 4 (E-4) = come to the=20 scene. The BC directed E-4 to go the rear of the warehouse and set the = deck gun.=20 At approximately 1948 hours, the BC requested Truck 1 (T-1) to come to = the=20 scene.

The mutual aid BC radioed E-4 to hold up at the highway to let T-1 = come down=20 the back street first. T-1 arrived on scene at approximately 1950 hours = and was=20 set up at the rear of the warehouse to direct a master stream of water = down onto=20 the roof of the warehouse. At approximately 1952 hours, E-4 radioed the = BC that=20 the city fire department wanted E-4 to set up water supply to the city = fire=20 department=92s Ladder 4 (L-4) in the parking lot at the front of the = main=20 showroom. At approximately 2000 hours, the E-4 acting captain announced = E-4 was=20 pumping water to the city=92s L-4.

Water Supply

Water supply was a critical factor in the sequence of events leading = up to=20 the nine fatalities. Engine 10 should have been the second due engine = and=20 established the water supply to Engine 11. However, E-10 arrived first = at 1911=20 hours and was directed to back down the alley to the loading dock on the = D-side=20 of the structure since that was where visible fire was located. Engine = 11=20 positioned in front of the main showroom and the E-11 acting captain = went inside=20 the showroom while the E-11 fire fighter looked for a hydrant so E-11 = could=20 supply water to E-10. Engine 11 re-positioned closer to the main = entrance when=20 L-5 arrived in front of the showroom. Pre-plan information indicated the = closest=20 hydrant was located on the street behind the warehouse but this = information was=20 not utilized.

Engine 12 was dispatched at 1912 hours and directed to lay a single 2 = =BD=94=20 supply line to Engine 10. Engine 16 was already enroute as the third-due = engine.=20 Engine 16 arrived on scene at 1915 hours and Engine 12 arrived on scene = at 1917=20 hours. Engine 12 stretched approximately 750 feet of 2 =BD=94 supply = line and had=20 water supply established to E-10 at approximately 1920 hours. Engine 16=20 stretched approximately 1,850 feet of supply line and had water supply=20 established to E-11 at approximately 1926 hours.

Both E-10 and E-11 put 1 =BD=94 pre-connected hand lines into = operation using=20 tank water while waiting for supply lines to be established. The E-11 = engineer=20 reported experiencing problems with water pressure after water supply = was=20 established. The E-12 and E-16 engineers both radioed that vehicle = traffic=20 running over the supply lines were causing problems. Pressure had to be = boosted=20 by both E-12 and E-16 well above the 200 psi working limit of the supply = hoses=20 being used in order to accommodate for the friction losses and low water = volume.=20

Adequate water supply for the size of the structure and fuel loads = inside was=20 never established and hose lines capable of attacking the fire with = adequate=20 fire streams were not deployed. Ladder 5 was not put into master stream=20 operation until after the fire had escalated. Additional supply lines = for Engine=20 11, Ladder 5 and Ladder 4 were laid after the fire had escalated.

E19 / E3 laid a second 2 =BD=94 supply line to L-5 at approximately = 1944 hours.=20 BC-5 directed the acting captain on E-11 to drive E-15 west to the next = hydrant=20 to lay another supply line back to E-11. Then BC-5 told him to take E-19 = instead. Engine 3 arrived on scene just as E-19 was positioning to the=20 hydrant.

A small mutual aid department (mutual aid # 2) supplied L-5 with tank = water=20 at approximately 1940 hours until a supply line was established at = approximately=20 1944 hours. A second supply line from E-12 to L-5 was also put into = service=20 after 2000 hours.

Ladder 4 was put into operation at approximately 2001 hours with a 2 = =BD=94=20 supply line laid by E-9. The first responding mutual aid department = (mutual aid=20 # 1) stretched a 4=94 supply line to L-4 at approximately 2005 hours so = that both=20 fire nozzles could be put into operation.

The mutual aid departments utilized 4=94 supply lines. After the = larger=20 diameter supply lines were put into service, the water pressure issues = with L-4=20 and L-5 improved.

ADDITIONAL PHOTOS

Additional photos pertaining to the incident are available in Appen= dix=20 V.

CAUSE OF DEATH

According to the county coroner=92s report, the cause of death for = all nine=20 victims was carbon monoxide toxicity, smoke inhalation and thermal = injury due to=20 fire. Diagram= =20 4 shows the approximate location where each of the nine victims was = located=20 inside the structure per the city.

RECOMMENDATIONS

Recommendation # 1: Fire departments should develop, implement and = enforce=20 written standard operating procedures (SOPs) for an occupational safety = and=20 health program in accordance with NFPA 1500.

Discussion: The risk for fatal injury among fire fighters is high = compared to=20 other occupations.¹¹=20 There is an increasing body of scientific literature demonstrating that=20 organizational practices that demonstrate top level management = commitment to=20 safety, establish and foster compliance with safety policies and = practices, and=20 involve workers in identifying safety hazards and promoting solutions = are=20 effective in reducing worker injuries.^12-1=
7=20 Many of these concepts are embodied in NFPA 1500, Standard for a = Fire=20 Department Occupational Safety and Health Program.¹⁸=20 Implementation of a strong fire department occupational safety and = health=20 program following written procedures and policies such as those outlined = by=20 NFPA 1500 can foster and improve the overall safety climate of = a fire=20 department, as well as improve specific safety and health areas, such as = respiratory protection, risk management, training and competency in = fireground=20 operations, tactics, and equipment and apparatus use.

During this investigation, NIOSH investigators reviewed some written=20 departmental SOPs. While these documents contained some individual SOPs, = they=20 mainly contained administrative guidelines and did not contain detailed=20 fireground operation procedures that would enhance fire fighter safety = and=20 health, such as a risk management plan, a fire department occupational = safety=20 and health policy, and other components of a fire department = occupational safety=20 and health program as outlined in NFPA 1500.¹⁸=20

It is important to understand the difference between a=20 policy and a procedure. A department policy is = a guide=20 to decision-making that originates with or is approved by top management = in a=20 fire department. Policies define the boundaries within which the = administration=20 expects department personnel to act in specified situations. A procedure = is a=20 written communication closely related to a policy. A=20 procedure describes in writing the steps to be = followed in carrying out organizational policies. SOPs are standard = methods or=20 rules in which an organization or a fire department operates to carry = out a=20 routine function. Usually these procedures are written in a policies and = procedures handbook and all fire fighters should be well versed as to = their=20 content.¹⁹=20 Operational procedures that are standardized, clearly written, and = mandated to=20 each department member establish accountability and increase command and = control=20 effectiveness.¹⁹=20 The benefits of having clear, concise, and practiced SOPs are numerous. = For=20 example, they can become a training outline and a tool to guide fire = department=20 members. Above all, a well applied SOP improves departmental safety. = ²⁰

Recommendation #2: Fire departments should develop, implement = and=20 enforce a written Incident Management System to be followed at all = emergency=20 incident operations.

Discussion: National Fire Protection Association (NFPA) 1500 = Standard on=20 Fire Department Occupational Safety and Health Program, 2007=20 Edition,¹⁸=20 and NFPA 1561 Standard on Emergency Services Incident Management=20 System, 2008 Edition,²¹=20 both state that an Incident Management System (IMS) should be utilized = at all=20 emergency incidents (including but not limited to training exercises). = The U.S.=20 Department of Labor, Occupational Safety and Health Administration has = issued a=20 guidance document intended to be used by agencies to prepare emergency = response=20 plans. The intent of the National Response Team (NRT) guidance is to = provide a=20 mechanism for consolidating multiple agencies=92 plans into one = functional=20 emergency response plan or integrated contingency plan (ICP). ²²=20

NFPA 1561, Chapter 3.3.29 defines the Incident Management System = (also known=20 as the Incident Command System (or ICS) as =93A system that defines the = roles and=20 responsibilities to be assumed by responders and the standard operating=20 procedures to be used in the management and direction of emergency = incidents and=20 other functions.²¹=20 Chapter 4.1 states =93The incident management system shall provide = structure and=20 coordination to the management of emergency incident operations to = provide for=20 the safety and health of emergency services organization (ESO) = responders and=20 other persons involved in those activities.=94 Chapter 4.2 states =93The = incident=20 management system shall integrate risk management into the regular = functions of=20 incident command.=94 Each fire department or emergency services = organization (ESO)=20 should adopt an incident management system to manage all emergency = incidents.=20 The IMS should be defined and in writing and include standard operating=20 procedure (SOPs) covering the implementation of the IMS. The IMS should = include=20 written plans that address the requirements of different types of = incidents that=20 can be anticipated in each fire department=92s or ESO=92s jurisdiction. = The IMS=20 should address both routine and unusual incidents of differing types, = sizes and=20 complexities. The IMS covers more than just fireground operations. The = IMS must=20 cover incident command, accountability, risk management, communications, = rapid=20 intervention crews (RIC), roles and responsibilities of the Incident = Safety=20 Officer (ISO), and inter-operability with multiple agencies (police, = emergency=20 medical services, state and federal government, etc.) and surrounding=20 jurisdictions (mutual aid responders).

NIOSH investigators identified several examples in this incident in = which=20 recognized guidelines for IMS were not followed. Specific examples = include=20 multiple chief officers serving in command roles in an uncoordinated = manner,=20 lack of an established accountability system to track fire fighters on = scene, a=20 RIC was not established, an ISO was not assigned, and the fire = department and=20 police department did not work effectively together to control traffic = and=20 protect hoselines delivering water to the scene.

Recommendation # 3: Fire departments should develop, implement = and=20 enforce written SOPs that identify incident management training = standards and=20 requirements for members expected to serve in command roles.

Discussion: NFPA 1561, Chapter 4.8.3 states =93Responders who are = expected to=20 perform as incident commanders or to be assigned to supervisory levels = within=20 the command structure shall be trained in and familiar with the incident = management system and the particular levels at which they are expected = to=20 perform.=94 ²¹=20 NFPA 1001,⁶⁼1021,²³=20 1500¹⁸=20 and 1521²⁴=20 are just a few examples of recognized standards addressing fire fighter = and=20 officer qualifications.

One of the fire officer=92s primary responsibilities is safety both = on the=20 fireground and during normal operations. A partial list of officer=20 qualifications (knowledge, skills, and abilities) necessary to = accomplish the=20 primary responsibility of fireground safety identified in these = standards=20 include: fire behavior; building construction; conducting pre-incident = planning;=20 development applicable codes, ordinances, and standards; identification = of fire=20 and life safety hazards; supervising emergency operations; and, = deploying=20 assigned resources in accordance with the local emergency plan. Training = records=20 for the chief officers who initially responded to this incident were = provided to=20 NIOSH by the city=92s Safety Management Division. These records = consisted mainly=20 of NIMS certifications with little additional records to document = specific=20 training related to fire fighter and fire officer qualifications. =

Recommendation #4: Fire departments should ensure that the Incident=20 Commander is clearly identified as the only individual with overall = authority=20 and responsibility for management of all activities at an incident.

Discussion: NFPA 1561, Chapter 5 identifies the responsibilities and = overall=20 duties of the Incident Commander (IC).²¹=20 Chapter A.3.3.28 states =93The IC has overall authority and = responsibility for=20 conducting incident operations and for managing all incident operations = at the=20 incident site.=94 There should be one, clearly identifiable Incident = Commander for=20 the duration of the incident, from the arrival of the first fire = department unit=20 until the incident is terminated. The Incident Commander must clearly be = in=20 charge of all fireground operations to ensure successful completion. If = there is=20 no established or single Incident Commander, fireground operations and = incident=20 conditions can break down.

