Firefighter Fatality Investigation Firefighter Stanley Wilson Dallas Fire-Rescue Department Investigation FY 13-07 Dallas, Texas May 20, 2013 TEXSFIE MR Fl EXA DEPRTMET T/ae subsequent investigation of their incident provide: valuable information to tbe?re .rerviee by examining tbe [mane learned, to prevent [055 of ana?prepery. Investigation Number FY 13-07 ?r Table of Contents Acknowledgements Executive Summary Introduction Building Structure and Systems Fire Investigation Fire Ground Operations and Tactics Timeline Equipment Evaluation: Personal Protective Equipment Findings and Recommendations Appendix 1: Timeline 2: Dallas Fire?Rescue Department . PPe?dix 3: National Response Framework, Cond Edition i Number FY 13- Acknowledgements The Texas State Fire Marshal wishes to thank the following entities for their cooperation and assistance in the investigation of this incident and the preparation of this report: Dallas Fire-Rescue Department Dallas Police Department Austin Fire Department Bureau of Alcohol, Tobacco, Firearms, and Explosives State Firemen?s and Fire Marshals? Association Texas Commission on Fire Protection Texas Engineering Extension Service Texas Forest Service National Institute for Occupational Safety and Health The following Austin Fire Department members conducted the review of the operations and tactics, and provided recommendations. We commend these individuals for their com? mitment to the review of this incident, in the pursuit of ?re?ghter safety for the Texas Fire Service. Assistant Chief Kenneth Crooks Battalion Chief Rene Garza Captain Matt Rush Lieutenant Brooks Frederick Investigation Number FY 13-07 3 ?if Executive Summary On May 20, 2013, City of Dallas Fire?Rescue Department Truck 53 Fire?ghter Stanley Wil? son was fatally injured during ?re?ghting operations at a three?story apartment ?re. At ap? proximately 2:51 Dallas Fire-Rescue Dispatch received a call from an alarm monitor? ing company advising that the ?re alarm system at the Hearthwood North 2 Condomini? ums had activated. The address is 12363 Abrams Road, inside the city limits of Dallas, Texas. The ?rst ?re apparatus to arrive at the condominium complex was Truck 57. Seeing ?re in the complex, the captain on Truck 57 requested that Dispatch change the alarm type to a Box Alarm (structure Tenants were rescued and evacuated and a search of the structure was completed. Approximately 45 minutes after the initial response, ?re ground operations transitioned to a defensive attack and master streams were ?owing. Fire?ghter Stanley Wilson responded to the scene on Truck 53 at 4:05 after the fourth alarm. Truck 53 reported to Command and was assigned to search an adjacent building not yet involved with ?re. Upon completion of the assignment, Truck 53 was assigned to con? duct a ?primary? search of the ground ?oor of the ?re building. During the search, the structure collapsed, trapping Fire?ghter Wilson under debris and other ?re?ghters at condo entry door areas. The Truck 53 captain announced a Mayday and the Rapid Intervention Team was deployed to Search and rescue the trapped ?re?ghters. The ?re?ghters mapped in the void spaces at condo entry doors were rescued several minutes later. Fire- ?ghter Wilson was recovered from under the collapse debris in the main corridor after an extensive search and debris removal was conducted. Fire?ghter Wilson died from compres? sion Investigation Number FY 13-07 4 This report is intended to honor Fire?ghter Stanley Wilson by taking the lessons learned from this incident so others may not perish. Fire?ghter Wilson was a 28?year veteran with Dallas Fire?Rescue. Fire?ghter Stanley Wilson Dallas Fire?Rescue Department Investigation Number FY 1 3-07 5 Introduction . On Monday, May 20, 2013, the Texas State Fire Marshal?s Of?Ce (SFMO) was noti?ed that Fire?ghter Stanley Wilson with Dallas Fire?Rescue Department died from injuries sustained while conducting ?re ground operations at a structure ?re. The SFMO commenced the ?re?ghter fatality investigation under the authority of Texas Government Code 417.0075. In this section, the term 'j?irijighter" incliides an individual who performs fire suppression duties for a governmental entigr or volnnteer?re department. If a ?refighter dies in the line of day) or the ?rg?ighterfs death occurs in connection with an on- diiyi incident in this state, the state fire marshal shall investigate the circumstances surrounding the death of the ?refighter; including any factors that may have contrihiited to the death of the ?re- ?ghter. In conducting an investigation tinder this section, the state fire marshal has the same powers as those granted to the state fire marshal under Section 417. 00 7. The state fire marshal will coordinate the investigative efforts of local government o?icials and mtg; enlist estahlished?re service organizations and private entities to assist in the investigation. (.529 The state ?re marshal will release a report concerning an investigation conducted tinder this section on completion of the investigation. Not later than Octoher 31 of each year, the state ?re marshal will deliver to the commissioner a detailed report ahoiit the ?ndings of each investigation tinder this section in the preceding year. Investigation Number FY 13-07 6 I information gathered in an investigation conducted under thie Jettion it enhjeet to Seetz'on 552.108. The anthorig/ granted to the etate?re marshal nnder thie .reetion will not limit in any way the an- thorigl 0f the man or inaninjbal?re marshal to conduct the county or maniapal?re nearehal't own inreetzgatien into the death of a ?refighter within the canny! or inaniezjbal?re marshal'ejnrie- diction. The investigation began on May 20, 2013, with the initial assessment and survey of the in? volved property, including examination of the ?re scene and obtaining witness information. SFMO staff at the scene sent periodic updates to the investigation team members, and an action plan of assignments and objectives for the investigation was established.1 The Texas State Fire Marshal?s Of?ce and Dallas Fire-Rescue led the efforts to investigate the circumstances and factors contributing to the fatality of Fire?ghter Wilson. Assign? ments included examination of the ?re scene to determine the origin and cause of the ?re; examination of the structure and systems, including the gathering of historical information and known conditions of the structure; an evaluation of the structure?s ?re protection sys- tems; an examination of the personal protective equipment; and a review and examination of the ?re ground operations and tactics employed. The State Fire Marshal?s Of?ce noti?ed the Bureau of Alcohol, Tobacco, Firearms, and Ex? plosives (ATF) and requested assistance