Lessons from the Fireground
Boston (MA) FD March 26, 2014Â Box 9-1579 298 Beacon Street Fire Reports Issued
NIOSH LODD Report: http://www.cityofboston.gov/fire/pdfs/nioshbeacon.pdf
BFD Board of Inquiry Report: http://www.cityofboston.gov/fire/pdfs/boi-fire-march16.pdf
Executive Summary from the Boston Fire Department
Board of Inquiry Report on the Line-of-Duty Deaths on March 26, 2014
298 Beacon Street Boston, Massachusetts
Box 9-1579 District 4 Division 1
Incident # 16454
On Wednesday, March 26, 2014 at 14:42 hours Box 1579 was struck for a building fire at 298 Beacon Street in the Back Bay section of the City of Boston. Engine Company 33 (E33) with an Officer, Chauffeur and two Firefighters responded to the alarm of fire from their quarters located at 941 Boylston Street, arriving on scene at 14:45 hours. Engine 33 was the first company to arrive and reported smoke showing from the first floor of a four story brick building. In their post fire interviews, the Chauffeur and Hydrant Man stated that before entering the building Lieutenant (LT) Walsh spoke to a tenant as she exited from the front door.
This tenant was overheard telling LT Walsh that there was smoke in the basement outside her apartment. She stated that another tenant lived in the basement but she did not know if that tenant was home. As LT Walsh spoke with the tenant his Pipe Man, Firefighter (FF) Kennedy, advanced E33â€™s 1 Â¾ inch line of hose into the building via the first floor front door. Shortly thereafter he reported over the radio to LT Walsh that â€œitâ€ was in the basement and that LT Walsh should go to the rear of the front hall and descend the basement stairs to where he was located.
At 14:49:45 E33 declared a MAYDAY in the basement of the building. Seconds before the MAYDAY, Engine Companies entering the first floor to back up E33 were driven from the first floor of the building as wind driven fire and superheated smoke came up the stairway that LT Walsh and FF Kennedy had descended in search of the fire. The Firefighters forced to evacuate the first floor sustained first and second degree burns in the seconds it took to escape to the exterior of the building.
Simultaneous with this spontaneous emergency evacuation, at 14:48:48, LT Walsh excitedly called for his line of hose to be charged. The District 4 Chief (D04) arrived on scene and assumed command approximately one minute after E33â€™s arrival. The Chief observed the dramatic change in the smoke venting from the building and the forced evacuation of the Firefighters from the first floor. At 14:48:51 he struck a second alarm and ordered Fire Alarm (FAO) to announce an emergency evacuation of all members from the first floor of the building.
LT Walsh and FF Kennedy directed rescuers to their location in the basement over the radio several times. Multiple heroic rescue attempts using Rapid Intervention Teams (RIT) were attempted from both the Alpha (A) and Charlie (C) sides of the building, but the superheated smoke and fire conditions prohibited the Firefighters from reaching LT Walsh and FF Kennedy in time to rescue them.
The Board believes as LT Walsh and FF Kennedy searched for the source of the smoke in the rear basement apartment, they were suddenly trapped there by a sudden and dramatic change in conditions in the basement hallway. The apartment provided them temporary refuge from the superheated smoke and fire gases which flowed down the hallway from the rear of the building, up the basement stairway and vented turbulently from the front doors. Ultimately LT Walsh and FF Kennedy sustained fatal injuries when the conditions within the rear apartment deteriorated and became untenable and unsurvivable.
The fire at 298 Beacon Street that led to the deaths of Fire Lieutenant Edward Walsh and Firefighter Michael Kennedy was caused by an unpermitted and improperly performed welding operation that ignited a wood frame shed attached to 298 Beacon Street. The high wind conditions at the rear of the building increased the intensity and contributed to the rapid extension of the fire into the building, accounting for the resulting hot, dense, high velocity smoke venting from the front of the building during the initial stages of the fire. The Board has attempted to understand and interpret all of the information it has gathered during this investigation and describe, to the degree possible, the conditions that led to the deaths of LT Walsh and FF Kennedy.