Some of the key responsibilities of the Incident Commander, as = detailed in=20 NFPA 1561, Chapter 5.3, which are relevant to this incident include:

Overall authority for the management of the = incident=20 (Chapter 5.3.1)=20
Ensuring adequate safety measures are in place = (Chapter=20 5.3.2)=20
Establishing a stationary command post = (Chapter 5.3.7.1)=20
Continually conducting a thorough evaluation = of the=20 situation (Chapter 5.3.8)=20
Maintaining an awareness of the location and = function of=20 all companies or units at the scene (Chapter 5.3.10)=20
Overall responder accountability for each = incident=20 (Chapter 5.3.11)=20
Initiating an accountability / inventory = worksheet at=20 the beginning of operations and maintaining that system throughout = operations=20 (Chapter 5.3.12)=20
Evaluating the risk to responders with respect = to the=20 purpose and potential results of their actions in each situation = (Chapter=20 5.3.17)=20
Utilizing risk management principles (Chapter = 5.3.19)=20
- Activities presenting significant risk to the = safety of=20 responders should be limited to situations having the potential to = save=20 endangered lives.=20
- Activities employed to protect property should be = recognized=20 as inherent risks to the safety of the responders and actions should = be=20 taken to reduce or avoid these risks.=20
- No risk to the safety of responders should be = acceptable=20 where there is no possibility to save lives or property.
Developing the command organization for the = incident=20 (Chapter 5.3.20)=20
Assigning intermediate levels of supervision = and=20 organizing resources following SOPs based on the scale and complexity = of=20 operations (Chapter 5.10.1.2)=20
All supervisory personnel assigned to = operations=20 functions shall support an overall strategic plan, as directed by the = Incident=20 Commander, and shall work toward the accomplishment of tactical = objectives=20 (Chapter 5.10.1.3)

Chief Officers at the scene of an incident who are not officially a = part of=20 the command structure should refrain from giving tactical directions. = One of the=20 clear tenets of the Incident Command System is =93unity of command.=94 = By directing=20 units outside of a role in the IMS, chief officers, by virtue of their = rank, can=20 create uncoordinated efforts outside the IMS which may not benefit the=20 operational strategy and can actually have negative impacts upon the = operational=20 strategy. The resources that are taken from the operational structure to = achieve=20 the goals of the chief officers operating outside the IMS are lost to = the=20 tactical level operations or management elements that count on these = resources=20 to achieve their tactical objectives. During this incident, formal = incident=20 command was never formally announced or transferred as ranking officers = arrived=20 on scene. Fire attack operations at the loading dock (D-side) and the = main=20 showroom (A-side) were directed by different chief officers and were not = coordinated.

Recommendation #5: Fire departments should ensure that the Incident=20 Commander conducts an initial size-up and risk assessment of the = incident scene=20 before beginning interior fire fighting operations.

Discussion: Among the most important duties of the first officer on = the scene=20 is conducting an initial size-up of the incident. This information lays = the=20 foundation for the entire operation. It determines the number of fire = fighters=20 and the amount of apparatus and equipment needed to control the blaze, = assists=20 in determining the most effective point of fire extinguishment attack, = the most=20 effective method of venting heat and smoke, and whether the attack = should be=20 offensive or defensive. A proper size-up begins from the moment the = alarm is=20 received and it continues until the fire is under control. The size-up = should=20 also include assessments of risk versus gain during incident operations. = ¹⁹^,=20^25-2=
9=20 Retired Chief Alan Brunacini recommends that the arriving IC drive = partially or=20 completely around the structure whenever possible to get a complete view = of the=20 structure. While this may delay the IC=92s arrival by a few seconds, = this drive-by=20 may provide significant details not visible from the command = post.²⁷=20 The size-up should include an evaluation of factors such as the fire = size and=20 location, length of time the fire has been burning, conditions on = arrival,=20 occupancy, fuel load and presence of combustible or hazardous materials, = exposures, time of day, and weather conditions. Information on the = structure=20 itself including size, construction type, age, condition (evidence of=20 deterioration, weathering, etc), evidence of renovations, lightweight=20 construction, loads on roof and walls (air conditioning units, = ventilation=20 ductwork, utility entrances, etc.), and available pre-plan information = are all=20 key information which can effect whether an offensive or defensive = strategy is=20 employed. The size-up and risk assessment should continue throughout the = incident.

Fires in commercial structures are typically more dangerous than = residential=20 building fires. Retired Assistant Chief Vince Dunn states that defensive = operations should be used more often at special occupancy and commercial = buildings. Chief Dunn cites statistics that 4 fire fighters die for = every=20 100,000 residential fires compared to 9 fire fighter deaths for every = 100,000=20 commercial structure fires.³⁰=20

Interior size-up is just as important as exterior size-up. Since the = IC is=20 staged at the command post (outside), the interior conditions should be=20 communicated to the IC as soon as possible. Interior conditions could = change the=20 IC=92s strategy or tactics. For example, if heavy smoke is emitting from = the=20 exterior roof system, but fire fighters cannot find any fire in the = interior, it=20 is a good possibility that the fire is above them in the roof system. = Other=20 warning signs that should be relayed to the IC include dense black = smoke,=20 turbulent smoke, smoke puffing around doorframes, discolored glass, and = a=20 reverse flow of smoke back inside the building. It is important for the = IC to=20 immediately obtain this type of information to help make the proper = decisions.=20 Departments should ensure that the first officer or fire fighter inside = the=20 structure evaluates interior conditions and reports them immediately to = the IC.=20

In this incident, arriving officers concentrated on the A and D-sides = of the=20 structure. A complete 360 degree size-up was never conducted. Pre-plan=20 information did not identify the potential hazards associated with the=20 lightweight metal roof trusses, and the excessive fuel loads associated = with the=20 contents. Only one hydrant location was noted on the pre-plan form but = it was=20 not used. Smoke emitting from the connection between the original = structure and=20 the right-side addition, the deteriorating conditions in the main = showroom, a=20 rapid decrease in visibility coupled with a rapid rise in temperature, = heavy=20 smoke stains on windows, no visible fire in the showroom with a build-up = of=20 smoke and heat, and delays in establishing water supply, were all = indicators=20 that could have prompted consideration of switching from offensive to = defensive=20 strategies.

Recommendation #6: Fire departments should train fire fighters to=20 communicate interior conditions to the Incident Commander as soon as = possible=20 and to provide regular updates.

Discussion: Proper size-up and risk versus gain analysis requires = that the=20 Incident Commander have a number of key pieces of information and keep = informed=20 of the constantly changing conditions on the fireground. New decisions = must be=20 made and old ones revised based upon increased data and improved = information.=20 Decisions can be no better than the information on which they are based. = The=20 Incident Commander must use an evaluation system that considers and = accounts for=20 changing fireground conditions in order to stay ahead of the fire. If = this is=20 not done, the attack plan will be out of sequence with the phase of the = fire and=20 the IC will be constantly surprised by changing conditions.²⁷^,=20²⁹^,=20³¹=20 Interior size-up is just as important as exterior size-up. Since the IC = is=20 staged at the command post (outside), the interior conditions should be=20 communicated by interior crews as soon as possible to the IC. Interior=20 conditions could change the IC=92s strategy or tactics. Interior crews = can aid the=20 IC in this process by providing reports of the interior conditions as = soon as=20 they enter the fire building and by providing regular updates. According = to=20 Chief Dunn, one such example would be whenever a suspended ceiling is = discovered=20 in a commercial structure, this information should be immediately = communicated=20 to the IC.³¹=20

Based on a review of the training curriculum and available fire = department=20 SOPs, fire fighters and officers at this department were not trained to=20 communicate interior conditions to the outside. During the initial = attack, the=20 interior conditions in the front show room (lack of fire) did not match = the=20 exterior conditions on the D-side (loading dock area fully involved and = also the=20 amount of smoke overhead). During NIOSH interviews, fire fighters and = officers=20 who had operated inside the structure reported signs of deteriorating = conditions=20 to the NIOSH investigators. However, no interior condition reports were=20 broadcast over the radio (to the chief officers or other fire fighters) = during=20 this incident. Verbal exchanges between the attack crews and chief = officers took=20 place but this information did not impact the tactics being used. = Information=20 concerning the interior conditions could have been used to consider = changing=20 from a fast attack mode to a more cautious defensive operation.

Recommendation #7: Fire departments should ensure that the Incident=20 Commander establishes a stationary command post, maintains the role of = director=20 of fireground operations, and does not become involved in fire-fighting = efforts.=20

Discussion: According to NFPA 1561, =A75.3.1, =93The incident = commander shall=20 have overall authority for management of the incident.=94 ²¹=20 In addition to conducting an initial size-up, the Incident Commander = must=20 establish and maintain a command post outside of the structure to assign = companies and delegate functions, and continually evaluate the risk = versus gain=20 of continued fire fighting efforts. In establishing a command post, the = Incident=20 Commander shall ensure the following (NFPA 1561, =A75.3.7.2):

The command post is located in or tied to a vehicle to establish = presence=20 and visibility.=20
The command post includes radio capability to monitor and = communicate with=20 assigned tactical, command, and designated emergency traffic channels = for that=20 incident.=20
The location of the command post is communicated to the = communications=20 center.=20
The incident commander, or his or her designee, is present at the = command=20 post.=20
The command post should be located in the incident cold zone. =

The use of a tactical worksheet can assist the IC in keeping track of = various=20 task assignments on the fireground. It can be used along with pre-plan=20 information and other relevant data to integrate information management, = fire=20 evaluation and decision making. The tactical worksheet should record = unit=20 status, benchmark times, and include a diagram of the fireground, = occupancy=20 information, activities checklist(s), and other relevant information. = This can=20 also aid the Incident Commander in continually conducting a situation = evaluation=20 and maintaining accountability. ²⁷=20 To effectively coordinate and direct fire fighting operations on the = scene, it=20 is essential that the IC does not become involved in fire fighting = efforts. A=20 delay in establishing an effective command post may result in confusion = of=20 assignments and lack of personnel and apparatus coordination which may=20 contribute to rapid fire progression. The involvement of the initial IC = in fire=20 fighting also hampers the collection and communication of essential = information=20 as command is transferred to later arriving officers. In this incident, = a=20 stationary command post was never established and separate and = uncoordinated=20 activities were taking place in multiple locations. This contributed to = a=20 failure to size-up the overall incident scene, to properly evaluate risk = versus=20 gain, and to maintain accountability on the fireground.

Recommendation #8: Fire departments should ensure the early = implementation=20 of division and group command into the Incident Command System.

Discussion: The early establishment of divisions and groups allows = the=20 command structure of an incident to grow more effectively than simply = deploying=20 resources and assigning division or group supervisors after units are in = place.=20 Delegating division / group command to other officers makes the = management of a=20 large incident more feasible by relieving the Incident Commander of = these=20 responsibilities which allows the IC to focus on the bigger picture = while still=20 maintaining the ability to react to progress reports and other = information=20 provided by the division / group commanders. The Model Procedures Guide = for=20 Structural Firefighting describes the application of the National Fire = Service=20 Incident Management System (NIMS) to structure fire incidents. These = procedures=20 recommend the establishment of division and group command.³²=20 In this incident, a strategy of coordinated division and group command = was not=20 employed.

Recommendation #9: Fire departments should ensure that the Incident=20 Commander continuously evaluates the risk versus gain when determining = whether=20 the fire suppression operation will be offensive or defensive.

Discussion: The initial size-up conducted by the first arriving = officer=20 allows the officer to make an assessment of the conditions and to assist = in=20 planning the suppression strategy. The following general factors are = important=20 considerations during a size-up: occupancy type involved, potential for=20 civilians in the structure, smoke and fire conditions, type of = construction, age=20 of structure, exposures, and time considerations such as the time of the = incident, length of time fire was burning before arrival, and time fire = was=20 burning after arrival.³³^,=20³⁴=20 The Incident Commander must perform a risk analysis to determine what = hazards=20 are present, what the risks to personnel are, how the risks can be = eliminated or=20 reduced, and the benefits to be gained from interior or offensive=20 operations.³⁵=20 The size-up must include continued assessment of risk versus gain during = incident operations. According to NFPA 1500 =A7A-8.3.3, =93The = acceptable level of=20 risk is directly related to the potential to save lives or property. = Where there=20 is no potential to save lives, the risk to the fire department members = must be=20 evaluated in proportion to the ability to save property of value. When = there is=20 no ability to save lives or property, there is no justification to = expose fire=20 department members to any avoidable risk, and defensive fire suppression = operations are the appropriate strategy.=94¹⁸^,=20³⁶=20 Retired New York City Fire Chief Vincent Dunn states =93When no other = person=92s=20 life is in danger, the life of the firefighter has a higher priority = than fire=20 containment.=94²⁵

The first-responding officer, as well as the IC, needs to make a = judgment as=20 to what is at risk =96 people or property. This will help determine the = risk=20 profile for the incident. Many fire fighters stand by the notion that = all=20 incidents are =93people=94 events until proven otherwise. Some fire = fighters are=20 willing to concede that a fire environment has become too hostile to = sustain=20 life and therefore, the only thing left to save is property. = Historically, the=20 fire service has a poor history of changing risk-taking based upon the=20 people/property issue.³⁷

In this incident, the store manager was present to inform the chief = officers=20 on the status of employees and patrons who had been inside the business. = The=20 fire department utilized offensive strategies focused on fire = suppression. Truck=20 company operations (search and rescue, ventilation, etc.) were not = utilized=20 until the fire department received word that an employee was trapped at = the rear=20 of the structure. As conditions inside deteriorated, offensive = strategies were=20 continued even as problems with establishing water supply mounted and = the=20 civilian was rescued.

