Lessons from the Fireground: Buffalo (NY) Fire Department
On August 24, 2009, 45-year-old Lieutenant Charles â€œChipâ€ McCarthy and 34-year-old Firefighter Jonathan S. Croom died in an early morning fire after a partial first floor collapse at a mixed occupancy commercial/residential structure.
Basement fires in both residential and commercial occupancies are one of the most challenging tactical operations that present numerous risk factors requiring the highest degree of situational awareness, training skill sets and continuous incident monitoring and assessment to gauge building structural integrity, fire behavior and fire dynamics and corresponding crew integrity and performance.
The predictability of performance in buildings on fire in residential and commercial occupancies varies based on building vintage (age), methods and materials of constructions and structural support components, assemblies and systems that when under duress by fire within the basement compartment create definable risks, limited operational time periods and the need for well coordinate tactical deployments managed under incident and command time compressions that are concurrently impacted by degrading building and systems resiliency and declining material integrity- which lead directly to compromise and collapse conditions.
On August 24, 2009, Fire Lieutenant (Lt Charles â€œChipâ€ McCarthy) and Firefighter (FF Jonathan Croom) died at a mixed commercial/residential structure fire ensuant to a first floor partial collapse.
- The involved buildingâ€™s design was two story flat roof brick and joist Type III construction.
- The first floor consisted of a heavily barricaded delicatessen with an adjacent rear apartment (unoccupied).
- The second floor contained two apartments, of which only the rear unit was occupied.
- The basement was also heavily fortified, with all basement windows covered over in concrete and steel bars.
- Of the two entry points to the basement, one was a barred steel door (below grade) and the other was a heavily secured wooden door accessible only through a panel wall in the first floor delicatessen.
At approximately 0351 hours crews were dispatched to a fire with an accompanying report of civilians trapped in the structure. The first arriving engine was met by a resident who directed them to a side door where he stated he heard trapped civilians calling for help.
Operations focused on this entry (side #2) which led to basement stairs. A simultaneous primary search was undertaken on the second floor since additional information was obtained suggesting possible trapped person(s) there. Incoming units supplemented operations in these areas since verbal reports from bystanders strongly suggested viable victims.
The initial engine on scene and other first arriving units reported fire in the basement, but access was limited with the main entry point through side #2 barred by a metal door set in a masonry wall.
A remote entrance to the basement was searched for through the delicatessen store in the front of the building. Once the general location was ascertained a hand line was stretched to that area from a front entry door on side #1 (1/2 corner). Units operating at the alleyway door (side #2) were not able to gain access through the steel basement door (below grade), and after conditions deteriorated they were ordered out of the structure.
The incident site was a two story, type III, non-fireproof structure, measuring approximately 27-feet wide and 85-feet in length. The structure had a flat roof extending from the front wall approximately 40 feet back. At that juncture the construction changed to a gable type, slate shingled roof rising slightly above the level of the flat roof. The mixed commercial/residential, â€œtax-payerâ€a type structure, built in 1934, was of ordinary construction consisting of wood floors and masonry/brick load bearing walls. The 2nd floor apartment located above the deli had a flat, membrane-type roof, but the rear apartment contained an attic constructed by conventional framing covered with wood planking and a slate roof. All exterior windows on the first floor and casement windows at the basement level had been bricked over for security purposes. There were two doors located on Side 1, 1st floor: one for the deli and one to access the stairway to the 2nd floor apartments. The store front was protected by wire mesh and steel-grated doors/bars on the exterior and solid panels behind the plate glass store fron
The building’s front wall was angled in relation to the rest of the walls, keeping side #1 parallel to Genesee Street while sides #2 and #4 ran parallel to nearby Burgard Place.
The structure was partially attached to an adjacent building located on side #2. The attachment consisted of two second floor walkways that were completely sealed off, blocking access to either structure from its neighbor. The address of the adjacent building was 1817 Genesee, also an ordinary type construction with mixed commercial/residential occupancy.
The first floor consisted of a delicatessen that was heavily fortified. Steel mesh overlaid the front display windows (plate glass). Behind the plate glass there was yet another barrier consisting of solid panels. The main entry point, a commercial door located near the 1/2 corner, had a locked steel security gate in place at the time of the incident.
There were no window openings on either the #2 or #4 side of the delicatessen area. An unused steel entry door was located on the #2 side, approximately 40 feet from the front corner, but it too was heavily barred and the interior blocked by a set of floor coolers. Extending past the delicatessen on the first floor was a vacated apartment unit. The entry point for this unit, which led directly to an interior stairway running from basement to second floor, was located approximately 60 feet from the front corner. This doorway became the main entry point for attempting basement access during firefighting operations. (The fire departmentâ€™s Bureau of Fire Investigation determined the origin of the fire to be the basement under the delicatessen.)
