Report of Investigation Committee into Firefighter Injuries Sustained at 41 Eaton Street in...

7/26/2019 Report of Investigation Committee into Firefighter Injuries Sustained at 41 Eaton Street in Providence

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Report of Investigation Committee into Firefighter Injuries Sustained at 41 Eaton Street

31 March 201

Su!mitted to"

Commissioner of #u!$ic Safet% Steven M& #are

'ssistant Chief of the (epartment Scott Me$$o

I'FF )oca$ *++ #resident #au$ (ought%

Su!mitted !%"

,atta$ion -enneth Rainone

'cting ,atta$ion Chief Stephen Capricotta

'cting ,atta$ion Chief -evin .utras

.une 201


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E/ecutive Summar%

n 31 March 201 the #rovidence Fire (epartment e/perienced to mu$tip$e

a$arm ind driven fires that tested the (epartments command and contro$ communications

strateg% and tactics training operations for $arge sca$e events and mutua$ aid response andcapa!i$ities& hese fire events high$ighted the effects that ind driven fire conditions can have on

department operations at structure fires the demand for ade5uate and rapid dep$o%ment of

firefighting resources and the great ph%sio$ogica$ demands p$aced upon firefighters or6ing at

these t%pes of $ong duration events& ' tota$ of tent% si/ #rovidence Fire (epartment mem!ers

ere injured& Fourteen mem!ers ere injured at the Eaton Street fire& ' senior fire captain and

senior firefighter e/perienced critica$ injuries at the Eaton Street& f the tent% si/ injured ten

#rovidence mem!ers ere treated for presumed c%anide poisoning& he fire event high$ighted

the comp$e/it% of c%anide issue the dangers of h%drogen c%anide in smo6e the danger to

firefighters from smo6e e/posure and need for continued education of #rovidence Fire

(epartment mem!ers and the Rhode Is$and medica$ communit% a!out the dangers of h%drogen

c%anide poisoning from smo6e e/posure& his fire event provides $earning opportunities

regarding the need for firefighters to maintain a $eve$ of fitness throughout the course of their

careers to meet these ph%sio$ogica$ demands during structura$ firefighting7 the need to ensure

ade5uate trac6ing rotation reha!i$itation and rest of fatigued fire fighters7 $earning

opportunities regarding the #rovidence Fire (epartment Incident Command S%stem 8ICS9 and

the command and contro$ of a $arge sca$e emergenc% incident& his fire event high$ighted the

#rovidence Fire (epartments ina!i$it% to fu$fi$$ ICS Command Staff and :enera$ Staff positions

ith chief officers ith Fire :round Command e/perience& his fire event a$so high$ighted the

demands p$aced upon the #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9

during emergenc% operations of this si;e and demonstrated the cha$$enges for the present on

dut% staffing $eve$s of the ,C& he universa$ consensus of this committee as that Eaton Street

fire presented $earning opportunities for the entire (epartment and as such the focus of this

report is to provide $earning o!jectives for a$$ departmenta$ ran6s&

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a!$e of Contents

E/ecutive Summar%


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Introduction

8#hoto 1 Side 1 and 2 !efore Fire (epartment arriva$9

n 31 March 201 the #rovidence Fire (epartment simu$taneous$% e/perienced to

mu$tip$e a$arm ind driven fires that tested the departments command and contro$

communications strateg% and tactics training operations for $arge sca$e events and mutua$ aid

response and capa!i$ities& hese events !egan ith a genera$ a$arm fire during hich a secondthree a$arm fire occurred&

he #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9 !egan receiving

phone ca$$s for a report of a house fire in the vicinit% of 41 Eaton Street at 14"04 hours& his fire

5uic6$% gre to a genera$ a$arm fire& 'ppro/imate$% to and a ha$f hours into the Eaton Street

fire the ,C as6ed the Incident Commander if he had an% units avai$a!$e to c$ear the first fire

!ecause the ,C as receiving mu$tip$e phone ca$$s for the second fire&

't 1"3+ hours the ,C dispatched mutua$ companies a$ong ith #rovidence Fire

(epartment companies that ere a!$e to c$ear the Eaton Street fire to the area of )aure$ ?i$$

've& and )a!an Street for reports of mu$tip$e houses on fire& his fire 5uic6$% gre to three

a$arms&

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hese ind driven fire events tested the entire +4 mem!er p$atoon of the #rovidence Fire

(epartment off dut% mem!ers ho returned to or6 on their on initiative as e$$ as

firefighters of severa$ surrounding communities that provided mutua$ aid to the cit% of

#rovidence& It as the training dedication and professiona$ism disp$a%ed that da% a$ong ith

the time tested aggressive interior structura$ firefighting strategies and tactics emp$o%ed !% the

#rovidence Fire (epartment mem!ers 8for hich the (epartment has traditiona$$% !een

recogni;ed for9 that 6ept !oth fire incidents from !ecoming major conf$agrations&

he #rovidence Fire (epartment companies on the scene at 41 Eaton Street and $ater at

)aure$ ?i$$ 've& faced rapid$% esca$ating e/treme$% fast moving fires that ere enhanced !% the

effects of the ind& Meteoro$ogist Steve Cascione from $oca$ nes station ',C@es as

contacted for the recorded ind speeds for the time of the fires& ?e provided the investigation

committee recorded eather statistics from the e!site &underground&com that shoed

sustained inds of 20&* to 34&> mph ith the highest gust of ind recorded at 4 mph for the

five hour period of time during the fire events&1he inds ere !$oing from Side 1 to the Side

3A4 corner of the origina$ fire !ui$ding for the fire event on Eaton Street&

hese fire events high$ight the danger of ind driven fires the effects that ind can have

on department operations at structure fires the demand for ade5uate and rapid dep$o%ment of

firefighting resources and the great ph%sio$ogica$ demands p$aced upon firefighters or6ing at

these t%pes of $ong duration events& f the +4 mem!ers or6ing that da% Fift% nine of those

mem!ers operated at !oth fire events&

's a resu$t of these to fire events tent% si/ #rovidence Fire (epartment mem!ers ere

injured& Fourteen mem!ers ere injured at the Eaton Street fire& ' senior fire captain and senior

firefighter e/perienced critica$ injuries at the Eaton Street fire re5uiring e/tended sta%s in area

hospita$s& f the tent% si/ injured ten #rovidence mem!ers ere treated for presumed c%anide

poisoning&

,ecause of the num!er of injuries at these fires 'ssistant Chief of the (epartment

perations Scott Me$$o ordered an investigation into the circumstances surrounding the to

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incidents& o committees ere formed to investigate the incidents and re$ated injuries and

prepare reports on each incident&

,atta$ion Chief -enneth Rainone 'cting ,atta$ion Chief Stephen Capracotta and 'cting

,atta$ion Chief -evin .utras ere assigned the duties of investigating the injuries that occurred

at 41 Eaton Street&

'$$ officers ho responded to 41 Eaton Street ere instructed !% 'cting ,atta$ion Chief

-evin .utras to su!mit a #rovidence Fire (epartment Form 1* regarding compan% actions at this

incident a$ong ith the names of individua$s ho ere injured and circumstances re$ated to

those injuries& -e% individua$ mem!ers invo$ved ith the events of this fire ere intervieed !%

committee mem!ers&

he intent of the committee as to o!jective$% co$$ect and revie the facts of the

Eaton Street fire ana$%;e departmenta$ procedures and to ma6e recommendations for

improvement in departmenta$ po$ic% and procedures&

he universa$ consensus of this committee as that Eaton Street fire presented $earning

opportunities for the entire (epartment and as such the focus of this report is to provide $earning

o!jectives for a$$ departmenta$ ran6s&

he fire event at 41 Eaton Street once again high$ighted the dangers of h%drogen c%anide

as a product of com!ustion and the potentia$ danger to firefighters re$ated to h%drogen c%anide

poisoning from accidenta$ smo6e e/posure& he #rovidence Fire (epartment had !een invo$ved

in !ringing this danger $ight to the nations fire service e/act$% 10 %ears ago 8to the month9 !ac6

in March of 200&2he Eaton Street fire event reiterates the need for continued education of

department mem!ers and the medica$ communit% a!out the dangers of h%drogen c%anide

poisoning from smo6e e/posure&

he fire provides $earning opportunities regarding the ph%sio$ogica$ demands p$aced on

the firefighters& he fire demonstrates the need of firefighters to maintain a $eve$ of fitness

throughout the course of their careers to meet these ph%sio$ogica$ demands during structura$

2 (orce%.&&.utras -& Mo$is .& arone .& Darren &Report of Investigative Committee into Cyanide Poisoning

of Providence Firefighters. Ma% 200&


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firefighting and $ong duration events& In addition this fire event provides $essons on the need to

ensure ade5uate trac6ing rotation rest and reha!i$itation of fatigued fire fighters&

he $arge sca$e fire event at Eaton Street a$so provided $earning opportunities regarding

the #rovidence Fire (epartment Incident Command S%stem 8ICS9 and the command and contro$

of $arge sca$e emergenc% incidents&

Dithin the rea$m of ICS this fire event high$ighted the #rovidence Fire (epartments

ina!i$it% to fu$fi$$ ICS Command Staff and :enera$ Staff positions ith chief officers ith Fire

:round Command e/perience&

his fire event a$so high$ighted the demands p$aced upon the #rovidence Fire (epartment

,ureau of perationa$ Contro$ 8,C9 during emergenc% operations of this si;e& his event

further demonstrated the cha$$enges for the present on dut% staffing $eve$s of the ,C&

he (epartment can !e ver% than6fu$ that no civi$ian death or firefighter $ine of dut%

death occurred at 41 Eaton Street& his fact is a testament to the training and professiona$ism

e/hi!ited !% department mem!ers operating at this cha$$enging fire scene& he cha$$enge for the