Recommendation #10: Fire departments should ensure that the Incident = Commander maintains close accountability for all personnel operating on = the=20 fireground

Discussion: Personnel accountability on a fireground means = identifying and=20 tracking all personnel working at the incident. A fire department should = develop=20 its own system and standardize it for all incidents. Accountability on = the=20 fireground can be maintained by several methods: a system using = individual tags=20 assigned to each fire fighter, a riding list provided by the company = officer, a=20 SCBA tag system, or incident command board.¹⁸^,=20¹⁹^,=20²¹=20 Modern radio systems also incorporate a means of tracking the identity = of fire=20 fighters at an incident scene.

As the incident escalates, additional staffing and resources will be = needed,=20 adding to the burden of tracking personnel accountability. An incident = command=20 board should be established at this point with an assigned = accountability=20 officer or aide. The Incident Commander should also utilize the Incident = Management System (IMS). Additionally, fire fighters should not work = beyond the=20 sight or sound of their supervising officer unless equipped with a = portable=20 radio.

In this incident, the only accountability system used was the daily = work=20 roster. Several off-duty fire fighters and mutual aid companies = responded=20 without being dispatched. Not all fire fighters entering the structure = had their=20 designated hand held radio. Fire fighters were known to be trapped = inside the=20 structure, but the number and their identities were not determined until = their=20 bodies were recovered.

Recommendation #11: Fire departments should ensure that a separate = Incident=20 Safety Officer, independent from the Incident Commander, is appointed at = each=20 structure fire.

Discussion: According to NFPA 1561 Standard on Emergency Services = Incident Management System, 2008 Edition, paragraph 5.3, =93The = Incident=20 Commander shall have overall authority for management of the incident = (5.3.1)=20 and the Incident Commander shall ensure that adequate safety measures = are in=20 place (5.3.2).=94 This shall include overall responsibility for the = safety and=20 health of all personnel and for other persons operating within the = incident=20 management system. While the Incident Commander (IC) is in overall = command at=20 the scene, certain functions must be delegated to ensure adequate scene=20 management is accomplished.²¹=20 According to NFPA 1500 Standard on Fire Department Occupational = Safety and=20 Health Program, 2007 Edition, =93as incidents escalate in size and=20 complexity, the Incident Commander shall divide the incident into = tactical-level=20 management units and assign an incident safety officer (ISO) to assess = the=20 incident scene for hazards or potential hazards (8.1.6).=94¹⁸=20 These standards indicate that the IC is in overall command at the scene, = but=20 acknowledge that oversight of all operations is difficult. On-scene fire = fighter=20 health and safety is best preserved by delegating the function of safety = and=20 health oversight to the ISO. Additionally, the IC relies upon fire = fighters and=20 the ISO to relay feedback on fireground conditions in order to make = timely,=20 informed decisions regarding risk versus gain and offensive versus = defensive=20 operations. The safety of all personnel on the fireground is directly = impacted=20 by clear, concise, and timely communications among mutual aid fire = departments,=20 sector command, the ISO, and IC.

Chapter 6 of NFPA 1521, Standard for Fire Department Safety = Officer,=20 defines the role of the ISO at an incident scene and identifies duties = such as:=20 recon of the fireground and reporting pertinent information back to the = Incident=20 Commander; ensuring the department=92s accountability system is in place = and=20 operational; monitoring radio transmissions and identifying barriers to=20 effective communications; and ensuring established safety zones, = collapse zones,=20 hot zones, and other designated hazard areas are communicated to all = members on=20 scene.²⁴=20 Larger fire departments may assign one or more full-time staff officers = as=20 safety officers who respond to working fires. In smaller departments, = every=20 officer should be prepared to function as the ISO when assigned by the = IC. The=20 presence of a safety officer does not diminish the responsibility of = individual=20 fire fighters and fire officers for safety. The ISO adds a higher level = of=20 attention and expertise to help the fire fighters and fire officers. The = ISO=20 must have particular expertise in analyzing safety hazards and must know = the=20 particular uses and limitations of protective equipment.²⁶

A designated safety officer could have assisted at this incident with = continual size-up, accountability, and timely communications regarding = safety on=20 the fireground and the rapidly deteriorating conditions inside the = structure.=20 Note: Since the fatal incident, the fire department has hired a full = time,=20 permanent Safety Officer.

Recommendation #12: Fire departments should ensure that crew = integrity is=20 maintained during fire suppression operations.

Discussion: Fire fighters should always work and remain in teams = whenever=20 they are operating in a hazardous environment.¹⁹=20 Team continuity means team members knowing who is on their team and who = is the=20 team leader; team members staying within visual contact at all times (if = visibility is low, teams must stay within touch or voice distance of = each=20 other); team members communicating needs and observations to the team = leader,=20 and team members rotating together to rehabilitation, staging as a team, = and=20 watching out for each other (practicing a strong buddy system). = Following these=20 basic rules helps prevent serious injury or even death by providing = personnel=20 with the added safety net of fellow team members. Teams that enter a = hazardous=20 environment together should leave together to ensure that team = continuity is=20 maintained.²⁵=20 In this incident, there were numerous instances where fire fighters were = working=20 independently, entering and exiting the structure alone, operating hose = lines,=20 pulling walls and ceiling, and other related activities. Working alone = increases=20 the risk for themselves, and possibly to others during search and rescue = efforts. Federal regulations [the OSHA 2-in-2-out rule, 29 CFR 1910.134=20 (g)(4)(i)] states =93=85at least two employees enter the=20 immediately-dangerous-to-life-or-health (IDLH) atmosphere and remain in = visual=20 or voice contact with one another at all times.=94⁸⁼=20

Recommendation #13: Fire departments should ensure that a rapid = intervention=20 crew (RIC) / rapid intervention team (RIT) is established and available = to=20 immediately respond to emergency rescue incidents.

Discussion: A rapid intervention crew (RIC) or team (RIT) should be=20 designated and available to respond during all fireground operations. = ¹⁸^,=20¹⁹^,=20²¹=20 The rescue crew should report to the Incident Commander (IC) and be = available=20 within the incident=92s staging area. The rescue crew should be = comprised of=20 fresh, well-rested fire fighters, and be positioned and ready to respond = when a=20 fire fighter(s) is down or in trouble.¹⁸=20 NFPA 1500, Chapter 8.8, Rapid Intervention for Rescue of Members, = provides=20 detailed guidelines for the deployment of rescue teams at emergency = incidents.=20 Chapter 8.8.1 states =93The fire department shall provide personnel for = the rescue=20 of members operating at emergency incidents.=94 During the initial = stages of an=20 incident, the rescue crew members may be engaged in support operations = outside=20 the structure. Once the incident expands in size or complexity and the = IC=20 requests additional resources, the rescue crew must be dedicated to = stand-by in=20 case rescue operations are needed.¹⁸=20 The rapid intervention crew or team should have all tools necessary to = complete=20 the job, e.g., search and rescue ropes, Haligan bar and flat-head axe = combo,=20 first-aid kit, resuscitation equipment, extra SCBA cylinders and/or = transfill=20 hoses, etc. RIC or RIT teams should have specialized rescue training to = prepare=20 them for rescue operations. RIC or RIT teams can intervene quickly to = rescue a=20 fire fighter who becomes disoriented, lost in smoke filled environments, = trapped=20 by fire, involved in a structural collapse, or has run out of breathing = air. In=20 this incident a dedicated rescue crew was never employed and no crews = were held=20 outside in standby or rescue mode. Once it was realized that fire = fighters were=20 trapped inside the structure, fire fighters from the first-responding = mutual aid=20 department as well as off-duty city fire fighters who came to the scene = were=20 pressed into service to attempt search and rescue operations at the = front=20 entrance.

Recommendation #14: Fire departments should ensure that adequate = numbers of=20 staff are available to immediately respond to emergency incidents.

Discussion: NFPA 1710 Standard for the Organization and Deployment of = Fire=20 Suppression Operations, Emergency Medical Operations, and Special = Operations to=20 the Public by Career Fire Departments (2004 Edition) contains = recommended=20 guidelines for minimum staffing of career fire departments.³⁸=20 NFPA 1710 =A7 5.2.2 (Staffing) states the following: =93On-duty fire = suppression=20 personnel shall be comprised of the numbers necessary for fire-fighting=20 performance relative to the expected fire-fighting conditions. These = numbers=20 shall be determined through task analyses that take the following = factors into=20 consideration:

Life hazard to the populace protected=20
Provisions of safe and effective fire-fighting performance = conditions for=20 the fire fighters=20
Potential property loss=20
Nature, configuration, hazards, and internal protection of the = properties=20 involved=20
Types of fireground tactics and evolutions employed as standard = procedure,=20 type of apparatus used, and results expected to be obtained at the = fire=20 scene.=94

The NFPA standard states that both engine and truck companies shall = be=20 staffed with a minimum of four on-duty personnel. The standard also = states that=20 in jurisdictions with tactical hazards, high hazard occupancies, high = incident=20 frequencies, geographical restrictions, or other pertinent factors = identified by=20 the authority having jurisdiction, these companies shall be staffed with = a=20 minimum of five or six on-duty members.

NFPA 1710 also states that the fire department=92s fire suppression = resources=20 shall be deployed to provide for the arrival of an engine company within = a=20 4-minute response time and/or the initial full alarm assignment within = an=20 8-minute response time to 90 percent of the incidents as established in = Chapter=20 4. The fire department shall have the capability to deploy an initial = full alarm=20 assignment within an 8-minute response time to 90 percent of the = incidents as=20 established in Chapter 4. The initial full alarm assignment shall = provide for=20 the following (Chapter 5.2.4.2):

Establishment of incident command outside of the hazard area for = the=20 overall coordination and direction of the initial full alarm = assignment. A=20 minimum of one individual shall be dedicated to this task.=20
Establishment of an uninterrupted water supply of a minimum 1520 = L/min=20 (400 gpm) for 30 minutes. Supply line(s) shall be maintained by an = operator=20 who shall ensure uninterrupted water flow application.=20
Establishment of an effective water flow application rate of 1140 = L/min=20 (300 gpm) from two hand lines, each of which shall have a minimum of = 380 L/min=20 (100 gpm). Each attack and backup line shall be operated by a minimum = of two=20 individuals to effectively and safely maintain the line.=20
Provision of one support person for each attack and backup line = deployed=20 to provide hydrant hookup and to assist in line lays, utility control, = and=20 forcible entry.=20
A minimum of one victim search and rescue team shall be part of = the=20 initial full alarm assignment. Each search and rescue team shall = consist of a=20 minimum of two individuals.=20
A minimum of one ventilation team shall be part of the initial = full alarm=20 assignment. Each ventilation team shall consist of a minimum of two=20 individuals.=20
If an aerial device is used in operations, one person shall = function as an=20 aerial operator who shall maintain primary control of the aerial = device at all=20 times.=20
Establishment of an Incident Rapid Intervention Crew (IRIC) that = shall=20 consist of a minimum of two properly equipped and trained individuals. =

The municipal fire department involved in this incident routinely = operated=20 with three fire fighters per apparatus depending on the staffing = available=20 during each shift. During this incident, many of the routine and = necessary=20 fireground operations were not initiated=97e.g., establishment of = Incident Command=20 outside the hazard area overseeing all operations, search and rescue, a = staged=20 rapid intervention crew (RIC), hydrant connection and water supply, and=20 coordinated ventilation. All resources on scene were engaged in = attacking the=20 interior fire. Due to the limited staffing, several fire fighters were = operating=20 alone inside the burning structure instead of pairing up with other fire = fighters.

Recommendation #15: Fire departments should ensure that ventilation = to=20 release heat and smoke is closely coordinated with interior fire = suppression=20 operations.

Discussion: Ventilation is the systematic removal and replacement of = heated=20 air, smoke, and gases from inside a structure with cooler air. The = cooler air=20 facilitates entry by fire fighters and improves life safety for rescue = and other=20 fire fighting operations. Ventilation improves visibility and reduces = the chance=20 of flashover or backdraft.¹⁹=20 The ventilation opening may produce a chimney effect causing air = movement from=20 within a structure toward the opening. This air movement helps = facilitate the=20 venting of smoke, hot gases and products of combustion, but may also = cause the=20 fire to grow in intensity and may endanger fire fighters who are between = the=20 fire and the ventilation opening. For this reason, ventilation should be = closely=20 coordinated with hose line placement and offensive fire suppression = tactics.=20 Close coordination means the hose line is in place and ready to operate = so that=20 when ventilation occurs, the hose line can overcome the increase in = combustion=20 likely to occur. If a ventilation opening is made directly above a fire, = fire=20 spread may be reduced, allowing fire fighters the opportunity to = extinguish the=20 fire. If the opening is made elsewhere, the chimney effect may actually=20 contribute to the spread of the fire.¹⁹^,=20³⁹=20 Proper ventilation during a structure fire will reduce the tendency for = rising=20 heat, smoke, and fire gases, trapped by the roof or ceiling, to = accumulate, bank=20 down, and spread laterally to other areas within the structure. Proper=20 ventilation reduces the threat of flashover by removing heat before = combustibles=20 in a room or enclosed area reach their ignition temperatures. Proper = ventilation=20 reduces the risk of a backdraft by reducing the potential for = superheated fire=20 gases and smoke to accumulate in an enclosed area.