from the ATP National Response Team NRT) in the examination of the incident. The State Fire Marshal?s Of?ce noti?ed the Texas Forest Service, requesting that it respond and assist in incident management and planning the investigative activity. The Texas State Fire Marshal has agreements with the major metropolitan ?re departments in Texas to provide assistance in the investigation of ?re?ghter fatalities in departments of Texas? major cities. Departments assign members to assist the SFMO in the investigation of the incident, and the evaluation of the ?re ground operations and tactics to assist in devel? oping recommendations. The major metropolitan ?re departments rotate annually and 1National Response Framework, Second Edition (See Appendix 3) Investigation Number FY 1 3-07 7 Dallas Fire-Rescue was the assisting department for ?scal year 2013. The procedure pro? vides for requesting assistance from the previous year?s assigned department whenever the ?re?ghter loss is with the currently assigned ?re department. Since Dallas Fire-Rescue De? partment experienced the ?re?ghter loss, the previous year?s assigned department was re- quested to assist, and so the SFMO requested assistance from the Austin Fire Department (AFD). AFD assigned Assistant Chief Ken Crooks, Battalion Chief Rene Garza, Captain Matt Rush, and Lieutenant Brooks Frederick to assist. AFD responded to the scene on May 20, 2013. Chief Crooks was assigned as the group supervisor for the operations and tactics evaluation team. The Texas Commission on Fire Protection (TCFP) regulates personal protection equipment (PPE) in the state and assisted in the evaluation of the PPE. TCFP compliance of?cers Robert Manley and Lamar Ford were assigned and responded to evaluate the personal pro- tection equipment. The National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program was noti?ed. NIOSH responded to the scene with a team to conduct an independent investigation. Investigation Number FY 13-07 8 Building Structure and Systems The State Fire Martha/?1 O?iee rg?erenee: the 2012 edition of the National Fire Protection MPA) 101, Life 5 @2191 Code, a: the haeiejor lz? safety evaluation of the fire ineident building .gibeoe?e to this inoeetigation. The Ciy of Dallas has adopted the 2006 edition of the International Fire Code Where def?ereneei? may exth among loealh/ adopted eodee, and prenionib/ approved condi- tione, the Cigl of Dallas retainejnriedietion of code under their adopted codex. The ?re incident was located at the Hearthwood North Condominiums, 12363 Abrams Road. The property was a multi-family residential complex. According to Dallas Fire-Rescue authorities, the complex had a history of ?res and alarm activations, including one other multiple-alarm ?re; Pre-?re p110 to ofpropergz, 2012 (Google Earth) Investigation Number FY 1 3-07 9 Building Structure and Systems The Hearthwood Condominiums consisted of a complex of eight, three?story residential buildings, classi?ed as an R?l residential building according to the Dallas Fire Inspections Division. All residential buildings on the property were said to be constructed of the same materials and by the same methods during the period of June 1978 through March 1979. Because unsafe conditions prevented internal examination of Building 5 at the time of in? vestigation, exemplar buildings in the same complex were examined to obtain information for construction and ?re safety features that would be representative of Building 5. Building 5 was identi?ed as the building of ?re origin. The building was a three?story resi- dential building containing 24 living units of wood?frame construction with exterior wall materials Consisting of brick veneer, stucco and ?berboard. The main roof structure was ?at with an asphalt overlay. A mansard?style roof structure wrapped the building at the third?floor level with a standing seam metal roof covering. The supporting structural mem? bers consisted of pre-engineered roof trusses and ?oor joists using metal gusset plate con? nectors. The building was constructed on a concrete slab foundation. Investigation Number FY 1 3-07 10 Wew of corridor in exemplar structure Each living unit door discharged to an interior corridor. Interior ?nish of the corridor con- sisted of gypsum wall board and a suspended acoustical tile ceiling. The structural members were unprotected wood framing above the ceiling membrane. The central corridor on each ?oor provided access to an exit stair enclosure on the north end of the building. The south end of the corridor led to an area to access a stairwell to the ground ?oor and the exits to the breezeways to Building 4 and Building 6. The building had a ?re alarm system with off?premises monitoring. The ?re alarm system had automatic smoke detection in the corridors and manual pull boxes located at each stair? way exit door. Fire alarm noti?cation appliances consisted of a single alarm bell centrally located in the corridor. The interior exit corridor on each floor had emergency lighu'ng units, portable ?re extin- guishers and illuminated exit signs. Investigation Number FY 13-07 1 'e ?w - 5% .7 View of the south end 5 showing the lobby area, exit doors, and breezeways Each condo living space was all electric; the only gas to the building supplied the water heater boilers. The building had a gravity trash chute serving the second and third ?oors and terminating in a collection room on the ground floor. The chute was protected with an internal sprin? kler system, and a heat-actuated chute cut?off door in the ground floor room equipped with 165 degree thermal links. Dallas Code Review Information contained below, and any references to code [9237001, wereprooz'doo? through 22}: the Dollar Department I mpectz'om Dioixz'on. Construction permits issued by the Dallas Building Department for the Hearthwood Con? dominiums are dated between June 1978 and March 1979. The adopted codes at the time of building construction were the 1976 Dallas Building Code and the 1976 Dallas Fire Code Investigation Number FY 13-07 12 According to DFRD, existing ?re protection features for the building were approved for continued use based on the previously adopted codes in effect at the time of construction approval. Conditions that require an upgrade to current codes depend on the alteration of Square footage, stories in height, or a change of occupancy use. Building 5 was equipped with a ?re alarm system, but it was not considered a required sys? tem based on the occupancy classi?cation at the time of construction. In accordance with the 1976 Dallas Fire Code, Section (1), an R-1 occupancy four stories or less is exempt from a required ?re alarm system. At the time of the ?re investigation, it was reported