In preparing the summary of this incident, the Board relied upon its extensive combined firefighting experience and a vast amount of information compiled from a multitude of sources. The sources listed here are described in a generalized fashion since the specific sources, documents, contacts et cetera are too numerous to mention in their entirety. In no particular order of importance or sequence they include: site visits, radio transcripts and recorded interviews; conversations with the FIU inspectors, BPD detectives and representatives from the District Attorneyâ€™s office; inspection of physical evidence, inspection and functional testing of LT Walshâ€™s and FF Kennedyâ€™s Personal Protective Equipment (PPE); review of numerous videos and photos from both Department and non Department sources; heat exposure testing of hose at Worcester Polytechnic Institute and at the Boston Fire Academy; fire modeling and an NFPA presentation on wind driven fires; NFPA standards, Underwriters Laboratory and National Institute of Standards and Technology research; BFD Standard Operating Procedures, memos and training records; web based literature searches; and permit and building history from Boston Inspectional Services Department and the City of Boston Archives.
The cause and origin investigation determined that the fire originated in the attached shed in the rear of 298 Beacon Street when windblown molten slag from an unpermitted and improperly performed welding operation at 296 Beacon Street made its way under the shedâ€™s exterior cedar shingle siding. This smoldering slag ignited the siding and sill plate and quickly extended into the shedâ€™s interior structure and its contents. The fire subsequently extended into 298 Beacon Street. The abnormally high winds coming from the direction of the Charles River intensified the rapid growth of the fire by increasing the amount of oxygen available to support combustion. The subsequent failure of the glass in the door between the entry foyer and the basement hallway, in conjunction with the opening or failure of the shedâ€™s exterior and vestibule doors, is believed to have been the catalyst that caused the sudden and dramatic change in fire conditions behind LT Walsh and FF Kennedy, leading to their entrapment as they searched for the source of the fire within the basement.
From a fire service perspective, ordinary Class III structures like 298 Beacon Street have an inherent fire safety design flaw resulting from an older structural framing technique known as balloon framing. This technique created open interior voids within the horizontal ceiling/floor assemblies and vertical stud bays extending from the basement to the attic. Additional voids were often created during renovations. These void spaces often lack proper fire stopping. When a fire occurs in a balloon frame structure these void spaces become pathways for smoke and fire to rapidly spread throughout the building.
Investigators observed that the fire had destroyed the plaster-on-wood lath ceilings and walls, exposing many formerly hidden vertical and horizontal void spaces. This was most noticeable in the basement exit hallway where there was no visible fire stopping in the joist bays above the original plaster ceiling between the hallway and the adjoining apartment. Also noted above the hallwayâ€™s suspended gypsum drywall ceiling was a large open vertical shaft from the basement ceiling to the underside of the second floor. The shaft contained a large cylindrical heating duct that was abandoned in place when the heating system was converted to a forced hot water system. Although the preexisting plaster wall/ceiling assembly may have been adequate to contain a fire within the hallway from extending to the adjoining apartment, the lack of horizontal and vertical fire stopping above the ceiling likely allowed fire to travel unimpeded in the combustible joist bays once it extended into this space.
When questioned about a particular vertical penetration visible between the first and second floor, the property manager explained that a 4 inch PVC drain pipe had been located there for a first floor washing machine installation that was never completed. He stated that the open pipe had allowed visibility into the closet of the first floor apartment from the basement hallway.
The closet was reported to have been filled with a considerable amount of stored combustible materials. This opening was another likely avenue of vertical extension of fire, smoke and gases to the upper floor. Investigators also noted that one of the rear basement apartment windows faced directly into the shedâ€™s vestibule separated only by the window glass. Since the exit hallway passed through the shed, the shed vestibule would be considered part of the exit passageway. From interviews with the buildingâ€™s occupants it was determined that this glass window was intact prior to the fire. Since the window frame was the same type as the other apartment windows, it is believed the window had not been replaced with one having a fire rated glazing or other fire resistant material.
The Board believes with the assistance of the wind, the fire quickly extended from the shed into the basement ceiling/floor void space and then rapidly extended above the ceiling throughout the entire basement. The lack of horizontal fire stopping above the original ceiling between the hallway and the rear apartment likely contributed to the rapid fire extension above the ceiling in the apartment and subsequently to other areas of the structure via vertical openings and shafts. Due to the early extension of fire above the ceiling, the floor joists failed much sooner than would normally occur causing the heavy plaster on lath ceiling to fail.
Through fire modeling, it is also known that the window between the apartment and shed vestibule failed very early due to the direct exposure to the fire in the shed. Whether the ceiling collapse or the window failure occurred first is unknown and somewhat irrelevant since each scenario allowed fire to extend into the apartment, setting the stage for the apartment to transition to full involvement. It is difficult to determine whether the lack of fire stopping, the lack of a fire rated window, the window grates, or the combustible materials present in the basement hallway and stairway were code compliant due to the complexity in determining which building code(s) was applicable at the time building alterations occurred. This requires an ability to identify whether provisions of the applicable building code(s) would have allowed the building official discretion to approve existing conditions that did not meet the prescriptive code but may have met the equivalent performance criteria.
