BY THOMAS C. LAKAMP, MICHAEL KIRBY, and GRANT LIGHT
On March 21, 2003, Cincinnati Firefighter Oscar Armstrong III tragically died in the line of duty. The Cincinnati Fire Department (CFD) and the Armstrong family suffered a tremendous loss. Armstrong died after becoming trapped in a flashover while battling a residential structure fire. The fire started in the first-floor kitchen of a two-story, single-family residence. The CFD had not experienced a line-of-duty death since January 28, 1981.
Friday, March 21, 2003, began like any other day. Engine 9 was out of quarters drilling at 0845 hours when a call for a one-alarm fire at 1131 Laidlaw Avenue was received. Engine 9 responded with the full one-alarm complement (Engine 2, Engine 9, Truck 2, Truck 32, and District 4).
District 4 arrived on-scene first and reported a working fire with heavy fire from the rear of the structure. Engine 9 arrived shortly after District 4 and secured a water supply by going into front suction to a hydrant directly in front of the structure. Engine 9 (captain, firefighter riding out of class as the fire apparatus operator, and two firefighters) stretched a 350-foot 13⁄4-inch hoseline to the front door. Finding the front door secured, the officer decided to attempt to find an alternate entrance on the “D” side of the structure. Engine 9’s officer had a face-to-face meeting with the incident commander (IC) on the “D” side of the building and was ordered to reposition his line through the front door and attack the fire from the unburned side.
Engine 9’s officer and Armstrong repositioned the line to the front door as the second firefighter retrieved an ax from the apparatus to force entry. Once on the porch, Engine 9’s officer twice requested over the radio that the line be charged; he made the request several times-yelling and making hand gestures from the front porch. When he did not receive water, Engine 9’s officer left the porch to investigate the source of the water problem. (A firefighter from Engine 2 had now joined the two firefighters from Engine 9 on the front porch.) Engine 9’s officer discovered that the hoseline was charged at the pumper but that numerous kinks in the front yard were preventing the water from reaching the nozzle. Engine 9’s officer then set to work unkinking the line in the front yard.
At this time, Armstrong, the second Engine 9 firefighter, and the firefighter from Engine 2 entered the building through the front door with the uncharged line. On entering the structure, the members encountered a rapid increase in heat conditions, decreased visibility, and the off-gassing of vapors from the carpet. The structure then flashed over, trapping Armstrong inside. The second Engine 9 firefighter grabbed the Engine 2 firefighter and threw him out the front door. Both firefighters ended up in the front yard with their fire clothes smoldering.
SECOND ALARM AND FATALITY
The IC requested a second alarm after the flashover and changed to a defensive strategy. Fire companies in the front yard by the porch witnessed Armstrong, engulfed in fire, running toward the front door. He turned away from the front door and ran back into the structure. The firefighters assembled in the front yard (Engine 2’s officer and firefighter, Truck 32 Firefighter, Truck 2 officer and firefighter), picked up a hoseline, and began an interior attack to rescue him. The Truck 32 firefighter located Armstrong in the dining room; Engine 2’s officer dropped his line to assist. Engine 2’s firefighter kept attacking the fire, keeping it away from the rescuers. Armstrong was removed from the structure through a window on the “D” side. Paramedic personnel transported him to the hospital, where he was pronounced dead.
POST-FIRE
The CFD Fire Investigation Unit had begun a fire cause investigation and the Cincinnati Police Homicide Unit was on-scene assisting with the investigation and documentation.
The first-alarm companies were relieved from the scene and sent for critical incident stress management counseling. We had requested permission to have the first-alarm companies write out witness statements; Administration refused our request. The fire companies listening to the radio in quarters also needed information. It was then decided that each fire district would send one company per hour to the scene and that a member of the Training Bureau would walk each group of companies through the scene, explaining the events to the best of their ability with the information on hand. This process continued for the next two shift days until all personnel had an opportunity to walk through the scene.
On Monday, March 24, 2003, Chief Robert Wright agreed to form a committee to investigate Armstrong’s death. A joint committee of CFD staff and International Association of Fire Fighters Local 48 Safety Committee members was formed.
Armstrong was laid to rest on March 27, 2003. Almost all on-duty Cincinnati firefighters were able to attend the funeral, thanks to the brothers and sisters from surrounding communities who staffed our fire stations; more than 200 firefighters assisted.
THE INVESTIGATION
The day after the funeral, the Investigation Committee convened for the first time. At the first meeting, a mission statement was developed and the format of the investigation was determined. The committee developed the following mission statement: “The focus of this investigation shall be to identify the facts pertaining to the line-of-duty death of Oscar Armstrong III and to recommend actions to prevent the risk of similar events.”
The investigation was divided into two major parts-the Preliminary Investigation and the Final Comprehensive Report.
The Preliminary Report parameters would be to determine a factual account and time line of the events that led up to Armstrong’s death. The Final Comprehensive Report would be an in-depth study of the events with recommendations to prevent similar events from occurring again within the CFD. Battalion Chief Todd Harms of the Phoenix (AZ) Fire Department assisted with the format of the investigation.
