“Near Miss” at Bread-and-Butter Fire

BY SKIP HEFLIN

On Saturday, August 4, 2007, at 14:29:07 hours, Hall County (GA) Fire Services responded to a report of a residential structure fire that resulted in the injury of one of our firefighters. This was as close to a firefighter fatality as you can get. It was a bread-and-butter fire that turned out to be anything but.

A neighbor reported a residential building fire at 5945 Chimney Springs Road. Four engine, two medic, and two rescue units and a battalion chief responded on the first alarm. On arrival, the lieutenant on the first-in engine sized up the structure: 4,000 to 5,000 square feet, two stories and a basement. Smoke was showing. The lieutenant completed a walk-around and determined that entry should be made on the A side of the structure, first floor, with a 1¾-inch handline.

MAYDAY CALLED

The lieutenant, a firefighter/paramedic, and a firefighter/EMT made entry, sounding the floor for stability. After progressing about 10 feet into the structure, the floor collapsed, and Firefighter Angie Roach fell through to the basement. The lieutenant called a Mayday and instructed incoming units to go to the basement to search for the firefighter. A second alarm was sounded. Another engine and medic unit and a battalion chief responded. Another engine and a battalion chief were requested through mutual aid from a nearby department. The lieutenant notified the staff officers of the events. Emory Flight was placed on air alert and reported that it would be heading for our site.

(1) The hole through which Firefighter Angie Roach fell after entering the structure with her crew. (Photos by author.)

The lieutenant flowed water into the floor opening to protect the downed firefighter. A second 1¾-inch handline was deployed to the basement. The crew assigned to the basement entered the structure searching for the downed firefighter. After she fell, the victim firefighter attempted to crawl and found that she was only able to crawl several feet before becoming entangled in debris that had fallen on her. In extreme pain from the heat, she kept attempting to free herself. She realized that her PASS device would not sound with constant movement. In a fine example of courage, she remained still for the 30 seconds it required to allow her PASS device to alert.

(2) The fire room into which Roach fell had a very high fuel load. At least 50 percent of the debris (fuel load) was removed before this photo was taken.

Roach was found on the A side of the basement in a mechanical closet that housed the water heater and HVAC unit. The crew removed her from the structure through a hole in the basement garage door, where they entered and began medical treatment. Emory Flight transported Roach to the Grady Memorial Burn Center in Atlanta for treatment. She had suffered multiple second- and third-degree burns to approximately 35 percent of her body and remained in the burn center for 38 days.

(3) The floor in this area was covered only by these boards. The 2 × 10 joists and one-half-inch subfloor were completely burned through. This is the 3⁄8-inch, glue-down, laminate flooring covering the area through which Roach fell. All of the flooring was recovered from the fire room debris; thermal damage was found only on the bottom side. The entire surface area of the hole, except for one and a half inches, was recovered. We believe this was in place when she placed her weight on it.

The mechanical room was the room of origin for the fire. It is believed that the fire in the mechanical room burned, filling the house with smoke, displacing the oxygen, and consuming the fuel left in the room until it was out of oxygen. The fire in the room, therefore, was in the decay stage until Roach fell into the room, inadvertently supplying a rush of fresh air (oxygen) to the fire. The spot through which she fell was covered by a 3⁄8-inch floating floor, the only portion of the floor still intact when she fell. The floor system consisted of 2 × 10 floor joists with ½-inch plywood and then a 3⁄8-inch composite wood laminate floating floor.

SEARCHES

The basement crew reentered the basement, completed a primary search, and extinguished the remaining fire there. They found no victims in the primary search. The incident commander established an on-deck area, assigned personnel to staff rehab, and assigned a crew to a rapid intervention team (RIT). Positive-pressure ventilation was established. While the crew operated in the basement, another crew was assigned to advance a 2½-inch handline into the first floor. The crew completed a primary search of the first floor and extinguished the remaining fire on the first floor. Another crew with a 1¾-inch hoseline was assigned to the second floor to perform a primary search. After the search was completed, the crew began searching for fire extension. Utilities (gas and power) were secured. A secondary search was completed, and, again, no victims were found. The crews, equipped with two 1¾-inch handlines, a booster line, and a thermal imaging camera (TIC) to look for hot spots throughout the structure, completed salvage and overhaul operations.

LESSONS LEARNED

Several key factors played a major role in the outcome of this incident. The downed firefighter did not remove her SCBA mask. During safety and survival training, our firefighters are taught standard actions for a lost or trapped firefighter. These actions are printed on a card that is given to every firefighter who goes through the training. The injured firefighter acted as if she had one of these cards in front of her during her ordeal. She followed it to the letter. Her lieutenant used a hoseline to extinguish the fire into which she fell; he also used the hoseline to cool her. We do not believe any of her burn injuries were caused from this action. The RIT that was formed did an exceptional job of getting her out in the time they did, especially considering the debris through which they had to go to enter and return. Without these key elements, the outcome may have been very different.

(4) Roach’s protective clothing held up well considering the circumstances. The charred area shown here indicates the area of her body that suffered third-degree burns.

