BY CHARLES J. KORTLANG
One of those “routine” incidents-a fire in the kitchen of a bakery on March 31, 1999-shocked the City of Mount Vernon (NY) Fire Department into a rude awakening. Although no deaths or serious injuries occurred, the experience, nevertheless, had a significant impact on the department. Immediately after the incident, the chief of operations requested an investigation. In conducting this investigation, I kept in mind the following quote from U.S. Army General George C. Marshall: “Fix the problem, not the blame.”
To determine what needed to be fixed, we developed an investigation plan. Phase 1 would entail documenting the entire building, focusing especially on the occupancy involved in the fire. Phase 2 would include interviewing every member present at the incident and reviewing all pertinent department Official Action Guides (OAGs). During Phase 3, the information gathered would be analyzed, to define a course of action that would help us avoid repeating what went wrong at this incident.
THE INCIDENT
The incident started out just like any other call. It was just a “routine” fire. How often have those few words been repeated? How often have they been a prelude to difficulties that we encountered?
We operate, as most departments do, with fewer line personnel than we would like. To adapt to this condition, we developed aggressive tactics that allow us to bring a significant amount of firepower to bear in a relatively short period of time. If the fire isn’t extinguished by the time the first-in companies are changing air cylinders, chances are we are going to be there for a while.
The first-arriving companies were not very concerned by the smoke conditions on arrival. Later interviews established that the smoke was heavy to moderate with enough buoyancy to keep it off the floor. Crew members remarked among themselves as they entered the kitchen that this was going to be an easy one. In a matter of a few minutes, however, these comments turned out to be far from the truth.
The building, built in 1929, was of ordinary construction and occupied a corner of the block, presenting sides A and D to streets. Four occupancies were on the first floor: a flower/chocolate shop, a bakery, and two unoccupied stores. A social club was on the second floor. The bakery and social club were open for business at the time of the fire. Discovery of the fire was not delayed and did not cause any undue concern. The first alarm was transmitted at 1916 hours. The response consisted of Engines 2, 4, and 3; Ladders 2 and 3; Rescue 1; and Car 2.
The first-arriving unit, at 1918 hours, was the working deputy chief, Car 2. His initial report was “10-75”; this report advises all units that the incident is a working fire. His aide made an initial reconnaissance into the bakery and then proceeded to the second floor through the rear of the structure.
On the second floor, he encountered a light haze condition. At 1922 hours, Car 2 gave a follow-up report: “Two-story, 15 2 30. Heavy smoke 1 and 2 floors. First line operational. Second line being stretched. Truck and rescue operating inside.”
Engine 2’s crew on the first-arriving engine had dropped the manifold, a three-inch line with a water thief attached, per department OAGs. They also stretched and placed into operation a 13/4-inch line from the preconnect bed. Engine 2 then proceeded to a hydrant and fed the initial attack line. Per OAGs, the first-arriving ladder, Ladder 2 (Station 1), split its crew and went into both floors. Rescue 1 also entered the first floor.
Engine 4, the second-arriving engine, had connected a 150-foot 13/4-inch manifold pack to the water thief and advanced the line into the building. Ladder 3 (Station 3), the second-arriving ladder, was ordered to the roof. Members of Engine 3, the third-arriving engine, dismounted and entered the structure to assist with handline operations.
Up until this time, it appeared that this was just another routine fire. Engine 2 chocked one of the two front doors open on entering and accessed the kitchen in the rear of the bakery by immediately turning right just inside the front doors and going behind the display cases to the rear of the room. All other personnel followed their lead. Car 2 ordered that all glass in the front of the bakery be removed. The order went unanswered. The time was approximately 1925 hours. Command was transferred to the chief of operations.
The crews in the kitchen area encountered fire in three places. A small fire was burning on a commercial stove. There was a fire behind it. There was also a small fire on the floor about four feet in front of the stove. The rescue crew was attempting to shut off the gas supply to the stove by accessing the valve behind the stove. Personnel unable to enter the kitchen area were huddled in the small transition area between the display room and kitchen. A member of Ladder 2, standing in this area, saw sparks fall from the ceiling. He advised his captain, who was standing next to him, and then prodded the ceiling with his pike pole.
The captain of Ladder 2 had just completed checking the second floor. He then proceeded to the first floor and began to undo the traffic jam in the transition area. When he was told about the sparks in the ceiling, he redoubled his efforts to move personnel. He radioed Car 1 that the building should be evacuated, and he directed the crews to exit. It was too late! The ceiling collapsed into the display area of the bakery, releasing fire and intense heat. Some personnel were struck by the ceiling, which fell as one piece. It was now 1928 hours. The incident commander, on receipt of the message from the Station 2 captain, ordered all personnel to evacuate the building.
Engine 6 had arrived on the scene just as the ceiling was collapsing. Its crew heard a lot of radio traffic but did not observe personnel on the street. They also observed that the front doors were closed and the windows were intact. Somehow, the door wedges had been displaced, allowing the doors to close on the hoselines but not stopping the flow of water.