#rovidence Fire (epartment is to $earn from this incident identif% actions that ma% have

contri!uted to the event and $earn an% $essons from the injuries that occurred at this fire& he

u$timate goa$ is to share these $essons ith future generations of #rovidence Firefighters and

prevent future injuries or deaths&

,ac6ground and Significance

he devastating effect of ind on structura$ firefighting strategies and tactics has !een

recogni;ed for man% %ears& hrough the investigative or6 of the @ationa$ Institute for

ccupationa$ Safet% and ?ea$th 8@IS?9 and the scientific research performed !% the @ationa$

Institute of Standards and echno$ogies 8@IS9 the fire service has !ecome !etter educated a!out

the devastating effects of ind driven fires&3@IS? has repeated$% identified the effects of ind

driven fires as a contri!uting factor in man% )ine of (ut% (eaths 8)((9 that this agenc% has

investigated&

3 @ationa$ Institute of Standards and echno$og% Firefighting tactics under wind driven fire

conditions: 7-story buiding e!periments.echnica$ @ote 12+& 200+

*


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Most recent$% the @IS? )(( report F2014A0+ on the deaths of to ,oston Fire

(epartment mem!ers re$eased in March of 201 reiterate the dangers associated ith ind

driven structure fires& his report stated hen responding to a reported structure fire an

overriding consideration concerning si;eAup must !e ind conditions and its potentia$ effect on

the fire& he 6e% to successfu$$% operating at indAimpacted fires in a structure depends on

recogni;ing the indAimpacted fire conditions that ma% change a seeming$% routine fire into a

!$otorching fire& ,$otorching is the appropriate description of hat i$$ occur hen fire

conditions are impacted !% ind conditions&4

he #rovidence Fire (epartment a$so has e/perienced the effects of ind driven fires in

the past most nota!$% on 14 'pri$ 2014&> n that da% the #rovidence Fire (epartment

e/perienced a firefighter near miss event and mu$tip$e ma%da%s ere transmitted hen

department mem!ers ere over run !% a ind driven fire event&

's a resu$t of the near miss and ma%da%s on 14 'pri$ 2014 a department investigation

as conducted& hat report stated"

In 200= he @ationa$ Institute of Standards and echno$ogies 8@IS9 in

conjunction ith Fire (epartment of @e Gor6 8F(@G9 #o$%technic Institute of @e

Gor6 Hniversit% and support from the (epartment of ?ome$and Securit% conducted

research on the effects of ind driven fires& he o!jective of this stud% as to improve

the safet% of fire fighters and !ui$ding occupants !% deve$oping a !etter understanding of

ind driven fires and ind driven firefighting tactics inc$uding structura$ venti$ation and

suppression 8@IS 200= p& viii9& he research as a$so intended to stud% the effects of

positive pressure venti$ation fans ind contro$ devices and e/terna$ ater app$ication

ith f$oor !e$o no;;$es to mitigate the ha;ards of the ind in structure fires 8@IS

200= p& i9&

4 @ationa$ Institute of ccupationa$ Safet% and ?ea$th Fire Fighter Fata$it% Investigation Report F2014A0+ Mar

201

> ,ates M& Cro$e% (& (ought% #& .utras -& oro '&Report of Investigation Committee

into Firefighter "ayday and In#uries $ustained at %% Pymouth $treet& 'pri$ 2014

=


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's a resu$t of these ind driven e/periments" ' !ase$ine as deve$oped for the

ha;ards associated ith a ind driven fire and the impact of pressure venti$ation and

f$o paths ithin a structure& Dind created conditions that rapid$% caused the

environment in the structure to deteriorate !% forcing fire gases through the apartment of

origin and into the pu!$ic corridor and staire$$& hese conditions ou$d !e untena!$e

for advancing fire fighters& Mu$tip$e tactics used in conjunction ith each other ere

ver% effective at improving conditions for fire fighter operations and occupant egress

8@IS 200= p& i9&

From the @IS stud% information has !een gained a!out the understanding of

f$o paths ithin structure fires and the effects that ind pressure and venti$ation i$$

have on these f$o paths& he f$o path of the energ% of the fire is inf$uenced !% areas of

high and $o pressure& Simp$% put ind creates areas of high pressure and i$$ push

heat smo6e 8un!urned fue$s9 and to/ic products of com!ustion toards areas of $o

pressure& he ind i$$ push the fire from the room of origin out into areas of $o

pressure such as adjacent rooms ha$$a%s and staire$$s&

(epending on the ind ve$ocit% this movement ma% !e ver% e/p$osive and fire

fighters operating in these areas ma% !e overArun !% intense radiant heat& It is imperative

that fire fighters !e a!$e to recogni;e these dangers ithin the structure and operate inareas outside of these f$o paths hen ind is inf$uencing the progression of the fire&

'ppropriate$% app$ied venti$ation tactics are a a% for fire fighters to contro$ these

f$o paths and ensure their safet%& his re5uires strong 6no$edge of fire !ehavior and

venti$ation tactics& ,% understanding the effects of ind and !% app$%ing the appropriate

venti$ation tactics fire fighters can contro$ the fire and these dangerous f$o paths&

Simp$% c$osing doors is another tactic is to contro$ the f$o path of the fire& his

can !e accomp$ished !% contro$$ing the door of the room of origin& If this is not possi!$e

contro$ of other interior doors ma% assist in contro$$ing the f$o path& In highArise fires

the contro$ of staire$$ doors !ecomes ver% important hen the apartment door is $eft

open during these t%pes of fire events&

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In some cases depending on the ind ve$ocit% and pressure head $ong direct

attac6 ith a hose $ine from the $o pressure area to the high pressure area 8from the

un!urned to !urned9 direct$% against the f$o path of the fire ma% not !e prudent& Fire

officers and Incident Commanders need to recogni;e this danger& Standard aggressive

tactics ma% have to !e a$tered to ensure the safet% of mem!ers&

Research into ind driven fires provided the $ine of dut% death reports $isted

a!ove& hese reports are just a sma$$ samp$e of $ine of dut% deaths that indicated ind

as found to !e a contri!uting factor& he investigations into these events demonstrated

the effect that ind had on the progression of the fires& he e/tensive documentation of

these events are indicators for the fire service of the need to incorporate the 6no$edge

gained from these investigations and the research from the @IS stud% into dai$%

structura$ firefighting training&

@IS research has determined that ind speeds as $o as 10 mph 81 6mBhr&9 are

sufficient to create indAdriven fire conditions if the f$o path is uncontro$$ed& @IS in a

recent stud% on indAdriven fires in structures has shon that ind speeds as $o as 10

mph can turn a routine room and contents fire into a f$oor to cei$ing fire storm or

!$otorch effect generating untena!$e conditions for fire fighters even outside of the

room of origin& emperatures in e/cess of 00 C 81100 F9 and tota$ heat f$u/es in e/cessof *0 6DBmJ ere measured at 4 ft& a!ove the f$oor a$ong the f$o path !eteen the fire

room and the donind e/it vent& hese conditions ere attained ithin 30 seconds of

the f$o path !eing formed !% an open vent on the upind side of the structure and an

open vent on the donind side of the structure&

he or6 !% @IS? and @IS indicate that the fire service as a ho$e sti$$ has

or6 to do understanding the dangers of ind driven fires educating mem!ers on

identif%ing ind driven fire potentia$ incorporating recognition of ind speeds in initia$si;eAup identif%ing potentia$ e/p$osive f$o paths and choosing the appropriate tactics

hen com!ating these t%pes of fires&

,ates M& Cro$e% (& (ought% #& .utras -& oro '&Report of Investigation Committee into Firefighter"ayday and In#uries $ustained at %% Pymouth $treet& 'pri$ 2014

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he #rovidence Fire (epartment has in p$ace >0 preAesta!$ished standard operating procedures

8S#s9& he standard operating procedures are intended to act as decision ma6ing guides for

compan% officers and mem!ers& hese standard operating procedures are !ased upon nationa$$%

recogni;ed consensus standards that are intended to ma6e fire ground activities as safe as

inherent$% possi!$e& here are a num!er of #rovidence Fire (epartment S#s re$ated to

structure fires most nota!$% perations at Structure Fires 'ccounta!i$it% Ma%da% Fast

Compan% and Safet% Compan% perations& he department a$so fo$$os the princip$es of

Incident Command out $ined in a document tit$ed #rovidence Fire (epartment Incident

Command 81++39& (ecisions officers ma6e and actions that the% ta6e shou$d !e guided and !e

inf$uenced !% the departments S#s Incident Command document (epartment Ru$es and

Regu$ations standing :enera$ rders and the officers training and e/perience&

he #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9 is responsi!$e for

the dispatch of fire companies to emergencies& he ,C or Fire '$arm 8F'9 receives te$ephone

ca$$s for emergencies and via the state operated +11 Enhanced S%stem& he department a$so has

te$egraph fire a$arm street !o/es as e$$ as municipa$ a$arm !o/es in !ui$dings throughout the

cit% referred to as master !o/es&

he standard assignment for a master !o/ is three engines to $adders and a chief&

Dhen !oth chiefs are unavai$a!$e a command compan% i$$ !e dispatched& ' command

compan% can !e an engine or $adder compan% ith a captain in command of the compan%&

he standard first a$arm assignment for a !ui$ding fire is three engines to $adders the

Specia$ ?a;ards a rescue and a chief& Immediate$% fo$$oing the dispatch of the first a$arm

companies the ,C dispatches a Fast 'ssist Search eam 8F'S9 compan%& he F'S

Compan% is comprised of a )adder and Engine Compan%& Dhen a or6ing fire is confirmed the