- The deli floor consisted of tongue-and-groove flooring covered by ceramic tile. Structural stability for the deli floor was maintained by joists that ran the length of the deli and two steel beams that ran perpendicular to the joists.
- The wood floor joists rested on the steel beams. The deli floor setup consisted of wall coolers lining the interior walls and display shelves placed throughout the deli space.
- (Note: According to building officials, the dead load rating for the floor was 80 pounds per square foot, and it was not believed to have been over loaded at the time of the incident.)
- The basement contained excess stock for store operations, coolers, and other store/deli equipment.
- The fire department conducts preplan inspection of occupied structures and recently implemented a hazard identification program of abandoned structures. (2009)
It was determined by Command that the fire had progressed to the point where companies operating inside the structure were greatly endangered and ordered to evacuate.
It was determined by Command that the fire had progressed to the point where companies operating inside the structure were greatly endangered and ordered to evacuate.
At approximately 0422 hours members of Rescue 1 entered the delicatessen to verify all firefighters were evacuated from the first floor. Less than two minutes after their entry the structural members supporting the floor collapsed under and around a set of commercial wall coolers located at the rear of the delicatessen. Rescue 1 Lieutenant (Lt McCarthy), while searching along an established hand line running adjacent to these coolers, fell into the basement as the floor collapsed under him.
The other members of Rescue 1 were unaware of the collapse, only reporting that a loud noise was heard. The Lieutenant immediately began issuing calls for help over the radio and to those in proximity. The remaining members of Rescue 1 could not determine the origin of the â€œmaydayâ€ since the lieutenant was now below their grade level. They exited the building from side #1 unaware that their officer was the endangered member.
Command deployed the Firefighter Assist and Search Team (FAST â€“ Ladder 7) to side #2 of the structure where it was thought the â€œmaydayâ€ was emanating. Simultaneous to this FF Croom (Ladder 7), stationed in front of the building with his crew, heard the calls for help and ascertained that the distressed firefighter had entered from side #1. At approximately 0423 hours FF Croom entered the front of the building through the delicatessen door to initiate a rescue of the trapped member. FF Croom did not exit the structure after this point, apparently falling through the first floor into the basement in close proximity to Lt McCarthy.
- Command prioritized the identification/rescue of what was believed to be one unknown victim, unaware that a second member had fallen through while undertaking a rescue attempt.
- At approximately 0431 hours the Rescue Group Chief ordered an â€œemergency head countâ€ to ascertain which member was missing.
- At 0432 hours it was reported through the headcount process that Lt McCarthy of Rescue 1 was missing.
- FF Croom was not reported missing at this point in the operation, as his company officer had responded to Dispatch that they were â€œOKâ€ at the time.
Rescue operations eventually focused on the first floor delicatessen (rear of store) since all members operating at the basement door (side #2) were accounted for with low probability of endangered personnel in that area. Firefighters operating in the storefront reported hearing a pass alarm activated but could not reach its origination due to extreme fire conditions, weakened flooring and continuing collapse. Command determined that it had become unsafe for interior operations and at approximately 0448 hours crews were ordered out of the structure.
Concerns began to arise later on in the operation that FF Croom was no longer accounted for. Multiple attempts to verify his whereabouts were undertaken and he was erroneously reported to be located operating in a remote area. At approximately 0546 it was evident to on scene personnel that FF Croom was missing and his location unknown, but likely somewhere inside the structure. At 0610 hours another head count was undertaken and FF Croom was reported as missing by his company officer.
- Over the course of the next three hours a massive effort to reach the collapse area was made. Fire conditions and concern over structural stability hindered attempts to reach the victims.
- The exterior wall on side #4 was eventually breached to gain access to this section of flooring in the delicatessen.
- The department collapse team attempted shoring of this wall and the interior floor of the delicatessen.
- At 0918 hours the Recovery Group Chief reported that members had located the two missing firefighters, reportedly covered with fallen debris and below grade in the aforementioned site.
Recovery Group firefighters were able to clear debris and reach Lt McCarthy and FF Croom by 0932 hours. Command arranged for an ambulance to be placed on standby, and from approximately 0940 â€“ 0945 hours both fallen members were removed from the structure and transported to the hospital. Command placed the incident at 1815 Genesee Street under control at 0948 hours.
