SAFETY BULLETIN 57March 15, 1997

FIRE CASE STUDIES - LESSONS LEARNED

It is an established fact that firefighting is the most hazardous profession in the United States. We, as professional firefighters, must always continue our learning process to insure that we perform as professionals, particularly in emergency situations where serious injuries or deaths may occur.

In the past, when one of our members was seriously injured or killed, the circumstances of the incident were learned principally from the news media or by word of mouth on the job. Some of the information obtained in this manner was incorrect and could adversely affect our job performance when similar conditions are encountered.

A suggestion has been received to disseminate particulars of past incidents to all units to permit all of us to learn from these experiences and, hopefully, prevent repeat occurrences. This will be accomplished by issuing a series of Bulletins, "Fire Case Studies - Lessons Learned" to all units of the Department.

These case studies will describe incidents in which the New York Fire Department and other fire departments have been involved. They will give only the particulars of the incident and the lessons learned. No names, unit identification, dates or locations mentioned.

It is realized that the findings and recommendations in these bulletins will be presented after the incidents have occurred and complete investigations have been made. There will be no pressure or need to make instantaneous decisions. These bulletins are not, in any way, intended as criticism or to embarrass anyone, but only to provide us with enough information to permit all of us to be more aware of the hazards encountered by members of this department and the lessons learned from these experiences.

Case studies shall be forwarded by Division Commanders to the Div. of Safety for review & editing. A draft will then be forwarded to Chief of Operations for review & approval. The approved copy will be returned to Div. of Safety for issuance as an official bulletin, i.e.: Case Study No. 1, No .2, etc.

Case Study No. 1, which was issued during the pilot program is being issued to all units. It is suggested that the same format be used for Case Studies submitted in the future.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

FIRE CASE STUDIES - LESSONS LEARNED

CASE STUDY NUMBER SUBJECT ISSUE DATE

1 ENTRAPMENT - VACANT BUILDING FIRE 2/79

2BUILDING ALTERATIONS - HAZARDS AT FIRES

3 REVOKED / 97

4 ELECTRICAL FIRE - HIGH RISE OFFICE BLDG

5 COLLAPSE - VACANT FRAME BUILDING

6 ELECTRICAL EMERGENCY - OPEN GROUND

7 PARAPET WALL STRUCK BY A TOWER LADDER

8 FALL OF FF FROM MOVING APPARATUS

9SERIOUS INJURY POTENTIAL OF SMOKE GRENADES

10 NEAR DISASTER AT A ROUTING FIRE

11 TL APPARATUS TIPPED OVER

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 1

ENTRAPMENT - VACANT BUILDING FIRE

FIRE BUILDING 6 STORY - NFP50' X 75'NEW LAW TENEMENTVACANT

PARTICULARS

An engine company, when returning to quarters after responding to a false alarm, observed smoke several blocks away and responded to investigate. On arrival at the location, the unit, found a heavy fire condition in the rear apartments on the 5th floor of a vacant building. Several calls for assistance were transmitted via radio (signal 10-75). A 4th alarm in progress at the same time, in the same borough, caused complications in radio communications and in subsequent response of units to this signal 10-75.

The interior stairs were found to be unsafe, due to missing steps, and a line was stretched by the engine company to the 5th floor via the front fire escape. The line was advanced to the rear apartments and operated in this position attempting to extinguish the fire.

When additional units arrived, the fire had communicated to exposure #3, an occupied multiple dwelling. These arriving units were committed to operate in this exposure and the engine company continued to operate alone in the original fire building. At this time, an arsonist started a fire in one of the front apartments on the 2nd floor using diesel oil or a similar accelerant. This caused a heavy fire condition on that floor and created a very large volume of thick black smoke entrapping the engine company on the 5th floor. The engine company retreated to the fire escape of the 5th floor with their line. Flames, excessive heat and thick black smoke endangered these men in that position. The position became so untenable that the members considered jumping to the street. Visibility on the fire escape was zero because of the smoke condition. A tower ladder bucket was positioned to the 5th floor fire escape balcony using the cries for help as a guide. The officer and two firemen stepped into the bucket and were safely removed to the street. Unfortunately, the third firemen fell to the sidewalk below and was fatally injured.