,C i$$ dispatch Engine > ith the 'ir Supp$% Hnit& he officer of Engine > i$$ !e assigned

the Incident Safet% fficer duties at the incident&

Fires !e%ond the capa!i$ities of the first a$arm assignment are 6non as mu$tip$e a$arm

fires& 'n additiona$ a$arm has to engines and one $adder assigned to it& he #rovidence Fire

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(epartment has the a!i$it% to assign si/ a$arms after hich the fire ou$d !e referred to as a

:enera$ '$arm fire&*

Hpon the announcement of a Ma%da% on a fire ground the department has procedures to

ma6e the fire and automatic mu$tip$e a$arms ith hat is 6non as a Ma%da% response&

Ma%da% response is comprised of to engines to $adders and to rescues&

he #rovidence Fire (epartment changed over to a h%!rid =00 M?; s%stem in 200+&

his seven channe$ s%stem is a com!ination of digita$ and ana$og radio channe$s& Channe$s 1 >

and * are digita$& #orta!$e radios on 1 > and * transmit to a series of repeater toers

throughout the Cit%& Fire ground channe$s 2 3 and 4 are ana$og& #orta!$e radios on 2 3 and 4

transmit direct$% to one another a$6ie ta$6ie st%$e& ?oever apparatus or mo!i$e radios

transmit direct$% to the toers on a$$ channe$s& 'pparatus radios i$$ not receive the porta!$es on

channe$s 2 3 or 4 the a$6ie ta$6ie st%$e un$ess a vehic$e repeater s%stem 8RS9 is manua$$%

turned on& he RS repeats the ana$og message over the digita$ fre5uenc%& Engines $adders and

the $ine chief vehic$es are e5uipped ith RS& his is a ver% genera$ e/p$anation of the fair$%

intricate communication s%stem& #ertinent to this investigation porta!$e radios on channe$s 2 3

or 4 on$% transmit to other porta!$es or need to !e repeated through a RS on the same channe$&

If no apparatus radio is on the same channe$ ith a RS the transmission i$$ not reach fire

a$arm or apparatus&

his intricate radio s%stem re5uires strict adherence to S# 1* and S# 3> hich dictate the

procedures for using mu$tip$e radio channe$s for one incident& hese procedures re5uire one RS

!e sitched to the second radio channe$ assigned for the Rescue Sector during Ma%da% events at

fires&=

#rocedures

he Investigative Committee as se$ected !% 'ssistant Chief of (epartment Scott Me$$o& 'n

organi;ationa$ meeting as he$d& From this meeting three o!jectives ere set& he first o!jective

* #rovidence Fire (epartmentRues and Reguations1++

= #rovidence Fire (epartment"aydays Standard perating #rocedure 3>& 2012

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as to gather as much data as possi!$e& Second to eva$uate the information co$$ected& )ast$%

report an% $essons that can !e $earned to prevent injur% or death&

he data co$$ection !egan ith the retrieva$ of the radio transmissions for the Eaton Street

Fire Captain .u$ia Rou6e provided the committee a C( audio recording for each radio channe$

8#rimar% (ispatch Channe$ 1 and Fire ground Channe$ 29& 'cting ,atta$ion Chief -evin .utras

instructed a$$ compan% officers to su!mit a #rovidence Fire (epartment Form 1* regarding

compan% actions at this incident a$ong ith the names of individua$s ho ere injured and

circumstances re$ated to those injuries& #hotos that had !een ta6en at the fire scene !% itnesses

and provided to Car *+ ere a$so given to the committee& Mem!ers of the committee co$$ected

data regarding the t%pe of injur% and functions !eing performed that contri!uted to the injur%&

Incident at 41 Eaton Street

n 31 March 201 at 14"0* hours the #rovidence Fire (epartment ,ureau of

perationa$ Contro$ 8,C9 dispatched Engines 12 * 1> )adder 4 and Specia$ ?a;ards 1

Rescue 4 and ,atta$ion 3 to 41 Eaton Street for a report of a !ui$ding fire&+he ,C a$so

reported that #rovidence #o$ice ere on the scene and that there as a !rush fire on )eigh Street

e/tending to a house on Eaton Street&

Dhi$e responding a$ong (oug$as 'venue to Eaton Street Engine 12 and )adder 3 eredirected to )eigh Street !% civi$ians& Engine 12 reported to the ,C that he as !eing directed to

)eigh Street and that there as a possi!$e !rush fire on )eigh Street& he ,C radioed Engine

12 and reiterated that #rovidence #o$ice stated a there as a possi!$e !rush fire !ehind 41 Eaton&

his radio transmission as immediate$% fo$$oed !% a transmission from Engine 12 stating that

there as a house fire on Eaton and that Engine 12 ou$d !e !ac6ing don )eigh Street to

respond to the origina$ address of 41 Eaton Street&

't appro/imate$% 14"10 hours Rescue 4 as the first fire apparatus to arrive on the scene

at 41 Eaton Street& Rescue 4 transmitted a Code Red and gave a si;e up that stated there as a

fu$$% invo$ve house fire ith heav% fire shoing second third and fourth f$oor of a three fami$%

residentia$ ood frame& his transmission as immediate$% fo$$oed !% Engine * and Rescue 4

+ Recorded 'udio Fi$es #rovidence Fire (epartment 'pri$ 201

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!oth re5uesting a second a$arm& ,atta$ion 3 arrived on the scene and informed the ,C to

prepare for a third a$arm&

he officer of Rescue 4 esta!$ished the EMS sector !ecame the EMS Sector officer& ?e

!egan assessing the need to e/pand the EMS sector !ased upon the potentia$ for injured mem!ers

and reha! of mem!ers as the incident progressed& he EMS Sector fficer !egan to re5uest

additiona$ rescues to ensure that EMS services ere provided on the est and east sides of the

rapid$% e/panding incident&

8#hoto 2 Ear$% Stages of peration Side 19

't 14"11 hours ,atta$ion 3 re5uested a third a$arm& 't 14"12 hours )adder radioed the,C and reported that there as fire in E/posure 4& his transmission as fo$$oed ith a

transmission from ,atta$ion 3 esta!$ishing Eaton Command& Eaton Command provided the ,C

ith the first status report hich stated one three and one ha$f stor% ood frame !ui$ding fu$$%

invo$ved in fire E/posure 4 as on fire ith fire shoing on the second and third f$oors

E/posure 2 as on fire ith fire in the $oft and that the fire as dou!tfu$ at this time&

First a$arm companies se$fAdep$o%ed fo$$oing #rovidence Fire (epartment Standard perating

#rocedures and the departments Incident Command se5uence of preAesta!$ished incident

priorities si;eAup strategic o!jectives and tactica$ operations out$ined in the departments

Incident Command S%stem Manua$& he first a$arm compan% officers a$$ recogni;ed the

esca$ating fire event unfo$ding !efore them and understood the Incident 'ction #$an of riting

off hat as a$read% $ost 8the origina$ fire !ui$ding9 and focusing actions on e/posure protection

and fire contro$&

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Engine * arrived first to the Eaton Street side of the event& Engine 12 esta!$ished a ater

supp$% to Engine *& Engine * stretched a to and a ha$f inch hand $ine to !egin e/posure

protection of Side 2 of E/posure 4& he chauffer of Engine * used his dec6 gun to !egin

e/posure protection on Side 4 of E/posure 2&

)adder 3 remained on )eigh Street here the% ere origina$$% directed !% !%standers&

he fire fighters assigned to )adder 3 positioned their apparatus and attempted to provide

vertica$ venti$ation on E/posure 4 hi$e the officer of )adder 3 contro$$ed the groing !rush

fire that threatened !ui$dings on )eigh Street& Engine 4 supp$ied )adder 3 ith ater from a

h%drant on (oug$as 've&

)adder 4 and )adder arrived and positioned and prepared their apparatus for defensive

operations on the origina$ fire !ui$ding and e/posure protection of Side 2 of E/posure 4&

8#hoto 3 )adder 4 Setting up for defensive perations Side19

Engine 14 fo$$oed )adder in on the origina$ dispatch& Engine 14 positioned their

apparatus to use the dec6 gun on the third f$oor of E/posure 4 and #rotect E/posure 4'& he

mem!ers of Engine 14 !egan to prepare feeders to supp$% )adder 4 )adder and $ater )adder 1&

Engine 3 supp$ied Engine 14 ith a five inch feeder from a6$and 've&

Engine 1> stretched a three inch attac6 $ine fitted ith a ,$i;tfire no;;$e to !egin

e/posure protection in the rear of E/posure 2& he chauffer of Engine 1> $ater returned to his

apparatus to !egin ater supp$% operations to )adder * hich as dispatched on the second

a$arm and as no positioned in front of E/posure 2&

1>


16/44

Mem!ers of Specia$ ?a;ards made entr% into E/posure 4 hich as no on fire& he%

performed primar% searches on the first f$oor and some areas on the second f$oor that did not

contain fire& he officer of Specia$ ?a;ards notified the Incident Commander 8IC9 of the search

resu$ts and informed the IC his mem!ers ere stretching hand $ine into E/posure 4 and ere

operating on the second f$oor&

Engine 2 arrived on the second a$arm& he% stretched a hand $ine into E/posure 2 and

performed a search on f$oors one and to& Engine 2 then informed the IC that the% ere

operating on the third f$oor Side 4 of E/posure 2& 'fter securing a ater source for Engine *

Engine 12 dep$o%ed hand $ine into E/posure 2 and made their a% up to the $oft of E/posure 2&