Members operating in the kitchen, although a mere eight feet away, had no idea that the ceiling they had passed under was on fire. When the ceiling collapsed, they also were confronted with fire and high heat. To compound the situation, it was later discovered that the rear portion of the ceiling in the front room opened to the kitchen area. There was no floor-to-ceiling partition to stop the spread of fire. It had stopped being a routine fire.
Those who had not been wearing facepieces quickly donned them. Those who had not been wearing their hoods pulled them up into position. The second hoseline was in an ideal location from which to fight the fire. All the crew had to do was turn around and open the nozzle.
Basic survival skills began to surface immediately. Company members began to look for partners and to make sure they were all right. The rescue company began to look for a second way out and found a window in a bathroom and a storeroom. Both were secured from the outside with 3/4-inch bars. Even if the bars could have been forced, they would not have escaped. The windows opened to a small loading area that was now sealed to the exterior by a solid steel rolldown gate.
Stairs in the kitchen that led to the rear of the building would bring the crews higher into the fire. An exit door was located in that area. Beyond that door was the same loading area to which the windows led. Exiting the door would still leave them trapped. The anti-theft covering on the door made egress even more complicated. The door was covered with heavy-gauge expanded steel mesh, similar to that found on stair safety treads. One-quarter-inch bolts and fender washers held the mesh in place. Two padlocked hasps, one directly under an electrical box, secured the door.
Although visibility was reduced, personnel located the hoselines; they knew they could find their way out if they found a hoseline. One firefighter remarked that he remembered the way in and had noticed that the lights in the display cases were on. When he saw them again, he knew he had found the way out. Both lines were directed at the fire as all the crews made it out of the building.
At 1929 hours, the IC transmitted that message no firefighter wants to hear: “Report of possible firefighters trapped.” Pump operators, on hearing the evacuation order, had begun to signal the evacuation signal by sounding apparatus air horns. The Ladder 3 crew, operating on the roof, looked over the side of the parapet to see members evacuating the building. The ladder operator observed firefighters exiting the building and collapsing on the sidewalk. At 1930 hours, the IC issued a call for all members to report to the scene and for Engine 5. At 1932 hours, he ordered that the previously requested mutual-aid companies be redirected to the scene. He requested an additional two and two for mutual aid.
By 1936 hours, two head counts revealed that all members were accounted for and that the fire was being attacked from the exterior. It was discovered that the ceiling that fell in one piece was in fact a renovation and was being supported by the display counters. At 1952, all visible fire was reported to be knocked down. Twelve members were transported to the hospital; all were released after treatment.
THE INVESTIGATION
The following day, an evaluation of the incident began with a survey of the scene. This survey was done independently of the fire investigation taking place at the same time. A quick walk-through helped us gain a better appreciation for the site. The building was photographed from grade level and the air. The photographs were to fully document the structure, its relationship to other buildings, and the terrain that affected the incident.
The interior of the structure was then photographed to document the layout of the occupancy and the hazards firefighters encountered. Emphasis was placed on the means of egress and the collapsed ceiling. We measured the building and the bakery.
It was determined that the ceiling was comprised of a framework of 2 3 4s and 2 3 6s covered by plasterboard and then covered by ceiling tile. Fluorescent lighting and audio speakers were in the ceiling. The entire assembly was supported by plumber’s strapping nailed to joists above.
The original building plans called for the ceiling to be tin-covered plaster and lath. Just the tin was in place. It had been penetrated so that the strapping could be applied to the second-floor floor joists. The straps were attached by driving a single nail through one of the holes in the strap and then bending over the nail. That is what caused the ceiling to fail. The heat softened the strapping, allowing the strapping to be pulled over the nails’ heads.
CRITIQUE/DEBRIEFING
A critical incident stress debriefing was held the evening following the incident. The day tour was held over until the debriefing was concluded. Fortunately, that night proved to be uneventful. On the following day tour, we conducted a group critique of the incident. Members who had been present at the incident were interviewed individually so that we could learn what each person observed during the three phases of the incident.
The focus was on conditions and actions on arrival, during the collapse, and after the collapse. The acquired information was written on an interview sheet developed for that purpose. The goal was that this process would identify areas of commonality that may have minimized the incident’s outcome and identify the precursors to the event.
Two weeks after the incident, briefings were held with all four groups. The objective was to keep the focus of the session on what worked and what didn’t. Areas needing change were presented, with solutions. Those items that worked reinforced the policies and procedures in place. A dedicated effort was made to keep each session on track and avoid finger pointing. All four groups exhibited a heightened sense of awareness that we had narrowly escaped a serious incident and that it could happen again.
STATE INVESTIGATION
The New York State Public Employee’s Safety and Health (PESH) agency, a division of the state’s Department of Labor, investigated the incident to determine if the department had complied with current standards. The major areas of concern were the policies covering SCBA and FAST teams and the related training and record keeping. PESH also reviewed annual reports of injuries and illnesses. The agency also inquired whether we had evaluated the incident and, if so, what our findings were. PESH expressed concern about whether the department had taken any actions to prevent a similar incident from occurring again.