LESSONS LEARNED

1. All operations in vacant buildings must be conducted with extreme caution being exercised for the safety of operating personnel.

2. No unit should operate alone in a vacant building. Call for help immediately.

3. The stretching of two lines by the 1st to arrive engine company could prove beneficial. One line to be used for fire extinguishment and the other for protection of personnel operating in the building in the event conditions suddenly require its use.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

4. When there is a tower ladder at the scene of a vacant building fire, it should be positioned and made ready for immediate use as either an elevated stream or as a ready means to evacuate members in need of assistance at upper levels.

5. If trapped, maintain your composure, take a positive action that will get you out and inform others on the scene of your plight and location.

5.1 A charged line may be used as follows:

5.1.1 As a life line to provide direction out of areas of poor visibility.

5.1.2 To provide protection when retreating to an area of safety.

5.1.3 To pinpoint your location by operating it out of a window or from the fire escape.

5.1.4 To push smoke away so you can see or be seen.

5.1.5 To reduce heat and protect your position by using the stream as an umbrella.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No 2

BUILDING ALTERATIONS HAZARDS AT FIRE OPERATIONS

FIRE BUILDING 3 STORY - NFP25 X 75COMMERCIALOCCUPIED - FURNITURE

PARTICULARS

On arrival, a 10-75 signal was transmitted due to the heavy fire and severe smoke condition on all three floors of the fire building. The time was 2130 hours. This heavy involvement dictated an initial exterior operation with tower ladder stream.

Since operations in the fire building by the first to arrive ladder company were ruled out, the determination was to check for life and/or fire extension in exposure #2, a similar attached building, also occupied as a furniture warehouse.

The inside team of the first to arrive ladder company made the second floor of exposure #2, but were impeded by the large volume of furniture piled to the ceiling, front to back. The heavy smoke condition mandated the use of masks.

The third floor was void of stock and furniture, and the ladder company search was unimpeded except for the darkness and the smoke condition. Having reached the rear wall and finding the windows bricked up, the company then searched for a secondary means of egress. In finding the secondary egress, the company was fortunate to note that the floor in front of the door had been cut away presenting a 4 foot by 4 foot opening to the lower floor. This illegal opening had apparently been cut at the door entrance to prevent burglars from entering, causing them to fall to the floor below, thus negating any theft within the building. Had this not been a well conducted and organized search, severe injuries could have occurred to one or more members operating in the area.

LESSONS LEARNED

1. Never assume your unit is working in a safe operating area.

2. Before operating in the darkness and smoke, with a mask, equip yourself with the best possible lighting equipment.

3. In a similar situation, have your men sweep the floor in front of them with a hook or any available tool, as they move across the floor.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

4. When a hole of this type is found, cover it. In this instance, the door to the secondary egress was removed and used to cover the hole. Before leaving the scene, notify the officer in charge and any other units who are in the area.

5. When searching large, smoke filled commercial occupancies, members should operate in pairs.

6. Always expect the unexpected.

7. Thorough inspections while on AFID can uncover and correct potential hazards to our members.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 3 REVOKED / 97 (HAZARDS OF CO INFORMATION NOW FOUND IN MASKS ADD 2 REFERENCES)

Case Study No. 4

ELECTRICAL FIRE - HIGH RISE OFFICE BUILDING

FIRE BUILDING 20 STORIES - FP300 X 300COMMERCIAL - HIGH-RISEOFFICE BUILDING - CORE CONSTRUCTIONOCCUPANCY GROUP - E

PARTICULARS

While responding to telephone alarm at 0746 hours, for fire on the 17th floor of a 20-story office building, the first due engine company transmitted 10-75 signal due to smoke issuing from the roof of the fire building.