Dith defensive operations undera% on the origina$ fire !ui$ding and companies moving

offensive$% into the E/posure 2 and E/posure 4 the IC !egan to sectori;e the incident& he IC

designated the officer of Specia$ ?a;ards as the E/posure 4 Sector fficer and the IC designated

the officer of Engine 12 as the E/posure 2 Sector fficer& he IC esta!$ished a third sector on the

e/terior of Side 3 of a$$ !ui$dings invo$ved& Engine 1> as assigned as the Side 3 Sector fficer&

he IC then !egan to assign companies to the three sectors no esta!$ished& Engine 14

!ac6up the mem!ers of Specia$ ?a;ards in E/posure 4 and stretched up the front stairs of

E/posure 4& he officers of )adder 1 and )adder moved into the E/posure 4 to assist ith

offensive operations no ta6ing p$ace in that !ui$ding&

Engine = and the officer of )adder * moved into the E/posure 2 to assist offensive

operations no ta6ing p$ace in that !ui$ding&

Car 2 arrived on the scene and at 14"2 hours he re5uested a fourth a$arm just 1+ minutes

after the dispatch of the first a$arm& en minutes $ater Car 2 re5uested a genera$ a$arm !e struc6

at 14"3 hours&

Dith the remainder of avai$a!$e #rovidence Fire Companies arriving on scene the IC

assigned companies into the e/posure !ui$dings to gain contro$ of the fires in these !ui$dings and

6eep the incident from groing an% further&

1


17/44

Engine 13 and )adder 2 ere assigned to the E/posure 2 Sector and the IC made the

officer of Engine 13 the E/posure 2 Sector fficer& his a$$oed for Engine 12 to maintain their

position in the $oft and provided greater supervision of companies operating in E/posure 2&

Engine 10 Engine 8after providing Engine 14 a second five inch feeder9 and )adder >

ere assigned to E/posure 4 Sector and the officer of )adder 1 as assigned as the E/posure 4

Sector fficer& he change in the assignment of the Sector fficer ro$e as made again to gain

!etter supervision of companies operating in E/posure 4&

Engine 11 and )adder = ere assigned the duties of the F'S Compan%& Engine 4 and

)adder 1 ere origina$$% assigned the F'S Compan% duties !ut the rapid$% esca$ating fire

event re5uired use of these companies !% the IC for tactica$ operations&

't 14">1 hours the IC provided the ,C ith another incident status update& he IC

reported that he had one !ui$ding fu$$% invo$ved heav% fire in E/posure 2 and heav% fire in

E/posure 4 fire sti$$ dou!tfu$& 's the incident duration progressed the IC re5uested an additiona$

$adder and engine to have in staging& ' @orth #rovidence engine and $adder ere dispatched to

the scene& he @orth #rovidence )adder as used to re$ieve some of the #rovidence cres in

E/posure 2 hi$e the @orth #rovidence Engine as used in E/posure 4&

he mem!ers operating at 41 Eaton Street faced fierce fire conditions as a resu$t of the

effect that ind p$a%ed upon the incident& he effects of the ind made the tas6s of contro$$ing

fire spread overhau$ing e/tinguished areas of fire and comp$ete$% e/tinguish poc6ets of fire that

ou$d f$are up hen inf$uenced !% the ind an e/treme$% arduous time consuming tas6&

E/posure 2 as the first !ui$ding here head a% as gained and contro$ of the fire in

that !ui$ding as comp$eted& Cres operating on f$oor to and three performed e/tensive

overhau$ to comp$ete$% e/tinguish the fire on those f$oors& Cres operating in the $oft of

E/posure 2 faced an unfinished $oft hich a$$oed them to cover the entire f$oor ith their hose$ine from the re$ative safet% of the rear staire$$& he officer of Engine 12 reported that his cre

as a!$e to ma6e it up onto the f$oor and s$o$% move toard Side 1 to comp$ete the

e/tinguishment of the fire in the $oft&

1*


18/44

he contro$ of the fire in E/posure 4 as more difficu$t& he $oft of that !ui$ding had

!een finished into an occupied $iving space& he unit as divided front to !ac6 ith a stair to the

fourth f$oor on Side 1 and Side 3& ,ecause it as a finished space additiona$ hose as re5uired

to cover the ha$$a%s and rooms off of the ha$$a% to reach a$$ areas of the f$oor un$i6e the open

f$oor area in the $oft of E/posure 2&

he first hose $ine advanced up the rear stairs stretched short& rigina$ heada% into the

$oft as $ost hen the hose $ine had to !e !ac6ed don to piece in additiona$ hose to ma6e the

stretch& 't one point during the !att$e to gain the fourth f$oor companies attempting to move up

to the fourth ere ordered don to the third f$oor !% the IC& he IC as concerned a!out the

conditions he as itnessing from the e/terior that interior cres ere not aare of& Dhen it

as confirmed that a$$ mem!ers ere in a safe $ocation on the third f$oor the IC directed )adder

3 and )adder 1 to p$ace their master streams into the $oft of E/posure 4 to 6noc6 don the

groing !u$6 of the fire on the fourth f$oor&

#rior to the use of the master streams on the fourth f$oor mem!ers cou$d dar6en don the

f$ames on Side 3 and move up the stairs on$% to !e driven don the stairs hen gusts of ind

ou$d drive hidden fire and heat out of the concea$ed spaces don onto the hose $ine cre& 'fter

the master streams 6noc6ed don the !u$6 of the f$ames on the fourth f$oor the master streams

ere redirected !ac6 on the origina$ fire !ui$ding& Cres in E/posure 4 cou$d no move !ac6 up

to comp$ete the e/tinguishment or the fourth f$oor !% opening up the finished cei$ings and a$$s

to comp$ete the e/tinguishment of hidden poc6ets of fire&

he fire as p$aced under contro$ at 1>"41 hours& Some companies remained on the scene

for appro/imate$% to more hours ith #rovidence Fire (epartment 'rson Investigators

remaining on the scene unti$ 1+"4> hours&

(iscussion

he dangers of acute h%drogen c%anide poisoning from smo6e inha$ation are not ne to

the #rovidence Fire (epartment& n March 23 and 24 of 200 the #rovidence Fire (epartment

$earned of the true magnitude of the dangers of c%anide in smo6e as the resu$t of three fires over

the course of to da%s& In the aftermath of the three fires a tota$ of 2= mem!ers sought medica$

1=


19/44

fo$$o up 2* of ho ere tested for c%anide poisoning& 10Eight of those mem!ers ere found to

have e$evated $eve$s of c%anide&11

ne mem!er ho had e$evated c%anide $eve$s from an e/posure to smo6e at the second fire

suffered a heart attac6 at the third fire& Dhi$e the investigation committee as not a!$e to

conc$ude that c%anide re$ated arrh%thmia $ed to the mem!ers heart attac6 it as determined

ith certaint% that the mem!er had e$evated $eve$s of c%anide in his !$ood at the time of he

suffered the heart attac6&12 he investigation did determine that c%anide poisoning can $ead to

death !% affecting the !od%s a!i$it% to carr% o/%genated to the vita$ organs as e$$ as having the

a!i$it% to causes heart arrh%thmias and that the arrh%thmias can occur up to to ee6s after the

e/posure&13

he investigative report from the events in 200 !rought the dangers of acute c%anide poisoning

from smo6e inha$ation to the nationa$ $eve$& he investigative report from 200 discovered that

h%drogen c%anide is produced in significant 5uantities at fires invo$ving materia$s that are

common$% present in modern !ui$dings such as p$astics s%nthetics and nitri$es&14't that time

the investigation committee found research that supported the most common cause of c%anide

poisoning as from smo6e inha$ation&1>

10 (orce% .&&.utras -& Mo$is .& arone .& Darren &Report of Investigative Committee into

Cyanide Poisoning of Providence Firefighters& Ma% 200

11 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma%

200(orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma%

200

12(orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

Firefighters& Ma% 200

13 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


14 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


1+


20/44

#rior to 200 the C%anide #oisoning reatment Coa$ition 8C#C9 had !een s$o$% raising the

aareness of the dangers of c%anide in smo6e !ut as a resu$t of the events in #rovidence in

200 the nations fire service is no great$% aare of the dangers& C%anide is no 6non as one

of the dead$% to/ic tins a$ong ith Car!on Mono/ide that can have acute affects to

firefighters from smo6e inha$ation&

he investigative report in 200 found that the e/posures to c%anide ere a resu$t of

trained seasoned firefighters misperceiving the ris6 and ma6ing a ca$cu$ated ris6 versus !enefit

ana$%sis on the fire ground ithout a$$ of the pertinent information&1he 200 report found that

firefighters are e/pected to ma6e the decision to ear or not ear their SC,' at a variet% of

incidents from !ui$ding fires to investigations of fa$se or accidenta$ a$arms to investigating

strange odors or the sme$$ of smo6e to operating at !rush fires ru!!ish fires and car fires&1*he

200 report a$so stated that the decisions firefighters are re5uired to ma6e re$ated to air use is

often made re$%ing on their s6i$$ judgement and e/perience in determining hen to mas6 up& 1=

his decision to mas6 up is inf$uenced !% the potentia$ for the atmosphere to !e ha;ardous the

$imited air supp$% duration the a!i$it% of the cre to accomp$ish tactica$ assignments and the

desire of mem!ers not anting to consume air in nonAcontaminated areas so that the% have air

hen needed to ensure the units tactica$ effectiveness&1+

1> Ec6stein M and Manisca$co #MFocus on $mo&e Inhaation - 'he "ost Common Cause of (cuteCyanidePoisoning #rehospita$ and (isaster Medicine http"BBpdm&medicine&isc&edu o$& 21@o& 2 8MarA

'pr 200

1 (orce%. et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


1* (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


1= (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma% 200

1+ (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


20


21/44

he Investigative Committee conducted a $ength% intervie ith the Fire Captain ho as

hospita$i;ed for c%anide poisoning from the Eaton Street fire& (uring the intervie the Fire