The committee worked with the National Institute for Occupational Safety and Health (NIOSH) to facilitate interviews of fire department members as soon as possible. To minimize the stress on our members who were continually rehashing the events of the fire, one member of the investigation committee responsible for creating the fire time line sat in on all of the NIOSH interviews, with the witnesses’ permission. Detailed notes were taken from the interviews, and a time line of events was created.
The actions of the first-alarm companies were recreated and noted in the Preliminary Report. An accompanying video explained the Preliminary Report. Just prior to the release of the Preliminary Report to the public, all fire companies received an electronic copy of the report, and the video was aired over the internal cable television network.
After publication of the Preliminary Report, the committee set to work on the Final Comprehensive or Enhanced Report. Three subcommittees were formed: Training, Equipment and Technology, and Standard Operating Procedures. All committees were opened up to any CFD firefighter who wanted to attend. Meeting times and dates were published through the internal electronic mail system.
The Training Committee investigated the aspects of the on-scene activities as they related to the firefighters’ training-basically, they wanted to determine if the firefighters’ training was commensurate with their duties and responsibilities. The committee examined the training level of all firefighters and made recommendations for additional training programs. The major recommendations revolved around command and company officer training, driver/operator training, and firefighter proficiency training.
The Equipment and Technology Committee examined all protective equipment and its performance. The committee also looked at existing and new technology to determine if there is anything currently available that would have possibly influenced the outcome of the fire. Numerous recommendations were made relative to equipment, including thermal imaging cameras; improvements in personal protective equipment; standardization of tools and equipment issued to firefighters; and apparatus improvements.
The Operating Procedures Committee evaluated all relative standard operating procedures as they may have influenced the actions on the fireground. Numerous recommendations were made for procedural improvements, including structural firefighting procedures, command procedures, accountability improvements, investigation of injuries and deaths, and firefighter training.
The committees met over nine months and compiled the recommendations over three to four weeks; the text was revised several times. Once the report was completed, it was reviewed by the City Solicitor’s office and then published.
LESSONS LEARNED AND REINFORCED
Chapter 7 of the final report, “Lessons Learned and Reinforced,” noted, “Basic firefighting skills and tactics were reinforced at the 1131 Laidlaw fire.” It also pointed out, that many of the “basic operational functions” are performed daily “with little consideration of their impact on firefighter safety and operational outcomes.” The report also noted the following:
• The tactics and actions used at this fire “have become standard practices in the CFD for many years.”
• Firefighters, company officers, and command officers cannot be faulted for the actions that occurred at the fire. These tactics and actions have been common practice for many years within the CFD and had not resulted in the loss of a firefighter until March 21, 2003, although similar actions have resulted in previous injuries
• To improve the operations of the CFD, the department must closely examine fireground operations to ensure that they “represent acceptable safe practices within the American Fire Service.”
• “These basic skills, tasks, functions, and operations are key to firefighter safety and survival and should be reinforced at all levels of the organization and be frequently reviewed. The CFD also needs to implement an enhanced approach to training because firefighters’ lives depend on adequate and appropriate training.”
Among the skills/areas specifically cited were stretching, deploying, and positioning hoselines; firefighter orientation within the fire structure; crews’ staying together during operations; company officers’ supervision of crew members, especially inexperienced firefighters; enforcement of radio discipline and the means to make communications in full personal protective equipment effective; implementing and maintaining a strong command presence and system; and frequent training on and adherence to standard operating procedures on the fireground
The complete report can be downloaded from the CFD Web site www.cincinnati-oh. gov/cityfire/pages/-6664-/ or the International Association of Fire Fighters Local 48 Web site at www.iafflocal48.org/.
● THOMAS LAKAMP is a district chief and 16-year veteran of the Cincinnati (OH) Fire Department, assigned to the Training Bureau. He has served in volunteer, combination, and career departments over the 18 years he has been in the fire service. Lakamp is a member of FEMA USAR Ohio Task Force One and is a state of Ohio fire instructor. He has a bachelor’s degree from the University of Cincinnati Fire Science Program.
● MICHAEL KIRBY, a 12-year veteran of the fire service, has spent the past six years with the Cincinnati (OH) Fire Department, where he is a lieutenan assigned to the Fire Training Bureau. He is a member of the IAFF Local 48 Safety Committee and is a state fire and EMS instructor.
● GRANT LIGHT, a 26-year veteran of the fire service, has served for the past 11 years with the Cincinnati (OH) Fire Department, where he is a lieutenant assigned to the Fire Training Bureau. He is a rescue team manager with FEMA USAR Ohio Task Force One and is a state fire instructor.
Thomas Lakamp, Michael Kirby, and Grant Light will present “Preventing Line-of-Duty Deaths: the Cincinnati Experience” at the Fire Department Instructors Conference in Indianapolis, April 11-16. Consult the FDIC Official Show Program for exact date and time.