Apparatus and Personnel
0350 hours dispatch – Initial dispatch included:
- Engine 31 (Officer, firefighter/driver and 2 firefighters);
- Engine 22 (Officer, firefighter/driver and 2 firefighters);
- Engine 23 (Officer, firefighter/driver and 2 firefighters);
- Ladder 14 (Officer, firefighter/driver and 2 firefighters);
- Ladder 6 (Officer, firefighter/driver and 2 firefighters);
- Ladder 7 (Officer, firefighter/driver and 2 firefighters);
- Rescue 1 (Officer, firefighter/driver and 3 firefighters);
- EMS Lieutenant (F20)
- 3rd Battalion Chief (B43) – Initial Incident Commander (IC)
- Division Chief (B56) – Shift Commander; Incident Commander (IC)
0353 hours dispatch â€“ Extra Companies
- Engine 33(Officer, firefighter/driver and 2 firefighters)
- Engine 28(Officer, firefighter/driver and 2 firefighters)
- Ladder 15 (Officer, firefighter/driver and 2 firefighters)
0414 hours dispatch â€“ Balance of 2nd Alarm
- Engine 21 (Officer, firefighter/driver and 2 firefighters)
- Ladder 2 (Officer, firefighter/driver and 2 firefighters).
- Department Safety Chief (B41)
- 4th Battalion Chief (B44)
- BFD Commissioner (C1)
- BFD Deputy Commissioner (B51)
- BFD Deputy Commissioner (B53)
0444 hours dispatch – 3rd Alarms
- Engine 34 (Officer, firefighter/driver and 2 firefighters);
- Engine 35 (Officer, firefighter/driver and 2 firefighters);
- Engine 3 (Officer, firefighter/driver and 2 firefighters);
- Ladder 4 (Officer, firefighter/driver and 2 firefighters);
- Ladder 5 (Officer, firefighter/driver and 2 firefighters);
- 6th Battalion Chief (B46)
The insistence by civilians of trapped victims was never resolved during fire operations. The Commissioner of Fire ordered a complete examination of the structure to ascertain if there were victims remaining. After demolition and inspection no persons were found. The insistence of bystanders that people were inside proved unfounded.
Buffalo (NY) Fire Department- December, 2009: 1815 Genesee Street Report HERE
NIOSH FIRE FIGHTER FATALITY INVESTIGATION AND PREVENTION PROGRAM Report
From the NIOSH Report
On August 24, 2009, a 45-year-old male career lieutenant (Victim #1) died following a partial floor collapse into a basement fire, and a 34-year-old male career fire fighter (Victim #2) was fatally injured while attempting to rescue Victim #1.
- The career fire department was dispatched for â€œan alarm of fireâ€ with reported civilian(s) entrapment. Arriving units discovered a heavily secured mixed commercial/residential structure with smoke showing.
- Following failed initial attempts to locate an entry to the basement, crews located a door on Side 2 that provided access down a flight of stairs to a basement entry door.
- Repeated attempts were made to force open this basement door in order to search for trapped civilians, but crews had difficulty gaining access through this door because it was made of steel and locked and dead-bolted on both sides.
- Other crews on scene performed primary searches of the 1st and 2nd floors with no civilians found.
Approximately 30 minutes into the basement fire, command ordered all interior crews to exit the structure to regroup because crews were still unable to gain access into the basement from Side 2.
Additional manpower was sent with special tools to assist in breaching the basement door on Side 2.
Victim #1 and two fire fighters from his crew entered into the structure from Side 1 to verify all fire fighters had exited a 1st floor deli. Victim #1, following a hoseline into the structure, was well ahead of the other two fire fighters when the 1st floor partially collapsed beneath him. Victim #1 fell with the floor into the basement, exposing him to the basement fire.
The other two fire fighters immediately exited the deli after fire conditions quickly changed and shelving and displays fell on them; they were unaware of what had just occurred. Victim #1 made several Mayday calls from within the structure and activated his PASS device. Confusion erupted exteriorly on scene when trying to verify who was calling the Mayday, their exact location, and how they got into the basement.
The incident commander was aware that he had crews attempting to gain access into the basement from Side 2 but was unaware that there had been a floor collapse within the deli section of the structure.
Simultaneously, Victim #2, a member of the fire fighter assistance and search team (FAST), was standing by outside Victim #1â€™s point of entry when the Mayday calls came out. It is believed that Victim #2 knew where Victim #1 was since he had gone in the structure with him earlier in the incident. Victim #2 grabbed a tool, went on air, and rushed into the structure.
The FAST and additional personnel on scene concentrated on Side 2 initially while other fire fighters followed an unmanned hoseline into the deli. Crews within the deli quickly discovered a floor collapse and reported hearing a PASS device alarming. Victim #1 was immediately identified as missing during the first accountability check, but Victim #2 was not accounted for as missing until the third accountability check, more than 50 minutes after Victim #1â€™s Mayday.