that dwelling units were equipped with] hardwired smoke alarms in the hallways outside of the sleeping rooms. The Dallas Fire Code only required single?station, battery?operated smoke alarms at the time of construc? tlon. In 2011, permits were taken out for a ?re alarm system upgrade to buildings 4, 5 and 6. At the time of the ?re, the system was still being installed and not yet in service. Work was to include a new ?re alarm control panel, noti?cation devices, smoke detection and manual pull boxes. The ?re alarm con trolpancl in Building 5 was monitored by an o??lpremrise monitoring ?rm Investigation Number FY 1 3-07 3 The Licensing Investigation Division of the State Fire Marshal?s Of?ce reported that the ?re protection ?rm that last serviced the systems indicated the ?re alarm and sprinkler sys? tem in Building 5 was in compliance and no de?ciencies were noted. Dallas Fire?Rescue Department Inspections report indicates a complex? wide inspection was conducted on May 6, 2013. The report indicates multiple deficiencies in Building 5 including, but not limited to, the following: (1) Inoperable exit signs. (2) Improper storage of flammable and combustible materials. (3) Inoperable self?closing devices on ?re?rated trash chute loading doors and ?re- rated exit stairway doors. (4) No documentation of annual service and maintenance for trash chute compo? nents. (5) Painting of ?re alarm components, smoke detectors outside elevators, and other life safety components. A letter of intent dated May 9, 2013, to comply with the inspection ?ndings, was provided to the Dallas Fire?Rescue Department Inspections Division from property representatives. Examination of exemplar buildings by the investigation team revealed the following ?nd- ings: (1) Inoperable self?closing devices were present on stairway exit doors, or doors would not close and latch because of damage to the door leaf. (2) Self?closers were removed from trash service room access doors. (3) Inoperable self-closing devices on trash chute loading doors prevented doors from closing and latching in the frame assembly. (4) Fire?resistance ratings were not con?rmed on ?re doors because paint coverage obscured the UL label, or the labels were missing from the doors. Investigation Number FY 13-07 14 Trash Chute Details and Fire Protection Features The trash chute installation and associated fire protection features would have been approved by the Dallas Building Department, in accor- dance with the adopted Dallas Building Code in effect at the time of construction approval, which was reported to be the 1976 edition. The trash chute was constructed of a light gauge metal tube approximately 24 inches in diameter, and the chute?s perimeter was not contained within an enclosed shaft. The chute extended vertically from the ground floor col? lection room into the building?s attic space. The chute terminated and vented through an eight?inch pipe into the attic space of the building above the third?floor ceiling. It could not be confirmed whether the Dallas Building Code in effect at the time of con- st'ructiOn approval would have permitted the trash chute to terminate in the attic space. Current code standards require a trash chute to terminate a minimum of three feet above the roof line of a structure (see Exhibit Al). Chute extends above roof Firs prints-cunn? ratad loading dour Sprinkler Fire-rated enclosure Service opening room with ?re door typical on each cor) Sp?nkisr Self?closin ?re-rated oor Typical gm my rubbish chute (current codes) Bidg. 6 trash chute vented into the attic space. Bldg. 5 reported to be similar. (A TF Photo) The trash chute service room was accessed from the corridor on each floor level by a fire? rated door assembly. The trash chute loading doors on each level were provided with an Underwriters Laboratories (UL) labeled 1?1 2 hour ?re rated assembly. Codes at the time of construction approval required trash chutes in R?l occupancies to terminate in rooms separated from the remainder of the building by a one?hour fire-rated construction. Investigation Number FY 1 3-07 A trash chute cut-off door was provided at the chute opening in the ground ?oor trash col- lection room that was operated by a 165 fusible link and spring loaded closer. The interior wall ?nish in the exemplar ground floor trash chute service rooms was a ce- ment board material. It could not be con?rmed whether this material and method of instal? lation meets an approved ?re resistance rating. According to the current Dallas Building Code, ?re sprinklers shall be installed in ground ?oor trash chute terminal rooms. Examination of exemplar buildings revealed that trash chute terminal rooms were not protected with ?re sprinklers. The trash chute was protected with two internal ?re sprinklers, with a thermal rating of 165 located on levels two and three of the chute. The ?re sprinklers were supplied from the domestic water system. . . I . . "?i'nuc~52 Valves that controlled water supply to the trash chute sprinklers were not electronically su- pervised through the ?re alarm system, nor were the valves secured by other means to pre- vent closure by unauthorized personnel. Investigation of the building?s water supply system determined that shutting off the domestic water supply to the building would effectively cut off water supply to the sprinkler system serving the trash chute. Investigation Number FY 1 3-07 16 NFPA 82, Standard on Waste and Incinerator and Linen Handling Systems and Equipment (2009), Chapter 5, requires protection of gravity waste chutes by sprinkler sys? tems, and references NFPA 13, Standard for the Installation of Sprinkler Systems. Chapter 8 and Annex 8.16 indicate that where electrical supervision is not provided, locks or seals should be provided on all valves and should be of a type acceptable to the authority having jurisdiction. The standard method of locking or sealing valves to prevent, so far as possible, their unnecessary closing is a satisfactory alternative to valve supervision. The au? thority having jurisdiction should be consulted regarding details for speci?c cases. Where water is shut off to the sprinkler systems, a guard or other quali?ed person should be placed on duty and required to continuously patrol the affected sections of the premises until such time as protection is restored. Dallas Fire?Rescue representatives provided the following information: The City of Dallas had adopted its own ?re code in 1976. The 1976 Fire Code did not require either a ?re alarm system or a ?re protection sprinkler system. The 1976 Building Code was a prescriptive code, which means that it would re- quire ?re protection features based on building type and occupancy. The 1976 Fire Code was a maintenance