Upon arrival units were met by the manager and maintenance superintendent. They said there was a small fire in the storage area on the 17th floor. The 17th, 18th, 19th and 20th floors were unoccupied. The maintenance men used extinguishers on the fire to hold it in check until the arrival of the Fire Department.

The first due engine and ladder companies took the elevator to the 16th floor. The engine company connected their rolled up hose to the standpipe floor outlet. The first due ladder company found the fire in the 17th floor storage room. There was a light haze of smoke and members operated on the 17th floor without their mask facepieces. Initially, the ladder officer saw boxes of air conditioner filters burning. He was unaware that the fire started in the electrical raceway and ignited the boxes which were piled against it. When he became aware of the electrical feeder cables burning, he directed all members to don facepieces.

The second due ladder company entered the 17th floor to locate the storage room in order to enable them to check for extension on the 18th floor. Upon entering the 18th floor, they found the same light smoke condition. The fire had extended into the 18th floor storage room.

The fire on the 17th and 18th floors was quickly extinguished by engine companies wearing their mask facepieces.

Members, who were operating in the light smoke without their facepieces on, complained of difficulty in breathing and tightness of the throat. These members were administered oxygen and examined by our Department doctors, resulting in eleven medical leaves granted plus four no time lost injuries. Engine companies operating in the area with facepieces on did not encounter any difficulty in breathing or complain of throat irritation. Scott masks provided protection against the toxic atmosphere. Masks were tested by units and the cylinders were changed. No defects were reported. All masks remained in service.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

CONCLUSIONS

1. The insulation on the electrical cables was POLYVINYL CHLORIDE (PVC) and, when it burns, it gives off an irritating odor similar to that of chlorine. Operating personnel would normally don their mask facepieces before entering the area. At this operation the PVC was widely dispersed and did not have its characteristic pungent, irritating odor.

2. There seems to be a delayed physical reaction when a light haze of PVC is inhaled. Members started to cough and had difficulty in stopping. Putting the mask facepieces on did not relieve the coughing spells.

3. Polyvinyl chloride is a great insulator for electrical wire. In addition to its dielectric qualities, PVC is resistant to water, acids, alkalis and alcohol. Great, when you are in the electrical business, but not too great for firefighters. When PVC burns hydrogen chloride gas is formed which, in the presence of moisture forms hydrochloric acid. Hydrochloric acid corrodes most metals. So unless you are a Bionic man be sure to use a mask at electrical fires. It is easier to change SCBA tanks than lungs.

LESSONS LEARNED

1. When there is a light smoke condition at fire operations and the source of the smoke is not obvious, units should wear their mask facepieces, especially in high-rise buildings, tunnels, subways below-ground areas, etc..

2. Chief officers relieved from the lobby command post and establishing an operating post on the floor below the fire or directing units on the fire floor shall have their Scott mask brought to the point of operations. When chief officers enter the affected area to direct fire operations, they should equip themselves with masks.

3. At all fires obviously involving electrical equipment members shall use breathing apparatus until the officer in command declares the area completely free of toxic smoke (including overhauling operations).

4. In order to acquaint members with the characteristic odor of PVC, a piece of PVC electrical cable insulation can be burnt at company drill.

5. Units responding as third due, or as additional engine and ladder companies, should carry extra Scott cylinders to the operational command post.

6. Evacuation of the fire floor and the floor above should be given prime consideration when we encounter fires involving electrical equipment and feeder cables, even though there is only a light haze of smoke.

7. The Fire Department has spent large sums of money in research, development, and purchase of the Scott 4.5 masks and maintenance equipment for the masks. In accordance with AUC 220, masks shall be utilized at all operations where the toxicity of the atmosphere may affect a member's health or operational ability.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNEDCase Study No. 5

COLLAPSE - VACANT FRAME BUILDING

FIRE BUILDING 3 STORY FRAME20' X 60'

ROW FRAME TYPEVACANT BUILDING

PARTICULARS

The fire building was one of a group of row frame buildings with buildings on each side having been previously demolished.