After the fire was controlled, both victims were discovered side-by-side in the basement where the 1st floor had partially collapsed. They were found without their face pieces on and with SCBA bottles empty. Victim #1â€™s PASS device was still alarming.
They were pronounced dead on scene. Four fire fighters and one lieutenant suffered minor injuries during the incident.
No civilians were discovered within the structure.
Key contributing factors identified in this investigation include working above an uncontrolled, freeburning basement fire; interior condition reports not communicated to command; inadequate risk versus- gain assessments; and, crew integrity not maintained.
NIOSH has concluded that, to minimize the risk of similar occurrences, fire departments should:
- Ensure that all personnel are aware of the dangers of working above a fire, especially a basement fire, and develop, implement, and enforce a standard operating procedure (SOP) that addresses strategies and tactics for this type of fire.
- Ensure that the incident commander (IC) receives interior status reports and performs/continues evaluating risk-versus-gain.
- Ensure that all personnel are aware of the dangers of working above a fire, especially a basement fire, and develop, implement, and enforce a standard operating procedure (SOP) that addresses strategies and tactics for this type of fire
- Ensure that the incident commander (IC) receives interior status reports and performs/continues evaluating risk-versus-gain.
Additionally, manufacturers, equipment designers, and researchers should:
Conduct research into refining existing and developing new technologies to track the movement of fire fighters inside structures.
- Continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communication in conjunction with properly worn self-contained breathing apparatus (SCBA).
This timeline is provided to set out, to the extent possible, the sequence of events. Times are approximate and were obtained from review of the dispatch records, witness interviews, photographs of the scene and other available information.
Some events may not have been included and many arrival times of units were not available. The timeline is not intended, nor should it be used, as a formal record of events.
- 0349.02 Hours 911 center receives a call for a fire inside a store
0350.00 Hours 911 center receives a call from alarm company of motion detector going off in basement area.
- 0350.35 Hours 911 center receives a call back from original caller stating, â€œSomeoneâ€™s inside.â€
- 0351.36 Hours 911 center dispatches E31, E22, E23, L14, L6, R1, L7 (as FAST), and B43 for â€œAlarm of fire, occupants still inside.â€
- 0352.27 Hours E31 en route from quarters and can see smoke and acknowledges report that people are trapped.
- 0353.01 Hours E31 arrives on scene and is met by unknown individual telling crew he heard people pounding and yelling on Side 2.
- 0353.14 Hours E31 officer advises dispatch they have reports from civilians of people trapped and there are steel gratings over doors and windows. While en route to the scene, B43 requests an extra â€œ2 and 1â€ to stage. Note: â€œ2 and 1â€ refers to two engines and one ladder truck, and these apparatus were part of the 2nd alarm assignment.
- 0353.52 Hours B56 en route.
- 0354.04 Hours Extra 2 and 1 dispatched that includes E33, E28, and L15.
- 0354.57 Hours L14 reports possible basement fire and heavy smoke visible.
- 0355.31 Hours B43 advises dispatch to have additional â€œ2 and 1â€ stage at cross street.
- 0356.32â€”0356.43 Hours E31 reports to B43 with confirmed basement fire. B43 acknowledges and arrives on scene taking initial command of the incident.
- R1 personnel make entry onto 2nd floor to conduct a primary search.
- 0357.59 Hours B43 updates dispatch on description of structure, search and rescue operations on the 2nd floor, and entry operations on Side 2. L7 (FAST) on location.
- 0359.02 Hours B56 arrives on scene.
- 0359.23 Hours Officer of E22, over radio, reports to B43 that a hoseline is being laid into basement and a second line is being laid in (second line laid in by E31). Note: The hoseline to the basement is only laid down a flight of stairs on Side 2 to the basement door.
- 0400.30 Hours Radio transmission from R1, â€œLooks like weâ€™re moving right alongâ€¦threeâ€¦ .â€
- 0402.30 Hours B56 assumes command and advises dispatch that there is no fire on the 1st floor or apartments, a 1Â¾-in line laid and in operation with two additional 1Â¾-in hoselines available, he will hold everyone he has on scene including the extra â€œ2 and 1.â€ B56 checks on location of E31. E31 advises B56 that they are in the basement. Note: L14 is still trying to breach the basement door; door is partially opened at top.
- 0404.37 Hours B43 advises B56 that witnesses believe victims may be in the basement.
- 0405.07 Hours B56 advises R1 that civilians stated that they heard pounding on a door in the basement. R1 advises B56 that the 2nd floor is negative and asks if the roof has been opened. L6 advises bulkhead is open.
