Excerpted from the report from the Porterville (CA) Fire Department
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.
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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. The process included the conducting of interviews, analysis of dispatch audios, CAD information, helmet camera footage, body camera footage, review of policies and procedures, research of laws, mandates, industry standards, and best practices, as well as regular meetings to comprehend, analyze, organize, and assemble the data into report form.
Early in the SART process, the team became aware that a significant number of potential factors were, once again, related to the National Institute of Occupational Safety and Health (NIOSH) Fire Fighter Investigation and Prevention Program (FFFIPP) contributing factors of Firefighter line-of-duty deaths.
Consistently the top ten contributing factors, as outlined in their most recent report, are:
- Medical screening
- Fitness and wellness program
- Training
- Medical clearance
- Standard Operating Procedures/Standard Operating Guidelines (SOPs/SOGs)
- Incident command
- Strategy and tactics
- Communications
- Personal protective equipment (PPE)
- Staffing
While each of the previously listed contributing factors are significant, and continue to remain a problem in the fire service, the following were the most prevalent during the Library Incident: Training, Standard Operating Procedures/Standard Operating Guidelines (SOPs/SOGs), Incident Command, Strategy and Tactics, Communications, and Staffing.
As the SART began to de-construct this tragedy, it became evident that other indirect factors were at play that all Fire Chiefs and Department Administrators should be perceptive to, so as to avoid long term systemic cultural and operational pitfalls. Vigilance in continual review and comparison to industry standards, policy updates, establishing relevant and realistic training programs, adjusting emergency deployment models, and strategically planning for organizational improvement, are some examples of preventive measures to avoid cultural complacency and creating an operational road map for the future.
This report is not intended to be unduly critical of the Porterville Fire Department or to place blame on any specific person(s). Unfortunately, these issues continue to be far too common across the country to simply focus on one organization. Until all Fire Service leaders begin to resist complacency and implement positive change, we will continue to lose our valiant Firefighters. Additionally, Fire Chiefs must continually educate appointed and elected officials on the importance of sufficient apparatus staffing. To their credit, the Porterville City Council is presently taking action to increase fire department staffing, even prior to the completion of this document.
