NEW JERSEY TRAINING BURN: REAL-LIFE LESSONS
On Sunday, December 6, 1992, at 9:52 a.m., three volunteer firefighters were injured during a fire training exercise conducted by the Greystone Park (NJ) Fire Department. The exercise was conducted under the name of the New Jersey State Fire Service Training Academy at a site in Parsippany-Troy Hills, New Jersey. It involved a primary search simulation inside a modified school bus owned by the Parsippany-Troy Hills Fire Department District #5. A foam rubber upholstered couch was set on fire using shredded paper.
The fire was allowed to burn for approximately five to 10 minutes with the doors to the bus closed to allow’ heat and smoke to build up. Firefighters then were sent into the rear of the bus. Their objective was to crawl past the fire and exit the bus through the front doors. Approximately 30 seconds after entry of the first firefighters, flashover occurred, turning the interior of the bus into a massive inferno, with temperatures instantaneously reaching approximately 1,100°F.
Three firefighters w’ere trapped inside the bus. Two of them escaped to safety (through the front doors of the bus. which had to be forced open by other students. The third firefighter became disoriented . and collapsed inside the bus. He sustained serious burns to his face and airway when his self-contained breathing apparatus burned off his body and his face piece connection became undone. He was rescued by another student.
The injured firefighters were rushed to f area hospitals and were eventually transferred to the Burn Intensive Care Unit at St. Barnabas Medical Center in Livingston, i New Jersey. The two least seriously injured firefighters were released within f one month of the accident. The third was released from the hospital 12 weeks later. His injuries at this time appear to be permanently disabling.
Following the accident, the Morris ‘ County Prosecutor’s Office, the Parsippany-Troy Hills Police Department, and the Morris County Sheriff’s Office Crime • Scene Unit initiated an investigation. They subsequently were joined by the New Jersey Division of Fire Safety, New Jersey Department of Health, New Jersey Department of Labor, National Institute of Standards and Technology (NIST), Bureau of Fire and Building Research, and National Institute of Occupational Safety and Health.
This investigation has involved an expensive analysis of the accident and pe, ripheral issues surrounding the conduct of ‘ the training school. The investigation ^yields many important lessons for the fire service. This article analyzes the unfortunate incident and provides suggestions for averting similar tragedies in the future.
BACKGROUND
The Greystone Park Fire Department ‘ provides fire prevention and fire suppress*on services to the Greystone Park State Psychiatric Hospital in Parsippany, New Jersey. The facility is operated by the New Jersey Department of Human Services and currently has a patient population of approximately 500, which has steadily dedined over the years from a high of 5,000, Fhe department consists of seven career members and approximately 16 volunteer firefighters.
Approximately two years ago, the department began to conduct formal proi»grams to train its volunteers; previously they were trained at the Morris County Firefighter and Police Training Academy, A chief officer of Greystone developed a training class that was offered not only to new Greystone firefighters but also to fire department members of nearby municipalities. The course lesson plans were modeled after those used at the Bergen County (NJ) Police and Fire Academy; the course was taught by three Greystone chief officers. Two. including the lead instructor, have taken the necessary courses to become certified by the New Jersey Division of Fire Safety as fire instructors. The third is currently in the process of taking these requisite courses. All three have extensive training in fire protection and suppression.
Session Number 25 was a live fire training exercise. In the past, these sessions had been conducted at a fire training building located behind fire headquarters. The building was torn down in 1991 due to its unsafe condition. This posed a problem for the instructors. However, they learned that Parsippany Fire Department District #5 had been conducting live fire training exercises in an old school bus located at the Parsippany-Troy Hills Sewage Treatment Plant and were granted permission by the Parsippany Fire Department to use it for fire training.
According to a 1989 directive from the Morris County Prosecutor’s Office, the practice of burning structures for firetraining is not permitted without a permit from the Department of Environmental Protection and Energy. Such a permit was not obtained for this or any other prior exercise conducted at this site, despite the fact that the assistant chief of Parsippany District #5 and the Township Joint Fire Chiefs’ Council were advised of the directive. (The Greystone Park Fire Department is a member of the Joint Chiefs’ Council.)
The bus used in the drill was a 1976 International Harvester School Bus, which had been donated to the fire department. It is 34 feet long and seven feet six inches wide. All student seats had been removed to facilitate training exercises. Steel plates had been welded over all windows to keep the heat and smoke in.