Upon arrival of units, the fire was throughout all floors of the building and an exterior attack with Stang nozzles and ladder pipe was employed. The main body of the fire was extinguished in approximately ten minutes, at which time a tower ladder was positioned in front of the building for stream operation on remaining fire. The tower ladder operated at this position for about one hour and then was repositioned at the rear of the building and operated for another thirty minutes.

Suddenly, without warning, the fire building totally collapsed, in "pancake" fashion, in just a few seconds. Fortunately, fireman and civilians had been kept clear of the building and its perimeter.

Prior to this collapse, water runoff was good and the building neither appeared nor gave any indications of being structurally unsound.

The primary conditions suspected of causing this collapse were:

1. Advanced age of the building.2. Previous fires within the building.3. Lack of structural support from adjoining buildings that had previously been demolished.4. Prolonged use of tower ladder stream.5. Extensive brick nogging adding to the dead weight load in the side walls.6. Vertical beam dry rot due to mortising into masonry sills. The cuts in the sills, where

beams rested, allowed water to collect causing rot.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

LESSONS LEARNED

1. Under heavy fire conditions, the stability of all fire buildings should be suspect, particularly buildings that formerly were supported on either side by walls of adjoining buildings.

2. When an exterior attack is employed, keep all firemen and civilians well away from building perimeter.

3. Position all apparatus used in the exterior attack outside the potential collapse area of the building.

4. At fires in such buildings where tower ladder streams have been in operation for extended periods, make every effort to completely extinguish the fire with outside lines rather than re-enter the building. In this regard, and where remaining fire is buried or deep seated, consider the use of a watch line.

5. If such buildings remain standing after extensive use of heavy caliber streams and stability is questionable, notify the Police for placement of barricades.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 6

ELECTRICAL EMERGENCY - OPEN GROUND

BUILDING DESCRIPTION: ROW FRAME 2 STORY20 X 50RESIDENTIAL

PARTICULARS

Upon arrival at the scene, units conducted a search of the building, (Building "A") and found sparking occurring on a metal ceiling in proximity to a steam pipe on the second floor. Further investigation revealed that both the ground wire circuits from the Con Ed manhole and the secondary ground attachment to the cold water pipe in the cellar were open. At this point, all electricity past the meters was shut down at the circuit breaker box, as there was no main switch, but sparking continued. The electricity in the similar, adjoining building, (Building "B"), was then shut down. This action stopped the sparking in the metal ceiling. Building "A" and Building "B" received their electricity through common circuitry, a condition found frequently in older buildings of this type

CONCLUSION

With an open Con Edison ground in the street, and an open house ground, the electricity in the circuit found its return by way of the grounding strip in the fuse box and through the BX Cable shielding, which came in contact with the metal ceiling.

LESSONS LEARNED

1. An open ground condition, as described herein, can cause any metal in the area to become electrically charged resulting in possible shock and/or fire. This electrical charge can also extend to metal siding and fences on the exterior of the building. To control a similar situation, all circuits in adjoining buildings or areas that use a common source of electrical supply must be shut down.

2. Reliance on the house ground is dangerous and unsafe. Besides being non-existent in many cases, such house grounds form poor connections due to insecure clamping or electrolytic action of dissimilar metals.

3. The unusual nature of electrical current demands that members do not attempt repairs or alterations to such circuits. Only actions necessary to protect life and prevent extension of fire shall be taken pending the arrival of competent electrical utility personnel.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

4. In summary, if you encounter a condition as described herein, and sparking continues after the electrical power switch has been placed in the "off" position in the affected building, the following conditions are probably present:

1. The Con-Ed ground circuit back to the manhole is "open" or broken and the house ground circuit is also "open" or broken.