- 0406.10 Hours B56 checks on location of E22. E22 advises they are working on the 1st floor (rear apartment) and flowing water on fire on Side 4 of the structure. L6 reports to B56 that chimney on roof is pushing smoke heavily.
- 0406.32 Hours B56 tells L6, â€œYeah, ok, I think we do have a basement fireâ€¦I believe weâ€™ve got 31 down in the basement.â€
- 0407.05 Hours B56 acknowledges radio transmission from Victim #1, â€œOk, you say you found the stairs to the basement, theyâ€™re where you thought they were in the rear of the 1st floor.â€ Note: Victim #1 was on the 1st floor inside the deli and his radio was on â€œdirect mode,â€ which was a nonrepeated or recorded channel. Only radios scanning and within a certain radius of his radio could copy his transmission. It is suspected that Victim #2 is with Victim #1 at this time. B43 asks, â€œR1, do you have a camera with youâ€”be carefulâ€¦that is clear, do what you can, but if it gets bad get out.â€ Note: It is believed B43 is talking to Victim #1.
- 0407.47 Hours B56 checks on location of E23. E23 is working on 2nd floor.
- 0409.15 Hours L14 officer reports primary search of the 2nd floor is negative and that there is no fire extension to that area.
- 0409.35 Hours E22 asks for ventilation on the 1st floor.
- 0409.50 Hours B56 acknowledges E22 request for ventilation on 1st floor, and he advises E22 that he has E23 coming in Side 1 with a hoseline. Note: E23 was going to advance this hoseline to a believed basement interior door that Victim #1 had discovered while searching the deli. Victim #1 had already exited the deli from Side 1 and advised B56 that he heard people calling out and banging. The fire department believes that Victim #1 may have mistaken the crew of E22, who was working behind the coolers in the same area, as being trapped civilians. Witnesses state that Victim #1 assisted in redeploying E23â€™s hoseline.
- 0410.20 Hours B56 requests L7 (FAST) to do what they can to ventilate the 1st floor.
- 0411.01 Hours Dispatch advises B56 that they are 20 minutes into the incident. B56 advises dispatch that they are now operating three 1Â¾-in hoselines, performing an aggressive interior search, and â€œwe still have a report of civilians trappedâ€¦we believe they may still be in the basement.â€
- 0412.40 Hours B56 repeats transmission from R1, â€œThatâ€™s clear; youâ€™ve got water on fire in the basement, still burning hot.â€ Note: B56 was talking to Victim #1. It is believed he was spraying water into the basement from the deli floor through a burned-through area at the rear of the deli on Side 4.
- 0413.36 Hours B56 requests balance of 2nd alarm to stage on a cross street.
- 0414.30 Hours Dispatch dispatches balance of 2nd alarm: E21, L2, B41, and B44.
- 0415.20 Hours E22 radios B56 stating, â€œCouldnâ€™t get door open in the basement. Everyone is coming out Side 2.â€
- 0417.11 Hours B56 advises dispatch that they are pulling all companies out of the 1st floor due to an inaccessible steel door on Side 2.
- 0419.20â€”0420.26 Hours Fire department reports that Victim #1, no longer with the E23 crew working within the deli, spoke to B56 in person regarding the interior conditions of the deli when he was with E23. B43 also meets with Victim #1 and B56 regarding conditions within the deli.
- 0420.40â€”0421.01 Hours B56 advises B43 that he is sending E31, E33, and L14 to basement door on Side 2 to force entry with a rabbit tool. B43 copies B56 and advises him that the store owner has provided him with a key possibly to the basement door on Side 2. B43 advises B56 that conditions on the 1st floor (rear apartment) are deteriorating.
- 0421.18 Hours Last visual sighting of Victim #1 outside the structure. At some point, Victim #1 re-enters the deli with R1 personnel to clear the deli.
- 0421.22 Hours B56 repeats B43â€™s previous transmission for verification. The fire department dispatcher confirms 1st floor conditions are deteriorating per B43 and advises B56 that they are 30 minutes into the incident. B56 acknowledges. B56 checks on L14 and status of basement door on Side 2. Garbled response is heard from L14.
- 0422.40 Hours Believed time of partial floor collapse of 1st floor into basement.
- 0423.06 Hours B56 transmits over radio, â€œWas that a Mayday?â€
- 0423.07-0423.21 Hours R1 transmits over radio, â€œI believe I hear screaming in the front of the basement Side 1.â€ B43 transmits over radio, â€œWhose yelling?â€ Several additional transmissions from B56 to Victim #1 attempting to verify location. Victim #2 begins to enter the deli through Side 1, but is pushed back by exiting R1 personnel.