The Incident Commander must consider many variables when deciding = upon the=20 plan of attack at a structure fire. Ventilation is just one of the many=20 variables that must be considered. Before initiating the fire attack, = the IC=20 should ask the following questions:¹⁹

Is there a need for ventilation at this = time?
The need must be based upon the heat, smoke, and = gas=20 conditions within the structure, the structural conditions, and the = life=20 hazard=20
Where is ventilation needed?
This=20 involves knowing the construction features of the building, the = contents,=20 exposures, wind direction and strength, extent of the fire, location = of the=20 fire, location of top or vertical openings and location of cross or = horizontal=20 openings
What type of ventilation should be used?
Horizontal (either natural or mechanical) or = vertical=20 (natural or mechanical)?
Do fire and structural conditions allow for safe = roof=20 operations?
Knowledge of the building is = paramount.=20

In this incident, the fire department did not attempt to coordinate=20 ventilation with the offensive interior attack. Chief officers = interviewed by=20 NIOSH stated they would not ventilate the type of structure involved in = this=20 fire. Crews were directed to attack the fire with hose lines at the = loading dock=20 (D-side) and inside the showroom at the right rear addition. Every fire = fighter=20 interviewed by NIOSH who was inside the showroom area reported rapidly=20 deteriorating conditions as thick gray and black smoke banked down to = floor=20 level reducing visibility to near zero with rapidly intensifying heat. = Different=20 ventilation techniques such as cutting holes in the roof or high on the = D-side=20 wall may have helped reduce the accumulation of smoke and hot gases = inside the=20 showroom. The use of a positive pressure fan at the front entrance along = with=20 adequate openings to vent the introduced air, may have helped reduce the = amount=20 of accumulating smoke in the front showroom and improved visibility, = possibly=20 allowing the disoriented fire fighters inside to find the front = entrance.

All ventilation techniques have both a positive and negative aspect. = Venting=20 can be a very effective life safety procedure. When venting for life = safety=20 purposes, the principle is to pull the fire, heat, smoke and toxic gases = away=20 from victims, stairs, and other egress routes. A vent opening made = between the=20 fire fighter or victims and their path of egress could be fatal if the = fire is=20 pulled to their location or cuts off there path of egress.³⁹=20 Note: The NIST Fire Dynamic Simulator, a computational fire model, = will=20 examine the possible impact of different ventilation strategies and = their effect=20 on this incident. The NIST fire = model will=20 be available in the future at = http://www.bfrl.nist.gov/.

Recommendation #16: Fire departments should conduct pre-incident = planning=20 inspections of buildings within their jurisdictions to facilitate = development of=20 safe fireground strategies and tactics.

Discussion: National Fire Protection Association (NFPA) 1620 = Recommended=20 Practice for Pre-Incident Planning, 2003 Edition, =A7 4.4.1 states = =93the=20 pre-incident plan should be the foundation for decision making during an = emergency situation and provides important data that will assist the = Incident=20 Commander in developing appropriate strategies and tactics for managing = the=20 incident.=94 This standard also states that =93the primary purpose of a = pre-incident=20 plan is to help responding personnel effectively manage emergencies with = available resources. Pre-incident planning involves evaluating the = protection=20 systems, building construction, contents, and operating procedures that = can=20 impact emergency operations.=94 ⁴⁰=20 A pre-incident plan identifies deviations from normal operations and can = be=20 complex and formal, or simply a notation about a particular problem such = as the=20 presence of flammable liquids, explosive hazards, modifications to = structural=20 building components, or structural damage from a previous fire.²⁹^,=20³⁰^,=20⁴⁰

In addition, NFPA 1620 outlines the steps involved in developing,=20 maintaining, and using a pre-incident plan by breaking the incident down = into=20 pre-, during- and post-incident phases. In the pre-incident phase, for = example,=20 it covers factors such as physical elements and site considerations, = occupant=20 considerations, protection systems and water supplies, hydrant = locations, and=20 special hazard considerations. Building characteristics including type = of=20 construction, materials used, occupancy, fuel load, roof and floor = design, and=20 unusual or distinguishing characteristics should be recorded, shared = with other=20 departments who provide mutual aid, and if possible, entered into the=20 dispatcher=92s computer so that the information is readily available if = an=20 incident is reported at the noted address. Since many fire departments = have tens=20 and hundreds of thousands of structures within their jurisdiction, = making it=20 impossible to pre-plan them all, priority should be given to those = having=20 elevated or unusual fire hazards and life safety considerations.

The fire department had conducted several pre-plan inspections of the = structure involved in this incident. A building pre-plan form obtained = from the=20 fire department dated April 26, 2006 noted that store contents were = =93household=20 furniture and office equipment=94 and that the rear warehouse contained = racks=20 approximately 30 feet high (see = Appendix=20 III). A more thorough building inspection and pre-incident plan for = this=20 single-story commercial building could have potentially identified the = flat roof=20 supported by lightweight metal bar joists (metal roof trusses), the = immense fuel=20 load considerations (i.e. large quantity of furniture and associated = highly=20 flammable furnishings in the showroom as well as stored in various = locations=20 throughout the facility), the presence of a drop ceiling and hydrant = locations.=20 Evaluating the size and construction features of the structure allows = the fire=20 department the opportunity to determine a response protocol for the = specific=20 identified hazards and to develop fireground strategies and tactics = (hose line=20 placement, water flow calculations, ventilation strategies, etc.) before = an=20 incident occurs. The hydrant location closest to the structure was noted = on the=20 April 2006 form (on the street to the rear of the warehouse), but was = not used=20 until the first mutual aid department set up operations at the rear of = the=20 warehouse. The construction features, occupancy (furniture retail), and = fuel=20 load present suggested large volumes of water would be necessary to = fight a=20 major fire at the site, which should have prompted the need to identify=20 additional nearby hydrants. A more complete pre-planning process could = have=20 noted this information which may have aided the Incident Commander in = developing=20 a safer and more effective defensive strategy. Individual fire companies = should=20 be involved in pre-plan inspections outside their first-alarm = territories so=20 that they can become familiar with hazardous structures they may respond = to on=20 second and subsequent alarm assignments.

Recommendation #17: Fire departments should consider establishing = and=20 enforcing standardized resource deployment approaches and utilize = dispatch=20 entities to move resources to fill service gaps.

Discussion: On-scene commanders need to focus on the events occurring = at the=20 incident scene. Pre-planned resource deployment can be delegated = to the=20 dispatch system. Computer-aided dispatch can make this process=20 automatic. Without a standardized deployment approach, on-scene = commanders=20 spend time making decisions that could have already been made. The = movement of resources around the jurisdiction to fill coverage gaps = should be=20 delegated to others who do not have to focus their attention on the = safety of=20 the responders in the hazard zone, such as the dispatch center. = According=20 to retired Chief Alan Brunacini, =93The IC must be highly familiar with = dispatch /=20 communications procedures and stay actively connected to the details of = how that=20 system works throughout operations. =85 The com center knows what = resources=20 are available, where they are, and directly controls the status keeping = and=20 dispatch system that can move and manage them. The IC must always = use the=20 IMS to get the right resources (closest to the incident / appropriate = type) in=20 the right place, doing the right things. =85 Having com work in concert = with the=20 IC many times makes a huge difference in the overall command and=20 control.=94⁴¹=20 For example, the dispatch center can advise the incident commander of = time=20 intervals since the initial dispatch (i.e. 10 minute or 15 minute = intervals).=20 Another example would be for dispatch to monitor fireground traffic or = signs of=20 problems, such as a Mayday call. The Incident Command System (ICS) = Module=20 Procedures Guide provides guidelines for managing major incidents and = providing=20 support to the IC by the establishment of a Planning Section to handle = duties=20 such as maintaining resource status and evaluating future resource=20 requirements.⁴²

In this incident, the fire department=92s procedure was for chief = officers to=20 call for additional resources as they deemed necessary. Delegating the = tactical=20 deployment and relocation of resources to dispatch or chief officers = backfilling=20 at other locations within the jurisdiction will allow Incident = Commanders to=20 focus on the fireground events. Using a standardized resource deployment = approach, any Mayday should trigger the dispatcher to initiate = additional=20 measures in response to the emergency, such as notifying the Fire Chief = and=20 chief officers of the Mayday transmission and sending additional = resources to=20 the incident scene.

Recommendation #18: Fire departments should develop and coordinate=20 pre-incident planning protocols with mutual aid departments.

Discussion: NFPA 1620 provides guidance to assist departments in = establishing=20 pre-incident plans. Pre-incident planning that includes agreements = formed by a=20 coalition of all involved parties including mutual aid fire departments, = emergency medical services companies, and police, will present a = coordinated=20 response to emergency situations, and may save valuable time by a more = rapid=20 implementation of pre-determined protocols.⁴⁰=20 Examples of such pre-incident planning for this incident include better=20 coordination with the police department concerning traffic control and = better=20 utilization of the resources available from mutual aid departments, such = as=20 large diameter supply hoses.

Recommendation #19: Fire departments should ensure that any = offensive attack=20 is conducted using adequate fire streams based on characteristics of the = structure and fuel load present.

Discussion: The objective of the offensive fire attack is to apply = enough=20 water directly to the burning fuel to achieve extinguishment.³⁹=20 Determining the number and size of hose lines to deploy at a fire can be = estimated by first estimating the size of the structure and applying = various=20 flowrate calculations such as what is taught at the U.S. National Fire = Academy=20 (area divided by 3) or by estimating the size of the fire. Retired Chief = Alan=20 Brunacini in his book Fire Command states =93Big Fire =3D Big = Water, Little=20 Fire =3D Little Water.=94²⁷=20 In addition to the location and extent of the fire, factors affecting = selection=20 and placement of hose lines include the building=92s occupancy, = construction, and=20 size. In addition, fire load and material involved, mobility = requirements, and=20 number of persons available to handle the hose lines are important = factors.=20 Regardless of the choice of attack method or the type of fire stream = used,=20 successful fire suppression depends upon discharging a sufficient = quantity of=20 water to remove the heat being generated, and ensuring that it reaches = the fire=20 rather than being turned into steam or being carried away by convective=20 currents. A back-up line, at least as large as the initial attack line, = should=20 be in place and charged to protect the initial attack crew before = interior fire=20 fighting efforts begin.³⁰=20 Some experts recommend that a 2 =BD-inch-line attack hose lineroutinely = be used=20 with commercial and industrial structures if a sizable body of fire is = present.=20 The rational is that, compared to a residence, the fire load in = commercial=20 structures is usually heavier, will burn longer, and in need of harder = hitting=20 streams. In this incident, the loading dock area contained approximately = 2,300=20 square feet of floor space, the right showroom addition contained = approximately=20 7,000 square feet, and the main showroom contained approximately 17,000 = square=20 feet of floor space. Applying the National Fire Academy rule (area = divided by=20 3), a minimum of 800 gallons per minute (gpm) of water would have been = required=20 at the loading dock. Crews operating at both the loading dock and the = right=20 showroom addition initially employed 1 =BD=94 preconnected hand lines = capable of=20 flowing 90 gpm. 1-inch booster lines were also deployed. As the fire = progressed,=20 2 =BD=94 hand lines capable of flowing 350 gpm were put into operation, = but their=20 use was hindered by inadequate water supply so that the actual flow = rates likely=20 never approached these capacities during the incipient fire stage due to = the=20 small diameter of the supply lines. Table 1 provides examples of hose = sizes and=20 the corresponding flow rates.

**Table 1: Example Hose Sizes and = Corresponding Flow=20 Rates.**^e=20

Generic 2 =BD=94 supply hose
Discharge Pressure =3D = 175=20 psi
Intake Pressure =3D 20 psi
Distance =3D 750 = feet
Hose Size	Flow Available =
2 =BD inch	321 gallons per minute
(2) 2 =BD inch	643 gallons per minute
4 inch	1, 017 gallons per minute
5 inch	1, 607 gallons per minute =

^e Partial Table 13.15 courtesy of IFSTA = Pumping=20 Apparatus Driver/Operator Handbook (1999).⁴³

Recommendation #20: Fire departments should ensure that an adequate = water=20 supply is established and maintained.