Previous operations in the bus had been conducted using wood scraps soaked in kerosene placed in cut-down 55-gallon drums. At the time of the incident, these drums were present in the bus; however, their fuel was not ignited until postflashover.
The sewage treatment plant is operated by the Parsippany-Troy Hills Sewage Authority. The Parsippany District #5 assistant chief is a foreman for this agency. He gave permission to use the bus and the property at the plant for the fire training evolution. At no time did the administration of the fire district seek approval for this request through the Township of Parsippany.
THE DAY OF THE EXERCISE
The training exercise was scheduled for Sunday, December 6, 1992. At approximately 9 a.m. on that day, 17 students assembled at the sewage treatment plant to participate in the exercise. An engine company from Parsippany-Troy Hills Fire Department District #5 was connected to a city hydrant on the property, and a ¾inch booster line was stretched to the rear door of the bus. Four firefighters were on the engine. With the exception of the driver/pump operator, these firefighters were present for observation purposes only. No other hoselines were stretched. No secondary source of water supply was secured. A heavy rescue truck from the Denville Fire Department was also at the site. This unit was used only to transport students and had no predesignated official role in the training exercise.
There were no on-site emergency medical services. However, direct radio communication with the Parsippany-Troy Hills Police Department was maintained. The Greystone Park assistant chief who developed the course was designated the instructor-in-charge—in fact, he was the only designated instructor for the exercise. The Parsippany District #5 assistant chief was designated the ignition officer. No designations were made for a safety officer, interior instructors, exterior instructors, backup crews, or rescue crews. No effort was made to institute the incident command system (ICS).
The instructor-in-charge briefly explained the exercise to the students. The exercise was going to consist of an evolution simulating a “primary search,” which was to be conducted without the use of a hoseline, and an interior fire attack evolution. While there was a briefing prior to the exercise, there was no preburn student tour for familiarization purposes, no written plan for conducting the exercise, no safety checklist for the students’ personal protective equipment, no arrangements for communications inside the bus, no established emergency procedures, and no established means of emergency signal.
All students were instructed to wear their hill personal protective equipment. While the course announcement stated that all students’ gear must conform to current New Jersey Public Employees Occupational Safety and Health Administration (PEOSHA) standards, the gear was not checked prior to the beginning of the evolution. Protective equipment consisted of a helmet, a Nomex® hood (if provided by the respective department), turnout coat, turnout pants, boots, and SCBA. It was up to the students to check their own and their partner’s equipment to ensure it was on and functioning properly. At no time did the instructor check the gear of any student prior to entering the bus.
Sometime after 9 a m., the ignition officer entered the bus and placed shredded paper in, on, and under a six-foot-long upholstered foam rubber couch and ignited it with a highway flare. He allowed a student to accompany him to ignite the couch. Neither one wore SCBA at the time. The ignition officer did not remove combustible material, including three cutdown steel drums containing wood soaked with diesel fuel, a truck tire, a hollow-core wood door, and a five-gallon “Jerry” can containing a small amount of diesel fuel, from the bus prior to the evolution.
The ignition officer and the student left through the front doors of the bus and pushed them tightly closed. Apparently, the doors jammed shut at this point. The rear doors also were shut, and the fire was allowed to bum for approximately five to 10 minutes to allow heat and smoke to build up.
Following this bum period, the lead instructor allowed students to enter the bus. Three students entered the bus ahead of the lead instructor. Two students then followed this group.
All students were carrying a forcible entry tool in this primary search evolution. There was no charged hoseline inside the bus. The booster line w’as stretched to the rear of the bus and charged; however, it was not manned. The rear door of the bus remained open while the students were in the bus. There were no ventilation holes cut in the bus.
FLASHOVER TRAPS FIREFIGHTER
Approximately two minutes after the students began entering the bus, flashover occurred. The firefighters in the bus at the time describe a rapid buildup of heat that became intolerable. In addition, several students outside heard screams coming from the bus just prior to the flashover. The lead instructor and the two students behind him escaped via the rear door without injury.
At this time, an unorganized rescue effort began. Several students grabbed j forcible entry tools and attempted to open, the front doors. They described the doors I as being jammed shut; they would noti open by hand. As the doors were forced open, the students encountered a large volume of superheated air venting from the doorway, causing them to temporarily I back away. Black smoke was banked down-] to floor level. Two of the trapped students _ then exited the bus via the front doors. 1 Their personal protective equipment was smoking, and they had to be wet down by ■ the booster line.
