BY DAVID ROHR
On December 17, 2001, at 02:46 hours, the Fairfax County (VA) Fire and Rescue Department responded to a reported fire on the third-floor balcony of a residential apartment building at 13849 Braddock Springs Road. Initial arriving units found heavy fire conditions in the attic area of the building.
Approximately 16 minutes after the initial dispatch, the roof structure collapsed, trapping three firefighters on the third floor. They were inside the apartment attempting to breach the ceiling and direct an attack line into the burning attic. Command declared a Mayday and requested additional resources for the third floor.
The collapse added a tremendous amount of confusion to the efforts to organize the incident scene, command post operations, and transfer of command. Command was besieged with communications from several units in addition to the rescue group on the top floor. Command continued efforts to organize the incident while responding to radio transmissions from several units on the top floor. Several of these transmissions relayed inaccurate information to command.
Photos by Sheldon Levi.
One firefighter was able to escape using the open exterior stairway by which the three had accessed the apartment. But a subsequent collapse eliminated this primary means of egress for the other two firefighters. They were only able to access the landing outside of the apartment door. The stairs were blocked, forcing them to find an alternate means of egress after they emerged from the apartment.
Attempting to escape from the third floor, both firefighters went over the third-floor railing; one climbed over the railing onto the second-floor landing and climbed over the railing to the first floor landing and then to the ground floor. The second firefighter went over the third-floor railing, missed the second floor, and fell 18 feet to the ground. He was knocked unconscious after striking a landing or railing during his fall. He also suffered a partial avulsion to his ear. Rescue attempts continued for approximately 49 minutes in the collapse area until it was determined that all firefighters had been evacuated from the structure.
Following this event, the department activated its Significant Injury Investigation Team (SIIT) to investigate this near-miss incident. The inquiry and subsequent report identified National Institute of Occupational Safety and Health (NIOSH) findings with which we all have become too familiar and that duplicate findings and recommendations found in numerous NIOSH firefighter fatality investigations.
After the release of the SIIT report, a focus group that included members from all levels of the organization met to develop a recommendation implementation plan. This group organized the SIIT report’s 41 individual recommendations into six areas of responsibility within which to address issues: command and control, personnel accountability, communication, strategic and tactical coordination, safety, and administration.
LESSONS LEARNED, ACTIONS TAKEN
Command and control. The lack of command and control at this incident resulted in the violation of or deviation from a number of existing operating policies that would have allowed a better incident outcome if followed. These included lack of initial interior operations support; limited timely implementation of accountability procedures early in the incident; delayed rapid intervention team (RIT) identification, organization, and deployment; neglect of arriving senior staff members to fill critical ICS positions, and inadequate crew discipline at the time of the collapse.
During the past year, there has been regional command-level training in incident command, fireground management, RIT operations, and personnel accountability involving all Washington D.C. metropolitan area fire departments. There has also been some RIT training at acquired structures in Fairfax County, and we recently completed a two-day seminar with RIT operations as the main theme. Additionally, our in-station drill program has focused on the RIT operations’ increased resource and planning demands. The next step is to develop a standardized training package for the battalion level for all company officers that includes an evaluation tool. The evaluation would review the procedures overall and those participating in them. We always find room for improvement as we refine our procedures and train with them.
Personnel accountability. From the onset of command operations, an accurate picture of crew accountability did not exist. Unit officers failed to maintain crew unity. The accountability system hardware (i.e., the actual tags and passports placed on a board to track where units are assigned on the fireground) was incomplete for many units on the scene, and accurately accounting for all personnel after the situation deteriorated was delayed.
As noted above, there has been command-level accountability training since then. Company-level accountability procedures are under review, and six northern Virginia fire and rescue departments are developing a command procedures manual. These departments share operational manuals and procedures for use in our mutual/automatic aid system. Personnel accountability procedures make up one portion of this manual.
Communication. Communication issues involved hardware, operability, and personnel unfamiliarity with the radio system and its capabilities. At times, radio discipline was not maintained, and established communication safety procedures were disregarded. The dispatch center did not follow several communication policies.
During the past year, the communication section visited each work location to provide training and operational familiarity with the still somewhat new 800-mHz system. Additional plans include providing training to companies during Operations Academy Rotations (OARS) during calendar year 2003. A communication unit is also on order to address fireground communication issues on large-scale events. The unit will support the command team and bring additional resources to the scene. The current communication users group addressed training issues involving the use of multiple channels and command terminology. This involved training with dispatchers and command personnel and will continue at all levels.
Strategic and tactical coordination. The initial action plan was not fully supported early in the incident. Crews were left operating within the structure and were not notified of the rapidly changing conditions—i.e., heavy fire involvement in the overhead lightweight construction attic area. Command did not verbalize a change in operational modes on the fireground, and later-arriving command officers did not make it known that exterior master streams were operating with personnel still working inside the building.
As noted above in command and control actions taken, there has been command-level training regarding this issue, but it must also continue at the company-officer level. A scenario-based training package has been recommended that would provide some type of evaluation tool. The department currently has several operating manuals in place that address fires in Type V construction occupancies. Personnel at all levels must train and be held accountable for decisions made on these types of operations.
Safety. The safety issues outlined involved personnel violating established policies and command staff and company officers failing in some cases to hold them accountable. Crew unity was inconsistent throughout the incident; some personnel were not wearing proper respiratory protection while operating in the immediately dangerous to life and health atmosphere.
These issues were addressed in the command-level training and will be included in the recommended battalion training packages. There were also protocol issues involving dispatch of the duty safety officer and some inconsistencies involving backup or fill-in safety officers. A retreat is being planned by the Health and Safety Section to discuss expectations and consistency across shift lines.
Administration. The administrative issues identified dealt mostly with the implementation of the SIIT report findings. This included the information-gathering process from companies leaving the scene and the entire department’s poor understanding of the SIIT’s roles and responsibilities. Another key item identified was the lack of up-to-date personal contact information for some personnel at the station level and within the computer-aided dispatch system. This became critical when it was necessary to contact family members.
Enhancements in the way the SIIT team is activated have been discussed, and recommendations in some of the team’s administrative procedures have been reviewed.
The entire department realized how hard it is to look into the mirror when things go wrong. In most cases, it has little to do with the individuals in certain positions but may simply point to policies and procedures already in place that need to be reinforced. We found this to be the case in this incident and have many valuable lessons to work from each day.
Although great progress has been made since the Braddock Springs incident, the lessons learned should never be forgotten and should remain in the forefront of our training and operations at all levels of the organization.
DAVID ROHR is the assistant chief of administrative services and a 25-year veteran of the Fairfax County (VA) Fire and Rescue Department, where he has held various ranks and positions in operations and administration. He is a member of Virginia Task Force 1 (US&R) and served on the department’s hazardous materials response team for eight years. He has a bachelor’s degree in technology and management/fire science from the University of Maryland and is a graduate of the National Fire Academy’s Executive Fire Officer Program. He is an adjunct professor with Northern Virginia Community College.