On Thursday, June 2, 2011 at 10:45 a.m., the San Francisco Fire Department responded to Box 8155, at 133 Berkeley Way. What was seemingly a routine working fire in a single family residence quickly transformed into a fierce and unrelenting incident with ultimately tragic results. When we answered the call to a career in the Fire Service and took our Oath of Allegiance, we were aware of the inherent danger of our occupation.
Despite this awareness, we do not expect to encounter a line of duty death of a brother or sister, especially not in our very own Department. The profound loss of Lieutenant Vincent Perez and Firefighter/Paramedic Anthony Valerio has left an indelible impression in our hearts and will forever be remembered in the annals of SFFD history.
On March 21, 2003, Oscar Armstrong III was tragically killed in the line of duty. The Cincinnati Fire Department and the Armstrong family suffered a tremendous loss. This report is dedicated to Fire Fighter Armstrong, his mother, Annette Armstrong, his fiancée, Sakina Devereaux, his three children, Isaiah, Oscar IV, and Imani, and his brother and sister fire fighters within the Cincinnati Fire Department.
Our goal is to ensure that his death was not in vain by enhancing the operations of the Cincinnati Fire Department. The committees commissioned by the Fire Chief have dedicated hundreds of hours of time since Oscar’s death to improve the Cincinnati Fire Department. Without his ultimate sacrifice, it would have taken many years to accomplish the mission of this report.
On November 25, 2000, a 30-year-old career male fire fighter (Maurice Bartholomew # 201) died in a residential house fire. At 0135 hours, fire fighters received a call of a reported structure fire. Engines 5, 2, 1, Ladder 11, and Rescue 32 responded to the early morning call. At 0141 hours, Engine 5 arrived on the scene and the Captain assumed incident command. The IC reported to dispatch that they had a well-involved, single-story house fire.
The FF Maurice Bartholomew, Captain, and Lieutenant advanced a 1¾-inch handline through the front door as a positive pressure ventilation (PPV) fan was setup at the front door. The hallway became heavily involved with fire. The Lieutenant and Captain fell over debris and the victim became disoriented. Approximately 56 minutes later, fire fighters found the victim. He was pronounced dead at the scene.
On March 30, 2010, a 28-year-old male career firefighter paramedic (victim) died and a 21-year-old
female part-time firefighter paramedic was injured when caught in an apparent flashover while operating a hoseline within a residence. Units arrived on scene to find heavy fire conditions at the rear of a house and moderate smoke conditions within the uninvolved areas of the house.
The victim, the injured firefighter paramedic, and a third fire fighter made entry into the home with a charged 2 1⁄2 inch hoseline. Thick, black rolling smoke banked down to knee level after the hoseline was advanced 12 feet into the kitchen area. While ventilation activities were occurring, the search and rescue crew observed fire rolling across the ceiling within the smoke. They immediately yelled to the hoseline crew to “get out.”
On Thursday, November 23, 2006, Thanksgiving evening, Atlanta Firefighter Steven Solomon was fatally burned while conducting firefighting operations in an abandoned dwelling at 257 Elm Street Northwest. On November 24, while Firefighter Solomon was in critical condition at Grady Memorial Hospital Burn Center, Chief Rubin requested the assistance of an independent review committee to
fully examine the causes of this incident and determine the actions that should be taken to prevent any similar occurrences in the future. Firefighter Solomon died on November 29, 2006 as a result of his injuries. On Saturday, November 26, 2006, Chief Rubin convened a special meeting at Atlanta Fire Rescue Station 4 to begin a detailed review and analysis of the incident that fatally injured Firefighter Solomon
On December 22, 1999 a fire in a two story duplex house in Iowa claimed the lives of three children and three firefighters. The fire occurred in the right half of a two story duplex. NIST has examined the fire dynamics of this incident. NIST has performed computer simulations of the fire using the newly developed, NIST Fire Dynamics Simulator (FDS) and Smokeview.
On the morning of December 22, 1999, a fire started in plastic materials on top of the stove in the kitchen on the first floor of the residence. An adult occupant, sleeping upstairs in the front bedroom, awoke to the cries of a child. The adult opened the front bedroom door to the hall and found hot smoky conditions.
On July 21, 2007, a 34-year-old career captain and a 37-year-old engineer (riding in the fire fighter position) died while conducting a primary search for two trapped civilians at a residential structure fire. The two victims were from the first arriving crew at 0150 hours. They made a fast attack and quickly knocked down the visible fire in the living room.
They requested vertical ventilation, grabbed a thermal imaging camera, and made re-entry without a handline to search for the two residents known to be inside. Another crew entered without a handline and began a search for the two residents in the kitchen area. A positive pressure ventilation fan was set at the front door to increase visibility for the search teams.
On July 23, 2018, the Howard County Department of Fire and Rescue Services experienced the tragic line of duty death of Lt. Nathan Flynn during a fire at 7005 Woodscape Drive. The event was devastating to the Flynn family, who lost a husband and a dad, and to the members of the Department, and the citizens of Howard County, who lost a firefighter and a friend.
To grow as a Department, we need to take an in-depth look at our policies and procedures, be willing to be vulnerable, and make difficult changes. It is my hope that from the lessons we learn and the adjustments we make, we can help reduce risk, prevent future tragic events from occurring in our Department, and be an example to other Departments.
- Crew Integrity and Communication Flaws: There was a breakdown in crew integrity and effective communication, leading to confusion during the Mayday situation where Flynn was trapped.
- Operational Shortcomings: The investigation noted lapses like no strategic action plan, inadequate size-up of the scene, and failure to recognize benchmarks critical to the incident. Additionally, problems arose when members operated on incorrect radio channels, exacerbating command saturation.