The students outside the bus then heard a low-air alarm from an air pack going off | inside the bus. They then realized a fire-. fighter was unaccounted for. Students attempted to stretch additional preconnect-1 ed 1 Vi-inch handlines from the engine but, found no nozzles were attached to them. !
At some point, a student went to thet rear of the bus and took possession of the booster line. He was able to extinguish | visible fire via the rear doors. At approximately the same time, the ignition officer 1 entered the front doors of the bus in an -j attempt to rescue the trapped firefighter. ‘ He was not wearing SCBA. A sewer depart] ment employee was watching the exercise. When he realized someone was trapped, he entered the bus with no i personal protective equipment on and attempted to assist in the rescue effort. He was overcome by smoke and was taken to ■! a local hospital, where he refused treatment. *
The ignition officer was able to reach the stricken firefighter first. He observed him lying on his back on the right side of the bus near a partition protecting the stairwell. The trapped firefighter’s SCBA was lying approximately four feet from 1⅛ body, the straps burned off, discharging air through the regulator.
The face piece was still on the student’s face, with the regulator connection in his left hand and tucked into his left turnout coat pocket. The ignition officer attempted to grab the trapped firefighter, butbecause he was not wearing gloves, the ignition officer burned his hands and had to back out of the bus.
The lead instructor and some other students were able to reach the trapped’ firefighter via the front doors. Since this firefighter was large in size, they were unable to get his body through the door opening and onto the stairwell. A student then entered the bus via the rear door, grabbed the injured firefighter by the coat, and removed him through the rear door.
INJURIES
Witnesses say the injured firefighter screamed and went into respiratory arrest. Cardiopulmonary resuscitation was initiated and revived him. The ParsippanyTroy Hills Police Department was called via radio, and emergency medical services ‘were dispatched. Students who were also emergency medical technicians provided interim first aid.
One of the injured firefighters was treated at the scene by paramedics and transported to a hospital. After initial stabilization, he was transferred to the Burn StepDown Unit at St. Barnabas Medical Center. He sustained secondand third-degree burns to his arms, hands, back, knees, and head. Approximately 15 percent of his body area was burned. He was released from the hospital 10 days later.
¶ Another injured firefighter was treated at the scene by paramedics and transported to a hospital. He was initially admitted to the Intensive Care Unit but was later transferred to the Burn Intensive Care Unit at St. Barnabas Medical Center, after he developed an infection. He sustained ⅛ secondand third-degree burns to his head, back, arms, and hands. Approximately 20 percent of his body area was burned. He was released from the hospital three weeks later.
The most seriously injured firefighter i was treated by flight medics from New Jersey State Police Northstar Medevac and ^transported directly to the Burn Intensive Care Unit at St. Barnabas Medical Center following his intubation at the scene. His initial evaluation showed extensive secondand third-degree burns to his upper body, head, and face. He also suffered serious respiratory damage. Approximately 30 percent of his body area was burned. He was released from the hospital after 12 weeks of hospitalization.
THE INVESTIGATION
The Parsippany Police Department and t the Morris County Prosecutor’s Office Arson Unit immediately initiated an inves-
* tigation into the incident. After the preliminary investigation was complete, it was decided that the Morris County Prosecu-
»tor’s Office would be the lead agency in the investigation, to avoid the appearance
* of conflict of interest with the Township | °f Parsippany. I was the lead investigator.
The New Jersey Department of Community Affairs, Division of Fire Safety, soon joined the investigation. By state statute, it is required to conduct an in-depth investigation into any fire incident resulting in the death or serious injury of a firefighter. In a meeting held shortly after the incident, a joint investigation was agreed on. The reasons for doing this were to avoid duplication of effort and to use each agency’s expertise in the best manner possible. The approach worked well.
Very early in the investigation, the Morris County Prosecutor’s Office recognized the need for an expert analysis of this incident by an authority in fire training. A battalion chief from a nearby urban fire department who had extensive background and education in fire department training was asked to join the investigation. His input in the compilation of this investigation has been invaluable.
The data from this incident were forwarded to the NIST in Gaithersburg, Maryland, which has as one of its missions applying scientific research to fires and fire protection systems. NIST conducted a computer reconstruction of this incident using the HAZARD I program, which confirmed the feet that flashover conditions existed inside the bus and that the witnesses’ descriptions of the incident were accurate.