code, which means that if the building code required a ?re prevention feature, the ?re code regulated how to maintain the feature. The building department was responsible for performing the building inspections and approvals for new construction when the building was built. The trash chute installation methods and ?re protection features within the chute would have been in accordance with the building code in effect at the time of construction. The Dallas Building Department could have approved the trash chute as installed. According to the City of Dallas Fire Prevention Of?ce, a ?re alarm system was not required for these buildings; it is believed that the ?re alarm system was added as supplemental protection. The 1976 Dallas Fire Code did not require hardwired 110v standalone smoke alarms in the living units. The 1976 Dallas Fire Code required that the building owner provide standalone battery operated smoke alarms as part of a retroactivity clause. Investigation Number FY 1 3-07 17 0 Dallas inspectors informed us that because of an incident where the Dallas city records are archived, the previous records, including the original plans and ap? provals, were lost because of water damage. 0 With the loss of records, there is no information as to when the ?re alarm system was installed or about the design criteria used to plan the ?re alarm system. 0 The City of Dallas currently has its own ?re code, known as the ?Dallas Fire Code,? based on the 2006 edition of the International Fire Code (IFC) with adopted amendments. The investigation revealed that the fire alarm system was working at the time of the inci- dent and that it functioned as designed and installed. The information gathered by this investigation would indicate the installation of the sprin? klers in the trash chute was an approved installation in accordance with the Dallas Building Code that was in effect at the time of construction. This investigation also indicated that as of November 8, 2012, the sprinklers were in operating condition in Building 5, and it also indicated that the sprinklers in buildings were in operating condition. Because of the damage caused by the incident, the status of the trash chute sprinklers in Building 5 at the time of the incident could not be determined. It can be determined that if the water supply to the building was shut off, this would also shut off the water supply to the trash chute sprinklers. The DFRD did not require noti?cation of a trash chute fire sprinkler shut off at this facility. Investigation Number FY 1 3-07 1 3 Fire Investigation The ?re scene examination was conducted by the State Fire Marshal?s Of?ce, Dallas Fire? Rescue, and the National Response Team of the ATP. The conclusions are based upon wit? ness statements, photographs and Video taken during the ?re, and the ?re scene examina- tion. Following the scienti?c methodology of ?re investigation as prescribed by NFPA 921, the area of origin of the ?re at Building 5 is centered around the trash chute on the north? west corner of the structure. CAP. 29x26 3* 4: i, SPRINKLER HEAD I. \r Area of Origin ?and: ?our-Io ?oor atomic-n ii 1mm noon I I-nn. mm LEI. (3RD. inf-ii" Area ofoa'gin The ?re originated in the interior tube of the trash chute below the trash chute door to the second floor and abdve the spring?loaded trap door to the trash collection room. A speci?c ignition source could not be determined, because of the amount of ?re damage to the trash chute tube, the trash dumpster and the surrounding environment. Investigation Number FY 1 3-07 19 Area ofodgin 20 Investigation Number FY 1 3-07 Condition oftrasb chute spring-loaded door at ?rst ?oor in exemplar building Examination of the trash chute revealed that the entire interior of the tube was cleared of debris, which was the result of an intense ?re spreading upward and within the trash chute. Exemplar trash chutes within the complex were found to be heavily greased and coated with residual trash debris at all levels. At approximately 12:30 the maintenance man was noti?ed of a water leak in a resi? dence on the third floor of Building 5. The water leak was reported by a second??oor resi- dent as water leaked through from the residence above. The maintenance man attempted to contact the third??oor resident and there was no answer. After several attempts to contact the resident the maintenance man shut off the main water supply to the building. The ?re sprinkler system protecting the trash chute was connected to the building main water sup? ply- The ?re alarm system installed in Building 5 was monitored by an off?premise alarm moni- toring ?rm. The monitoring ?rm received an alarm and called 911 to report the alarm in Building 5. The ?re in the trash chute spread to the upper eight-inch ventilation tube and then into the attic space. The metal spring-loaded door at the bottom of the trash chute did not close as designed, as it may have been blocked by trash debris above. The open trash door served to ventilate the ?re, allowing it to grow in intensity. With the trash chute acting as a chimney, the ?re traveled into the attic space and ignited the wood roof structure in the attic space. Investigation Number FY 1 3-07 21 The ?re spread undetected in the attic space until enough smoke developed to initiate the smoke alarm systems in the hallways and various living units on the second and third ?oors. The 16 gauge aluminized steel tube of the trash chute became further heated from the bot- tom to top and acted like a conductive metal object. The thermal radiation from the metal tube heated the wooden support systems within the void spaces and advanced the ?re to multiple levels. The origin was determined to be in the trash chute, which was in the interstitial space (void space ?oor truss bay) between the ceiling of the trash collection room on the ground ?oor and the second ?oor. The trash debris lodged in the trash chute at the second ?oor level is believed to have caught ?re and spread vertically to the attic space and then spread laterally across the attic space and upper-level residences. A speci?c ignition source for what started the ?re could not be determined. Based on the ?re scene examination and the witness interviews to date, this ?re is ruled as UNDETERMINED pending development of further information or examinable evidence. Trash chute with ?rst ?oor at Id? and attic vent at tight Investigation Number FY 1 3-07 22 Fire Ground Operations and Tactics Timeline The following information inrom'ded the 517M 0 inoeitzgation team". The following Jeanenee of event; was developed from radio transmim'onr, photographs, video, ?re?ghter .rtatementr and witnen" iiy?ormation. Those events with known time: are identified. Events without known time: are approximated in the qnente of the event; hared on fire?ghter .rtatements regarding their aetiom and/ or ohieroationi. Weather at the time of the ?re was partly cloudy with winds from the east southeast at 5?10 mph. 2 On May 20, 2013, at 02:51, the Dallas Fire?Rescue Dispatch received a call from an alarm monitoring company reporting automated alarm activation at the Hearthwood Condomini? ums. The condominiums were located at 12363 Abrams Road in north Dallas, Texas. 