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Report On Calif. Double-FF Fatalities Released

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.

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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.

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*  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. 

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*  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.

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*  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.

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Comments - Add Yours

  • http://positivepressureattack.com/ Kriss Garcia

    For years we have been stating that what is needed more than anything else with regards to Positive Pressure Attack and Positive Pressure Ventilation is education. As major proponents of PPA and PPV we have published several articles and books stating three main precautions that must be taken when using a pressurized attack. 1st and foremost is a strong incident command system with good command and control. Second is the fire has to have a safe place to exhaust the volumes of lethal products of combustion to. The quantity of exhaust has to be ample and has to match the fire load and extent of fire. In most cases this is accomplished by opening a minimum of 2 large or three smaller windows in the area of the building where the majority of the fire is located. Fire will travel to the area of least resistance or to the largest negative space. If this area is outside through a window that is great. If this area is in an attic or throughout other areas in the building extreme fire behavior may be the result. Third, that if firefighters have entered the building before a blower is placed into operation, they should exit the building assess the ventilation efforts and only re-enter as part of a coordinated effort. All three of these absolute precautions were violated. We have to stop doing what we don’t understand.
    If is inexcusable that most basic fire training manuals give pressurized attack such a limited amount of space and consideration. It is also inexcusable to place a tool on an apparatus with inadequate training. There is no tool other than a charged nozzle on any engine that has the ability to change the fire more than a blower, yet we provide crews with little or no training and education on the use of them.
    We have taught over 10,000 firefighters from 100′s of departments over the last 12 years in the safe application of pressurized attack. In all of these encounters we have never seen a department have bad results if they implement tactics as we have stated.
    We would like to offer our condolences to these fine firefighters, their families and their department members. We would also like to offer our resources and services to any department considering using PPA and PPV for free if necessary. We strive to put everything good, bad or indifferent regarding pressurized fire attack on our web site located at positivepressureattack.com
    Remember – > +!!! You have to consider the negative space your blower is going to move the fire to before you start it…coordinate, exhaust, observe, react to conditions and implement one of the safest most effective fire tactics ever developed.
    We have several articles coming out in the next few months on this subject in both fire rescue and fire engineering.
    Please educate and train on this technique before you use it.

  • http://positivepressureattack.com Kriss Garcia

    For years we have been stating that what is needed more than anything else with regards to Positive Pressure Attack and Positive Pressure Ventilation is education. As major proponents of PPA and PPV we have published several articles and books stating three main precautions that must be taken when using a pressurized attack. 1st and foremost is a strong incident command system with good command and control. Second is the fire has to have a safe place to exhaust the volumes of lethal products of combustion to. The quantity of exhaust has to be ample and has to match the fire load and extent of fire. In most cases this is accomplished by opening a minimum of 2 large or three smaller windows in the area of the building where the majority of the fire is located. Fire will travel to the area of least resistance or to the largest negative space. If this area is outside through a window that is great. If this area is in an attic or throughout other areas in the building extreme fire behavior may be the result. Third, that if firefighters have entered the building before a blower is placed into operation, they should exit the building assess the ventilation efforts and only re-enter as part of a coordinated effort. All three of these absolute precautions were violated. We have to stop doing what we don’t understand.
    If is inexcusable that most basic fire training manuals give pressurized attack such a limited amount of space and consideration. It is also inexcusable to place a tool on an apparatus with inadequate training. There is no tool other than a charged nozzle on any engine that has the ability to change the fire more than a blower, yet we provide crews with little or no training and education on the use of them.
    We have taught over 10,000 firefighters from 100′s of departments over the last 12 years in the safe application of pressurized attack. In all of these encounters we have never seen a department have bad results if they implement tactics as we have stated.
    We would like to offer our condolences to these fine firefighters, their families and their department members. We would also like to offer our resources and services to any department considering using PPA and PPV for free if necessary. We strive to put everything good, bad or indifferent regarding pressurized fire attack on our web site located at positivepressureattack.com
    Remember – > +!!! You have to consider the negative space your blower is going to move the fire to before you start it…coordinate, exhaust, observe, react to conditions and implement one of the safest most effective fire tactics ever developed.
    We have several articles coming out in the next few months on this subject in both fire rescue and fire engineering.
    Please educate and train on this technique before you use it.

  • Dan

    Right on Kriss. I continue to battle with people that dismiss the use of PPV because of their own past mistakes due to lack of training. I continue to run into people that went to a class and only seemed to listen to half of what was taught or they are taught by someone that THINKS they know about PPV. I have seen PPV reduce the chance for firefighter injury if conducted properly. I have also seen people use it wrong and many of those same people also do not know the proper use of nozzles also. Get the new NIST DVD on PPV. PPV is really not a new concept unless it is in the hands of an untrained person.

  • Dan

    Right on Kriss. I continue to battle with people that dismiss the use of PPV because of their own past mistakes due to lack of training. I continue to run into people that went to a class and only seemed to listen to half of what was taught or they are taught by someone that THINKS they know about PPV. I have seen PPV reduce the chance for firefighter injury if conducted properly. I have also seen people use it wrong and many of those same people also do not know the proper use of nozzles also. Get the new NIST DVD on PPV. PPV is really not a new concept unless it is in the hands of an untrained person.

  • Allan

    PPV and PPA certainly have there place in the fire service, but some so called experts are leading people who depend on national publications for good information down the anti vertical ventilation path, which is a huge mistake. The correct thing to do would be to evaluate what type ventilation would be appropriate for the exact situation you are dealing with. PPV/PPA is a good tool, but it is just that, a tool and probably the most missused tool in the fire service.Dont believe every thing you read, talk to people who have actually had a lot of experience on the fire ground and not just in the lab or who do more writing than doing….34 year BC Dallas

  • Allan

    PPV and PPA certainly have there place in the fire service, but some so called experts are leading people who depend on national publications for good information down the anti vertical ventilation path, which is a huge mistake. The correct thing to do would be to evaluate what type ventilation would be appropriate for the exact situation you are dealing with. PPV/PPA is a good tool, but it is just that, a tool and probably the most missused tool in the fire service.Dont believe every thing you read, talk to people who have actually had a lot of experience on the fire ground and not just in the lab or who do more writing than doing….34 year BC Dallas