- 0423.42 Hours Victim #2 enters through the deli door. Note: This was viewed from raw video footage.
- 0423.47 Hours B56 splits rescue and fire operations to two different channels; B43 in charge of rescue. B56 orders B43 to take the FAST to the basement Side 2.
- 0424.22 Hours A PASS alarm is heard from within the deli.
- 0424.34 Hours B56 contacts L14 to obtain update on what is happening in the basement on Side 2. Note: B56 believes that a fire fighter operating on Side 2 is his â€œMayday victim.â€ B56 is unaware of the floor collapse within the deli.
- 0426.58 Hours B43 on radio states, â€œâ€¦to fire fighter in basement what is your last known location?â€ B56 on radio states, â€œâ€¦did you enter the basement from Side 1 or 2?â€
- 0428.15 Hours R1, on fire operations channel, states, â€œâ€¦fire fighter fell through 1st floorâ€¦need waterâ€¦front of building.â€
- 0428.56 Hours Unknown transmission, on rescue channel, to B43 stating, â€œ43 fire broke through, fire broke through.â€
- 0429.34 Hours R1 reports on fire operations channel, â€œâ€¦hear him (PASS device) 1st floor near the back; not sure if heâ€™s in basement or not.â€
- 0431.02 Hours B43 orders emergency head count from rescue channel.
- 0431.06-0434.07 Hours Companies confirm assigned personnel. L7 (FAST) officer states status â€œokay.â€ Note: Victim #2 is not with other crew members of L7 (FAST). R1 reports missing Victim #1.
- 0434.42 Hours B56 advises that he will stay in command, B43 will remain in charge of rescue operations, and B44 will take over incident operations.
- 0435.08 Hours R1 reports Victim #1 last seen going in Side 1, possibly into a hole 10 ft down.
- 0436.09 Hours B56 advises B43 that he has reports that our member may have dropped into the basement through a hole in the 1st floor. E21 is trying to get to him, but it is untenable. Identity of Victim #1 verified by R1 members and dispatchâ€™s roll sheet.
- 0444.10 Hours 3rd alarm is dispatched.
- 0447.20 Hours All crews operating on 1st floor of deli are ordered out by B44.
- 0451.01 Hours Emergency head count ordered by B56. L7 officer states, â€œAll okay.â€ Note: Victim #2 is not with his crew. Fire becomes defensive with crews working on all sides on suppression and rescue/recovery operations.
- 0457.39 Hours Rescue/Recovery operations beginning on Side 4 by breaching through brick wall.
- 0510.20 Hours L7 officer over the radio states, â€œfire fighter ____, your location.â€ Note: This is the first acknowledgement that Victim #2 may be missing.
- 0511.09 Hours L7 officer over radio states, â€œFire fighter ____, acknowledge.â€
- 0511.53 Hours Dispatch over radio states, â€œDispatch to fire fighter ____ of ladder 7, Dispatch to fire fighter ____, of ladder 7, acknowledge.â€
- 0515.30 Hours L7 officer over the radio states, â€œFire fighter ____ acknowledge your locationâ€¦anybody seen fire fighter ___.â€ Unknown individual transmits over radio, â€œHeâ€™s got him here.â€ Note: The last names of Victim #2 and the other individual sound alike.
- 0524.28 Hours L7 officer over radio states, â€œFire fighter ____, acknowledge your presence.â€
- 0525.08â€”0529.27 Hours B56 asks dispatch to raise fire fighter ____ from ladder 7. Dispatch advises, â€œThey found him 10 minutes ago.â€ Dispatch raises tones and asks for fire fighter ____ to acknowledge several times. Dispatch notifies B56 of no response. B56 contacts the officer of L7.
- 0546.10 Hours Crews re-enter the deli to assess collapse and debris.
- 0547.44 Hours Dispatch contacts B56 on the radio to see if Victim #2 had been located. B56 advises they have not located Victim #2.
- 0553.07 Hours Crews within the deli are ordered out of the structure.
- 0610.35-0614.05 Hours B56 advises dispatch to perform a head count for the incident. Dispatch performs head count. L7 officer advises dispatch they are missing one (Victim #2). Note: His exact whereabouts unknown.
- 0804.13 Hours Rescue/Recovery operations initiated on Side 1 in conjunction with Side 4 operations.
- 0918.36 Hours Interior rescue/recovery crew on Side 1 from deli floor makes visual contact of two fire fighters. Confirmed as Victim #1 and Victim #2 in basement.
- 0932.21 Hours Hands on Victims #1 and #2.
- 0939.12 Hours Victim #1 and Victim #2 removed from structure.
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality.
