The Texas State Fire Marshal’s Office has released the findings from its investigation of a 2010 commercial structure fire that claimed the life of a Wharton Volunteer Fire Department captain.
On July 3, 2010, Wharton Volunteer Fire Department Captain Thomas Araguz III was killed during firefighting operations at an egg production and processing facility. More than 30 departments, some as far as 60 miles away, with 100 apparatus and more than 150 personnel responded.
Read The Report:
SFMO Firefighter Fatality Investigation Case FY 10-01
The fire involved the egg processing building which included the storage areas holding stacked pallets of foam, plastic, and cardboard egg cartons and boxes. The fire building was a large windowless, limited access structure with large open areas of over 58,000 square feet. Composed of mixed construction, it included a two-story business office, the egg processing plant, storage areas, coolers, and the shipping docks. It was primarily a metal frame construction with metal siding and roofing, build upon on a concrete slab foundation. The roof was composed of some wood framing.
Captain Araguz arrived at the south side main entrance 20 minutes after dispatch. Captain Araguz, Captain Juan Cano, and Firefighter Paul Maldonado advanced a 1 3/4-inch hoseline through the main entrance and along the south, interior wall to doors leading to a storage area at the Southeast corner. Maldonado stayed at the entry door and fed hose as the two captains advanced. During the process of advancing the hoseline Araguz and Cano became separated from the hoseline and then each other.
Captain Cano found an exterior wall and began kicking and hitting the wall as his SCBA supply ran out. Firefighters cut through the exterior metal wall at the location of the knocking and pulled him out. Several attempts were made to locate Captain Araguz including entering through the hole just cut to rescue Cano as well as cutting an additional hole where Araguz was believed to be located. Eventually fire conditions forced the crews to withdraw and defensive operations were started.
Captain Cano was transported to the Gulf Coast Medical Center where he was treated and released. Captain Araguz was recovered the following morning. He was transported by ambulance to the Wharton Funeral Home then taken to the Travis County Medical Examiner’s Office in Austin, Texas for a post-mortem examination.
The investigation revealed seven significant findings and recommendations:
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FINDING 1
There were no lives to save in the building. An inadequate water supply, lack of fire protection systems in the structure to assist in controlling the spread of the smoke and fire, and the heavy fire near the windward side facilitated smoke and fire spread further into the interior and toward “A” side operations. Along with the size of the building, the large fuel load, and the time period from fire discovery, interior firefighters were at increased risk.
Recommendation: Fire departments should develop Standard Operating Guidelines and conduct training involving risk management and risk benefit analysis during an incident according to Incident Management principles required by NFPA 1500 and 1561. -
FINDING 2
Initial crews failed to perform a 360-degree scene size-up and did not secure the utilities before operations began.
Recommendation: Fire departments should develop Standard Operating Guidelines that require crews to perform a complete scene size-up before beginning operations. A thorough size up will provide a good base for deciding tactics and operations. It provides the IC and on-scene personnel with a general understanding of fire conditions, building construction, and other special considerations such as weather, utilities, and exposures. Without a complete and accurate scene size-up, departments will have difficulty coordinating firefighting efforts. -
FINDING 3
The Incident Commander failed to maintain an adequate span of control for the type of incident. Safety, personnel accountability, staging of resources, and firefighting operations require additional supervision for the scope of incident. Radio recordings and interview statements indicate the IC performing several functions including: Command, Safety, Staging, Division A Operations, Interior Operations and Scene Security.
Recommendation: Incident Commanders should maintain an appropriate span of control and assign additional personnel to the command structure as needed. Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision. In ICS, the span of control of any individual with incident management supervisory responsibility should range from three to seven subordinates, with five being optimal. The type of incident, nature of the tasks, hazards and safety factors, and distances between personnel and resources all influence span-of-control considerations. -
FINDING 4
The interior fire team advanced into the building prior to the establishment of a rapid intervention crew (RIC).
Recommendation: Fire Departments should develop written procedures that comply with the Occupational Safety and Health Administration’s Final Rule, 29 CFR Section 1910.134 (g)(4) requiring at least two fire protection personnel to remain located outside the IDLH (Immediate Danger to Life or Health) atmosphere to perform rescue of the fire protection personnel inside the IDLH atmosphere. One of the outside fire protection personnel must actively monitor the status of the inside fire protection personnel and not be assigned other duties. NFPA 1500 8.8.7 At least one dedicated RIC shall be standing by with equipment to provide for the rescue of members that are performing special operations or for members that are in positions that present an immediate danger of injury in the event of equipment failure or collapse. -
FINDING 5
The interior team and Incident Commander did not verify the correct operation of communications equipment before entering the IDLH atmosphere and subsequently did not maintain communications between the interior crew and Command. Although Chief Barnett stated he communicated with Captain Cano, there was no contact with Captain Araguz.
Recommendation: Fire Departments should develop written policies requiring the verification of the correct operations of communications equipment of each firefighter before crews enter an IDLH atmosphere. Fire Departments should also include training for their members on the operation of communications equipment in zero visibility conditions. -
FINDING 6
The interior operating crew did not practice effective air management techniques for the size and complexity of the structure. Interviews indicate the crew expended breathing air while attempting to breach an exterior wall for approximately 10 minutes, then advanced a hose line into a 15,000 square feet room without monitoring their air supply. During interviews Captain Cano estimated his consumption limit at 15 — 20 minutes on a 45 minute SCBA.
Recommendation: Crews operating in IDLH atmospheres must monitor their air consumption rates and allot for sufficient evacuation time. Known as the point of no return, it is that time at which the remaining operation time of the SCBA is equal to the time necessary to return safely to a non-hazardous atmosphere. The three basic elements to effective air management are:
– Know your point of no return (beyond 50 percent of the air supply of the team member with the lowest gauge reading).
– Know how much air you have at all times.
– Make a conscious decision to stay or leave when your air is down to 50 percent. -
FINDING 7
Captains Araguz and Cano became separated from their hoseline. While it is unclear as to the reason they became separated from the hose line, interviews with Captain Cano indicate that while he was finding an exterior wall and took actions to alert the exterior by banging and kicking the wall, he lost contact with Captain Araguz.Captain Cano credits his survival to the actions he learned from recent Mayday, Firefighter Safety training.
Recommendation: Maintaining contact with the hose line is critical. Losing contact with the hose line meant leaving the only lifeline and pathway to safety. Team integrity provides an increased chance for survival. All firefighters should become familiar with and receive training on techniques for survival and self rescue.