02:52:40 Truck 57 and Engine 57 were dispatched to an AUTO Alarm at the Abrams Road address. Due to proximity, Engine 57 was replaced with Engine 29 on the incident. 02:58 Truck 57 arrived at the complex and upgraded the incident to a Box Alarm (structure ?re) because heavy ?re through the roof was visible from the road? way. i 02:58 Engine 57, Engine 28, Truck 37, Battalion 4, Battalion 2 and Rescue 57 were dispatched to the incident. 3 ww.wunderground.com Investigation Number FY 1 3-07 23 02:59:36 03:00:23 Truck 57 upgraded the incident to a second alarm because of the amount of ?re visible at the north end of Building 5 and multiple civilians requiring res- cue. Truck 57 began setting up for rescue operations. Engine 22, Engine 37, Engine 20, Truck 20, Truck 56, Rescue 19, Engine 19, Truck 19, USAR 19 (Urban Search and Rescue), Battalion 3, Battalion 7, Res? cue 29, Unit 806, Unit 829, Unit 896, Unit 685, Unit 684, Unit 782, and Unit 820 were dispatched to the incident. Truck 57 rescued a civilian from the third?floor balcony of condo 538, near the north end of Building 5 on the west side (Charlie side). A second civilian was seen on another balcony but evacuated the building through the stairwell. 03:05:06 Battalion 4 arrived on scene and assumed Command. Battalion 4 reported ?re coming through the roof. The Command Tech on Battalion 4 positioned the command post in the parking lot on the east side of Building 5. This was later established as the Alpha Division. Crews from Truck 57, Engine 57, Engine 29 and Engine 28 entered the structure with hoselines to complete a primary search and to check for ?re extension. Fire involved the north end of the second??oor and third-floor corridors. Photo of Truck 57 rescuing an occupant from the balcony 0111111? 534 on the Charlie side Investigation Number FY 13-07 24 03:09:14 03:10:36 03:12:41 03:13:44 03:14:10 03:20 - 03:35 Truck 37 arrived on the Alpha side (East side). Deputy Chief 806 arrived on scene to the west side of the structure and walked to the east side and assumed command as the Incident Commander. Battalion 2 arrived at entrance of the property, and walked to the Command Post. Approxi- mately 10 minutes later BC2 was assigned by Command as the ISO (Incident Safety Of?- cer) and to get a schematic of the building. The ISO entered the first ?oor and then the sec- ond floor and advised Com? mand of the building con?gura? tion. The then conducted a View of the operations at the north end trash chute dumpster access doors 360? exterior safety assessment. Truck 37 rescued one civilian from the balcony of condo 533. Battalion 3 arrived and provided an on scene size?up to dispatch. BC3 as- sumed a ?re attack position on the third ?oor. Battalion 3 ultimately assumed Bravo Division Supervisor on the second and third ?oors with the mission to prevent ?re spread to buildings 4 and 6. Battalion 3 later reports the third floor is untenable. Battalion 7 arrived on scene and set the Command Post and staging locations. BC 2 amgned Engine 20 2?0 yearn/9 the 1I??00r and BC 4 amgned Engine 3 7 to complete aprnnar} senrcb (yr the 2?14?00r5 in Building 5. Investigation Number FY 1 3-07 25 03:21 03:28:02 03:33:09 03:33 03:38 Truck 19, Engine 19, and Rescue USAR 19 established the Rapid Intervention Team on the Alpha/ Delta section of Building 5. RIT was later relocated to the Bravo division. Truck 19 was assigned to set up ladder pipe operations on Delta side (north end). Command assigned Battalion 7 as the Bravo Division Supervisor on the ground floor. Command requested a third alarm. Engine 39, Engine 55, Engine 56, Truck 39, Unit 825, Unit 784, and Unit 881 were dispatched to the incident. During interviews, Truck 39 personnel stated they heard radio traf?c calling for everyone to evacuate the building in order to transition to a defensive mode. Engine 39 arrived at staging and reported to Battalion 7. Engine 39 was assigned to check for ?re extension in the third-?oor breezeway ceiling. They raised a ground ladder to the third??oor breezeway at the south end of Building 5 and began pulling ceiling to check for ?re extension. 03:38-03:45 Tramz'z?z'an?om offensive to dg?emz've tactics began. Battalion 3 failed to answer radio calls and was unaccounted for. Command (Unit 806) as? signed the ISO, (Battalion 2), and USAR 19 to locate Battalion 3. The 180 located Battalion Chief 3 (BC3) on the second ?oor and advised him to evacuate the building for defensive operations. 03:45 Transition to defensive operations were completed. 180 (BCZ) was reassigned by Command (806) to establish cutoff at the breezeway at the south end of Building 5 between Buildings 4 and 6 (Bravo side). No other ISO was assigned immediately. Investigation Number FY 3-07 26 03:49 of 03:50 03:51 03:56 04:00 Truck 20, Truck 56, Engine 20 and Engine 55 pulled ceiling on the second and third ?oors, placed lines, set ground ladders and directed hoseline streams on the Alpha/ Bravo (southeast) corner of Building Five. Dispatch received calls regarding embers falling in the residential area north the ?re. Truck 57 began ?owing water onto the ?re with the ladder nozzle on the Charlie side (west side). Dispatch advised Command of embers falling into the residential area north of the ?re. Engine 55 was assigned by the Bravo Division supervisor to occupy the corri- dor and breezeway between buildings 4 and 5 (southeast corner of building). E55 crew members pulled ceiling to check for ?re extension in the breezeway. Heavy smoke was observed but no ?re, and a hoseline from Engine 28 was used to spray water into a third-?oor window on the Alpha side of Building 5. Truck 37 began ?owing water onto the ?re with ladder nozzle from the Alpha side. BC 3 assigned Engine 56 to pull ceiling and check for ?re extension on the second-?oor breezeway between buildings 4 and 5. A hoseline was also used to spray water onto Building 5 on the Charlie side. BC 3 assigned Truck 39 to set ground ladders to the second-?oor breezeway at the south end of Building 5 to check for ?re extension between buildings 4, 5, and 6. BC 7 assigned Truck 39 to evacuate Building 6. Several occupants were found and escorted out of the building. 