NIOSH investigators identified the following items as key contributing factors in this incident that may have led to the fatalities:
- Working above an uncontrolled, free-burning basement fire.
- Interior condition reports not communicated to command.
- Inadequate risk-versus-gain assessments.
- Crew integrity not maintained.
The following are a series of considerations in no special order to think about;
Safety Considerations related to Residential Occupancies (non-inclusive)
â€¢ Conduct a thorough fire size-up and communicate the findings to all personnel on-scene before entering the building.
â€¢ Conduct an assessment of the Building Profile (building construction type, structural assembly systems and features and age) and assess fire behavior and intensity levels.
â€¢ Identify probable Predictability of Building Performance based on assumed basement compartment size and volume, primary types of structural support systems, presence of alternate support systems (i.e. steel beams, engineered wood components etc.) Inclusion of possible occupancy hazards or inherent building features and presence or absence of inlet and outlet openings.
â€¢ For large basement compartments (square foot and volume): consider connectivity of rooms and access stairway points and layout complexities.
â€¢ Conduct a 360 degree perimeter assessment when feasible to determine access and egress points, fire location and travel and other mission critical operational parameters.
â€¢ Ensure an adequate Risk Assessment is conducted and operational factors are determined
â€¢ Maintain situational awareness throughout the tactical deployment of crews within the interior of the structure.
â€¢ Incident commanders and company officers should be trained and experienced in structure fire size up to avoid putting fire fighters at unneeded risk of working above fire-damaged floors.
â€¢ Consider discretionary tactical options for fire suppression for direct, indirect and remote suppression /flow points
â€¢ Do not enter a structure, room, or area when fire is suspected to be directly beneath the floor or area where fire fighters would be operating, or if the location of the fire is unknown.
â€¢ Never assume structural safety of any floor (regardless of the construction) having a significant fire under it.
â€¢ Conduct pre-incident planning inspections during the construction phase to identify the type of floor construction.
â€¢ If pre-planning is not conducted, assume residential buildings and occupancies built since the late 1990s have a high probability of having engineered structural systems (ESS) as floor assemblies with those built after 2000 with a variation of ESS, larger spans and integral wood and steel support assemblies, components and systems that are highly interdependent and prone to catastrophic failures and collapse versus isolated compromise.
â€¢ Report construction deficiencies noted during preplanning to local building code officials. For example, engineered wood floor joists should only be modified per manufacturer specifications usually limited to cutting to length and removing precut knockouts for utility access. Report damaged or cut chords or webs to building officials.
â€¢ Develop, enforce, and follow standard operating procedures (SOPs) on how to size up and combat fires safely in buildings of all construction types. Rapid intervention teams (RIT) should include a portable ladder with their RIT equipment when deployed at incidents involving basement fires.
â€¢ Ensure Time Compression is considered: Ensure Command has the ability to monitor progress or elapsed incident time and adjusts strategic and tactical plans accordingly and in a time effective manner.
â€¢ Provide training on identifying structural floor systems and the corresponding indications of weakened or compromised floor systems
â€¢ Ensure fire fighters are aware that all floor types can fail with little or no warning and that tactical deployments and task operations require fluid reassessment during the conduct of operations
â€¢ Consider the effects of flow paths, ventilation, projected fireload package, building anatomy and company level (personnel) experience and capabilities when determining tactical deployment and engagement
â€¢ Use a thermal imaging camera to help locate fires burning below or within floor systems, but recognize that the camera cannot be relied upon to assess the strength or safety of the floor. (Refer to the UL Test Data and Operational Safety Considerations Structural Stability of Engineered Lumber in Fire Conditionsâ€ available at http://www.uluniversity.us/
â€¢ Fire fighters should be trained on the use of thermal imaging cameras, including limitations and difficulties in detecting fire burning below floor systems. (See reference to UL above)
â€¢ Immediately evacuate and, if possible, use alternate exit routes when floor systems directly beneath the floor where fire fighters would be operating are weakened by fire.
â€¢ Use defensive overhaul procedures after fire extinguishment in structures containing fire-damaged floor systems of all types.
â€¢ Ensure that a rapid intervention team (RIT) is on the scene as part of the first alarm and in position to provide immediate assistance prior to crews entering a hazardous environment.
â€¢ Ensure RIT personnel area staged and have complete a site assessment of the building and occupancy upon their arrival and set-up.
â€¢ Identify and apply the Lessons from the Fireground from case studies, near-miss reporting and line of duty death report recommendations that may be applicable to your department, agency, community risk profile and buildings and occupancies.