Discussion: Establishing adequate water supply on the fireground is = an=20 integral part of fire suppression. A supply hose is used to move large = volumes=20 of water between a pressurized water source and a pump that is supplying = attack=20 hose lines. It is also used to maintain a water system as a continuous = conduit=20 or by connecting water supply sources. Usually, the pressure in supply = hose=20 lines are lower than those used for the attack fire hose. According to = Fire=20 Hose Practices by IFSTA, the use of a 2 =BD inch hose was = once=20 considered the minimum diameter for a supply line, but is no longer = recognized=20 as an adequate supply hose. A 3 =BD=94 supply line is now considered the = minimum. In=20 most instances, fire departments and industrial establishments have gone = to a=20 larger diameter supply line: 3 =BD, 4, 4 =BD, 5, 6, 8, 10 or 12 inches. = In most=20 cases, a short length of 5=94 or 6=94 diameter hose is used. With the=20 ever-increasing demand for greater fire flow (water supply) over long = distances,=20 large diameter hoses (LDH) are used as above-ground water mains to allow = for=20 greater flow of water available for fire suppression, and to decrease = friction=20 loss due to a smaller diameter hose.⁴⁴=20

The fire department involved in this incident routinely deployed 2 = =BD=94 hose as=20 the main water supply line. In this incident, 23 50-foot sections of 2 = =BD=94 supply=20 line were laid to a hydrant capable of supplying 1,256 gpm at 56 psi. = Engine 16,=20 stationed at the hydrant, pumped through the 23 sections of supply hose = to=20 supply Engine 11 located near the front entrance. Difficulties with the = Engine=20 11 pump delayed the establishment of a constant water supply to the = initial=20 attack line (500 feet of 1 =BD=94 hose line), causing the Engine 11 = engineer to=20 switch between tank water and the supply line. Crews also attempted to = deploy a=20 1=94 booster line and a 2 =BD=94 attack line (200 feet) from Engine 11. = The deployment=20 of a 1 =BD=94 attack line over 250 feet increased the friction loss and = lowered the=20 water flow below safe and acceptable levels (150 gpm minimum). As the = fire=20 progressed and the need for additional water increased, chief officers = radioed=20 to the E-16 engineer to increase the water pressure. The officers = ordered the=20 E-16 engineer to go to 300 psi which was well over the maximum limit of = 200 psi=20 working pressure for the hose. It is likely that every time the 1" or = the 2 =BD"=20 line nozzles were opened, the 1 =BD" line pressure would drop. The 1 = =BD" line was=20 the only one that was in position to effectively attack the fire at the = rear of=20 the showroom. To offset the reduced water flow (perceived as lack of = water=20 pressure at the nozzle), the engine operator was instructed to increase = the=20 pressure to pump more water, but this action would only increase the = friction=20 losses in the small diameter hose. A similar scenario developed on the = D-side of=20 the structure where Engine 12 was stationed at a hydrant pumping water = through a=20 single 2 =BD=94 supply hose over 600 feet to Engine 10 which was pumping = to multiple=20 attack hoses. Additional supply hoses, increasing the volume of water = available=20 to both Engine 10 and Engine 11, were not added until after the fire = fighters=20 were determined to be missing. As the fire intensified and the need for=20 additional water flow increased, the use of large diameter hoses for = supply=20 lines would have increased the water available at the pumps (E-10 and = E-11).=20

Recommendation #21: Fire departments should consider using exit = locators=20 such as high intensity floodlights, flashing strobe lights, or hose = markings,=20 or safety ropes to guide lost or disoriented = fire=20 fighters to the exit.

Discussion: The use of high-intensity floodlights, flashing strobe = lights, or=20 other high visibility beacons can be set up at the entry portals of = burning=20 structures as an aid to assist fire fighters in situations requiring = emergency=20 escape.³⁹=20 If staffing permits, a fire fighter can be stationed at the doorway to = assist=20 with flaking hose through the entrance and to assist exiting fire = fighters. Hose=20 lines can be marked with raised chevrons pointing in the direction of = the pump=20 (to the outside). Another option for locating exits is the deployment of = safety=20 rope lines as crews enter a structure. The end of the safety rope is = secured=20 outside the doorway and the rope is laid out as the crew advances = inside. During=20 this incident, several fire fighters inside the structure became = disoriented as=20 the conditions deteriorated. Most of the fire fighters working inside = the=20 structure ran out of air. During the NIOSH interviews, fire fighters = stated they=20 had to search for a hoseline to follow outside. Other fire fighters = reported=20 hearing the sound of Engine 11 running in the parking lot and then = moving toward=20 the sound. Safety ropes were not deployed by the initial crews who = entered the=20 structure.

Recommendation #22: Fire departments should ensure that Mayday = transmissions=20 are received and prioritized by the Incident Commander.

Discussion: The Incident Commander must monitor and prioritize every = message,=20 but only respond to those that are critical during a period of heavy=20 communications on the fireground. A radio transmission reporting a = trapped fire=20 fighter is the highest priority transmission that Command can receive. = Mayday=20 transmissions must always be acknowledged and immediate action must be=20 taken.⁴⁵^,=20⁴⁶=20 As soon as fire fighters become lost or disoriented, trapped or = unsuccessful at=20 finding their way out of the interior of a structural fire, they must = initiate=20 emergency radio transmissions. A Mayday call should receive the highest=20 communications priority from dispatch, the IC, and all other units = on-scene. In=20 this incident, there were multiple radio transmissions of fire fighters = asking=20 for assistance in finding the exit. There was no reaction to these radio = transmissions for several minutes, possibly due to the large volume of = radio=20 traffic and/or the chief officers being distracted by engaging in = fireground=20 activities. The sooner the IC is notified and a RIT is activated, the = greater=20 the chance of the fire fighter(s) being rescued.

Recommendation # 23: Fire departments should train fire fighters on = actions=20 to take if they become trapped or disoriented inside a burning = structure.

Discussion: Fire fighters must act promptly when they become lost,=20 disoriented, injured, low on air, or trapped.^45-5=
0=20 First, they must transmit a distress signal while they still have the = capability=20 and sufficient air, noting their location if possible. The next step is = to=20 manually activate their PASS device. To conserve air while waiting to be = rescued, fire fighters should try to stay calm, be focused on their = situation=20 and avoid unnecessary physical activity. They should survey their = surroundings=20 to get their bearings and determine potential escape routes such as = windows,=20 doors, hallways, changes in flooring surfaces, etc.; and stay in radio = contact=20 with the IC and other rescuers. Additionally, fire fighters can attract=20 attention by maximizing the sound of their PASS device (e.g. by pointing = it in=20 an open direction); pointing their flashlight toward the ceiling or = moving it=20 around; and using a tool to make tapping noises on the floor or wall. A = crew=20 member who initiates a Mayday call for another person should quickly try = to=20 communicate with the missing member via radio and, if unsuccessful, = initiate=20 another Mayday providing relevant information on the missing fire = fighter=92s last=20 known location.

In this incident, fire fighters radioed that they had lost contact = with the=20 hose, needed assistance getting out, and at least one fire fighter = radioed=20 =93Mayday=94 then activated the emergency button on his radio. None of = these radio=20 transmissions gave any information regarding the fire fighters=92 = locations =96 i.e.=20 =93rear of the main showroom,=94 =93near the loading dock,=94 etc. At = least one fire=20 fighter entered the structure without a radio.

Recommendation #24: Fire departments should ensure that all fire = fighters=20 and line officers receive fundamental and annual refresher training = according to=20 NFPA 1001 and NFPA 1021.

Discussion: Initial and continual training provides an opportunity to = ensure=20 that all fire fighters and line officers are proficient in their = knowledge and=20 skills in recognizing and mitigating hazards. Training on structural = fire=20 fighting should include, but not be limited to, departmental standard = operating=20 procedures, fire fighter safety, building construction, and fireground = tactics.=20 NFPA 1500, Chapter 5, requires that the fire department provide an = annual skills=20 check to verify minimum professional qualifications of its = members.¹⁸=20 NFPA 1001 Standard for Fire Fighter Professional Qualifications = was=20 established to facilitate the development of nationally applicable = performance=20 standards for uniformed fire service personnel.⁶⁼=20 NFPA 1021 Standard for Fire Officer Professional Qualifications = was=20 developed in the same way to determine that an individual possesses the = skills=20 and knowledge to perform as a fire officer.²³=20 The intent of both of these standards is to develop clear and concise = job=20 performance requirements (JPRs) that can be used to determine that an=20 individual, when measured to the standard, possesses the skills and = knowledge to=20 perform as a fire fighter or a fire officer, and that these JPRs can be = used by=20 any fire department in the country.

Training is an ongoing process, whether held daily, weekly or = monthly, it=20 allows members to maintain proficiency at their present levels, meet=20 certification requirements, learn new procedures, and keep up with = emerging=20 technology. This fire department required fire fighters to receive basic = fire=20 fighter training certification before being considered for employment. = Once=20 recruits were hired they were put through a ten day hands-on training = and then=20 assigned to their station. This ten day training included equipment use, = SCBA=20 use, ladder drills, hydrant hookup, hose lays, hose pulls, rescue = drills, and=20 live-burn exercises. The training provided for basic hose line = operations was=20 minimal. Hands-on training should also include topics such as hazard=20 recognition, ventilation tactics, ICS/NIMS, scene size-up, and basic = hose line=20 operations. The basic training certification required by the fire = department at=20 the time of this incident did not meet NFPA Fire Fighter I = requirements.

Recommendation #25: Fire departments should implement joint training = on=20 response protocols with mutual aid departments.

Discussion: Mutual aid companies should train together and not wait = until an=20 incident occurs to attempt to integrate the participating departments = into a=20 functional team. Differences in equipment and procedures need to be = identified=20 and resolved before an emergency occurs when lives may be at stake. = Procedures=20 and protocols that are jointly developed, and have the support of the = majority=20 of participating departments, will greatly enhance overall safety and = efficiency=20 on the fireground. Once methods and procedures are agreed upon, training = protocols must be developed and joint-training sessions conducted to = relay=20 appropriate information to all affected department members.

Fire departments should develop and establish good working = relationships with=20 surrounding departments so that reciprocal assistance and mutual aid is = readily=20 available when emergency situations escalate beyond response = capabilities.=20 During this incident, there was little coordination and communication = between=20 the municipal and the mutual aid departments, although fire fighters = from the=20 mutual aid department played key roles in rescuing the trapped employee, = attempting to search the main showroom for missing fire fighters, and=20 establishing water supply. Coordination of fireground efforts could have = been=20 enhanced if protocol planning, communication procedures (such as radio=20 frequency/channel selection), and prior training had taken place among = mutual=20 aid departments.

Recommendation #26: Fire departments should ensure apparatus = operators are=20 properly trained and familiar with their apparatus

Discussion: Modern fire apparatus are complex equipment. Fire = fighters=20 require considerable knowledge, skills and abilities in order to = properly and=20 safely operate fire apparatus. NFPA 1002 Standard for Fire Apparatus = Driver/Operator Professional Qualifications, Chapter 5 lists the = requisite=20 knowledge and skills necessary to safely operate fire apparatus equipped = with=20 fire pumps.⁵¹=20 Prior to this incident, the fire department provided driver / operator = training=20 that consisted mainly of on-the-job training. Individual fire fighters = could=20 request to be trained as a driver / operator and this request would be = approved=20 through the fire department chain-of-command. Fire fighters then = received=20 hands-on training during normal work hours. During this incident, an = operator=20 who was not experienced with one of the engines encountered trouble = getting the=20 pump to go into gear for pump operations. A detailed inspection report = provided=20 by the city (see = Appendix=20 II) demonstrates that specialized training and experience was needed = to=20 properly engage the pump.

Recommendation #27: Fire departments should protect stretched hose = lines=20 from vehicular traffic and work with law enforcement or other = appropriate=20 agencies to provide traffic control.