04:03:02 Dispatch assigned Engine 41 to respond to the residential area north of the ?re. Investigation Number FY 1 3-07 27 04:03:50 04:04:07 04:05 04:07:30 04:09 Photo oftbe north end of Charlie dl'w'sions at 04:06 Command requested a fourth alarm. Engine 48, Engine 31, Engine 2, Truck 53, and Unit 802 were dispatched to the incident. A portable monitor was set near the Charlie/ Delta corner (northwest corner) and began ?owing water. The Incident Commander (1C) began walking the perimeter of the ?re build? ing and did not remain at the Command Post. Truck 41 was dispatched to the ?re. The apartment units of Building 5 on the second and third ?oors were in? volved in ?re and the north end, first-?oor units were burning. Investigation Number FY 1 3-07 28 04:10 04:10 04:11:31 04:12 04:17 04:20 04:20:35 04:22 04:23 04:31 The apartment units at the north end of Building 5 collapsed. A portable monitor nozzle was set on the Charlie side near the Bravo Charlie (southwest) corner and began ?owing water. Truck 53 arrived to staging, disembarked the unit, and walked to the com? mand post. Engine 48 arrived and began laying a ?ve?inch supply line toward the ?re but the line did not get connected. The IC returned to the Command Post. Engine 31 arrived and was assigned to assist with extinguishment on the third ?oor of Bravo Division between buildings 5 and 6. (E31 later assisted with debris removal during the search and rescue of missing ?re?ghters). Truck 19 began ?owing water onto the ?re at the Alpha/ Delta corner (northeast corner). non?ed Dz'Jpaten that the incident load #anrz'tioned to a De?enn'ne tnode. Three ladder nozzles and two portable monitor nozzles were operating on Building 5. Huck 53 arrived at t/Je and was arr?gned to ream/7 and eoaenate Building 4. The door was looked to bat/ding but was opened by a tenant. T53 ordered t/oe?enz re? maining tenant: to evacuate. Truck 41 arrived at the staging area and walked to the Command Post. Battalion Chief 701, an EMS Division Chief, arrived on scene and walked to the command post. Command ordered BC 701 to get geared up (put on PPE). BC 701 returned to his unit, put on PPE and returned to the command post. Investigation Number FY 1 3-07 29 04:37 04:40 04:40 T41 Captain arrived at the Command Post and was assigned as the ISO (Incident Safety Of?cer). T41 Captain did not know who he was relieving and a face?to-face transition was not conducted. (As noted at 03:45, the ISO was reassigned by Command to supervise efforts to prevent ?re extension to buildings 4 and 6 at the Bravo side). Based on this information there was no Safety Of?cer assigned on this incident for nearly 60 minutes. Command assigned the USAR 19 Captain to evaluate the structural sta? bility of Building 5 in preparation for conducting a primary search of the ?rst ?oor T53 completed the search of Building 4 andpon?ed a Dallas PD O?ieer at the emf end door of Building 4 to prevent T53 returned to the eommaodposz? to au?gmrzentr. This photo at 04:44 shows Truck 37 master stream ?omng water While Truck 53 ?re?ghters Espree and Wilson walk toward the Bravo end ofBuilding 701 BC Tomasaw'c is talla'ng with tuck 3 7 Captain Watson to cease water flow from T3 7 Investigation Number FY 1 3-07 . 3O 04:43 04:45 04:46 04:46 04:48 04:49 Command amgned BC 7 01 and Truck 53 to seem/o of Building 5. (Interm?em and statement; of personnel provide con?icting information regarding the extent of the Jeane/9 ordered by Command) USAR 19 Captain walked to the Charlie side and met with the Charlie Divi? sion Supervisor (Battalion 4). BC 4 informed the USAR 19 Captain that a pri- mary search was completed earlier. After meeting with Charlie Division Com- mand, the USAR 19 Captain transmitted to Command that a primary search of the ?rst floor was complete. The USAR 19 (RIT) Captain walked to the Alpha side and met with Com- mand and advised Command that a primary search of Building 5 had been completed on floors 1 and 3 and approximately two?thirds of floor 2. BC 701 spoke with BC 7 about areas that had already been searched and how long ladder pipes had been ?owing. The USAR 19 Captain walked to the Bravo Division and spoke to BC7 and BC 701 to advise that a primary search was completed earlier. BC 701 and Truck 53 crew entered the ?re building through the Bravo Divi? sion ?rst floor, and the team was broken into two teams. BC 701, Truck 53 Captain (T53A) and one ?re?ghter (T53B) comprised one team and ?re?ghter (T 53C) and ?re?ghter (T5313) comprised the other team. The balcony of condo 534 collapsed onto the balcony of condo 524. Approximate time of collapse of the corridor trapping the ?re?ghters. At the time of the collapse BC 701 stepped out of condo 512 and was struck by fal? ling debris, forcing him back into the doorway of condo 512. Debris fell onto his legs and trapped him at the doorway. Investigation Number FY 1 3-07 31 04:50 04:51 04:55 05:04 05:12:10 05:20 05:22 05:22:45 05:37:44 Truck 53 Captain transmitted a Mayday call by portable radio. In the transmis? sion, the Captain noti?ed Command that he had lost contact with two of his personnel because of a building collapse. An RIT response through the Bravo side and then the Charlie side was blocked by debris and ?re. RIT entered through the Alpha side and began searching for the missing Truck 53 personnel. Command requested a ?fth alarm to address the reported Mayday situation. Engine 41, Engine 3, Engine 11 and Unit 800 were dispatched to the incident. A missing Truck 53 ?re?ghter (T53D) transmitted to Command by portable radio and informed Command that he was trapped in a void space at condo door 516, but was unharmed. Truck 53 Captain and Fire?ghter (T 53B) pulled BC 701 from the debris, leav? ing his boots buried under debris Truck 57 ladder pipe and portable monitor shut down. Truck 53 Fire?ghter (T53D) was pulled from the entry area of condo 516 by RIT members. Truck 33, Engine 33 and Rescue 33 were dispatched to the incident to estab- lish a replacement RIT. Truck 37, Truck 19 ladder pipes and the portable monitor were shut down. Command requested a sixth alarm. Engine 7, Engine 8, Engine 15, Unit 803 and Unit 848 were dispatched. Truck 33, Engine 33, and Rescue 33 arrived on scene. Investigation Number FY 1 3-07 32 06:16:00 The Plano Fire Department USAR Team was dispatched to the scene. 06:29:55 Command reported that the ?re was contained to the building of origin and that search and rescue was in progress. 08:15 Truck 53C Fire?ghter Stanley Wilson was found under collapse debris in the" ?rst floor hallway of Building 5 near the door to condo 513. Dallas Fire-Rescue Fire?ghter Stanley Wilson was transported to Parkland Memorial Hospi? tal. An autopsy examination conducted by the Dallas County Medical Examiner?s Of?ce concluded that Fire?ghter Wilson died as the result of mechanical compression. Investigation Number FY 1 3-07 33 a f??i??j?'ig'iiu??l 'N'i??i'tEiF A.