Take the time to review the Lessons Learned from this Near-Miss event from 2010
July 28, 2010 Single Family Residential Basement Fire, Fairdale, Kentucky
Captain Michael Long: Near-Miss Close Call, Camp Taylor (KY) Fire Protection District
â€¢ Podcast on Taking it to the Streets with Chris Naum & Captain Long and Guests (March 16, 2011) http://www.firefighternetcast.com/archives/1108
Another pertinent LODD report that all officers and commanders should study:
April 11, 2006 Single Family Residential Basement Fire 1008 SF: Franklin Township-Somerset County, New Jersey FF Kevin Apuzzio LODD East Franklin (NJ) Fire Department
Here are some resources and case studies resulting from operations at floor collapses;
- NIOSH ALERT: Preventing Deaths and Injuries of Fire Fighters Working Above Fire-Damaged Floors
- UL University CBT: â€œStructural Stability of Engineered Lumber in Fire Conditionsâ€
- Eleven Minutes to Mayday; What You Need to Know, Here
- NIOSH Fire Fighter Fatality Investigation Report F2008-09| CDC/NIOSH July, 2009, Report HERE
- Buffalo, NY Three Alarm Fire and Double LODD Report
- Remembering Brackenridge 1991 Floor Collapse and LODD
- Brackenridge-USFA Report; HERE
- Brackenridge-NFPA Summary; HERE
- Maintaining Situational Awareness
UL Knowledge Services:The main objective of this study was to improve firefighter safety by increasing the level of knowledge on the response of residential flooring systems to fire.
New Dynamics of Basement Fires. Basement fires are among the most dangerous. UL plays a critical role in examining the hazards associated with various types of residential flooring systems to better understand this risk.
Basement Fire Computer Modeling; Demonstrates how modeling can help predict fire growth and spread within a variety of residential basement scenarios that all feature unprotected wood ceilings.
Improving Fire Safety by Understanding the Fire Performance of Engineered Floor Systems
NIOSH FIRE FIGHTER FATALITY INVESTIGATION AND PREVENTION PROGRAM- Select Collapse Reports
|Report No.||Incident Date||Title|
|F2013-02||Jan 22, 2013||Volunteer captain dies after floor collapse traps him in basement â€“ New York.||PDFÂ|
|F2009-23||Aug 24, 2009||Career lieutenant dies following floor collapse into basement fire and a career fire fighter dies attempting to rescue the career lieutenant â€“ New York.||PDFÂ|
|F2008-26||Jul 22, 2008||A volunteer mutual aid fire fighter dies in a floor collapse in a residential basement fire â€“ Illinois.||PDFÂ|
|F2008-09||Apr 08, 2008||A career captain and a part-time fire fighter die in a residential floor collapse â€“ Ohio.||PDFÂ|
|F2007-07||Nov 16, 2007||Volunteer fire fighter dies after falling through floor supported by engineered wooden-I beams at residential structure fire â€“ Tennessee.||PDFÂ|
|F2006-26||Aug 13, 2006||Career engineer dies and fire fighter injured after falling through floor while conducting a primary search at a residential structure fire â€“ Wisconsin.||PDFÂ|
|F2006-24||Jun 25, 2006||Volunteer deputy fire chief dies after falling through floor hole in residential structure during fire attack â€“ Indiana.||PDFÂ|
|F2004-05||Jan 09, 2004||Residential basement fire claims the life of career lieutenant â€“ Pennsylvania.||PDFÂ|
|F2002-11||Mar 04, 2002||One career fire fighter dies and a captain is hospitalized after floor collapses in residential fire â€“ North Carolina.||PDFÂ|
|F2002-06||Mar 07, 2002||First-floor collapse during residential basement fire claims the life of two fire fighters (career and volunteer) and injures a career fire fighter captain â€“ New York.||PDFÂ|
|F2001-27||Jun 16, 2001||Career fire fighter dies after single-family-residence house fire â€“ South Carolina.||PDFÂ|
|F2001-16||Mar 08, 2001||Career fire fighter dies after falling through the floor fighting a structure fire at a local residence â€“ Ohio.||PDFÂ|
|F2001-15||Mar 18, 2001||Residential fire claims the lives of two volunteer fire fighters and seriously injures an assistant chief â€“ Missouri.||PDFÂ|
|99-F03||Jan 10, 1999||Floor collapse claims the life of one fire fighter and injures two â€“ California.||PDFÂ|
|98-F17||Jun 05, 1998||Sudden floor collapse claims the lives of two fire fighters and four are hospitalized with serious burns in a five-alarm fire â€“ New York.||PDFÂ|
|97-04||Feb 17, 1997||Floor collapse in a single family dwelling fire claims the life of one fire fighter and injures another â€“ Kentucky.||PDFÂ|