Captain e/p$ained his air use as inf$uenced e/act$% as as e/p$ained in the previous paragraph&

Dhi$e operating on the third f$oor of E/posure 4 the Captain removed his face piece once the

fire on the third f$oor as comp$ete$% 6noc6ed don a$$s ere opened up and chec6ed for

hidden fire and indos ere ta6en out to venti$ate the third f$oor& he Captain did

ac6no$edge that mem!ers did operate in and out of smo6e for sma$$ periods of time due to the

sir$ing ind conditions& 't times it as accepta!$e to remove face pieces on$% to have the ind

change direction and push smo6e don from the fourth f$oor onto their position& he Captain

and other compan% officers operating in that sector 6ne that the% ou$d have to push up the

rear stairs to the fourth f$oor to contro$ and e/tinguish the fire on the fourth f$oor in E/posure 4&

he first hose $ine !rought up the rear stairs to the third and fourth f$oor stretched short

hen mem!ers attempted to push up to the fourth f$oor& he mem!ers of )adder 3 had attempted

to venti$ate the roof on E/posure 4 !ut ere pushed off of the roof !ecause of the radiant heat

from the origina$ fire !ui$ding and the sir$ing fire coming up Side 2 of E/posure 4& 's the

mem!ers ere $eaving the roof the% ere on$% a!$e to venti$ate an e/isting s6% $ight opening on

the roof of E/posure 4& he $ac6 of enough hose to reach the fourth f$oor the ind driven fire

conditions that da% and the ina!i$it% of the mem!ers of )adder 3 to ade5uate$% venti$ate

E/posure 4 made the push up to the fourth f$oor a difficu$t ph%sica$$% demanding and time and

air consuming tas6&

hose mem!ers not on the rear stairs and or6ing on the third f$oor aiting to move up

to the fourth f$oor removed face pieces !e$ieving the atmosphere as safe on the venti$ated third

f$oor& he Fire Captain stated during his intervie that he had operated that da% 8March 31

2019 just as he had done for ever% other fire he had operated at during his thirt% one %ear

career& ?e perceived the atmosphere on the third f$oor to !e safe !ecause of the strong inds

!$oing in from Side 1 toards Side 3 of E/posure 4& ?e a$so anted to conserve his air for

hen his cre moved up the rear stairs to the fourth f$oor& he Fire Captain a$so stated that his

cre as mas6ed up hen the% ere on the rear stairs to the fourth f$oor and hi$e on the fourth

f$oor !efore !eing re$ieved&

21


22/44

Fo$$oing the events in 200 the #rovidence Fire (epartment imp$emented severa$

changes to attempt to address the c%anide issue& he first change as to assess the presence of

c%anide at fire scenes and assist department officers in identif%ing unsafe Immediate$%

(angerous to )ife and ?ea$th 8I()?9 atmospheres and ma6e correct ris6 versus !enefit

ana$%sis& he second change as to move to a $onger duration air supp$%&

In 200 the #rovidence Fire (epartment or6ed ith one manufacturer of gas

monitoring devices& his compan% partnered ith the #F( and provided 23 sing$e gas meters&

he c%anide gas meters ere p$aced on a$$ compan% officers air pac6s& he idea as to turn on

the devices hen entering structure fires to a$$o the devices to a$ert compan% officers of the

presence of c%anide&

'fter the imp$ementation and use of the detectors it !ecame apparent that the gas meters

ere not !ui$t to meet the rigors of structura$ firefighting& he fi$ters on the gas meters as e$$ as

other components are on$% rated for temperature environments of one hundred and tent%

degrees Fahrenheit or $oer& Soon meters ere !eing damaged !ecause the meters ere !eing

used in e$evated temperature environments& 'fter !eing damaged the meters ere returned to

manufacturer for repairs& he manufacturer anted to !e paid to repair or rep$ace the meters& he

#rovidence Fire (epartment made a fisca$ decision to move aa% from air monitoring for

c%anide& Compan% officers no $onger carr% the c%anide sing$e gas meters&

Dhat did !ecome readi$% apparent as the preva$ence of c%anide at fire scenes& Dhen the

meters ere in service the% cou$d !e heard a$arming at man% t%pes of fire events that #F(

mem!ers responded to& #rior to the presence of the meters mem!ers performing a ris6 versus

!enefit ana$%sis at simi$ar t%pes of fire events assumed the atmospheres ere safe&

'ir monitoring of fire environments after the fire has !een 6noc6ed don has no

!ecome a standard operating procedure for some fire departments around the countr%& he

#rovidence Fire (epartment no $onger emp$o%s air monitoring procedures for fire scenes&

he idea !ehind air monitoring is to provide officers ith additiona$ information a!out

the atmosphere as to hether it is safe to remove face pieces or not& 'ir monitoring is a

procedure that the #rovidence Fire (epartment shou$d consider to incorporate !ac6 in to

22


23/44

department procedures& ' compan% at each fire cou$d !e assigned the responsi!i$it% of providing

air monitoring once the fire is under contro$&

Dith respect to air monitoring not a$$ the dangers associated ith the to/ic products of

com!ustion can !e monitored for& he gas detection e5uipment can on$% provide information

ith respect to the t%pe of gas !eing monitored& Car!on mono/ide and c%anide $eve$s cou$d !e

monitored for !ut other 6non dangerous carcinogens present in smo6e cannot !e monitored

for& Firefighters need to !e educated and understand that other dangers are present in smo6e and

it is not accepta!$e to !reathe smo6e even hen the gas meters are not a$arming for car!on

mono/ide or c%anide&

' recommendation from the 200 investigation as for the #rovidence Fire (epartment

to investigate the idea of comprehensive air management&20't that time four mem!ers of the

Seatt$e Dashington Fire (epartment had !een moving to educate the 'merican fire service of the

need for firefighters to !etter manage air use& he motivation for !etter air management !% the

Seatt$e mem!ers as the resu$t of firefighter near misses and severa$ )ine of (ut% (eath

8)((9 incidents e/perienced !% the Seatt$e Fire (epartment& he )((s ere the resu$t of

firefighters running out of air in I(?) atmospheres&21

In 200= the #rovidence Fire (epartment moved to a $onger duration air supp$% c%$inder&

he Seatt$e Fire (epartment and other departments around the countr% had moved to the $onger

duration c%$inders to com!at the issue of firefighters running out of air in an I()? atmosphere

and !eing e/posed to smo6e& he move to the $onger duration c%$inders as done to a$$o fire

fighters to mas6 up ear$ier enter or6 and e/it the Immediate$% (angerous to )ife and ?ea$th

8I()?9 atmosphere hi$e sti$$ !eing on air&

20 (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


21 ,ernocco S& :ag$iano M& .ose #& #hi$ips C&(ir "anagement for the Fire $ervice 200=

#enne$$ #u!&

23


24/44

his method of 6noing ho much air %ou have upon entering monitoring that air hi$e

in the I()? atmosphere and e/iting the I()? atmosphere !efore the $o air a$arm indicator

!egins to sound has !ecome 6non to the fire service as the Ru$e of 'ir Management22

Since 2013 the princip$e of the Ru$e of 'ir Management a$ong ith the re5uirement of

training mem!ers on individua$ consumption rates and the re5uirement to manage air

consumption as part of a cre has !een incorporated into the @ationa$ Fire #rotection

'ssociation 8@F#'9 Standard 1404 $tandard for Fire $ervice Respiratory Protection 'raining.

Dhen the #rovidence Fire (epartment moved to the $onger duration air supp$% the intent

of getting mem!ers to go on air sooner and sta% on air $onger as not conve%ed to a$$ mem!ers

of the department& he training on the intent and purpose of the $onger duration air supp$% as

presented as a point schoo$ presentation& Chiefs officers and firefighters not needing or not

interested in receiving a ha$f a point toard promotion did not attended&

he department did not revise its Standard perating #rocedure 8S#9 2 to ref$ect the

intent of the change to the $onger duration air supp$%& In 2010 a draft revision of the

(epartments S# 2 as su!mitted to the administration upon their re5uest& he draft S#

incorporated the Ru$e of 'ir Management and out$ined the necessar% resources needed to meet

the tenants of the Ru$e of 'ir Management& his draft as not adopted nor has the S# !een

revised since !eing esta!$ished in 1+++&

he administration at that time as main$% concerned ith the aspects of the draft S#

that out$ined hat is 6non as three deep dep$o%ment resource a$$ocation mode$& he three

deep dep$o%ment mode$ is descri!ed in the !oo6 'ir Management for the Fire Service 23his

dep$o%ment mode$ had !een used primari$% in the past for high rise t%pe fires as e$$ as $ong

duration events here mem!ers ere re5uired to remain on air hi$e in the I()? atmosphere&

he #rovidence Fire (epartment S# 2+ ?igh Rise Fires recommends incident commanders use

this method of resource a$$ocation for re$ief trac6ing and reha!!ing of cres&24#rogressive

departments around the countr% have !een moving to this t%pe dep$o%ment mode$ for ever% da%

22 ,ernocco S& et a$&(ir "anagement for the Fire $ervice 200= #enne$$

23 ,ernocco S& et a$(ir "anagement for the Fire $ervice 200= #enne$$ #u!