A thorough code analysis performed by a professional will be required to make that determination. Whether code compliant or not, the Board has identified these deficiencies as factors in the extension of the fire into 298 Beacon Street followed by extension into the rear apartment where LT Walsh and FF Kennedy likely sought refuge from the extreme fire conditions in the hallway. The Board believes when LT Walsh and FF Kennedy initially reached the foot of the basement stairs they found a smoke condition with no visible fire because the fire had not yet breached the window in the door separating the entry foyer from the basement hallway. The hallway ceiling above them had a double layer created by the suspended gypsum ceiling covered with fiberglass insulation beneath the original plaster on lath ceiling. This double layered ceiling likely insulated the fire fighters from the heat of the fire that had extended above the original ceiling very early in the fire due to the increased wind pressurization.
It is believed that LT Walsh and FF Kennedy then entered the rear basement apartment in search of the source of the fire led by the increasing temperatures they detected. The apartment was likely hotter than the hallway since the fire had already extended above the apartments original single layered plaster ceiling which lacked the additional insulation of the suspended ceiling layer found in the adjacent basement hallway. The early extension or fire into the ceiling void is further supported by testimony of a first floor tenant who, upon being alarmed to the fire in the building by the basement tenant, was initially puzzled by what she thought was steam coming from her dishwasher when in fact her dishwasher was not operating. This is believed to have been smoke under pressure exiting the joist bays through the penetrations created for the plumbing and wiring for the dishwasher. There were at least two other pathways for heated smoke and gases to have extended into the rear basement apartment: the window facing into the rear vestibule, which fire modeling indicated would have failed very early in the fire; and the apartment door left unlocked by the escaping tenant, who stated that this door rarely remained closed when left unlocked. This door was further obstructed from fully closing by the line of hose which was stretched into the apartment by LT Walsh and FF Kennedy.
Shortly after they entered the apartment, it is believed a triggering event for the sudden intensification of the fire occurred. This intensification is believed to have been caused by the sudden failure of the window in the entry foyer door. This created a pressurized flow path of superheated fire and gases driven by the high winds entering through the open shed exterior and vestibule doors. This sudden and dramatic deterioration of conditions trapped LT Walsh and FF Kennedy in the apartment as the hallway became untenable. The stairway acted as a chimney for the superheated fire, smoke and gases which ignited the stairway carpeting and the numerous combustibles located in the basement hallway, stairwell and cabinet at the top of the stairs. The elevated temperatures created from this wind driven event quickly destroyed E33â€™s line of hose as it lay on the stairway. Since the hose was directly in the flow path, the extreme heat passing over the hose was enough to destroy it very quickly.
Hose tests conducted at Worcester Polytechnic Institute (WPI) and the Boston Fire Academy both demonstrated that hose failure will occur very quickly at the temperatures believed to have been generated during that initial event. (See XIII. Hose Tests.) When E33 called for their line of hose to be filled, E33â€™s pump operator opened the gate valve and observed the line of hose fill with water. However, because the hose had been burned through, the water never reached the nozzle. The water flowed freely from the burned breach in the hose located near the top of the stairway.
Based on the interviews with E33â€™s pump operator and several other Officers and Firefighters, the Board concluded that E33â€™s 1 Â¾ inch line of hose was immediately charged when LT Walsh requested it. Firefighters who made attempts to rescue the trapped members from the front of the building reported that E33â€™s hose was free flowing water in the first floor hallway at the top of the stairs. One Officer stated that the hose appeared to pulse as it trailed away from the pump discharge toward the building. This pulsing is consistent with what is seen when water flows through a hose without a nozzle.
Engine 7, the second due Engine Company, advanced their 2 Â½ inch line of hose to back up E33 by following E33â€™s hose into the building. Engine 7â€™s Officer stated that the smoke and heat conditions initially appeared to be unremarkable. As E07 was about to charge their 2 Â½ inch line of hose before heading down the stairs, the interior fire conditions dramatically changed. Fire, along with hot, black, â€œsootyâ€ smoke mixed with embers and intense heat, suddenly extended over their heads from the basement stairway. The extreme conditions drove them away from the top of the stairway and caused them to scramble to evacuate the first floor. In the seconds it took to exit the twenty feet back out to the front exterior stairway, all of E07â€™s Firefighters sustained first and second degree burns to their ears and exposed skin. Their uncharged 2 Â½ inch line of hose, which had been dragged out behind them, was destroyed in the time it took to evacuate. (See figures XV27, XV28) The outer lining was charred away and the elastomeric bumper on the nozzle was distorted and melted from the heat.