ANALYSIS
• Cause of incident. The fireball inside the bus was caused by the phenomenon known as “flashover.” Firefighters are or should be well familiar with the dynamics, dangers, and warning signs of flashover. Flashover should have been predictable to the people running this exercise, due to the high heat of combustion produced by burning polyurethane foam cushions, hydrocarbon-soaked wood, and tires. This flashover could have been prevented. If a hoseline capable of flowing at least 100 gallons per minute had been inside the bus and operating on the fire, the heat release rate would have been reduced to preclude flashover. If ventilation holes had been cut in the roof of the bus prior to the fire’s ignition, flashover would have been averted.
Flashover is recognized throughout the fire service as a condition that is extremely hazardous to firefighters. Training in flashover is provided at all levels of the fire service. A review of the training files of the instructional staff involved in this accident reveals several courses in which flashover recognition would have been taught. The lessons learned in these courses would have reduced the chance of an accident.
- The training facility. In 1982, two
- Boulder, Colorado, firefighters were killed when a flashover occurred during a live fire training exercise. In 1987, three Milford, Michigan, firefighters were killed when a flashover occurred during a livefire training exercise. As a result of such incidents, the National Fire Protection Association developed a voluntary standard for conducting live fire training (NFPA 1403, Live Fire Training Evolutions in Structures). This standard delineates the acceptable and safe manner in which to conduct this type of training. The program under development in New Jersey (the instructors from this program had attended all requisite courses) is structured along the guidelines of this standard.
This training facility violated all applicable standards, such as those governing emergency ventilation, emergency lighting, fuel sources, communications, and emergency evacuation. This facility was constructed similar to an oven. To consider conducting a live fire training exercise in this type of structure is also a deviation from accepted state and national standards.
The investigation also revealed a disregard for safety concerns inherent in the design of this facility. In the Live Burn Safety Course, a preburn checklist is offered to ensure that a facility is safe for the exercise. The investigation revealed the front door of the bus was jammed shut and the door-opening mechanism was broken and inoperable.
In addition, a large quantity of fuel, including some combustible liquids, was present in die bus at the time of the exercise. Had a safety inspection of the bus been conducted, these hazards would have been identified.
In his report, the independent fire training expert clearly outlined the similarities between the Parsippany incident and the aforementioned fire training tragedies. All of the contributing factors to this incident in Parsippany-Troy Hills were known to the fire service at least a decade before the three firefighters were severely injured.
• The training course. The training course in question was sponsored by an organization calling itself the “New Jersey State Fire Service Training Academy, Greystone Park Hospital.” It was a Fire Fighter I course designed to meet the New Jersey state recommendations for a Fire Fighter 1 course as promulgated by Standards for Fire Sendee Training and Certification. The lesson plans w’ere modeled after those used at the Bergen County Police and Fire Academy. Note that there is no requirement for the course or the facility to be certified. However, these , standards are in place and are projected to be mandatory in the next few years.
Questions have been raised about the legitimacy of the name of this organization. The investigation has revealed the name “New Jersey State Fire Service” was developed to enable the members of the rfour fire departments assigned to New Jersey state facilities to form one local (Local 77) in the Firefighters Mutual Benevolent Association. This title is not a recognized New Jersey state agency and is not a recognized department within the Department of Human Services.
Several area fire chiefs brought this situation to the attention of the Morris County Prosecutor’s Office shortly after the incident. They stated they were under the impression they were sending their firefighters to a bona fide training program ithat had state sanction. The fire departments were paying SI00 per student to the Greystone Park Firemen’s Association. An inquiry into the purpose of the tuition revealed the course was ostensibly run as a fund-raiser for the Greystone Park Firemen’s Association. A review of the association’s books revealed no course-related expenses. These financial arrangements may violate state of New Jersey fiscal policies. The hospital administration is conducting an internal review of the situation. Ultimately, it is the chief officer’s responsibility to ensure he is sending his firefighters to appropriate and accredited training courses. It must be stressed that no evidence of financial impropriety has been uncovered during this investigation.
Note that the curriculum of this course is substantially consistent with the recommendations made in the state standards. All of the basic firematic topics were covered prior to this exercise. However, this was the first actual hands-on fire training session for these students. This fact was not taken into consideration when the evolution was designed. The students had no opportunity to experience the use of an SCBA in a minimally hazardous environment prior to being sent into an actual fire. The fire training expert’s report also deals with the inadequacies of this training program.
• The fire departments. A major contributor to the problems leading up to this incident involves the management of the two fire departments involved. Actions taken to correct various aspects of mismanagement are underway’. However, some are worthy of note.