24


25/44

fire events of shorter durations& he intent of the use of this dep$o%ment mode$ as to com!at the

dangers of mem!ers !eing e/posed to smo6e&

he practice of adhering to three deep dep$o%ment mode$s is resource dependent& ' $ot of

resources 8i&e& engine and $adder companies9 are re5uired to meet this dep$o%ment mode&

Essentia$$% for ever% hose $ine dep$o%ed there is one engine compan% on the $ine one engine

compan% on dec6 and one engine compan% in staging to re$ieve the mem!ers on the $ine hen

their air supp$% !egins to !ecome $o& he on dec6 cre can move up and re$ief the initia$ hose

$ine cre !efore their $o air a$arms activate if their tactica$ assignment and position re5uires

them to !e continua$$% on air& hen the cre in staging ou$d move up& his same process for

$adder companies ou$d need to !e used for those $adder compan% tactica$ assignments and

positions that re5uire the cre to !e on air continua$$%&

'n a$ternative to the three deep dep$o%ment resource a$$ocation mode$ for shorter

duration events is the staffing of engine and $adder companies ith one officer and three

firefighters& Four person cres hen operating in the I()? atmospheres re5uiring air use have

the a!i$it% to sp$it the cre and operate in the I()? in teams of to or more&2>Dhen the need

for rep$acing air supp$ies !ecomes apparent the officer can sp$it his cre and send to mem!ers

out to rep$ace their air c%$inders hi$e to remain in the I()?& Dhen the first to mem!ers

sent to rep$enish their air supp$% return the ne/t to mem!ers can rotate out for ne air

c%$inders& his procedure of air management and sp$itting the cre a$$os the compan% to

maintain their tactica$ assignment ithin the I()? atmosphere ithout the need for additiona$

cres&

hree person engine and $adder companies cannot fo$$o the same procedure for

rep$enishing their air supp$% as four person companies& hree person companies do not have the

a!i$it% to sp$it the cre and maintain tenants of the to in to out ru$e found in the

(epartments standard operating procedures&

2

24 #rovidence Fire (epartment Standard perating #rocedure 2+)igh Rise Fire1++>

2> #rovidence Fire (epartment Standard perating #rocedure 32 *perations at $tructure Fires

1+++

2>


26/44

Since 200 there have !een five $ess high profi$e fire events here an individua$

mem!er of the department as treated for c%anide poisoning as a resu$t of e/posure to smo6e

from structura$ firefighting& he events of March 31 2001 and the previous e/posures to

c%anide indicate that more education and training of department mem!ers is re5uired&

C$ear$% the continued e/posure of mem!ers to c%anide indicate the pro!$em for the

#rovidence Fire (epartment is hat has !ecome 6non as an adaptive cha$$enge and not a

technica$ cha$$enge for the department&2*he department has continued to address the c%anide

issue and air use ith technica$ so$utions !ut the pro!$em of mem!ers !eing e/posed to c%anide

continues to occur&

's as found in 200 this Investigation Committee finds that characteri;ing the pro!$em

strict$% as a discip$inar% issue ignores the comp$e/it% of the pro!$em&2='$so simp$% changing

tactica$ operations of the #rovidence Fire (epartment ou$d not address the issue of continued

e/posures to smo6e& his t%pe of change i$$ re5uire the t%pe of transformationa$ $eader that

?eifet; and )ins6% rite a!out in the !oo6 )eadership on the )ine&2+

he issue is e/treme$% comp$e/ re5uiring strong transformationa$ $eadership support

throughout the department 8!oth po$itica$$% and administrative$%9 continued education and

training of a$$ mem!ers and ran6s of the department&

here has !een much research of the ph%sio$ogica$ demands p$aced upon firefighters

during structura$ firefighting& he persona$ protective firefighting gear re5uired for therma$

2 #rovidence Fire (epartment Standard perating #rocedure 32 *perations at $tructure Fires

1+++

2*?eifet; Rona$d '& and Martin )ins6%+eadership on the +ine: $taying (ive through the

,angers of +eading& ,oston M'" ?arvard ,usiness Schoo$ 2002& #rint&

2= (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence


2+ ?eifet; Rona$d '& and Martin )ins6%+eadership on the +ine: $taying (ive through the

,angers of +eading& ,oston M'" ?arvard ,usiness Schoo$ 2002& #rint&

2


27/44

protection the se$fAcontained !reathing apparatus carried on the !ac6s of firefighters necessar%

e5uipment needed to perform inside the fire environment and the ph%sio$ogica$ and emotiona$

stress a$$ have a s%nergistic effect p$acing e/treme ph%sio$ogica$ demands on the firefighters

!od%& 'ccording to information provided !% the Hnited States Fire 'dministration 8HSF'9 the

$eading cause of fata$ities to firefighters is heart re$ated medica$ emergencies and HSF' data

a$so indicates that after age 3> the proportion of deaths due to traumatic injuries decrease and

the proportion of deaths due to medica$ causes steadi$% increase&30

' stud% found that the provision of fire suppression and emergenc% medica$ services

entai$s sporadic high $eve$s of ph%sica$ e/ertion uncontro$$ed environmenta$ e/posures and

ps%cho$ogica$ stress from o!serving intense human suffering&31Firefighters e/perience inordinate

num!ers of $ineAofAdut% deaths deaths due to occupationa$ diseases forced retirements and $ineA

ofAdut% injuries&32Firefighter fata$ities and injuries occur at a rate one and one ha$f times those of

po$ice officers&33

ften firefighter heart rates i$$ go from norma$ resting rates to e$$ a!ove age re$ated

ma/imum heart rates& his ph%sio$ogica$ demand can occur ith $itt$e or no arning as e$$ as

ith $itt$e or no arm up due to the nature of emergenc% response& Research has found that the

pattern of sedentar% periods interrupted !% catecho$amine surges and heav% ph%sica$ e/ertion has

30 Stoe$$ Frederic6 M& Chief *fficer& Sti$$ater -" Fire #rotection #u!$ications 6$ahoma

State H 2004& #rint&

31 MooreAMerre$$ )& 'inong K& Mc(ona$d S& Moore .& Fisher E&Reducing Firefighter

,eaths and In#uries: Changes in Concept Poicy and Practice Contributing Factors to

Firefighter +ine-of-,uty ,eath in the nited $tates&

32 MooreAMerre$$ )& et a$Reducing Firefighter ,eaths and In#uries: Changes in Concept

Poicy and Practice Contributing Factors to Firefighter +ine-of-,uty ,eath in the nited

$tates&

33 MooreAMerre$$ )& et a$Reducing Firefighter ,eaths and In#uries: Changes in Concept


$tates&

2*


28/44

!een suspected to put firefighters at an increased ris6 for acute heart attac6s&34' danger of

e/ceeding the ma/imum heart rate is the !od%s ina!i$it% to carr% o/%genated !$ood to vita$

organs of the !od%&

From the investigation of the events at the Eaton Street fire it is 6non that the

firefighter ho as critica$$% injured suffered a heart re$ated medica$ emergenc% that as

diagnosed as demand ischemia& (emand ischemia is a t%pe of heart re$ated event for hich

!$oc6ages in the arteries ma% not !e present& It occurs hen a patients heart needs more o/%gen

than is avai$a!$e in the !od%s supp$% and ma% occur in patients ith tach%arrh%thmias

8a!norma$$% fast heart rates9&3>,$ood tests i$$ sho the presence of en;%mes that indicate

damage to the heart musc$e&

he activities at the emergenc% scene of the critica$$% injured firefighter and su!se5uent

injur% high$ight the e/treme ph%sio$ogica$ demands p$aced upon firefighters during the

performance of their duties& he critica$$% injured firefighter as assigned to an engine compan%

for the fire on Eaton Street& ?is engine compan% staffed ith an officer and to firefighters as

dispatched upon the genera$ a$arm& he initia$ assignment for the engine compan% as to secure

an additiona$ ater source& he engine compan% $aid a one thousand foot five inch feeder from

the h%drant $ocated at the corner of Chad ,ron Street and a6$and 'venue&

he critica$$% injured firefighter as responsi!$e for turning in this h%drant and then ran

up to the fire scene& nce at the scene he retrieved his air pac6 and too$s and as instructed !%

his officer to assist the other firefighter in dep$o%ing an attac6 hose $ine into E/posure 4& he

cres assignment from the Incident Commander as to ta6e the $ine to the fourth f$oor and

re$ief cres a$read% operating on the fourth f$oor& Dhen intervieed the critica$$% injured

firefighter reported that he had moved up and don the four f$ights of the rear stairs severa$

times to ensure ade5uate hose as stretched up to the fourth f$oor& hese actions ere necessar%

to a$$o for the hose $ine to cover the entire foot print of the fourth f$oor&

34 ?a$es &)eart ,isease in the Fire $ervice: Cause for Concern 2011

3> http"BB&secondscount&orgBheartAconditionAcentersBinfoAdetai$A2Bt%pesAofAheartAattac6s

2=


29/44

Dhat needs to !e remem!ered is that this firefighter as carr%ing si/t% pounds of

persona$ protective e5uipment and too$s necessar% to perform safe$% and effective$% hi$e

performing these assigned tas6s& 'dditiona$$% this as a three person engine compan%& he

officer as needed on the fourth f$oor to supervise and direct the activities of the no;;$e man in

the ;ero visi!i$it% I()? atmosphere& )eaving a$$ of the or6 of stretching the hose $ine into

position on the shou$ders of the critica$$% injured firefighter&

'fter comp$eting duties as the !ac6up firefighter the critica$$% injured firefighter joined

his cre on the fourth f$oor& Short$% after reaching the fourth f$oor and ith improvements of

conditions on the fourth the injured firefighter informed his officer of the need to ta6e a 5uic6

!rea6& he firefighter ent outside to an area of Sector 3 here cou$d remove his SC,' and

persona$ protective e5uipment& ?e as given a !ott$e of ater !% mem!ers operating in that

Sector& 'fter drin6ing the ater and catching his !reath he then donned his persona$ protective

e5uipment and SC,' and joined his cre on the fourth f$oor& he cre remained on the fourth

f$oor unti$ the f$oor as comp$ete$% overhau$ed and the fire comp$ete$% e/tinguished&