- Structured Recommendations: NIOSH recommended that fire departments maintain crew integrity through visual, verbal, or direct contact and ensure commanders conduct thorough risk assessments. The implementation of procedures for unique situations, like below-grade fires and large residential structures, was also urged.
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On February 18th, 2020, a fire occurred in the City of Porterville Public Library. During the initial minutes of fire department operations, while searching for a reported victim, two members of the first arriving engine company became disoriented and tragically lost their lives in the line of duty. On April 29th, the Fire Chief issued a Delegation of Authority to a Serious Accident Review Team,
(SART) authorizing an investigation into the incident. The Chief stated, “It is my hope that the lessons to be learned from this incident might benefit the entire fire service and result in a safer standard of operations for the entire industry.” The SART timeline spanned a nine-month period, utilizing over 1,000 personnel hours.
Fire departments play a critical role in ensuring the safety of both their personnel and the public during emergencies. Improving fireground communications and incident management is essential for enhancing safety. Here’s how fire departments can achieve these objectives:
1. Strengthen Communication Channels
Reliable and effective communication is the backbone of incident management. Fire departments should establish robust protocols to convey critical incident information to incident commanders quickly. This includes ensuring all personnel in the hazard zone are tuned to the correct radio channel, facilitating real-time updates and reducing the risk of miscommunication.
2. Standardize Procedures for Radio Use
To maintain seamless communication, every crew member needs to understand and follow standard operating procedures regarding radio usage. Ensuring that radios are always on the designated channel can prevent potential interference and signal problems, thereby contributing to smoother operations.
3. Promote Command Safety Principles
Integrating Command Safety principles into the incident management system from the onset of any operation is crucial. These principles are designed to embed strategic safety responsibilities within command functions, enabling those in charge to make informed decisions that prioritize protection and resource management throughout the incident.
4. Continuous Training and Assessment
Regular training sessions and simulations can help personnel stay adept at using communication tools and following protocols efficiently. Assessing these drills can pinpoint areas for improvement, ensuring readiness for actual emergencies.
5. Maintain Situational Awareness
Incident commanders should consistently track and verify the status of situational conditions, available resources, and communication flows. This oversight ensures tactical objectives are met swiftly, and any arising challenges are swiftly managed.
By implementing these strategies, fire departments can significantly enhance safety on the fireground, ensuring all operations are carried out with precision and care. This holistic approach to incident management fosters a safer environment for both firefighting teams and the communities they serve.
Ensuring that Advanced Life Support (ALS) units equipped with Automatic External Defibrillators (AEDs) are available during training exercises is crucial for several reasons:
Preparedness in Real-World Scenarios: Having ALS capabilities ready familiarizes firefighters with life-saving equipment and ensures they are well-prepared for emergencies that might arise during actual operations.
Immediate Response Capability: Training situations, like any real-world environment, can be unpredictable. With AEDs on hand, the swift decentralization of medical aid is possible, significantly increasing the chances of survival for individuals who might experience cardiac events.
Lifesaving Equipment Familiarity: Hands-on experience with AEDs and other ALS tools during training allows the team to practice application, improving both confidence and proficiency in high-pressure situations.
Comprehensive Emergency Readiness: Fire departments that incorporate ALS units into their training regiment ensure their team can handle medical emergencies effectively, integrating medical care with traditional firefighting roles.
Ultimately, integrating ALS with AEDs in training is a proactive measure that enhances the safety and effectiveness of first responders, ensuring they are always ready to deliver crucial medical interventions.
- Annual Medical Evaluations: Implement regular health assessments in alignment with the NFPA 1582 guidelines. These evaluations are crucial for monitoring the well-being of firefighters.
- Physician Clearance: Ensure that firefighters are confirmed fit for duty by a physician familiar with the challenging physical requirements of firefighting. This physician should also understand the personal protective gear utilized and the standards outlined in 1582.
- Incident Scene Rehabilitation: Take into account weather conditions and the intensity of the work performed during rescues. Incorporating adequate rest and rehabilitation on-site is vital for maintaining the firefighters’ health and safety.
- Wellness and Fitness Program: Gradually establish a robust wellness and fitness routine. This initiative should focus on enhancing the overall health and physical fitness levels of firefighters to better prepare them for the demands of their job.
- Annual Medical Evaluations: Implement regular health assessments in alignment with the NFPA 1582 guidelines. These evaluations are crucial for monitoring the well-being of firefighters.
- Physician Clearance: Ensure that firefighters are confirmed fit for duty by a physician familiar with the challenging physical requirements of firefighting. This physician should also understand the personal protective gear utilized and the standards outlined in 1582.
- Incident Scene Rehabilitation: Take into account weather conditions and the intensity of the work performed during rescues. Incorporating adequate rest and rehabilitation on-site is vital for maintaining the firefighters’ health and safety.
- Wellness and Fitness Program: Gradually establish a robust wellness and fitness routine. This initiative should focus on enhancing the overall health and physical fitness levels of firefighters to better prepare them for the demands of their job.
- Annual Medical Evaluations: Implement regular health assessments in alignment with the NFPA 1582 guidelines. These evaluations are crucial for monitoring the well-being of firefighters.
- Physician Clearance: Ensure that firefighters are confirmed fit for duty by a physician familiar with the challenging physical requirements of firefighting. This physician should also understand the personal protective gear utilized and the standards outlined in 1582.
- Incident Scene Rehabilitation: Take into account weather conditions and the intensity of the work performed during rescues. Incorporating adequate rest and rehabilitation on-site is vital for maintaining the firefighters’ health and safety.
- Wellness and Fitness Program: Gradually establish a robust wellness and fitness routine. This initiative should focus on enhancing the overall health and physical fitness levels of firefighters to better prepare them for the demands of their job.
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