Our department has since developed standard operating procedures on thermal imaging and rapid intervention operations; training is also included. Plans for the procedures and training were already in the works, but they have since received more urgent attention.

(5) Thermal damage is evident on the left side of the coat liner.

Additional lessons include the following:

• Accountability.A separate person should be assigned as the accountability officer early in the incident. The incident commander (IC) has so much to deal with; it is difficult to account for everyone.
• Safety officer. Early assignment of an incident safety officer will help provide information to the IC that will keep the tactical plan safe, effective, and appropriate.
• Mayday SOP. If a Mayday is declared, the IC must ensure that all nonMayday-related traffic is moved to another talk group on the radio. This ensures that the victim firefighter, the RIT, and the IC will have a clear method of communication.
• Communications model. Before using the radio, think about what you will say before keying the mic. Make sure you are on the correct talk group to ensure your message is clear and accurate and doesn’t confuse those on the fireground. Many of the communications that occurred during this incident were verbal and, therefore, were not transmitted over the radio.
• Terminology. Use common terminology to avoid confusion when information is transmitted.
• Communications infrastructure. The infrastructure of the communication system must work in all areas of operation. If this is not possible, identify the areas where communications are limited or nonexistent before operating in those areas. Consider the use of a simplex talk group. The victim firefighter’s radio did not work after falling into the hole, which caused it to go out of signal range. We had just placed a new 800-MHz radio system in service and at that time were experiencing out-of-range tones in certain areas, such as portions of this basement area and the room into which she fell. The manufacturer has worked with us and has since corrected the problem.
• Complacency.As crews at this incident proved, you must treat every incident in the same way, to ensure the highest level of safety. The report of light smoke showing can still lead to tragedy.

• Thermal imaging cameras. Use the TIC early in the incident. Check the ceiling and floor area with a TIC before entering any fire building. A TIC was not present early in this incident; in fact, the RIT that removed the victim firefighter did not have one available at that time. We have since secured funding to purchase enough TICs to have one on each engine and rescue truck and one for use in the training division. Crews entered the building believing the fire was on the first floor; it was in the basement. The first-in crew did not have a TIC to check for the fire before entering the structure. At the time of the incident, our department owned four TICs. At the time, only two were in service, one on Rescue 7 and one on Engine 4.
• Rapid intervention team.Establish a RIT early for any incident that involves an immediately dangerous to life and health environment (IDLH). This cannot be emphasized enough. This will ensure that a team is ready at all times to assist firefighters operating in the IDLH.
• Location of the rehab and on-deck areas.Always try to separate these two areas slightly. When they are too close together, personnel have a tendency to be unprepared after being assigned to the on-deck area from the rehab area.
• Transfer of command or positions.Radio to all on the fireground any transfer of command or reassignment of personnel.
• Ten<-minute tactical timer.Central communications must monitor the cumulative tactical timer and notify command on-scene every 10 minutes.
• Personnel Accountability Reports (PAR).When a PAR is requested, all personnel must be accounted for, preferably by name, to ensure the safety of all involved.
• Training affects the outcomes of incidents.As noted, all firefighters at the scene followed what they had been taught in department survival training. The downed firefighter did not take off her SCBA mask, the lieutenant kept her cool with water from a hose, and the RIT got her out in time. Our department had been conducting firefighter safety and survival classes, which were almost completed when this incident occurred. In fact, the firefighter who was injured had just gone through the training on July 10.
• Learn the lessons, and share them.Chief David Kimbrell immediately ordered a full investigation of the incident, hoping to uncover anything that needed to be done differently to avoid a similar incident in the future. The department’s Fire Marshal’s Office and the training officer investigated the scene.

IN-SERVICE TRAINING

So that all our members could immediately learn the lessons from this incident, we scheduled in-service training for the same day. Ninety-nine percent of the department participated in the training, as did firefighters from many area departments. A post-incident analysis was held at the department’s fire academy the following week. We incorporated the results into the After Action Review, which we published, and created a training disk using a video made from the in-service training and scene photos. We distributed this information to all stations in our district and to many area departments.

Figure 2. Basement Division The basement of the home. The fire room was on this level. The first-in lieutenant forced entry into the window where the “Point of Origin” label is. He was 12 feet from the fire room. After breaking the window, he placed his hand inside to check for heat. Had he had a thermal imaging camera in his hand, he would have known the room of origin was on the basement level. [Illustration by Lieutenant Eric Harbin, Investigator, Fire Marshal’s Division, Hall County (GA) Fire Services.]

Figure 3. Division 1 The fire company made entry through the door at the foyer, six feet inside. Roach fell through the floor at the site of the “Hole to Basement” label. (Illustration by Lieutenant Eric Harbin.)

This incident opened the eyes of many of our members to the realities of our profession. The statement heard most often during the in-service classes was, “That could have been me.” Georgia has had two firefighter fatalities in the past year. Our near-miss experience has shown us that sometimes things go wrong on the bread-and-butter calls, even when you do things right.

SKIP HEFLIN is the training officer for Hall County (GA) Fire Services, where he has served for 18 years. He considers himself a lifelong student of the fire service and is working toward a degree in fire science from Lanier Technical College.