AFTER NEARLY A YEAR, THE INVESTIGATION AND SUBSEQUENT REPORT on a fatal fire in San Pablo, California on July 21, 2007, was released this week.
The 1 am house fire took the lives of the two elderly occupants and also killed two Contra Costa County firefighters. The report exposes a string of mistakes and improper procedures that occurred throughout the entire incident, beginning with the private alarm company.
The Contra Costa Times summarized the report (HERE).
* A serious mishandling of the initial call.
One of the most damning failures was a nearly 10-minute delay from the moment the homeowners’ fire alarm alerted their alarm company to when the first firefighter was dispatched, the investigators said.
Two fundamental mistakes by the alarm company employee — calling a nonemergency line and not making clear that the house was on fire — sent the call plummeting down the priority list, leading to the critical delay and lessened response.
The alarm co. employee never relayed to the dispatcher that there was a fire in the house, even though she had been told that by the occupant. As a result, the first fire engine was not dispatched until 9:44 after the call came in.
Also, by dispatching it as an alarm sounding, a lower priority call, the automatic-mutual aid dispatch was bypassed. The nearest fire station, which is in another jurisdiction, was never sent on the call.
* Understaffed engine magnified the problem.
The first-in engine had only 3 FF’s on board and when they arrived they were notified of people trapped. The captain had to pass command because of the need to become part of the attack line. Due to the mistaken dispatch procedure, he passed command to an engine company that was never dispatched.
This left the units on the scene without an established command post and they, in effect, operated independently throughout the fire.
When the two firefighters were reported missing, there was not yet a R.I.T. set up.
* A company set up a large fan outside the door and began a positive-pressure ventilation operation before a ventilation hole was made in the roof.
Shortly after the fan was turned on, a buildup of the fire was observed followed by a backdraft explosion. This is what is believed to have caused the FF’s to perish while they were in the room where the fire began.
* An inexperienced workforce.
The Contra Costa Fire Protection District has undergone a large turnover recently due to retirements, leaving a less-experienced overall force. About one-third of the uniformed force has less than five years on the job.
The report calls for a more intense training program. It also calls for increasing the minimum manning to four per engine. In the past 20 years the population of the district has increased by more than 20%, but the minimum daily staffing of the department has increase by only five FF’s.
There are more items and recommendations in the comprehensive report and you can read the entire 122-page document (.pdf format) HERE. It includes the transcripts of the alarm company’s report and the relevant fireground radio transmissions.