2. The electricity is still flowing even though you pulled the power switch, because an adjoining building is supplying electricity through common wiring.

DEFINITIONS

OPEN CIRCUIT - an electrical circuit that does not permit electricity to flow because there is a break in the circuit wire.

"CON ED" OR UTILITY GROUND - the wiring installed by the utility company that permits electricity to flow back into the manhole and then into the earth or "ground".

"HOUSE" GROUND - the wiring installed by the electrician in building a house that also permits electricity to flow back into the earth or ground in event the utility ground is broken or "open".

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Electricity leaves the manhole on the hot wire and enters the building at the junction box. It then goes through the meter to the fuse box and then from the fuse box to the appliance in use. From there it returns to the neutral bar (Ground Strip) in the fuse box and then to the ground in the manhole. If the ground is open then all circuits serviced by the open ground wire will feed back on their armored BX shielding or conduit and the electricity will be searching for a ground to complete the circuit. If by chance a person touches the live conduit and a grounded object such as a water pipe, the person will complete the circuit to ground through his own body, resulting in an electrical shock.

Note: See WNYF 1969 for similar problem.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 7

PARAPET WALL STRUCK BY A TOWER LADDER

FIRE BUILDING: 4 STORY N.F.P.M.D. WITH STORE ON 1ST FLOOR25 X 70

OCCUPIEDFIRE IN TOP FLOOR APARTMENT

PARTICULARS

Fire building was in a row of similar attached, 4 story NFP buildings. 10-75 was transmitted or arrival of first units.

The fire was an All Hands worker, 2 of the 3 lines stretched extinguished the fire with dispatch.

During the overhauling stage, a Tower Ladder was moving equipment to the roof to complete operations. This was accomplished without incident.

The Tower ladder controls were then activated to return basket to the street. When the basket was moved a section of the Parapet Wall, about 12' long, 12" deep and up to 18" high fell to the street. The bricks, mortar, and capstone just missed hitting members on the sidewalk and in the street. The top floor fire escape where men working moments before was very heavily damaged. Some of the sections of brick and mortar weighed several hundred pounds.

CONCLUSIONS

The cause of parapet falling was the basket of the Tower ladder dislodging a section of the Parapet Wall. When the member operating the controls moved the basket, he did not raise the basket, he retracted the boom. The basket resting on the Parapet Wall pulled the wall away from the building.

LESSONS LEARNED

1. Whenever the basket comes to rest close to a parapet or roof, prior to retracting the boom, the basket must be raised.This raising, prior to moving boom away from the building and retracting basket, will avoid any contact of basket with portions of the building.

2. The Pedestal man maintains proper control of the placement of the basket. He provides an extra pair of eyes to warn of impending contact of the basket or boom with the building.

If necessary, the pedestal man takes over the controls to provide a safe operation.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

3. What may have been an acceptable basket weight of two or three members during raising operation, may develop into unacceptable weight during the lower operation.

Weight may be added by additional members (5 or 6) with tools entering basket to descend from the roof, causing bottom of the basket to make contact with building. (Parapet or Roof)

4. That area under the operating Tower Ladder should be declared a "danger zone" and should be secured with tape, rope or barricades. These barriers shall be respected by all Fire Department personnel.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 8

FALL OF FIREFIGHTER FROM MOVING APPARATUS

PARTICULARS

A firefighter, while responding on a Tower Ladder apparatus to an alarm of fire, fell from his assigned riding position to the street and suffered severe injury. This fall occurred as the apparatus was slowing down as it approached the front of the building from which the alarm was sounded.

An investigation after the accident indicated that the firefighter released his grip on the handrail of the apparatus to reach for his equipment causing a loss of balance on the moving apparatus. This resulted in his falling to the street.