PESH determined that the department was in compliance with current requirements. Our investigation, analysis, and changes were all on target. The one area cited for improvement was the incident commander’s compliance with the department’s OAG to implement FAST teams so that operational personnel’s safety is safeguarded.
LESSONS LEARNED AND REINFORCED
- Tunnel vision, or focusing predominately on assigned tasks, was definitely a contributing factor. Neglecting the “big picture” view is constantly identified as a factor in many incidents, and it definitely was not eliminated here. It is natural for individuals to “micro focus.” Training must stress that it is important for all members to take the time to really see an incident. Everyone must do an individual size-up and relay the information to their respective partners.
- Every person at an incident must complete a size-up to identify potential hazards. Items of concern must be communicated within teams and crews, and the information must be transmitted throughout the chain of command.
- When the ceiling collapsed, crew members and officers immediately checked on each other and made sure everyone was accounted for and capable of performing whatever tasks awaited them. Teamwork and working with a partner eliminated the possibility of losing a lone individual working by himself. This drive to find a partner or company mate eliminated the chance of losing someone.
- The tendency of personnel’s “piling on” was quite evident during this incident. Personnel must resist the moth-to-flame syndrome. Company officers are responsible for ensuring that all tasks are accomplished in the order of importance during an operation. They must be aware of the situation around them at all times, including the incident, personnel issues, and tasks that need to be completed. They must distribute their forces so that the entire incident is covered and tasks are completed in order of importance. Luckily, some personnel were in the act of redistribution as the ceiling collapsed.
- As important as the issuance of orders is, verifying that the order was received and carried out is just as important. Radio communication requires the acknowledgment of a message to confirm that it was received. Just because you said it doesn’t mean the intended receiver of the message received it. Verify it! If the task issued wasn’t carried out, reissue it.
- The importance of identifying landmarks and pathways as you enter an occupancy cannot be overemphasized. It is imperative that each person entering an occupancy make a mental map that can be used for rapid exit if that need should arise. Numerous individuals used the unique layout of the front room to their advantage when they evacuated the bakery. Remarks personnel made included “I remembered the turn in the counter” and “I knew the counters ran along the wall and along the back of the bakery and would lead me at least to the front windows.” These simple but consciously made clues allowed the teams to move confidently (in the proper direction) toward safety.
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- When conditions in the kitchen deteriorated so that visibility was near zero, members relied on basic survival skills to find the way out. The attack lines were used as a conduit to direct them out of the kitchen area to the front of the bakery. Despite excess hose that was brought into the building to facilitate advancement, everyone knew that following the hoseline would get them out. Again, basic skills must be taught and reviewed constantly. When the chips are down, reactions have to be instinctive.
- Emergency evacuation signals were not acknowledged at this incident. Just because it is written in some standard operating procedure doesn’t mean that every person will immediately conform. Only two people hearing the evacuation signal could identify it as an evacuation signal. Those who heard air horns blowing thought the blasts were coming from responding apparatus. Because air horns are so common, perhaps they should not be used for emergency communication.
- The in-service training program was modified to increase exposure to OAGs, including those covering fireground operations, accountability, FAST team operations, and mask policy, which includes emergency procedures. Extra effort was made to concentrate on basic skills-the skills that were successfully demonstrated during this incident.
- At the time of the collapse, a FAST team was not in place. OAGs and department orders specifically call for one to be established. As in most departments, on-duty staffing requirements severely affect the deployment of a FAST team. This incident has shown us that even though there may not be enough personnel to accomplish all tasks, we must take care of our own first. Another point that must be addressed is the staffing of a FAST team: How many people would be needed to rescue four, seven, or even 15 firefighters?
- Accountability at the incident was achieved according to department practices. The working deputy keeps a roster/assignment list in his vehicle. When the evacuation was ordered, two head counts were conducted; all company officers reported results to the command post 30 minutes after the collapse. Safety conducted a third count and discovered a man missing. After some tense minutes of attempting to locate the missing member, he was located beyond the fire lines. Even after the incident is under control, all members must maintain their vigilance in complying with accountability.
“Fix the problem not the blame” has been the focus since the night of the incident. The lessons learned from this incident are very important; however, conducting an unbiased investigation, discovering findings, and making the necessary changes are just as important. We all face the same dangers-some of us not as often as others-and we tend to get complacent. Use this and other incidents to determine if you are ready or need to make some changes in your department. It can happen to you. It happened to us.
CHARLES J. KORTLANG, a 29-year veteran of the fire service, is a lieutenant with the Mt. Vernon (NY) Fire Department and the municipal training officer. He is fire commissioner for the Carmel (NY) Fire District. He is a certified Instructor 2. Kortlang attended Pennsylvania Military College and has an associate’s degree in fire protection technology from Westchester Community College.