- - Fri-113': Location of FF Wilson Building Building 4 Emilia?; Iq? Iii?? Apparatus locations and approximate base lines Investigation Number FY 13-07 34 Equipment Evaluation: Personal Protective Eq i pment . . The Texas Commiesion on Fire Protection conducted an eoalnation of tloe?rqigloterirpereonal protective equipment for performance of and compliance wit/9 TCFP ruler. Examination and evaluation of tbe PPE neayprooide important z'n?trrnation related to ?ee incident Tlae?ollowing are excerpt; of t/oe TCFP era/nation report. TCFP compliance of?cers evaluated the protective equipment for compliance with Texas . Administrative Code Title 37, Part 13, Chapter 435.1, Protective Clothing, Chapter 435.3, Segr- Containea? Breathing Apparatus; and associated NFPA standards adopted by TCFP for ?re? ?ghter safety. Photographs taken during the examination and supporting documentation are on ?le at the Texas Commission on Fire Protection. On Wednesday May 22, 2013, TCFP compliance of?cers Robert Manley and Lamar Ford arrived at the Dallas Fire?Rescue Department Training and Support Services Bureau, 5000 Dolphin Road, Dallas, Texas. The compliance of?cers met with the Texas State Fire Mar? shal?s Of?ce investigation team, and the ?re department of?cer assigned to manage the de- partment?s LODD investigation process. Compliance of?cers Manley and Ford collected TCFP compliance documentation from the ?re department. Fire?ghter Wilson?s personal protective equipment (PPE) and self? contained breathing apparatus (SCBA) were examined for obvious damage and TCFP com? pliance. All TCFP-regulated PPE components assigned to Fire?ghter Wilson were examined by TCFP compliance of?cers assigned to the investigation. Investigation Number FY 1 3-07 35 Each TCFP?regulated PPE component examined by TCFP compliance of?cers was veri?ed as being issued to Fire?ghter Wilson, by cross referencing serial numbers with inventory records, annual advance cleaning records, and annual advanced inspection records. Fire?ghter Wilson?s personal protective equipment, based on the examination and provided documentation, was NFPA 1971, NFPA 1851, and TCFP compliant at the time of the inci- dent. Fire?ghter Wilson?s self?contained breathing apparatus, based on the examination and pro? vided documentation, was NFPA 1852, NFPA 1981, NFPA 1982, NFPA 1989 and TCFP compliant at the time of the incident. Protective Clothing and SCBA According to Dallas Fire?Rescue, Fire?ghter Wilson was wearing all TCFP required protec? tive clothing: helmet, hood, coat, pants, gloves, boots, and SCBA. Pictures were taken of all items and found to be dirty, but with no apparent thermal or physical damage. Serial num- bers were recorded to be cross referenced with protective clothing and SCBA records pro- vided by DFRD. The protective clothing had passed an advanced inspection in March 2012 and a routine inspection conducted by TCFP personnel in April 2013. The SCBA was found in the ?on? position and the cylinder gauge showed it to be empty. The SCBA had passed a flow test in March 2012 and minor maintenance had been per? formed in February 2013. The SCBA cylinder was hydro tested in 2011. An inspection of the SCBA had been conducted by Fire?ghter Wilson at the beginning of the duty shift and the inspection report showed that all benchmarks had passed. Additional TCFP Safety Requirements A compliance inspection was conducted at DFRD in April 2013 where all required SOPs were found to be complete and in effect, and air quality tests for SCBA air compressors were up to date, having been tested quarterly, Additionally, Fire?ghter Wilson had met con- tinuing education hours for the period of 2011 through 2013. The personal protec?vc equipment worn by Fire?ghter Wilson was not a contributing fac- tor in the fatality. Investigation Number FY 1 3-07 36 Findings and Recommendations Recommendations are based upon nationalfy recognized consensus standards and sa??ty practices for t/oe?re service. All ?re department personnel should know and understand national?/ recognized consensus stan- dards, and al/?re departments s/oould create, update and follow SOGs and SOPs to ensure gj?ectine, cz'ent and sage ?re?ghting operations. Several decisions and actions taken at this incident had a positive impact and limited the loss of life and property. (1) First?arriving companies faced rapidly escalating ?re conditions with multiple vic? tims in need of rescue on the upper ?oors. Simultaneous rescues, coupled with aggressive ?re suppression, saved lives. (2) Exposure concerns were also effectively mitigated. Tactics deployed in two adja- cent and connected buildings protected both life and property. (3) Fire brand control in the complex and neighborhood, complicated by signi?cant wind conditions, also kept the incident contained to the building of origin. (4) Following the major collapse, excellent radio discipline was exercised following the Mayday initiated by Truck 53. All companies maintained radio silence allowing Command and the Rapid Intervention Team to communicate with Truck 53 personnel. There were Other decisions and actions that had a negative impact on the incident and ei? ther directly or indirectly contributed to the Line of Duty Death. Investigation Number FY 13-07 37 (1) Fire crews had been battling this structure ?re for two hours when the collapse and fatality occurred. At least sixty minutes of the incident included the deploy- ment of several master stream devices during defensive operations. The master streams added a large amount of water and weight to the structure. A risk assess? ment to consider the destructive impact of the ?re, coupled with the additional water weight in the structure, should have taken place prior to the decision to conduct the interior search of the ?re building: (2) Several communications issues were observed at the scene. Some of these were attributed to the radio system in use by Dallas Fire. Other communications prob? lems were caused by individual failures to properly communicate orders or con? cerns. At or about 0430 hours, the Incident Commander was informed that civil- ians were on the ?re ground. There was confusion as to which buildng these ci- vilians were actually located in. The Incident Commander ordered a search of the ?re building. A search operation requires communication of the operation to all supervisors to help insure safety through awareness and accountability. Search op? erations carried out by Unit 701 and Truck 53 were not adequately communicated to the Team Leaders, the Division Supervisors or, the Incident Safety Of?cer. (3) Unit 701 and Truck 53 were tasked with completing