LESSONS LEARNED

1. Each firefighter and officer responding or riding on or in a Department apparatus or vehicle should make use of all restraining devices provided to insure safe transport. The Department is currently researching and evaluating restraining devices, particularly for Tower Ladder apparatus. When such devices are installed and used by members they should prevent incidents and injuries as described herein.

2. When riding on Department apparatus, do not release your handgrips nor open seatbelts until the apparatus is brought to a stopped position.

3. Do not don or reach for equipment while apparatus is in motion.

4. The enclosed riding positions on apparatus are designed and provided to prevent falls while the apparatus is moving.

5. For additional information review Safety Bulletins Nos. 6

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 9

SERIOUS INJURY POTENTIAL OF SMOKE GRENADES

PARTICULARS

Units arriving found several police cars on the scene for a shooting incident on the first floor of a building. In addition, smoke was pushing out one window on the third floor of the same building.

An engine company stretched a line to the third floor while the ladder companies took their fire positions. When a ladder company forced entry to the apartment a medium smoke condition was encountered but no heat. After venting and not finding a fire it was assumed something like a smoldering chair cushion was the source of smoke.

Members removed their mask face pieces when the smoke appeared to have lightened. Upon breathing the smoke their throats burned and they had trouble breathing. Five firefighters were taken to a hospital where, after examination, two were admitted and all were placed on medical leave.

The source of the smoke was found to be a military HC smoke grenade which had been throb into the apartment by the same person involved in the shooting incident.

One of the firefighters, admitted originally for observation, was hospitalized for over a month with serious lung injuries.

CONCLUSION

The military uses a number of agents to produce screening smokes. The designation HC, is a mixture of grained aluminum, zinc oxide, and hexachloroethane. Burning the mixture produces zinc chloride which rapidly absorbs moisture from the air to form a grayish white smoke. The more humid the air the more dense the HC smoke. HC smoke has a sweetish, acrid odor.

LESSONS LEARNED

1. The color and amount of smoke is no indication of the hazard involved. The use of masks is important since we have no way of determining the toxic content of smoke at a fire scene.

2. The purpose of the HC smoke grenade is to produce a smoke screen which is not toxic in concentrations used for obscuring purposes. However, exposure to heavy concentrations of smoke generated in closed spaces are extremely dangerous and under these conditions have caused fatalities. Military personnel do operate in smoke screens without masks when outdoors but the US Army states that under no circumstances should HC munitions be used indoors or in closed compartments.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

Case Study No. 10

NEAR DISASTER AT A ROUTINE FIRE

FIRE BUILDING: 2 STORY NFP, 20'X60'OCCUPIED MD WITH TWO APARTMENTS

PER FLOORFIRE IN FIRST FLOOR REAR APARTMENT

PARTICULARS

While units were responding to this alarm in the pre dawn hours, additional information of trapped children in the first floor rear apartment was received. An additional engine and ladder company were dispatched. On arrival at the scene units were confronted with heavy fire from the windows in the rear and exposure four side of the fire apartment. The front door to the fire building and the fire apartment were open with heavy fire and smoke issuing up the interior stairs. Several people were trapped in the second floor apartments and were at the windows.

A portable ladder was raised and the trapped people were removed from the second floor. At the same time, a hand line was being stretched down the public hall to the fire apartment. For some unknown reason, the scuttle cover was removed prior to the arrival of our members. This produced the desired vertical ventilation, which when coupled with the fire venting from four of the five apartment windows would cause any veteran firefighter to think that extinguishment of this fire would be relatively easy. However, the fire and smoke obscured the roof firefighter’s vision of the skylight, which had he seen and vented, might have prevented the ensuing near disaster.

While waiting for water, the fire blowing out of the apartment door escalated to blow torch intensity causing the engine company and forcible entry team to retreat with their still uncharged line. This was possibly caused by the aggressive action of the outside vent man removing the only remaining window in the apartment which he climbed through to search for the reported trapped children.