This supports the Boardâ€™s belief that the conditions were severe enough to have quickly compromised E33â€™s 1 Â¾ inch hose. Tests conducted by the Board at the Boston Fire Academy demonstrated that a charged line of hose will fail less than 30 seconds later than an unchargedline of hose.
Despite valiant and heroic attempts to enter and rescue LT Walsh and FF Kennedy from the front of the building, Firefighters were repeatedly forced to back out of the building by the extreme temperatures of the superheated smoke violently exiting through all openings in the front of the building. The smoke then transitioned into free burning, wind driven fire from the basement windows in the front of the building. The extreme heat at that location forced rescue operations to shift to the windward/rear side of the building.
Within seconds of the onset of the wind driven event, LT Walsh reported increasing temperatures in the rear apartment and repeatedly called for his line to be charged. There is a radio transmission in which he is heard saying that they needed to get the smoke out. This statement leads the Board to believe these members were exposed to highly elevated temperatures and increasingly deteriorating conditions in the apartment as the fire continued to grow overhead and in the hallway. The Board believes, based on the description of increasing heat and smoke, and the specific lack of mention of â€œfireâ€, that LT Walsh and FF Kennedy were never directly exposed to open fire until just prior to their last radio transmission. The Board believes that fire eventually breached into the apartment either through the window facing into the vestibule or when the ceiling collapsed. With the rapidly expanding hot gas and smoke layer accumulating within the apartment, this area quickly became fully involved in fire.
Subsequent to the rear basement apartment becoming fully involved, Engine Companies obtained sufficient water supply in the rear of the building to make an aggressive attack into this apartment. With the wind at the back of the advancing Firefighters the heavy fire was quickly knocked down in the apartment. As they slowly advanced, they simultaneously conducted search operations but were interrupted when the ceiling collapsed on the first floor. This collapse shook the building and caused an evacuation of all members. Shortly after this event a smoke explosion occurred and a large volume of fire erupted from the rear windows of the first floor apartment. The pressure wave created by this event caused Firefighters operating in the vicinity of the front stairway to be blown down the stairs onto the sidewalk.
Additional attempts were made to rescue LT Walsh and FF Kennedy. FF Kennedy was locatedand removed within a short period of time. The fire conditions then worsened and the Incident Commander determined that no further rescue attempts could be made. Defensive firefighting operations were established and continued for the next three and a half hours. At approximately 1900 hours, LT Walsh was recovered and removed from the building.
The Board of Inquiry investigation supports the Boston Fire Departmentâ€™s Fire Investigation Unitâ€™s (FIU) conclusion that the unpermitted and improperly performed welding operation at 296 Beacon Street initiated the fire when windswept slag ignited the shed attached to 298 Beacon Street.
The Board has further concluded that once the shed became involved, the severity of the fire was drastically increased by the high wind conditions that fed its growth and extension into the interior of 298 Beacon Street. The subsequent failure of the shed doors allowed wind driven fire to extend throughout the basement hallway, following the flow path up the interior basement stairway and venting through the front door on Beacon Street. The fire also extended into a number of concealed spaces that allowed rapid extension of fire throughout the building and contributed to the fire phenomena witnessed that day.
Although 298 Beacon Street was never required by code to install an automatic sprinkler system, new apartment buildings are now required to have these systems. Based on the success of automatic sprinkler systems in residential occupancy fires and the extensive testing with these systems to control wood and furniture fires, the Board believes that voluntary installation of an automatic sprinkler system in the basement and shed of 298 Beacon Street would have prevented the tragedy and destruction that occurred on March 26, 2014. The Board also noted that the successful operation of the building smoke detection system notified the residents of the fire and allowed their escape and rescue.
The Board wishes to stress that it considers the unpermitted and improperly performed welding operation to be the primary cause of the fire but the wind driven conditions were the primary contributory factor to the entrapment and subsequent deaths of LT Walsh and FF Kennedy. Additionally, the high wind conditions were responsible for the extreme and rapidly deteriorating fire conditions, the extreme fire phenomena, as well as the difficulty in controlling and extinguishing the fire. The Board encourages the fire service and the Boston Fire Department to continue to research ways to more effectively control and extinguish such wind driven fires.
