Remember the fallen with the lessons learned
NIOSH Fire Fighter Fatality Investigation and Prevention Program
On May 18, 2017, a 31-year-old male career fire fighter died after fire conditions rapidly deteriorated inside a commercial strip mall. Ladder 35 was the first-apparatus on-scene at 2117 hours.
Texas State Fire Marshal’s Office:
Firefighter Fatality Investigation – Firefighter Scott Deem, San Antonio Fire Department
Investigation FFF FY 17-02
The Ladder 35 captain sized up the scene, assumed incident command, and directed Engine 35, the first arriving engine company, to pull a pre-connected hose line while the two Ladder 35 fire fighters forced open the front entrance door to a fitness center where smoke was showing. The Ladder 35 captain directed the Engine 35 lieutenant to take the charged hose line inside for an offensive attack and directed the two Ladder 35 fire fighters to conduct a quick and shallow search for victims. The Ladder 35 captain then radioed dispatch and requested a second-alarm.
Engine 26 arrived next and was instructed to open the Delta exposure. Engine 44 was assigned to Side Charlie. Battalion Chief 3 (BC3) arrived on-scene at 2120 hours and drove to the rear of the strip mall to do a 360-degree size up. He radioed the Ladder 35 captain and told him that he would assume Command after he completed the 360-degree sizeup. He discussed the conditions at Side Charlie with the Engine 44 crew, then drove to Side Alpha and radioed that he was assuming Command at 2122 hours, however not all fire fighters on the fireground heard the radio traffic and the Ladder 35 captain continued to direct fireground operations.
At 2124 hours, the Ladder 35 Fire Fighter 2 radioed Command and reported that “he found the seat of the fire, the fire is in the attic, and have the motor crew (Engine 35) do a right hand search and bring the nozzle back here to us.” At 2125 hours, Battlion Chief 3 radioed Ladder 35 captain and stated he had Command and instructed the captain to join up with his crew. Soon after, the Engine 44 officer radioed Command and reported fire through the roof at Side Charlie and that they could open a door and put water on the fire. Command instructed Engine 44 to open the door but not to put any water on the fire yet because he didn’t want to push the fire onto the crews inside. Conditions continued to deteriorate inside the fitness center.
At 2127 hours Command radioed for all interior crews to come out until ventilation was started. Command then instructed Engine 44 to open up the back door. At 2128 hours, the Ladder 35 Fire Fighter 2 radioed MayDay. BC 3 radioed for all companies to come outside and also requested a personnel accountability report (PAR). Once outside, the Engine 35 lieutenant reported that the Ladder 35 fire fighters did not exit the fitness center with the Engine 35 crew. Rapid intervention Team (RIT) crews were immediately assigned to look for the missing fire fighters.
During RIT operations, the missing Ladder 35 Fire Fighter 2 was found and quickly removed from the structure, and transported for treatment. During the continued search for the missing Ladder 35 Fire Fighter 1, a RIT member ran low on air and was overcome by the extreme fire conditions. He was removed from the structure and transported via ambulance for treatment.
Defensive supression continued until Command called for a site shut down to listen for the missing Ladder 35 Fire Fighter 1’s PASS device. While operations were shut down a fire fighter from Engine 37 saw the reflective trim of an SCBA near the Side Bravo wall. Recovery operations for Fire Fighter 1 began, and he was removed from the structure where he was pronounced dead. The cause of the fire was later determined to be arson.
- Arson fire
- No sprinkler system in commercial structure
- High wind conditions
- Zero-visibility and cluttered floorspace impeded hose line advancement
- Freelancing Fire Tactics (Ladder company searching for fire beyond protection of hose stream)
- Crew integrity not maintained
- Uncoordinated ventilation (rear door opened at Side Charlie).
- Fire departments should integrate current fire behavior research findings developed by the National Institute of Standards and Technology (NIST) and Underwriter’s Laboratories (UL) into operational procedures by developing or updating standard operating procedures, conducting live fire training, and revising fireground tactics including how to recognize and fight ventilation-limited fires, hose stream tactics, and wind-driven fires.
Additionally, state, local, and municipal governments, building owners and authorities having jurisdiction should:
- Consider requiring the use of sprinkler systems in commercial structures.