Firefighter Fatality Case Study

Farwest Truck & Auto Supply

Coos Bay, Oregon

November 25, 2002

Objectives

• To analyze firefighter fatality incidents in the name of eliciting lessons learned to prevent future occurrences.

• To increase the knowledge base of firefighters, and in particular fire officers, in the spirit of making firefighting safer.

Those who cannot remember the past are condemned to

repeat it.

- George Santayana

Community ProfileCoos Bay, Oregon

• Population – 16,000

• 10.5 square miles

• Major industries– Fishing

– Logging

Fire Department ProfileCoos Bay, OregonCombination Department

– 3 Stations– Career Chief– Battalion Chief (Operations/Training)– 1 Captain, 3 Lieutenants, 4 Firefighter/Engineers– 19 Career Firefighters– 25 Volunteer Firefighters (Residents, Cadets)– 4 Engines (3 Frontline, 1 Reserve)– 1 Quint (75’) – 1 Rapid Attack/Rescue– 1 Water Tender– 1400 runs per year

Coos Bay Fire Station 1Central Station 150 S. 4th St.

Personnel

• Career: • Captain - 1

Firefighter/Engineer - 2 Administration - 3

ChiefBattalion Chief (operation/training)Office Manager

• Cadet Firefighters (Up to 6) 

Apparatus located at Central

• 1 - Class A Pumper • 1 - Rapid Attack/Rescue Vehicle • 1 - 75 ft. Quint • 1 - Hazardous Materials Response

Unit • 1 - 19 ft. Jet boat for Water

Rescue • 1 - Command Vehicle • 2 - Staff Vehicles for Chief and • Operations Chief

Coos Bay Fire Station 2 Empire Station 189 Wall St.

Personnel

• Career:Lieutenant - 1 Firefighter/Engineer - 1

• Cadet Firefighters: Up to 3

Apparatus

• 1 - Class A Pumper • 1 - Rapid Attack

/Rescue Vehicle • 2 - Jet Skis for water

rescue

Coos Bay Fire Station 3Eastside Station 365 D St.Personnel

• Career :Firefighter/Engineer - 1

• Resident Volunteers: Up to 3

• Industrial Fire Brigade (SOMAR):

• 7 personnel Duty Hours 7am to 4 pm

Apparatus

• 2 - Class A Pumpers

• 1 - 3,200 gallon tender

•       Additional Equipment

• 1 - Class A Pumper

• 1 - 300 Gallon Foam Tender

• 1 - 3/4 ton Pick-Up Truck

Farwest Truck & Auto Supply

• Constructed approximately 1938

• Type IV – Heavy Timber

• Numerous Modifications

Construction Features

• Warehouse Addition• Mezzanine• Non-sprinklered• 13,250 square feet• Ceiling – 8” x ¾” old growth fir ship lap

with 3/8” Furtex glued to surface.• 2” x 10” wood ceiling joists

Construction Features

• Sales area ceiling height – 14’

• Mezzanine area ceiling height – 7’

• Roof support structure– 2” x 13” wood rafters

– 9” x 9” wood posts

– 9” x 13” wood beams

The Fire(1320 hours “D”)

• Store employees return from lunch.

• Light haze and burning odor noted.

• Search for source begins.

• Chimney found hot to touch (on roof).

• Red glow noted in bathroom area on mezzanine.

• First aid extinguishment begins – unsuccessful.

• 911 contacted at 1351 hours (D+ 31).

Coos Bay FD Response(D+32)

• Engine 8132 (5) (Victims 1, 2 & 3)• Engine 8131 (3)• Ladder* 8151 (3)• Rescue 8171 (2)• Staff 8101 (1) (Chief/IC)• Command 8111 (1)(BC)

*Quint

Mutual Aid Response(Requested After Initial Alarm)

• Engine 8306 (6)• Staff Vehicle 8301 (1 chief officer)• Staff Vehicle 8302 (1 chief officer)• Staff Vehicle 8303 (3 firefighters)• Ladder 8310 (3 firefighters)• Additional personnel from both

departments in POVs.

Operations(D+33)

• Command 8111 AOS and reports nothing showing, assumes command.

• Property owner informs 8111 that fire is near chimney in bathroom on mezzanine. All occupants out.

• IC notes light haze at drop ceiling level.

• Ladder 8151 arrives. IC shows crew location of fire.

D+361356 hours

• Staff 8101 arrives. Command transferred from 8111.

• Brown smoke visible from roof near chimney.

• 2 FFs from Ladder 8151 advance 1 ¾”, 200’ pre-connect through Side A door.– Observe fire at ceiling level

20-25’ from front wall.

– Visible fire knocked.

• 8111 assists Ladder 8151 with establishing supply line.

• IC orders 8111 to take a lap.• Mutual aid units requested.• Engine 8132 arrives and pulls back-up line

from Ladder 8151.• Initial attack line advances to mezzanine.

Finds fully involved bathroom, light haze and little heat.