Recommendations: (refer to Boston BOI report for ALL recommendations)
Boston Board of Inquiry
Fireground Operations Only
Fire ground operations are inherently dangerous and dynamic. It is important that all members are well trained and well equipped to accomplish the objectives of the Incident Commander (IC). The Boston Fire Department ensures that all firefighters receive proper training by the Training Division. District Chiefs and Company Officers regularly conduct company drills on Standard Operating Procedures and task oriented procedures.
The Training Division must constantly review, evaluate and improve the Departmentâ€™s own Standard Operating Procedures. It should continually review new firefighting related research, proactively evaluate the BFDâ€™s procedures and equipment and constantly educate the firefighting force with important information or improved procedures that are developed.
The Department must continually strive to improve its efficiency both operationally and administratively. When issues requiring change become apparent, the Department should advocate for change and improvement as necessary and implement new written policies in a timely fashion.
The Board of Inquiry makes the following recommendations:
1. The National Incident Management System (NIMS) has a provision which allows the ranking superior officer to forego assumption of Command. This is done for a number of reasons, one of which is to allow a subordinate officer the opportunity to continue in the role of Incident Commander in order to foster experience and confidence. The superior officer then takes on the role of advisor. When this situation occurs, the ranking superior officer maintains overall responsibility for the incident. In order to avoid confusion on the fire ground, the superior officer must resist the urge to give orders and radio transmissions that would be misinterpreted by those on scene as coming from Command. The Superior officer should announce over the radio that command will remain in the hands of the subordinate position.
2. Continue to emphasize the importance that all members review Standard Operating Procedures (SOPs) on a regular basis and ensure that all Engine Companies follow the guidelines of SOP #205 Engine Company Operations.
3. Identify areas of the City where row-type buildings are prevalent, e.g., Back Bay, South End. The Department should institute a written policy, for these identified areas and other specific occupancies, that assigns the third Engine Company on the first alarm to the Charlie side (rear) of the building, unless otherwise directed by the IC. The assigned Engine Company would announce their arrival, their specific location and give a report on conditions at the rear of the building.
4. Develop a written policy detailing when Engine Companies should charge lines of hose being advanced into a fire building. Additionally, the Department should constantly evaluate the latest fire service research on fire ground tactics and incorporate proven tactical advancements into Department training.
5. Provide input and support for the promulgation of improved thermal resistance testing by the NFPA in conjunction with the testing agencies and hose manufacturers. When approved by the NFPA, the Department should replace existing attack hose with hose meeting the latest standards.
6. Develop an SOP on the use of Thermal Imaging Cameras (TICs) and provide regular refresher training on their operation and use.
7. Develop an inventory control program to include written repair and replacement policies for all critical firefighting equipment, including TICs.
8. Develop a procedure for staging of Boston Emergency Medical Services (BEMS) ambulances and other non-Department assets to ensure they are properly and readily accessible during an incident.
9. Develop a training program on wind driven fires, control of flow paths and coordination of ventilation. This program should train all field personnel how to identify the conditions and locations that could give rise to the extreme fire behavior and growth rate created when these conditions are present. It should establish procedures to combat wind driven fires and similar phenomena based on the latest fire service research on tactics, strategies and specialized equipment.
10. In addition to the daily temperature and wind conditions announcement made by FAO at 0900 and 1900, the FAO should announce whenever elevated wind conditions exist to ensure that ICs and responding companies are aware of the conditions that could affect strategic and tactical decisions.
11.Request that the Boston Water and Sewer Commission review the need for the installation of hydrants on Back Street, in particular, and any other locations in the City where there are insufficient hydrants.
12. Assign a fourth Engine Company on box alarms to areas identified as lacking adequate hydrants, e.g., Back Street. Have the Engine Company stage at the nearest hydrant in preparation to provide a water supply to the rear of the building.
13. Recommend that the Department specify that all newly ordered fire engines have integral flow meters (GPM) and evaluate the possibility of retrofitting existing Engine Companies.
â€¢ Delayed notification to the fire department
â€¢ Uncontrolled ventilation by a civilian
â€¢ Occupied residential building with immediate life safety concerns
â€¢ Scene size-up
â€¢ Lack of fire hydrants on Side Charlie (a private street)
â€¢ Lack of training regarding wind-driven fires
â€¢ Unrestricted flow path of the fire
â€¢ Lack of fire sprinkler system
â€¢ Fire departments should define fireground strategy and tactics for an occupancy that are based upon the organizationâ€™s standard operating procedures. As part of the incident action plan, the incident commander should ensure a detailed scene size-up and risk assessment occurs during initial fireground operations, including the deployment of resources to Side Charlie. Scene size-up and risk assessment should occur throughout the incident.