On March 29, 2015, video captured the dramatic and frightening fall of a Fresno Fire Department fire officer through the roof of a burning structure. Captain Pete Dern was severely injured, suffering second- and third-degree burns to over 70 percent of his body after roof decking failed and he plunged into a residential garage. The fire service followed the reporting of the incident and Captain Dern’s remarkable recovery.
Now, the Multi-Agency Serious Accident Investigation Team (SART), composed of the Fresno Fire Department and six other California fire departments, has released a highly detailed and comprehensive report regading the Courtland Fire. The information provided gives readers a background into the Fresno Fire Department, their operations during the incident in quesiton, and many details from the investigation.
As you read the summary below, and the attached full report, consider how such an event would impact you and your department and what lessons learned could be introduced into your operations and fire department culture.
Informational Summary, Courtland Incident (released April 2015)
Read the Report: Courtland Incident
S.A.R.T. Investigation Report, Fresno Fire Department
On March 29, 2015, while performing vertical ventilation on a residential garage fire, a Fresno Fire Department truck company captain, due to penetration of “roof decking burn-through” with direct flame impingement of the lightweight truss, fell into the well involved fire compartment. The Truck Captain sustained critical burn injuries, but fortunately survived.
On April 6, as a result of this incident, the Fire Chief assembled a “Serious Accident Review Team” (SART). The Chief authorized the team to review the incident. In her words, “the primary purpose of this report is to educate and prevent any future injury or death to the department members.” Additionally, and to her credit, she directed the SART to look anywhere the research led us.
The review timeline spanned a seven month period. The process included conducting interviews, reviewing policies and procedures, researching laws, standards, and industry best practices, as well as regular meetings of the SART to analyze, comprehend, organize, and assemble the data into report form.
As the team began to investigate the incident, it became evident that the contributory and causal factors were not unique to this incident. In fact, many of the factors and recommendations have appeared for years in NIOSH Firefighter injury and fatality reports. These factors include:
- Personal Protective Equipment and Safety Gear
- Independent Action and Freelancing
- Leadership and Safety
- Stationary Incident Command Post
- Accountability and Procedures
- Size-Up and 360
- Incident Action Plan
- Transfer of Command
- OSHA 2 In / 2 Out Guidelines
- Vertical Ventilation
- Organizational Expectations
- Risk Management Process
- General Safety Guidelines
- Recognition of Modern
- Fire Science
- Fire Stream Tactics
- Training
- Communications, and
- Emergency Medical Service.
The SART, feeling frustration as a group, began to ask why. Why, with these factors being common in so many serious injury and LODD reports do we choose to ignore them as an industry? Or worse yet, why do we acknowledge them but fail to act? We have years of these investigative reports with documented factors, recommendations, as well as more scientifically proven, modern firefighting methods, that can and do make this profession safer for our people, yet we continue with business as usual, or simply write firefighting off as just being a dangerous profession.
Clearly, while this accident review and report focuses on the Fresno Cortland incident, it is in fact, much bigger than the Fresno Fire Department. This incident, with the associated video, has been seen across the nation. We all gasped as we watched the brave Captain disappear beneath the roof. However, because of the wide reaching exposure of this tragic event, we have an opportunity to effect national change.
This report is not intended to be critical of the Fresno Fire Department or to place blame on any specific person(s). The issues are far too common across the country to simply focus on one organization. The issues are those of the American Fire Service.
As you review this report, it is the hope of this SART that each of you will take a critical look at your organization, as well as yourselves. Fire departments are made up of individuals. A fire department cannot change its culture, and as a result improve the safety of its employees without the commitment of each individual collaboratively working together, regardless of rank or status, and certainly regardless of affiliation with labor or management.