Discussion: In urban settings, fire hose is commonly used on the = fireground=20 to transfer water from the distribution system (usually from a hydrant) = to the=20 fire apparatus supplying water to the attack lines. Fire hose is often = stretched=20 across roadways and through parking lots. Fire hose may be damaged in a = variety=20 of ways while being used on the fireground. Fire departments should = avoid laying=20 or pulling hose over rough terrain, sharp edges or objects. A damaged = hose may=20 impede fire suppression activities or put fire fighters in an unsafe = position by=20 reducing the water needed for fire suppression while attacking the fire. = Fire=20 departments should provide protection for deployed hose lines that may=20 potentially be run over by vehicular traffic or be damaged by vibration. = This=20 can be done by the use of chafing blocks, hose ramps, or hose = bridges.¹⁹=20 Many commercial versions are available or these items can be custom = made. Fire=20 departments should also position someone at these protective devices so=20 vehicular traffic can be properly guided across or re-routed, and to = make sure=20 the hose does not move around. Fire departments should work with the = local=20 police and law enforcement agencies to ensure adequate traffic control, = warning=20 barricades, and traffic re-direction takes place. During this incident, = fire=20 apparatus engineers radioed dispatch multiple times requesting public = safety=20 assistance for traffic control because civilian vehicle traffic was = running over=20 the 2 =BD=94 supply lines, disrupting the water supply. During the = incipient stage=20 of the fire, traffic was not being redirected and protective devices = were not in=20 use (see=20 Photo 11).

Recommendation #28: Fire departments should ensure that fire = fighters wear a=20 full array of turnout clothing and personal protective equipment = appropriate for=20 the assigned task while participating in fire suppression and overhaul=20 activities.

Discussion: NFPA 1500 Standard on Fire Department Occupational Safety = and=20 Health Program, Chapter 7 contains the general recommendations for fire = fighter=20 protective clothing and protective equipment.¹⁸=20 Chapter 7.1.1 specifies that =93the fire department shall provide each = member with=20 protective clothing and protective equipment that is designed to provide = protection from the hazards to which the member is likely to be exposed = and is=20 suitable for the tasks that the member is expected to perform.=94 = Chapter 7.1.2=20 states =93protective clothing and protective equipment shall be used = whenever the=20 member is exposed or potentially exposed to the hazards for which it is=20 provided.=94 Chapter 7.1.3 states =93structural fire-fighting protective = clothing=20 shall be cleaned at least every 6 months as specified in NFPA 1851 = Standard=20 on Selection, Care, and Maintenance of Structural Fire Fighting = Protective=20 Ensembles.=94 ⁵²=20 Chapter 7.2.1 states =93members who engage in or are exposed to the = hazards of=20 structural fire fighting shall be provided with and shall use a = protective=20 ensemble that shall meet the applicable requirements of NFPA 1971 = Standard=20 on Protective Ensembles for Structural Fire Fighting and Proximity Fire=20 Fighting.=94 ⁵³=20 Chapter 7.9.7 states =93when engaged in any operation where they could = encounter=20 atmospheres that are immediately-dangerous-to-life-or-health (IDLH) or=20 potentially IDLH, or where the atmosphere is unknown, the fire = department shall=20 provide and require all members to use SCBA that has been certified as = being=20 compliant with NFPA 1981 Standard on Open-Circuit Self-Contained = Breathing=20 Apparatus for Fire and Emergency Services.=94 ⁵⁴=20 Additionally, the OSHA Respirator Standard requires that all employees = engaged=20 in interior structural fire fighting use SCBAs.⁸⁼=20 During this incident, there were multiple instances where fire fighters = were=20 observed working in close proximity to the burning structure with = incomplete=20 personal protective ensembles including incomplete turnouts (i.e. no = turnout=20 pants, turnout coats unfastened, suspenders improperly worn, no gloves, = no=20 hoods), entering the burning structure without an SCBA, and off-duty = fire=20 fighters actively working in street clothing with no personal protection = at all.=20 The evaluation report of the PPE worn by the nine victims identified = instances=20 where the PPE was not properly worn such as turnout coat collars not = fully=20 extended upward and helmet ear flaps not deployed (see = Appendix=20 IV).

It is important to note that the 2007 revision to NFPA 1982 = Standard on=20 Personal Alert Safety Systems (PASS) includes new heat and flame = resistance=20 requirements resulting from documented reports where PASS devices were = not heard=20 during fatal fireground incidents.⁵⁵=20 Laboratory testing conducted by NIST determined that exposure to high=20 temperature environments caused the loudness of the tested PASS alarm = signal to=20 be reduced. This reduction in loudness can cause the alarm signal to = become=20 indistinguishable from background noise at an emergency scene. Initial=20 laboratory testing by NIST highlighted that this sound reduction may = begin to=20 occur at temperatures as low as 300=B0F. Thus the use of PASS devices = meeting NFPA=20 1982, 2007 Edition requirements is highly recommended.

Recommendation #29: Fire departments should ensure that fire = fighters are=20 trained in air management techniques to ensure they receive the maximum = benefit=20 from their self-contained breathing apparatus (SCBA).

Discussion: SCBA air cylinders contain a finite volume of air, = regardless of=20 the size. Air consumption will vary with each individual=92s physical = condition,=20 the level of training, the task performed, and the environment. = Depending on the=20 individual=92s air consumption and the amount of time required to exit = an=20 immediately-dangerous-to-life-and-health (IDLH) environment, the low air = alarm=20 may not provide adequate time to exit. Working in large structures (high = rise=20 buildings, warehouses, and supermarkets) requires that fire fighters be=20 cognizant of the distance traveled and the time required to reach the = point of=20 suppression activity from the point of entry. When conditions = deteriorate and=20 the visibility becomes limited, fire fighters may find that it takes = additional=20 time to exit when compared to the time it took to enter the = structure.⁴⁶^,=20⁵⁶=20 NFPA 1404 Standard for Fire Service Respiratory Protection Training=20 Paragraph 5.1.4.2 requires fire departments to train fire fighters = on air=20 management techniques so that the individual fire fighter will develop = the=20 ability to manage his or her air consumption while wearing an SCBA. NFPA = 1404=20 specifies that the individual air management program should include the=20 following directives:

Exit from an IDLH atmosphere should be before consumption of = reserve air=20 supply begins.=20
Low air alarm is notification that the individual is consuming the = reserve=20 air supply.=20
Activation of the reserve air alarm is an immediate action item = for the=20 individual and the team.⁵⁷=20

Fire departments and fire fighters should regularly conduct training=20 exercises in which fire fighters perform various exercises and work = tasks at=20 different work rates until their SCBA cylinder air is exhausted so that = fire=20 fighters become familiar with the time they can expect to work before = the low=20 air alarm sounds, and how long they have to exit once the low air alarm = sounds.=20 In order to comply with NFPA 1404, fire departments and fire fighters = should=20 follow the Rule of Air Management which states =93Know how much air = you have=20 in your SCBA and manage that air so that you leave the hazardous = environment=20 before your low-air alarm activiates.=94⁵⁷^,=20⁵⁸=20 By being aware of these time parameters, fire fighters can make educated = decisions on the time they can safely spend in IDLH atmospheres. In this = incident, the majority of fire fighters who entered the main showroom = ran out of=20 air. Some of the fire fighters were able to exit. The nine victims are = all=20 believed to have run out of air.

Recommendation #30: Fire departments should develop, implement and = enforce=20 written SOPs to ensure that SCBA cylinders are fully charged and ready = for use.=20

Discussion: During this incident, many of the fire fighters who = entered the=20 main showroom became disoriented due to the rapidly deteriorating = conditions and=20 ran low or completely exhausted their air supply. The examination of the = remains=20 of the SCBA used by the 9 victims suggested that all 9 SCBA were out of = air. The=20 SCBA used by this fire department include cylinders that are rated for a = 30-minute duration when fully charged to 2216 psi. During the NIOSH = interview=20 process, several fire fighters stated that the fire department=92s = procedures were=20 to refill cylinders when the pressure dropped to 1500 psi which is well = below=20 the required 90% level (1500 psi is 68% of full cylinder pressure). = Although=20 NIOSH did not examine all department SCBAs or a scientific sample of = SCBAs,=20 examination of a small convenience sample of in-service SCBAs did = identify some=20 below 2000 psi. Cylinders designed to be fully charged at 2,216 psi = should be=20 refilled whenever the pressure falls to 1,994 psi. Due to gauge accuracy = and the=20 type of scale used on the face of the cylinder pressure gauge, any = cylinder at=20 or below 2000 psi should be topped off to ensure fire fighters are = entering IDLH=20 conditions with a full cylinder. The OSHA Respirator Standard, 29 CFR=20 1910.134(h)(3)(iii) states =93Air and oxygen cylinders shall be = maintained in a=20 fully charged state and shall be recharged when the pressure falls to = 90% of the=20 manufacturer's recommended pressure level.=94⁸⁼=20 NFPA 1852 and good SCBA practice dictate that SCBA air cylinders be = refilled=20 whenever the cylinder pressure falls to 90% of the manufacturer=92s = recommended=20 pressure level.⁹⁼^,=20⁵⁹=20 A 30-minute cylinder typically holds 1,200 liters of air when fully = charged. A=20 cylinder charged to 1,500 psi would hold approximately 812 liters of = air. A fire=20 fighter working at a moderate work rate (40 liter per minute air = consumption=20 rate) would exhaust a cylinder holding 1500 psi in approximately 20 = minutes (812=20 liters divided by 40 liters per minute). Fire fighters working at a = higher work=20 rate or breathing under duress (such as in an emergency situation) would = exhaust=20 a cylinder much quicker. During extreme exertion, the actual service = time can be=20 reduced by 50 percent or more. ⁹⁼ A=20 number of fire fighters inside the showroom were running low on air = within 20-25=20 minutes.

Recommendation #31: Fire departments should use thermal imaging = cameras=20 (TICs) during the initial size-up and search phases of a fire.

Discussion: Thermal imaging cameras (TIC) can be a useful tool for = initial=20 size up and for locating the seat of a fire. Infrared thermal cameras = can assist=20 fire fighters in quickly getting crucial information about the location = of the=20 source (seat) of the fire from the exterior of the structure which can = help plan=20 an effective and rapid response. Knowing the location of the most = dangerous and=20 hottest part of the fire may help fire fighters determine a safer = approach and=20 avoid exposure to structural damage in a building that might have = otherwise been=20 undetectable. Ceilings and floors that have become dangerously weakened = by fire=20 damage and are threatening to collapse may be spotted with a thermal = imaging=20 camera. A fire fighter about to enter a room filled with flames and = smoke can=20 use a TIC to assist in judging whether or not it will be safe from = falling=20 beams, walls, or other dangers. The use of a thermal imaging camera may = provide=20 additional information the Incident Commander can use during the initial = size-up. Thermal imaging cameras (TICs) should be used in a timely = manner, and=20 fire fighters should be properly trained in their use and be aware of = their=20 limitations.⁶⁰=20

The use of a TIC during initial size-up and entry into the structure = might=20 have confirmed the presence of hot smoke and gases in the concealed = space above=20 the suspended ceiling, which would have been an indicator that more = defensive=20 tactics should be considered. TICs were available on the fireground but = never=20 put into service.

Recommendation #32: Fire departments should develop, implement and = enforce=20 written SOPs and provide fire fighters with training on the hazards of = truss=20 construction

Discussion: Fire departments should develop, implement and enforce = SOPs or=20 SOGs concerning safe fireground tactics when operating in structures = containing=20 truss construction and then train fire fighters to recognize the hazards = of=20 lightweight truss construction and the appropriate actions to take.61,62 = Fire=20 departments should use pre-incident planning and building inspections to = identify structures within their jurisdiction that contain truss = construction.=20 Pre-plan information should be entered into the dispatcher's computer so = that=20 when a fire is reported at pre-planned locations, the dispatcher can = notify by=20 radio all first responders with critical information.⁶¹^,=20⁶²=20 Fire departments should ensure that the Incident Commander conducts an = initial=20 size-up and risk assessment of the incident scene before beginning = interior=20 fire-fighting operations. Hidden voids within truss construction provide = large=20 areas for smoke and hot gases to accumulate unseen. These hidden voids = provide=20 the potential for rapid fire spread, which may go unnoticed by fire = fighters=20 working below. The Rapid Intervention Team should be immediately = notified when=20 truss construction is identified. Fire departments should use defensive=20 strategies whenever trusses have been exposed to fire or structural = integrity=20 cannot be verified. Unless life-saving operations are under way, fire = fighters=20 should immediately be evacuated and an exterior attack should be = used.⁶¹^,=20⁶²=20 Fire fighters performing fire-fighting operations under or above trusses = should=20 be evacuated as soon as it is determined that the trusses are exposed to = fire=20 (not according to a time limit). A collapse zone should be established = when=20 operating outside a burning building, since truss roof collapses can = push out on=20 the walls, causing a secondary collapse of the exterior walls. The = collapse zone=20 should be equal to the height of the building plus allowance for = scattering=20 debris, usually at least 1=BD times the height of the building.³⁹^,=20⁶¹^,=20⁶³=20 Defensive overhauling procedures should be used after fire = extinguishment in a=20 building containing truss construction. Outside master streams should be = used to=20 soak the smoldering truss building and prevent rekindling.³⁹^,=20⁶¹^,=20⁶³=20

Recommendation #33: Fire departments should establish a system to = facilitate=20 the reporting of unsafe conditions or code violations to the appropriate = authorities.