When the engine company reached the front door of the building, they found it had closed and locked behind them. They were unable to unlock and open the door due to the intensity of the heat in the hall. Fortunately, the special called truck arrived and seeing the hose line and one of the members fingers under the closed front door, forced the door freeing seven of our members from almost certain death.

(Each firefighter received burns severe enough to require treatment at the Burn Center) It should be noted that probably less than one minute had elapsed from the time of their arrival until the time the front door was forced, rescuing the trapped members.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

CONCLUSION

Had the hoseline under the front door been charged, it is doubtful that enough water would have been available to alleviate the conditions in the hall and it certainly would have required more time to free the trapped members.

LESSONS LEARNED AND REINFORCED

1. Never take what could be considered a routine operation for granted. It could result in disaster.

2. Basic rules of firefighting, through constant training should become so ingrained in our members that they are executed almost automatically. Never let reports of trapped occupants distract you to the degree that these basic rules of firefighting are overlooked.

3. Always chock the door. It could close behind you, blocking your escape.

4. Use booster water initially when conditions warrant, especially when stretches are short, and hose line is in position before hydrant water is available.

5. Outside vent man shall rely on handie talkie communications to coordinate ventilation with the charging of a hose line. Premature ventilation may rapidly increase the intensity of the fire.

6. Roofman shall ensure adequate ventilation depending on conditions encountered and/or orders from his officer.

7. All officers should constantly remind their subordinates to use their protective equipment in the manner for which it is intended. If not used to the fullest extent possible, the protection available is not being provided to them.

8. Engine officers, before advancing a hoseline, could consider using a checklist routine with their members, e.g., calling out in paratrooper jump school fashion, gloves on, boots up, collar up, ear flaps down, mask on, etc.

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Case Study No 11

TOWER LADDER APPARATUS TIPPED OVER

FIRE BUILDING 6-STORY - NFP50X100M.D. WITH STORE ON 1ST FLOOROCCUPIED - FIRE IN STORE

PARTICULARS

A 10-75 was transmitted on arrival of first units. Units could not determine the exact location of the fire because of heavy smoke obscured their visibility. It was not known if the fire was in the basement or the first floor, extending to the upper floors.

A second alarm was transmitted because of difficulties in venting and the number of occupants requiring evacuation.

The chauffeur of the first due ladder, a tower ladder, was readying his bucket for operation when he saw the second ladder arrive. After having set only the inboard outriggers, he felt his bucket would not be needed, he then went inside the building to join his company.

Concerned over the lack of ventilation, the Incident Commander directed another member of the company he knew to be a qualified LCC, to raise the bucket to vent the front of the building. The member, operating from the bucket, raised the bucket to the front of the fire building and removed a Firefighter and a civilian from the fire escape. When the bucket was moved away from the fire building to the other side of the street (outboard side of the apparatus), the apparatus tipped injuring the three people in the bucket and two civilians in the street.

CONCLUSION

The reason the tower ladder tipped, was that the second chauffeur did not realize that the outboard outriggers were not set when he lowered the boom on the outboard side of the apparatus to discharge the people in the bucket.

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SAFETY BULLETIN 57March 15, 1997 FIRE CASE STUDIES - LESSONS LEARNED

LESSONS LEARNED

1. Any member operating a tower ladder must personally verify the placement of all outriggers and jacks prior to raising the bucket from the bedded position.

2. All outriggers and jacks must be extended and lowered before raising the boom of a tower ladder. Tower ladders are not designed to operate with outriggers and Jacks down on one side only.

3. If a member commences to set up a tower ladder apparatus for an operation and then decides to abort the operation, the member must either:

A. Properly place all outriggers and jacks for operation.

B. Return all outriggers and jacks to the pre-setup position.

4. Whenever a tower ladder operation is in progress, the pedestal position must be staffed. This provides an extra pair of eyes to warn of impending danger and override basket controls in an emergency.

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