Hpon e/iting the !ui$ding the entire cre reported to the EMS Sector for reha!i$itation& It

as there that the critica$$% injured firefighters vita$ signs ere discovered not to !e ithin

accepta!$e $eve$s& ?is pu$se rate as initia$$% recorded at 1>4 !eats per minute& 'fter

appro/imate$% fifteen minutes of continued rest and o!servation his pu$se rate remained at 13>

!eats per minute& 't this point the EMS Sector fficer made the decision to have the firefighter

transported the hospita$& he other firefighter assigned to this engine compan% as a$so

transported to the hospita$ for overe/ertion and e/haustion re$ated s%mptoms&

he @ationa$ Fire #rotection 'ssociations 2014 Firefighter Injur% Report $isted that there

ere 33>0 firefighter injuries for 2014&3Strain sprain and muscu$ar pain resu$ted in more than

3 ?a%nes :& .& ?%$ton and .& Mo$is&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire

#rotection 'ssociation 2014& #rint&

2+


30/44

ha$f the major t%pes of injuries received during fireground operations&3*vere/ertion ran6ed

second at 2>L for the $eading cause of injuries&3=

'n investigation into the injuries at Eaton Street found that the majorit% of the injuries

ere overe/ertion& here ere fourteen origina$ injures from the Eaton Street fire& Dhen

c$assif%ing the t%pe of injuries sustained aside from to hand injuries 8one crushing one !urn9

and one e%e injur% the remaining e$ven injuries can !e c$assified as overe/ertion fatigue t%pe

injuries& hese injuries comprised strains and sprains of various !od% parts 8he Fire Captain

treated for c%anide poisoning as origina$$% transported for a 6nee injur%9&

ne da% fo$$oing the Eaton Street fire si/ additiona$ firefighters sought medica$ fo$$o

up& Four of the si/ mem!ers had operated at !oth the Eaton Street fire and the )aure$ ?i$$ 'venue

fire on March 31 201& '$$ of these mem!ers ere s%mptomatic ith overe/ertion and fatigue

t%pe injuries&

Dhen e/amined the injuries at the Eaton Street fire corre$ate ith research that has !een

done that identifies the major contri!uting factors for firefighter injuries& he contri!uting factors

are cre si;e standard operating guide$ines and hea$th e$$ness fitness and medica$ status of

firefighters&3+

Cre si;e has !een researched !% @ationa$ Institute of Standards and echno$ogies

8@IS9&40he @IS research addressed the effects that cre si;e has on firefighter safet% and

3* ?a%nes :& et a$&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire #rotection

'ssociation 2014& #rint&

3= ?a%nes :& et a$&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire #rotection 'ssociation 2014& #rint&

3+ MooreAMerre$$ )& et a$&Reducing Firefighter ,eaths and In#uries: Changes in Concept


$tates&

40 'veri$$ (& MooreAMerre$$ )& ,aro% '& Santos R& #eacoc6 R& @otarianni -&

Disso6er (&Report on Residentia Fireground Fied 3!periments.@IS echnica$ @ote 11&

2010

30


31/44

effectiveness& he research 5uantified the effectiveness of cre si;e firstAdue engine arriva$

time and apparatus arriva$ stagger on the duration and time to comp$etion of tent% to 6e%

fireground tas6s and the effect on occupant and firefighter safet%&41he research from @IS

e/periments su!stantiated the re5uirements in the @F#' 1*10 Standard for the rgani;ation and

(ep$o%ment of Fire Suppression perations Emergenc% Medica$ perations and Specia$

perations to the #u!$ic !% Career Fire (epartments&

In 200* @IS? pu!$ished a @IS? '$ert for the service re$ated to cardiovascu$ar

disease and other sudden cardiac events& he @IS? '$ert provided recommendations to

minimi;e the ris6 of injur% and death to fire fighters from cardiovascu$ar events& ne of the

recommendations ca$$s for fire departments to ensure ade5uate staffing $eve$s for emergenc%

operations to prevent overAe/ertion injuries42&

Dhat is interesting a!out the num!er and t%pes of injuries recorded of the fourteen

injuries nine of those mem!ers ere from three person cres hi$e the remaining five injuries

ere from four person cres& Research has demonstrated that cre si;e of four persons versus

three persons reduced the ris6 of injuries and improved overa$$ firefighter safet%&

's mentioned a!ove standard operating guide$ines have !een identified as a contri!uting

factor for firefighter injuries& he research cited a!ove particu$ar$% ref$ects the $ac6 of standard

operating guide$ines or fai$ure to fo$$o esta!$ished standard operating guide$ines as a

contri!uting factor for injuries&

he #rovidence Fire (epartment ICS provides for ensuring that mechanisms for trac6ing

and reha!i$itating personne$ are in p$ace and !eing used&43he #rovidence Fire (epartment ICS

a$so states that personne$ must !e a$so monitored for signs of ph%sica$ or emotiona$ e/haustion

41 'veri$$ (& et a$&Report on Residentia Fireground Fied 3!periments.@IS echnica$ @ote

11& 2010

42 @IS?&Preventing Fire Fighter Fataities ,ue to )eart (ttac&s and *ther $udden

Cardiovascuar 3vent.#u!$ication @o& 200*133& 200*

43 #rovidence Fire (epartment Incident Command $ystem1++3

31


32/44

indications of e/posure to smo6e ha;ardous materia$s or eather e/tremes&44he command

matri/ for trac6ing the $ocation and status as in p$ace and !eing used on March 31 201& he

EMS sector as esta!$ished and in p$ace to provide EMS and reha! to firefighters or6ing at the

scene&

Fo$$oing a discussion and revie of the num!er of overe/ertion and fatigue t%pe

injuries at the Eaton Street fire the IC ac6no$edged that the activation of additiona$

intermediate command $eve$ positions of the #rovidence Fire (epartment ICS ou$d have

improved direct supervision of mem!ers or6ing at the scene& he IC further ac6no$edged that

the additiona$ intermediate command $eve$ positions cou$d have assisted the IC in maintaining a

proper span of contro$ as out$ined in the (epartments ICS document&4>,% !ui$ding a proper

command structure the IC cou$d have improved the span of contro$ hich ou$d have improved

the monitoring of cres or6ing in the to e/posure !ui$dings as e$$ as monitoring the

amount of time these cres or6ed in the those I()? atmospheres& he intermediate command

$eve$ positions cou$d have or6ed more c$ose$% ith the compan% officers identif%ing those

mem!ers needing re$iefs& hen re$iefs cou$d have !een provided in a more time$% fashion to

prevent mem!ers from overe/erting themse$ves&

he injuries from the Eaton Street fire ref$ect the dangers associated aggressive interior

structura$ firefighting& he injuries further high$ight theph%sio$ogica$ demands p$aced upon

firefighters& he nature of the or6 performed and injuries sustained at the Eaton Street fire

ref$ect the need of firefighters to maintain $eve$s of fitness that invo$ve the components of cardio

vascu$ar strength and conditioning and f$e/i!i$it% training throughout the course of their careers&

It is important to note that rest is an important component of the aspects of fitness hea$th

and e$$ness for com!ating the ph%sio$ogica$ and ps%cho$ogica$ stressors of firefighting& Dhen

performing an o!jective revie of the injuries that occurred at the Eaton Street fire the recent

reorgani;ation of the p$atoon structure of the #rovidence Fire (epartment cannot !e over$oo6edhen e/amining the overe/ertion and fatigue re$ated injuries sustained !% department mem!ers&

44 #rovidence Fire (epartment Incident Command $ystem1++3

4> #rovidence Fire (epartment Incident Command $ystem1++3

32


33/44

he reorgani;ation to the Fire (epartment invo$ved no input from fire department

officia$s& ?ad the po$itica$ administration consu$ted the fire department mem!ers the

administration ou$d have !een informed of the impact that this t%pe of change ou$d have on

the overa$$ safet% of the firefighters&

@IS? through the Center for (isease Contro$ 8C(C9 has performed research that

identifies the impact of increased hours or6ed ith a decrease in the amount of time off for

recuperation&4' @ationa$ Response eam technica$ report found that fatigue i$$ !e a greater

impact on overa$$ safet% hen responders are or6ing $ong shifts and the tas6s are ver%

demanding such as high$% cognitive or emotiona$$% intense or6 ph%sica$ e/ertion e/treme

environments or e/posure to other hea$th or safet% ha;ards&4*hese findings suggest that

firefighters ho fre5uent$% or6 $onger shifts com!ined ith $onger or6 ee6s and night

shifts ma% !e at a higher ris6 of injur% and reduced performance&4='nother report found $onger

and more stressfu$ the or6 shiftBee6 the greater the need for recuperative time off&4+

he present or6 schedu$e does not provide ade5uate rest or recuperation for maintaining

proper fitness hea$th and e$$ness $eve$s to meet the ph%sio$ogica$ and ps%cho$ogica$ demands

of the jo!&

he Eaton Street fire provides $earning opportunities ith respect to the #rovidence Fire

(epartment ICS and command and contro$ of $arge sca$e emergenc% incidents& he #rovidence

Fire (epartment ICS provides a professiona$ approach to emergenc% management& ICS can

enhance the a!i$it% of fire officers to organi;e and contro$ resources and activities at the incident

4http"BB&cdc&govBnioshBemresB

4* @ation Response eam 4uidance for "anaging 5or&er Fatigue during ,isaster Response

200+

4= @ation Response eam 4uidance for "anaging 5or&er Fatigue during ,isaster Response

200+

4+ Sonnentag N Kij$stra 2007 .ohnson 2007 otterde$$ et a$ 1++>7 HS('BForest Service&