Discussion: In 1987 the responsibility for fire code inspections was=20 transferred from the fire department to the city. In order to facilitate = open=20 communication, fire department personnel and building code officials = should be=20 cross-trained on each-others=92 duties and responsibilities. Fire = fighters should=20 have a basic understanding of what a code violation is and building code = inspectors should have a basic understanding of fire fighter safety = issues. The=20 fire department conducted a number of pre-plan inspections at the = structure=20 involved in this incident. However, unsafe conditions and code = violations were=20 not noted on the pre-plan inspection form presented to NIOSH. The = pre-plan form=20 did note the presence of the warehouse with storage shelves = approximately 30=20 feet high, but did not note the light weight metal roof trusses and the=20 excessive fuel loads associated with the contents. Such information = could be=20 used to facilitate safer conditions for employees, the public and fire = fighters=20 and emergency responders called to the scene. The accumulation of trash = outside=20 the loading dock, large quantities of flammable liquids, solvents, and = thinners=20 in the loading dock area and storage of furniture and flammable = materials in=20 non-permitted areas were determined to be code violations after the = incident.=20 The identification and reporting of these conditions to the responsible=20 authorities prior to the incident could potentially have resulted in = corrective=20 actions.

Recommendation #34: Fire departments should ensure that fire = fighters and=20 emergency responders are provided with effective incident = rehabilitation

Discussion: Effective emergency incident rehabilitation is an = important=20 element of fire fighter health and safety. Quoting Gregory Cade, former = U.S.=20 Fire Administrator, =93Emergency responder rehabilitation is designed to = ensure=20 that the physical and mental well-being of members operating at the = scene of an=20 emergency do not deteriorate to the point where it effects their safety. = It can=20 prevent serious and life-threatening conditions such as heat stroke and = heart=20 attacks from occurring. Fireground rehab is the term often used for the = care=20 given to fire fighters and other responders while performing their = duties at an=20 emergency scene. Fireground rehab includes monitoring vital signs, = rehydration,=20 nourishment, and rest for responders between assignments.=94⁶⁴^,=20⁶⁵=20 During this incident, the municipal fire department did not practice = fireground=20 rehab.

Recommendation #35: Fire departments should provide fire fighters = with=20 station / work uniforms (e.g., pants and shirts) that are compliant with = NFPA=20 1975 and ensure the use and proper care of these garments.

Discussion: Fire fighters involved in structural fire fighting and = other=20 emergency activities should be provided, at a minimum, station / work = uniforms=20 that are certified and compliant with NFPA 1975 in order to avoid the = potential=20 for burn injuries that are more severe as the result of using thermally = unstable=20 or rapidly deteriorating materials (e.g., fabrics that contain a = significant=20 portion of polyester or other synthetic fabrics that easily melt at low=20 temperatures). Ideally, the prescribed station / work uniforms should = also be=20 flame resistant certified to the optional requirements specified in NFPA = 1975.⁷⁼=20 The use of NFPA 1975-compliant station / work uniforms is specified in = NFPA 1500=20 (paragraphs 7.1.5 and 7.1.6), which also recommends that departments = provide for=20 the adequate cleaning of station / work uniforms provided to their = members=20 (7.1.7).¹⁸=20 According to Appendix A.5.3.10 of NFPA 1500, clothing that is made from = 100=20 percent natural fibers or blends that are principally natural fibers = should be=20 selected over other fabrics that have poor thermal stability or ignite = easily.=20 Appendix A.5.3.10 further states =93The very fact that persons are fire = fighters=20 indicates that all clothing that they wear should be flame resistant (as = children's sleepwear is required to be) to give a degree of safety if=20 unanticipated happenings occur that expose the clothing to flame, flash, = sparks,=20 or hot substances. This would include clothing worn under their = structural=20 fire-fighting protective ensemble.=94 While compliance with NFPA = standards is=20 voluntary, in many instances NFPA standards represent fire service = =93best=20 practices=94 available for ensuring fire fighter safety and health, = especially=20 where state and federal laws are silent on health and safety issues.

In this incident, the fire fighters were not supplied with nor were = they=20 wearing station/work uniforms that were compliant with NFPA 1975. = Although the=20 use of polyester work clothing was not a direct contributing factor to = the nine=20 fatalities that occurred in this incident, the wearing of = polyester-based=20 uniforms can contribute to significant potential for severe burn injury. =

Recommendation #36: Federal and state occupational safety and health = administrations should consider developing additional regulations to = improve the=20 safety of fire fighters, including adopting National Fire Protection = Association=20 (NFPA) consensus standards.

Discussion: Fire fighters have a high rate of injury death compared = to other=20 occupations,¹¹=20 yet federal and state regulations addressing the risks of fire fighting = are=20 sparse. In September 2007, the federal Occupational Safety and Health=20 Administration (OSHA) requested information from the public to evaluate = what=20 action, if any, the US Department of Labor should take to further = address=20 emergency response and preparedness, including the safety of fire = fighters=20 during common responses such as structural fires, as well as rare and = unexpected=20 events, such as natural disasters and terrorist attacks.⁶⁶=20 In this request for information, OSHA noted that elements of emergency = responder=20 health and safety are currently regulated by a number of standards, many = of=20 which were promulgated decades ago, and none designed as a comprehensive = emergency response standard. Consequently, existing standards do not = address the=20 full range of hazards or concerns currently facing emergency responders, = including fire fighters.

NIOSH provided comments in response to this request.⁶⁷=20 NIOSH expressed support for this information gathering process, and = provided=20 data, information, and recommendations from NIOSH fire fighter fatality=20 investigations and research. NIOSH suggested that OSHA consider = regulating all=20 types of emergency incidents, both common and rare events, and that OSHA = consider the full continuum of emergency response activities, from = pre-planning=20 for emergency response activities through recovery and post-incident = treatment.=20 NIOSH provided information from fire fighter fatality investigations, = including=20 large numbers of investigations in which NIOSH recommended that fire=20 departments: comply with NFPA standards for personal protective clothing = and=20 equipment,⁵²^,=20⁵³=20 require the use of Personal Alert Safety Systems,⁵⁵=20 require minimum standards for safety and health training, require the = use of an=20 Incident Management System to manage emergency events,²¹=20 require a designated Safety Officer at emergency events, require the use = of=20 thermal imaging cameras at structure fires, require that fire = departments have=20 written SOPS and a written safety and health program, and require that = RIT teams=20 be established at emergency events before fire fighters enter IDLH = environments.=20 NIOSH referenced several NFPA standards in these comments.

Compliance with existing federal and state occupational safety and = health=20 regulations may not be adequately protecting fire fighters, and is = inconsistent=20 with industry =93best practices=94 developed through the NFPA consensus = process. In=20 addition to OSHA considering additional regulations to protect fire = fighters,=20 state occupational safety and health agencies that cover public = employees should=20 similarly consider enhancing the protection of fire fighters through = their state=20 regulations.

Recommendation #37: Manufacturers, equipment designers, and = researchers=20 should continue to develop and refine durable, easy-to-use radio systems = to=20 enhance verbal and radio communication in conjunction with properly worn = SCBA.

Discussion: The use of Personal Protective Equipment (PPE) and an = SCBA make=20 it difficult to communicate, with or without a radio.⁶⁸^,⁶⁹=20 Faced with the difficult task of communicating while wearing a SCBA, = fire=20 fighters sometimes momentarily remove their face pieces to transmit a = message=20 directly or over a portable radio. Considering the toxic and = oxygen-deficient=20 hazards posed by a fire and the resulting products of combustion, = removing the=20 SCBA face piece, even briefly, is a dangerous practice that should be=20 prohibited. Even small exposures to carbon monoxide and other toxic = agents=20 present during a fire can affect judgment and decision making abilities. = To=20 facilitate communication, equipment manufacturers have designed face=20 piece-integrated microphones, intercom systems, throat mikes and bone = mikes worn=20 in the ear or on the forehead.⁶⁹^,=20⁷⁰

Recent testing of portable radios in simulated fire fighting = environments by=20 the National Institute for Standards and Technology (NIST) has = identified that=20 radios are vulnerable to exposures to elevated temperatures. Some = degradation of=20 radio performance was measured at elevated temperatures ranging from = 100OC to=20 260OC, with the radios returning to normal function after cooling down.=20 Additional research is needed in this area.⁷¹=20

During this incident fire fighters experienced intermittent radio=20 communication problems and interruptions. Audio transcripts of the = fireground=20 channel recorded multiple instances where fire fighters inside the = structure=20 (including some of the victims) transmitted over the radio, but the=20 transmissions were not heard or could not be understood. Effective radio = communication is an important part of safe fireground = operations.

Recommendation #38: Manufacturers, equipment designers and = researchers=20 should conduct research into refining existing and developing new = technology to=20 track the movement of fire fighters inside structures.

Discussion: Fire fighter fatalities often are the result of fire = fighters=20 becoming lost or disoriented on the fireground. The use of systems for = locating=20 lost or disoriented fire fighters could be instrumental in reducing the = number=20 of fire fighter deaths on the fireground. The National Institute for = Standards=20 and Technology (NIST) has been evaluating the feasibility of real-time = fire=20 fighter tracking and locator systems.⁶⁸^,=20⁷²=20 Research into refining existing systems and developing new technologies = for=20 tracking the movement of fire fighters on the fireground should = continue.=20

Recommendation #39: Code setting organizations and municipalities = should=20 require the use of sprinkler systems in commercial structures, = especially ones=20 having high fuel loads and other unique life-safety hazards, and = establish=20 retroactive requirements for the installation of fire sprinkler systems = when=20 additions to commercial buildings increase the fire and life safety = hazards

Discussion: This recommendation focuses on fire prevention and = minimizing the=20 impact of a fire if one does start. The NFPA Fire Protection = Handbook=20 states =93throughout history there have been building regulations = for=20 preventing fire and restricting its spread. Over the years these = regulations=20 have evolved into the codes and standards developed by committees = concerned with=20 fire protection. The requirements contained in building codes are = generally=20 based upon the known properties of materials, the hazards presented by = various=20 occupancies, and the lessons learned from previous experiences, such as = fire and=20 natural disasters.=94⁷³=20 Although municipalities have adopted specific codes and standards for = the design=20 and construction of buildings, structures erected prior to the enactment = of=20 these building laws may not be compliant. Such new and improved codes = can=20 improve the safety of existing structures.⁷³=20 Sprinkler systems are one example of a safety feature that can be = retrofitted=20 into older structures. Sprinkler systems can reduce fire fighter = fatalities=20 since such systems can contain and may even extinguish fires prior to = the=20 arrival of the fire department. In this incident, this structure = incorporated=20 mixed-used construction types and was non-sprinklered. The original = structure=20 was built in the 1960s (17,500 square feet), with additions added in = 1994 (6,970=20 square feet) and 1995 (7,020 square feet). The structure was annexed = into the=20 city in 1990. City ordinances required commercial structures over 15,000 = square=20 feet to have a sprinkler system. The original structure was = grandfathered, and=20 the subsequent additions were treated as separate buildings so the = facility was=20 never sprinklered. The additions were treated as separate structures = with the=20 end result being that each addition did not meet the threshold at which = a=20 sprinkler system would be required.

Recommendation #40: Code setting organizations and municipalities = should=20 require the use of automatic ventilation systems in commercial = structures,=20 especially ones having high fuel loads and other unique life-safety=20 hazards.

Discussion: The use of automatic ventilation systems in roofs and = enclosed=20 void spaces that would open in the event of a fire and allow smoke, hot = fire=20 gases and heat to escape could aid fire fighters by helping control fire = spread.=20 Smoke venting through these openings would also give Incident Commanders = and=20 fire fighters very useful information related to the fire=92s size, = location and=20 stage of growth. Many European standards such as the UK legislation = requirements=20 of BS7346 part 1 (European National (EN) 12101) & BS 5588 part 5 = require=20 automatic roof ventilation systems that automatically open to ensure = rapid=20 dispersal of smoke, heat and toxic gases.⁷⁴

Recommendation #41: Municipalities and local authorities having = jurisdiction=20 should coordinate the collection of building information and the sharing = of=20 information between building authorities and fire departments.

