BY BILL MANNING
The death of Captain C. Thomas Moore of the Manteca City (CA) Fire Department raises serious firefighter training issues.
On June 16, 1999, Captain Moore tragically fell 18 feet to his death while involved as an instructor at a multiple-crew live fire training exercise at the Regional Fire Training Center in Modesto. According to the Manteca City Fire Department Board of Inquiry Report, released in December 1999, the drills were scheduled as annual live fire training for several area departments and were designed to emphasize fire attack tactics, hose aloft procedures, and victim ladder rescue techniques and to review Two-In/Two-Out requirements.
During participant debriefing prior to the first day’s drills, training officers added an emergency evacuation component, in which third-floor (fire floor) collapse was to be simulated and an emergency evacuation signal sounded, at which time participants were to egress the training tower via portable ladders, using traditional methods.
Moore was on the second floor with firefighter crews at the time the evacuation signal sounded, near a window that had been laddered. According to the Report, a student said to him, “Hey, this is a time I could use the emergency ladder slide,” referring to the now widespread fireground survival practice, also known as the “ladder bail” or “headfirst ladder slide.” Moore replied, “Yeah, let’s do it,” and then “immediately exited the window headfirst at a high rate of speed. Upon exiting the window, Captain Moore was grabbing the beams of the ladder, shuffling with both hands before he lost his grip and fell straight down, striking the ground with the left side of his face.” He was pronounced dead 45 minutes later.
The Board of Inquiry Report makes note of the fact that Moore, a 14-year veteran of the Manteca Fire Department, was an excellent, highly trained firefighter and officer, a competent instructor, and a dedicated leader. Thirty-eight years old, he stood six feet four inches tall, weighed 220 pounds, and was in excellent physical condition. The Report cites numerous contributory factors in his death, among them:
- The ladder slide was a spontaneous, unplanned action taken by Moore, who self-switched from instructor to participant. In effect, he was freelancing on the training ground.
- Moore performed the ladder bail without necessary safety precautions, including a harness and safety line, in place.
- Moore attended a two-day RIT training course, based on the “Illinois” method, in October 1998 at the Stockton (CA) Fire Department, an event sponsored by the San Joaquin County Training Officers Association (SJCTOA). It was his first exposure to ladder bail training. However, according to the report, “lesson plans and job breakdowns had not been developed at any time during Captain Moore’s exposure to the emergency ladder bail technique, neither by the instructors in Stockton nor in Illinois [where Stockton instructors received their training].” SJCTOA had not reviewed the bail method prior to sponsoring the training. Nor was the ladder bail reviewed or approved by the Manteca Fire Department Training Division, though Moore taught it to some Manteca firefighters in May 1999.
- The height of the windowsill through which Moore exited was 42.5 inches, higher than most windowsills and higher than those used in “standard” ladder bail training. The tip of the ladder extended nine additional inches above the sill. Thus, Moore had to practically launch himself up and over to clear the 51-inch height, resulting in his inability to control his downward movement. In addition, the ladder was pitched at a traditional 73 degrees–not at the 60-degree pitch typically used for the ladder bail drill–making it even more difficult for Moore to hook his arm under a rung or otherwise grip the ladder to stop his momentum. Moore’s previous training in the bail method, according to the report, did not prepare him for the variation in windowsill height, ladder extension, and ladder pitch he encountered at the training tower.
Following the incident, groups inside and outside the fire service began to address the issue. The California Department of Occupational Safety and Health cited the Manteca Fire Department for three violations of state regulations regarding the use of ladders.
The Manteca Board of Inquiry published its findings, in which it concluded, “After analyzing all the potential variables and the aspects of risk versus gain, it is unreasonable to conclude that the emergency ladder bail technique has any practical benefit to the fire service.”
The Office of the California State Fire Marshal, which had offered certification for firefighter survival training that included the ladder bail component, is now considering removing the method from the state curriculum. The Northern California Training Officers Association also is considering removing the ladder bail as an accepted practice in its training offerings.
Was the tragedy an anomaly, a worst-case-scenario-come-true? Or are there more Tom Moores waiting to happen? Is the response in California a predictable reaction to a terrible event, an attempt to prevent such incidents from happening again? Or is the ladder bail a justifiable, necessary training technique?
The ladder bail and other emergency ladder escape variations have been taught and practiced by thousands of firefighters around the country. Surely, the intention behind the practice is unassailable and follows common sense: Increase firefighter survivability in catastrophic fire events by giving them self-rescue tools. Anyone who says he cannot foresee circumstances wherein emergency ladder escapes might be the only recourse in a fire situation is living with blinders on, or is not fighting fires.
However, the ladder bail practice, like many operational methodologies in the fire service, has not been justified by empirical data but, rather, by conviction or popularity. Ladder bails under real fire conditions are an unfortunate part of the fire service experience, a byproduct of aggressive firefighting and sometimes misjudgment; but collective or individual anecdotal experience, however well-meaning, lacks intellectual buoyancy against quantifying the benefits of a training procedure against its risks, a call legitimized by the death of one of our own engaged in a practice designed to save him.
Numerous firefighters have been injured–mostly sprains, strains, and fractures–while practicing the ladder bail. And there have been near misses. It is not enough to say, “If we save the life of one firefighter by this technique, all the sprains, strains, fractures, and near misses are worth it.” That’s intellectually disingenuous. And we have lost one of our own attempting this practice–albeit the wrong way, for sure.
There must be some middle ground. Emergency escapes via portable ladders are real-they have happened and will continue to happen, whether anecdotally or quantitatively enumerated. Preparing for such an emergency is prudence, not recklessness. Whether a firefighter will encounter such an emergency once or twice or never in a lifetime is irrelevant. Fireground survival and rapid intervention training is one of the best things to happen to the fire service in the past 20 years. We simply owe it to our firefighters to teach them to “Get Out Alive” and “Save Our Own.”
Yet if the fire service is “guilty,” it is in part by not seeing ahead. A 60-degree ladder pitch builds student confidence and helps slow descent, but what happens in a real fire where the ladder is thrown at a 75-degree angle? What happens when it is placed well above the sill, as could easily happen–and has? What happens when you’re dealing with a sill 10 inches higher than what you’re used to training on? What about the variables of the human form–what works for the shorter firefighter or for the heavier firefighter? The Board of Inquiry Report complains, “follow-up training is never conducted at the standard climbing angle ellipse. Basic adult learning requires learning to occur from the simple to complex, known to unknown ellipse. However, when the additional steps necessary to replicate the actual use of the skill in real terms is neglected, students will overextend themselves without realizing the potential consequences.”
There are three emergency ladder escape methods currently taught and practiced around the country. Which is best, for what reasons, and under which conditions? Consider built-in safety protection for the drill: A safety line is required, for sure, but is it enough? Should a mechanical advantage or a belay line be added to the equation?
It is incumbent on progressive leaders in fire service training to evolve the ladder bail practice to the next level. Fire service training organizations must establish protocols and programs that reconcile issues of safety with issues of realism. Say what you want about personal responsibility, but it is clear that, on an organizational level, the system failed Tom Moore.
Remember, too, that no matter how onerous the letters O-S-H-A may sound to you, it is the fire service’s responsibility to work with regulatory agencies such that laws are consistent with fire department and firefighter goals and needs. CAL-OSHA already has warned the fire groups that any department that trains in the ladder bail technique will be cited for “improper laddering,” as occurred in San Jose recently. That’s sad.
Most importantly, let’s learn from the hard lesson of a good, departed firefighter, and let not the opportunity to train firefighters safely in what matters most–their survival–go by the wayside.