It was revealed that some of the involved fire chiefs were not told this training evolution would take place in Parsippany-Troy Hills. They were not aware until after the accident that their personnel had been involved in this type of training environment.
It is apparent that this training course was not adequately supervised by fire department or hospital administrators. Proper supervision of the course would have ensured adequate qualified instructional staff, a safe training environment, and continual quality review. It also would have ensured that all approvals and permits were in place prior to the commencement of live fire training exercises.
The investigation revealed that the Parsippany-Troy Hills Fire Department has been conducting training exercises of one form or another at the sewage treatment plant tor at least 10 years. Written approval was never obtained from the township for this purpose.
The chief of Parsippany-Troy Hills Fire Department District #5 was not present at the time of this incident; however, he, too, shoulders some of the responsibility. Although he was aware of the Morris County Prosecutor’s directive prohibiting live fire training at unauthorized sites, he continually allowed it to occur. In addition, he permitted his personnel to participate in this exercise without ensuring their safety.
• Personal protective equipment. One positive comment that can be made regarding this incident relates to the personal protective equipment worn by the three injured firefighters. Simply put, the reason these men are alive today is that they were properly wearing full sets of PEOSHAand NFPA-compliant turnout gear. This protective ensemble consists of a helmet, Nomex hood, Nomex or PBI® turnout coat and pants, compliant boots, firefighter gloves, and SCBA. This gear was severely damaged in the flashover. Even though it was subjected to conditions that greatly exceeded those the gear is designed to withstand, the firefighters survived the incident.
Members of the Division of Fire Safety, Department of Labor, and Morris County Prosecutor’s Office inspected the turnout gear. It was inventoried, photographed, and examined. A full report compiled by the Division of Fire Safety regarding this inspection is available from the New Jersey Division of Fire Safety.
One question remaining pertaining to the protective equipment is the SCBA worn by the trapped firefighter. The nylon straps burned off and caused the air pack to fall from his body; the pack was found approximately four feet from him.
The unit was blowing air through the regulator because the positive pressure switch was “on.” The face piece was still in place on the firefighter’s face, but the flexible mask hose was disconnected from the regulator. The end of the hose was in the firefighter’s left hand and was placed inside his coat pocket.
An inspection of the unit shows it was in proper working order. The unit was sent to the National Institute of Occupational Safety and Health tor testing. It was found to be severely damaged; however, it was still in working order.
• State laws and regulations. Firefighting is a dangerous undertaking—and one that requires intensive training. As a result of the previously referenced training accidents in Boulder, Colorado, and Milford, Michigan, the NFPA developed voluntary standards regarding the proper method of conducting live-fire training exercises. These standards were developed by a standing committee of fire service personnel from across the United States. They are recognized as the standards by which livefire training is to be conducted and judg
When New Jersey began to develop fare i training standards, it relied heavily on, NFPA 1403It then was customized for New Jersey and promulgated as part of the Uniform Fire Code. There has been a transition period to allow for the certification of instructors and facilities.
The drawback to NFPA standards is that they are voluntary. As a consensus standard, they do not have the power of law unless they are specifically adopted by the governing agency. However, since the NFPA is generally recognized as the foremost authority in fire protection standards, its standards are used in the adaptation of local and state codes.
New Jersey’s regulations are based on NFPA 1403. However, when adopted as law, they will apply only to certified fire training programs. As written, they will not apply to local fire department training. Conceivably, this type of incident could happen again under these regulations. Expanding these regulations to include all fire training in the state should prevent a tragedy of this magnitude from occurring in the future.
THE AFTERMATH
After hearing evidence and testimony, a Morris County grand jury stopped short of issuing criminal indictments regarding the actions of the people involved in this incident. It did, however, release a report calling on the New Jersey state legislature to enact mandatory regulations “to require fire service training organizations to apply to the Division of Fire Safety for livebum training permits.” It also recommended that mandatory certification procedures be established for fire training programs, instructors, and facilities. At this time, legislation to address these problems currently is being researched and developed.
The purpose of this article is not to place blame but to attempt to educate the fire service community on the hazards of providing training that is not conducted with the utmost concern for participants’ safety. This incident and the firefighters’ injuries were caused by a foreseeable series of events resulting from a disregard of established safety procedures and standards by the fire officials involved. The mistakes made in this incident have been made before and will be made again unless an effort is made to educate the fire service community and strengthen existing regulations. Perhaps this incident can be the impetus behind that effort.