Discussion: Municipalities and local authorities having jurisdiction = should=20 develop a questionnaire or checklist to ensure that pre-plan inspections = collect=20 the appropriate information. The questionnaire or checklist could focus = on=20 building characteristics including the type of construction, materials = used,=20 occupancy, fuel load, roof and floor design, and unusual or = distinguishing=20 characteristics. Once obtained, this information should be recorded, = shared with=20 all departments who provide mutual aid, and if possible, entered into = the=20 dispatcher=92s computer so that the information is readily available if = an=20 incident is reported at the noted address. Municipalities and local = authorities=20 having jurisdiction should also include experienced fire personnel = throughout=20 any zoning or building code developmental process concerning life safety = to the=20 public and fire department members. Typically, pre-incident planning = focuses on=20 commercial buildings and the specific hazards they have due to their = size,=20 construction, and contents.

Recommendation #42: Municipalities and local authorities having = jurisdiction=20 should consider establishing one central dispatch center to coordinate = and=20 communicate activities involving units from multiple jurisdictions. =

Discussion: An effective radio communication system is a key factor = in fire=20 department operations. The communication system, or central dispatch = center, is=20 used for receiving notification of emergencies, alerting personnel and = fire=20 apparatus, coordinating the activities of the units engaged in emergency = incidents, and providing non-emergency communications for the = coordinating fire=20 departments. The dispatch system must be able to identify the type and = number of=20 units due to respond to the type of incident in advance based on risk = criteria=20 and unit capabilities. The central dispatch center should also monitor=20 fireground activity and inform command of time intervals or of possible = missed=20 transmissions such as Maydays. A central dispatch center equipped with = regional=20 mutual aid channels could serve multiple jurisdictions.³⁸^,=20⁷⁰=20 This type of system would provide operational advantages in the = communication=20 system, reflect a more functional mutual aid system, and reduce overall = costs of=20 operating centers in individual jurisdictions. Having a pre-determined = response=20 for apparatus arranged by district, address or by type of incident, = makes the=20 job of the Incident Commander and the dispatcher much easier. The = pre-determined=20 assignment lists the apparatus slated to respond to the incident and = should take=20 into account apparatus that are out of service by filling in for such = units with=20 similar units. In this incident, the municipal fire department = maintained its=20 own dispatch center in cooperation with the city policy department. The=20 neighboring departments either had their own dispatch centers or were = serviced=20 by the county dispatch system. The municipal fire department relied upon = the=20 chief officers to request companies as the need was identified, instead = of=20 having predetermined response assignments.

Recommendation #43: Municipalities and local authorities having = jurisdiction=20 should ensure that fire departments responding to mutual aid incidents = are=20 equipped with mobile and portable communications equipment that are = capable of=20 handling the volume of radio traffic and allow communications among all=20 responding companies within their jurisdiction.

Discussion: Units responding to or engaged at incidents should have = the=20 necessary radio frequencies/channels to be in contact with other units = providing=20 mutual aid. These units should also have the capability to monitor the=20 fireground activities while en-route. ³⁸=20 During this incident, some mutual aid departments could not communicate = with the=20 IC or the municipal dispatch center on either their portable or mobile=20 radios.

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INVESTIGATOR INFORMATION

This investigation was conducted by Timothy Merinar, Safety Engineer, = Matt=20 Bowyer, General Engineer, Jay Tarley, Safety and Occupational Health = Specialist,=20 and J. Scott Jackson, Occupational Nurse Practitioner, with the NIOSH = Fire=20 Fighter Fatality Investigation and Prevention Program. Stacy Wertman, = Safety and=20 Occupational Health Specialist, NIOSH, Division of Safety Research, = provided=20 technical support. This report was authored by Timothy Merinar. Jeffrey = O.=20 Stull, President, International Personnel Protection, Inc., conducted a = forensic=20 evaluation of the personal protective equipment (PPE), protective = clothing and=20 station uniforms worn by the victims. Expert technical reviews were = provided by=20 Chief Alan Brunacini (retired), Phoenix Fire Department; I. David = Daniels, Fire=20 Chief / Emergency Services Administrator, Renton Washington; Assistant = Chief=20 Vincent Dunn (retired), Fire Department of New York; Battalion Chief = John Salka,=20 Fire Department of New York and President of Fire Command Training; = Gordon=20 Routley, fire service consultant and FRT Project Leader; Kevin Roche, = Phoenix=20 Fire Department and FRT member; Nelson Bryner, National Institute of = Standards=20 and Technology (NIST), and Ken Farmer, U.S. Fire Administration (USFA). =

Special thanks to Nelson Bryner, Paul Fuss, and Glenn Forney of NIST = for=20 their assistance during this investigation and to Lee Baughman, South = Carolina=20 OSHA, for his assistance at the site. The investigators would also like = to thank=20 the fire department, the International Association of Fire Fighters = local union,=20 local mutual aid departments, the county coroner, the city Director, = Safety=20 Management Division, and the city police department for their assistance = during=20 this investigation. Finally, a very special =93thank you=94 to all the = fire fighters=20 who provided valuable information during this investigation.

photos and diagrams

Photo1. Time approximately 1924 hours. = Fire is=20 visible over showroom roof. Smoke is dark gray in color and = becoming=20 turbulent. The flames may not have been visible from front parking = lot or=20 close to the building on the D-side.
(Photo = courtesy of=20 Dan Folk.)

Photo 2. Time approximately 1930 hours. = Note how=20 smoke has changed to dark black color indicating it is rich with = products=20 of incomplete combustion. Note Ladder 5 and Engine 11 in front of=20 structure as well as fire department vehicle in lower left corner. = The top=20 of Engine 10 is just visible over the fence at the lower=20 right.
(Photo courtesy of Associated Press, = Alexander Fox=20 photographer.)

Photo 3. Time approximately 1934 hours. = Note lack=20 of any fire personnel in front of structure. At this point, the = E-11, L-5,=20 E-16, E-15, E-19, and E-6 crews are inside the showroom. Also note = how the=20 color of smoke column appears different from previous photo which = may be=20 due to the angle of the photograph and position of the=20 sun.
(Photo courtesy of Police Department, Bill = Murton,=20 photographer.)

Photo 4. Last surviving members of the = initial=20 attack crews exit showroom at approximately 1935 hours.=20
(Photo courtesy of Police Department, Bill = Murton,=20 photographer.)

Photo 5. Time approximately 1935 hours. = Mutual aid=20 fire fighter breaking showroom front window. Photo taken just = prior to=20 mutual aid department making rescue attempt in front showroom. = Note the=20 heavy tar stains on the windows indicating the smoke inside the = showroom=20 is rich with flammable products of incomplete=20 combustion.
(Photo courtesy of Police Department, = Bill=20 Murton, photographer.)

Photo 6. Time approximately 1936 hours. = Note=20 turbulent dark gray smoke rolling out of the showroom as the front = windows=20 are being knocked out. Mutual aid crew is assembling for search = and rescue=20 attempt.
(Photo courtesy of Associated Press, = Alexander=20 Fox, photographer.)

Photo 7. Time approximately 1938 hours. = Photo=20 shows conditions at front of showroom just before the interior = search and=20 rescue attempts were halted due to the interior=20 conditions.
(Photo courtesy of the Charleston Post = and=20 Courier.)

Photo 8. Time approximately 1938 hours. = Photo=20 taken less than a minute after rescue crews are forced out of the = showroom=20 by the interior conditions. Note fire rolling out the showroom=20 windows.
(Photo courtesy of the Charleston Post = and=20 Courier.)

Photo 9. Storage racks in warehouse post = fire.=20 Storage racks were filled with various furniture and mattress = items. Note=20 the extent to which the storage racks filled the warehouse which = gives an=20 indication of the volume of merchandise and the fuel load inside = the=20 15,600 square foot warehouse. The warehouse measured approximately = 130 ft.=20 by 120 ft. and was 29 ft from floor to = roof.
(Photo =96=20 NIOSH.)

Photo 10. Time approximately 1942 hours. = Engine 10=20 and Engine 12 crews battle fire in warehouse from=20 outside.
(Photo courtesy of police department, = Bill=20 Murton, photographer.)

Photo 11. Time approximately 1925 hours. = Note=20 traffic on major highway in front of incident site driving over 2 = =BD inch=20 supply line. The hose line runs from Engine 12 (to left of photo) = to=20 Engine 10 (to right of photo. Photo shows mutual aid crew members = arriving=20 on scene.
(Photo courtesy of Dan = Folk.)=20

Diagram 1. Floor plan of furniture store and=20 warehouse

Diagram 2. Location of Engine 10 and = Engine 11,=20 supply lines and hose lines pulled at different times during the = incident.=20 Note accumulation of trash at loading dock on the day photo was = taken, 3=20 months prior to the incident. Note the absence of ventilation = ductworks or=20 other roof penetrations over the showroom, thus no path for smoke = and hot=20 gases to escape. From aerial photo taken in March 2007=20
(copyright Pictometry International =96 used with = permission of=20 Pictometry)

Diagram 3: Note location where mutual = aid crew cut=20 through exterior wall to extricate male employee trapped inside = the=20 warehouse. From aerial photo taken in 2007. = (copyright=20 Pictometry International =96 used with permission of = Pictometry)

Diagram 4. Approximate location of the 9 = victims.

Appendix I

Recruit Class Schedule

Appendix II

Appendix II

Engine 11 Inspection Report
Dated =
December 16,=20 2008.

The fire department reported that no change had = been made=20 to
Engine 11 since the day of the fire. =

Appendix III

Pre-plan Inspection Form

Pre-plan inspection form for the incident location. Note that = names,=20 addresses, phone numbers and other identifiers have been removed. = Page 1=20 of 2.

Pre-plan inspection form, page 2 of 2

Appendix IV

PPE=20 Evaluation Report

For a copy of the complete PPE Evaluation = Report,=20 contact
NIOSH Fire Fighter Fatality Investigation and Prevention=20 Program
304-285-5916

Appendix V

Additional Photos

Photo A-1. Time is approximately 1923 = hours. Fire=20 is visible over showroom roof. Smoke is dark gray in color and = becoming=20 turbulent. The flames may not have been visible from front parking = lot or=20 close to the building on the D-side.
(Photo = courtesy of=20 Dan Folk.)

Photo A-2. Time is approximately 1936 = hours.=20 Loading dock area approximately 20 minutes after first crews = arrived on=20 scene. Note heat damage to metal siding on loading dock and=20 warehouse.
(Photo courtesy of Police Department, = Bill=20 Murton, photographer.)

Photo A-3. Time approximately 1939 = hours. Fire=20 fighters near front entrance to showroom. Note lack of water = pressure on=20 the red booster line and the 2 =BD=94 hand line. Also note lack of = gloves and=20 hood.
(Photo courtesy of the Charleston Post and=20 Courier.)

Photo A-4. Time approximately 1951 = hours. Front=20 fa=E7ade beginning to collapse.
(Photo courtesy of = the=20 Charleston Post and Courier.)

The National Institute for Occupational Safety = and Health=20 (NIOSH), an institute within the Centers for Disease Control and=20 Prevention (CDC), is the federal agency responsible for conducting = research and making recommendations for the prevention of = work-related=20 injury and illness. In fiscal year 1998, the Congress appropriated = funds=20 to NIOSH to conduct a fire fighter initiative. NIOSH initiated the = Fire=20 Fighter Fatality Investigation and Prevention Program to examine = deaths of=20 fire fighters in the line of duty so that fire departments, fire = fighters,=20 fire service organizations, safety experts and researchers could = learn=20 from these incidents. The primary goal of these investigations is = for=20 NIOSH to make recommendations to prevent similar occurrences. = These NIOSH=20 investigations are intended to reduce or prevent future fire = fighter=20 deaths and are completely separate from the rulemaking, = enforcement and=20 inspection activities of any other federal or state agency. Under = its=20 program, NIOSH investigators interview persons with knowledge of = the=20 incident and review available records to develop a description of = the=20 conditions and circumstances leading to the deaths in order to = provide a=20 context for the agency=92s recommendations. The NIOSH summary of = these=20 conditions and circumstances in its reports is not intended as a = legal=20 statement of facts. This summary, as well as the conclusions and=20 recommendations made by NIOSH, should not be used for the purpose = of=20 litigation or the adjudication of any claim. To request additional = copies=20 of this report (specify the case number shown in the shield = above), for=20 other fatality investigation reports, or further information, = visit the=20 Program Website at www.cdc.gov/niosh/fire = or call=20 toll free 1-800-CDC-INFO = (1-800-232-4636).

Return to Fire = Fighter=20 Homepage

NIOSH Homepage

This page was last updated on 02/11/09.

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