• Ceiling opened, fire in rafters knocked. • 3 firefighters from 8132 (Victim #3, Firefighters #3

& #4) advance two handlines from Ladder 8151.– Line #1 goes to sales counter.

– Line #2 goes to mezzanine.

• GrayishGrayish/brownbrown smoke noted at ceiling level.*

*Ceiling height deceptive due to suspended lights and drop ceiling.

• Crews reach mezzanine and begin pulling walls/ceilings and extinguishing fire.

• Firefighter #5 and Victim #2 enter and follow handlines to mezzanine.

• Victim #1 enters and proceeds to mezzanine.• 8 firefighters in building operating 2 handlines

and pulling ceilings and walls.• Victim #1 requests (via radio) roof ventilation and

PPV on Side A.

D+481408 hours

• Mutual aid Engine 8306 arrives. 5 members to roof for ventilation.

• Staff 8301 arrives. Assigned Division C.• Staff 8302 arrives. Assigned Safety. • Engine 8306 arrives. • Roof reports small flame visible near chimney. • Firefighters pull handlines from Engine 8306 and

begin attacking fire through Side C doors.

81518132

8306

FARWEST AUTO AND TRUCK

SUPPLY

11/25/2002

1408 HOURS

(D+48)

1408 +(D+48+)

• Crews lose water momentarily.

• Firefighters 1, 2 & 4 low on air - exit.

• Firefighter 3 calls for more manpower.

• Firefighter #4 passes line to Victim #3.

• Firefighter #4 runs into Victim #1 while exiting and gives briefing.

• Visibility zero, heat relatively mild.

1408 +D+48++

• Operating inside:– Victim #1– Victim #2– Victim #3– Firefighter #3– Firefighter #5

V2 & V3 - handlinesV1, F3, F5 - hooking

1408 +(D+48+)

• Skylights broken out by roof vent crew.– First skylight initially yields no smoke. Then

heavy, dark, grayheavy, dark, gray smoke pours out.

• Second skylight yields heavy smoke immediately.

• IC ( Staff 8101) passes command back to 8111 to check on roof ops.

• Senior firefighter on roof notes “spongy” feeling.

• Senior firefighter orders crew roof.

• Staff 8101 reaches roof and notes bubbling tar, heavy smoke pushing from skylights, “soft and spongy” feel near Side A wall.

• Staff 8101 orders building evacuation.

• Firefighters 3 & 5 exit the building due to low air.

• Major ceiling collapse ensues knocking Firefighter 5 down stairs. Firefighter at bottom of stairs

forced to exit.

• Victim #3 trapped at top of stairs or knocked over railing.

• Victim #1 & Victim #2 buried under full force of collapse.

• Firefighter 5 calls out. No replies. Turns to see mezzanine fully involved. Runs out of air and exits building.

D+48+

• As Staff 8101 exits roof he sees skylights drop into building. Deep redred flame and heavy blackblack smoke begin blowing out of hole.

• Firefighter #5 exits and tells ISO that firefighters are trapped.

• ISO & other officers call missing on radios.• No response.

• Staff 8101 resumes command.– Orders Roof team to RIT.– Additional handlines pulled to protect Side A

entrances. • Division C enters building on Side C and hears

PASS alarms sounding overhead on mezzanine.• RIT enters Side A.

– Driven back by high heat, and rolling flame front.

D+55

• Firefighter #1 reports hearing PASS alarm while operating 2 ½” handline on Side A.

• Firefighters 1 & 5 enter structure and recover Victim #3.

• Victim #3 – Full PPE on, including SCBA, found near front counter.

• Apparently followed hoseline before collapsing.

1608+(D+175)

• Defensive operations in effect.

• Victim #1 & Victim #2 recovered and pronounced dead approximately 1708 (D+235).

NIOSH Recommendations

FD’s should ensure that:

1. firefighters provide the IC with interior size up reports.

2. firefighters open concealed spaces to determine if a fire has spread.

3. Pre-emergency planning is completed for mercantile and business occupancies.

4. RIT teams are established and in position.

NIOSH Recommendations

5. FD’s should consider the use of thermal imagers to assist with interior size-up.

6. FD’s should ensure that local citizens call the fire department immediately when they smell smoke or feel heat.

NIOSH Recommendations

• FDs should always maintain good accountability.

(Not a factor in this incident)

• Building owners should ensure that building permits are obtained local codes are followed.

• Chimney was improperly installed.

Coos Bay Fire and Rescue

Lt. Randall Carpenter

46 YO, 20+ years

Firefighter Jeffrey Common

30 YO, 8 years

Firefighter Robert Hanner

33 YO, 13 years

Sources

NIOSH Firefighter Fatality Investigation and Prevention Program

Report #2002-50

Firehouse.com“Roof Collapse Takes Three Oregon Firefighters”

“Community in Shock Over Deaths of Three Firefighters”

“Oregon Firefighters Leave Legacy of Bravery, Fellowship”

“Coos Bay Tragedy: The Victims and Memorial Information”

“Investigators: Hidden Fire Likely Burned for Hours”