33


34/44

scene to hand$e the situation in the most effective manner possi!$e&>0ICS can increase the overa$$

effectiveness of command officers hi$e at the same time ma6ing their jo! easier and $ess

stressfu$&>1

,ecause of the ever%da% use of the ICS the first arriving compan% officers a$ong ith the

first arriving ,atta$ion Chief ere a!$e to coordinate the activities of the units dispatched on the

first a$arm& Command as esta!$ished the command se5uence !egun incident priorities

identified si;e up performed strategic o!jectives esta!$ished and tactica$ operations assigned&

In an effort to maintain proper span of contro$ the IC 5uic6$% recogni;ed the need to

divide the scene into managea!$e units& he IC esta!$ished E/posure 4 as one sector and

E/posure 2 as a second sector and assigned the first compan% officers into these !ui$dings as the

sector officers& nce these sectors ere esta!$ished and resources assigned to each sector the IC

esta!$ished the Side 3 Sector to manage the companies operating on e/terior of Side 3 of the

incident&

he ICs span of contro$ as e/ceeded even ith esta!$ishment of the sectors and the

EMS sector !eing esta!$ished !% the officer of the first arriving rescue& (uring the course of the

fire the IC as responsi!$e for the accounta!i$it% of trac6ing of and assigning time$% re$iefs of

mem!ers assigned to tent% to #F( fire units si/ #F( ')S rescue units to @orth

#rovidence Fire units and four out of ton ')S rescue units&

he $esson to share from an o!jective revie of the command structure for this fire

event is the need to esta!$ish additiona$ intermediate command $eve$ positions to improve the

overa$$ safet% and accounta!i$it% of mem!ers operating at the scene& he IC shou$d have

considered assigning an perations Chief& 's e$$ the geographica$ area of the incident justified

the esta!$ishment of to (ivision Chief positions one (ivision Chief for contro$ of activities in

each of the to e/posure !ui$dings& he (ivision Chiefs cou$d then assign sector officers for

each f$oor of the e/posure !ui$dings improving direct supervision accounta!i$it% and overa$$

safet% of mem!ers or6ing in those !ui$dings&

>0 #rovidence Fire (epartment Incident Command $ystem1++3

>1 #rovidence Fire (epartment Incident Command $ystem1++3

34


35/44

he revie of the events of the Eaton Street fire high$ight the #rovidence Fire

(epartments ina!i$it% to fi$$ ICS Command Staff :enera$ Staff and intermediate command $eve$

positions ith chief officers ho have Fire :round Command e/perience&

?istorica$$% chief officers of the department ou$d promote up through the ran6s& hese

chief officers ou$d have had e/perience as Fire )ieutenants and Fire Captains& he Fire

Captains ou$d promote to Fire ,atta$ion Chiefs 8,C9& he ,Cs cou$d promote to (eput%

'ssistant Chief 8('C9 positions and the ('Cs ou$d move on to the 'ssistant Chief of the

(epartment 8'C(9 Staff positions or Chief of the (epartment 8C(9&

Since 200= the #rovidence Fire (epartment has moved to e$iminate severa$ Chief fficer

Staff positions& he Fire Marsha$$ and (irector of the (ivision of raining ere once Chief

fficer positions& he duties of these positions have since !een assigned to the Captains of those

respective divisions& In 2010 a reorgani;ation of the num!er of Chief fficer )ine positions

e$iminated a !atta$ion chief position from each of the four p$atoons& '$so since 2010 the

(epartment Safet% fficer position has !een vacant& his position traditiona$$% had !een a

,atta$ion Chief ran6& In 201 the (epartment as once again reorgani;ed& he restructuring of

the num!er of p$atoons e$iminated to more Chief fficer )ine positions 8one ('C one ,C9&

More recent$% the unfi$$ed C( 'C( perations and the unfi$$ed ('C )ine

positions have reduced the num!er of #rovidence Fire (epartment Chief fficers ith fire

ground command e/perience&

?istorica$$% hen the (epartment has had fires of the si;e and comp$e/it% of the Eaton

Street fire hether during the da% or night upon the occurrence of a mu$tip$e a$arms the C(

'C( Fire Marsha$$ (irector of (ivision of raining (epartment Safet% fficer EMS ,C

and Superintendent of 'utomotive Repair ou$d respond to the scene of the a$arm and carr% out

their assigned duties&>2he return of these chief officers to the mu$tip$e a$arm fires provided the

IC ith chief officers so that if the ICS command structure re5uired these chiefs cou$d !e

assigned ICS Command Staff ICS :enera$ Staff positions or intermediate command $eve$

positions&

>2 #rovidence Fire (epartmentRues and Reguations1++

3>


36/44

Dhen o!jective$% revieing the events surrounding the injuries at the Eaton Street fire

discussion of the unfi$$ed (epartment Safet% fficer position cannot !e over$oo6ed& 's

mentioned a!ove this position has !een $eft unfi$$ed since 2010& Since 2012 four (epartment

investigations and reports have !een done !ecause of fire events invo$ving ma%da%s firefighter

near miss events and fires resu$ting in serious injuries to firefighters& Each of these previous

reports has recommended the reAactivation of the (epartment Safet% fficer and ,atta$ion 2

Chief fficer positions&

he intent of these recommendations as to improve overa$$ firefighter safet%& he

(epartment Safet% fficer position had !een responsi!$e for the management of (epartment

ccupationa$ Safet% and ?ea$th program& he (epartment Safet% officer maintained a thorough

6no$edge of current and changing Federa$ State and $oca$ $as regu$ating safet% in the

or6ing environment app$ica!$e to the fire department& he Safet% fficer as responsi!$e

identif%ing and causing the correction of safet% and hea$th ha;ards& It as the Safet% fficers

responsi!i$it% to investigate a$$ occupationa$ injuries i$$nesses e/posures and fata$ities invo$ving

fire department personne$ and a$$ accidents invo$ving fire department vehic$es apparatus

e5uipment and faci$ities& he Safet% fficer managed the co$$ection and ana$%sis of the records

and data pertaining to apparatus accidents deaths injuries i$$nesses and e/posures of fire

department personne$& he Safet% fficer responded to emergenc% incidents that invo$ved a high

degree of ris6 to personne$ and integrated into the #rovidence Fire (epartment ICS to serve as

the incident safet% officer&

he repeated recommendation for the reAesta!$ishment of the ,atta$ion 2 Chief fficer

)ine position to each or6ing p$atoon as a$so intended to improve firefighter safet%& he

present structure of to Chief fficers per p$atoon ma6es each chief responsi!$e the direct

persona$ command contro$ and supervision over the personne$ of fifteen companies assigned to

each of the to !atta$ions& Each chief is re5uired to ma6e month$% inspection of the 5uarters and

a dai$% inspection of personne$ assigned to the !atta$ion&>3

Dith the present organi;ationa$ structure of to Chief fficers per p$atoon one Chief

fficer is responsi!$e for nine companies during the initia$ stages of a fire incident& he first

>3 #rovidence Fire (epartmentRues and Reguations1++

3


37/44

a$arm for a structure fire is three engines to $adders one heav% rescue one ')S rescue&

Immediate$% fo$$oing the dispatch of the first a$arm companies and engine and $adder is

dispatched as the Fast 'ssist Search eam 8F'S9 companies& his !rings the first a$arm

comp$iment to nine companies& he Internationa$ Fire Service raining 'ssociations Chief

fficer !oo6 states that the standard span of contro$ for an incident commander is three to seven

ith five !eing the optima$ num!er for appropriate span of contro$&>4he #rovidence Fire

(epartment ICS a$so states that this is the standard for span of contro$& Current$% the second

chief if avai$a!$e is !eing dispatched to fire incidents to assist ith managing a fire incident

$eaving no supervisor for the remaining nineteen companies in the cit%&

he decimation of the Chief fficer positions !% past and present administrations a$ong

ith the unfi$$ed e/isting chief officer positions has created a situation that prevents the

#rovidence Fire (epartment from fo$$oing command contro$ procedures out$ined in the

(epartments Ru$es and Regu$ations Incident Command S%stem and various Standard

perating #rocedures& 's stated previous$% $ac6 of fo$$oing standard operating guide$ines as

identified !% research as a contri!uting factor to firefighter injuries&

his fire event a$so high$ighted the demands p$aced upon the #rovidence Fire (epartment

,ureau of perationa$ Contro$ 8,C9 during emergenc% operations of this si;e& his event

further demonstrated the cha$$enges for the present on dut% staffing $eve$s of the ,C&

(uring the Eaton Street fire hich re5uired a$$ avai$a!$e #rovidence Fire (epartment

units he ,C as coordinating the re5uired mutua$ aid coverage throughout the remainder of

the cit% monitoring the primar% dispatch radio channe$ and continued to anser routine and

emergenc% te$ephone ca$$ vo$ume&

It as fortunate that the Eaton Street fire occurred during da% time operations for the

,C& he Captain of the ,C ho norma$$% or6s da% time hours stepped in to assist the

norma$ on dut% staff of one Fire )ieutenant and to civi$ian dispatchers to meet the demands of

cha$$enges faced !% the ,C& In addition to persona$$% assisting the on dut% staff the Captain of

>4 Internationa$ Fire Service raining 'ssociation Chief *fficer& Sti$$ater -" Fire #rotection

#u!$ications 6$ahoma State H 2004& #rint&

3*


38/44

the ,C immediate$% recogni;ed the need of additiona$ staff& he Captain of the ,C ordered

to civi$ian dispatchers to remain on dut% hen their re$iefs arrived for the change of shift&

'ppro/imate$% to hours and thirt% five minutes into the Eaton Street fire the ,C

!egan receiving phone ca$$s for a second ind driven fire on )aure$ ?i$$ 'venue& he ,C as

no monitoring to fire events and simu$taneous$% monitoring the radio channe$s assigned for

eac

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Report of Investigation Committee into Firefighter Injuries Sustained at 41 Eaton Street in...

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