a ?quick? search of the first floor of the ?re building. While each of these of?cers had only been on the ?re ground for a short period of time, they both were aware that this was a major in- cident that included the deployment of multiple master streams. The of?cers did not con?rm the intentions of the Incident Commander or participate in a risk analysis of the operation. It is incumbent upon company of?cers and Team Lead? ers to acknowledge and verbally repeat orders to ensure a clear understanding. (4) Although the Dallas Fire Rescue manual of procedures allows for a combination offensive/ defensive strategy, the deployment of a team to perform this type of search after a prolonged defensive operation in the same building was inherently dangerous. The Search plan should have included a deliberate use of a risk/ bene?t analysis, with input from the Incident Safety Of?cer and Division Super? visors. Investigation Number FY 13-07 38 Finding 1 Continuous risk assessments were not completed. A thorough risk analysis was not completed prior to the interior search of the ?rst floor of the ?re building. The Abrams Road fire was a dynamic, complicated incident that required constant re -evaluation of objectives and strategies. A consistent use of risk analysis during all phases of the incident must be considered. Although the Incident Commander has ultimate responsibility for risk analysis, supervisory personnel at all levels including Team Leaders are also responsible to perform risk management analysis to define unacceptable risk. Recommendation Continuous review of objectives and strategies, including an evaluation of the associ? ated risks, should take place throughout a complex emergency incident. The need for a focused risk assessment is highlighted whenever personnel are placed inside an IDLH atmosphere, especially while defensive operations are taking place. The search operation for potential victims required a deliberate evaluation of the risks involved utilizing Command resources, including the Incident Safety Of?cer. The responsibil- ity for risk analysis is shared by the Company Of?cers and Team Leaders. These leaders should evaluate the instructions they are given and determine whether the current conditions allow for safe completion of the assignment. References NFPA 1500, Standard on Fire Department Occupational Health and Safety Program, Chapter 8, 8.1.8 -At an emerging; incident, the Incident Commander shall have the responsibility for the following: (3) Perform situation evaluation that includes risk assessment. NFPA 1500, A8. 1.8 (4) Emergency Operations (Annex A - Explanatory Mate- rial) ?S?trategic decisions estah/ish the hasic positioning of resources and the type of functions they will he assigned to perform at the scene of a ?re or emergency incident. ?Risk identification, evaluation, and management concepts should he incorporated into each stage of the command process. Investigation Number FY 13-07 39 NFPA 1500, A.8.3.2 Emergency Operations (AnneXA - Explanatory Material) The risk to ?re department memhers is the most important factor considered h} the Incident Com- mander in determining the strategy that will he employed in each situation. The management of risk levels involves all of the following: (1) Routine evaluation of risk in all situations (2 Standard operating procedures NFPA 1561, Standard on Emergency Services Incident Management System and Command Safet}; Chapter 5, 5.3.17 - The incident commander shall evaluate the risk to responders with respect to the purpose and potential results of their actions in each situation. NFPA 1561, 5.3.18 - In situations where the risk to emergency service reronder is excessive, activi- ties shall he limited to defensive operations. Dallas Fire Rescue Manual of Procedure 600. 00 Emergency Response Proce- dures - Effective 10-15-12 - 601. 04 - Risk Management will he integrated into the I nci- dent Command System. Each congoonent of the ystem will maintain personnel safegr as the highest priorigl. IFSTA (2004) Chief Of?cer (2nd Edition), Ch. 72 pg. 401 Continuous monitoring of risk and gain is the essence of a chief of?cers responsihiliij/ in evaluating the strategy, IAP, and risk. The chief ty?icer then anahrszes that evaluation and translates it into scy?e and gj?ective operations. NFPA 1561, 5.8.2 - Supervisory personnel shall assume responsihiligr for activities within their span of control, including responsihility for the softy and health of responders and authorized persons within their designated areas. Investigation Number FY 1 3-07 40 Finding 2 Fire ground communications were not clear nor understood. There were a variety of communications issues at the Abrams Road incident. There were several instances of information not being communicated or properly under? stood. An attempt was made to separate the ?re ground into Divisions early in the incident. Later-arriving Incident Commanders modi?ed the location of the Divi? sions, but this change was not adequately communicated to on scene personnel. When questioned, several members, including company of?cers, admitted a lack of information regarding the divisions on the ?re ground and whether offensive or de- fensive operations were in place. The plan to search the ?rst floor was not adequately communiCated with the search team, the Division Supervisors, or the Incident Safety Of?cer prior to the operation taking place. Recommendation Ensuring effective communication on the incident scene is vital to effective mitiga- tion of an emergency incident while maintaining responder safety. Orders that are issued or received must be clari?ed if there is any confusion or doubt regarding the order. The Incident Commander must ensure that all personnel operating on the ?re ground are aware of the operational strategy in place, including the division of the ?re ground and mode of Operation (Offensive versus Defensive). The Incident Commander must ensure that the Division Supervisors understand the incident ob? jectives and strategy, including any changes. Inherently dangerous operations, such as the interior search of a ?re building while defensive operations are taking place, should only be attempted after discussing the operation with the appropriate Divi- sion Supervisors and the Incident Safety Of?cer. References NFPA 1021, Standard for Fire Of?cer Qualifica tions Chapter 6, Requi? site Skills - The abi/igj/ to use eoalnaiine met/Jody, to delegate ant/aerial, to communicate oraiiy and in writing, and to organize plant. NFPA 1561, 5.3.16 - Incident Commander Jbai/ keep i/ae fajita; O?icer informed of Jiraie- gic and iacz?icaip/am and an)! changing conditions. investigation Number FY 13-07 41 . IAFC, Fire Of?cer?s Desk Reference, (2006), Ch. 1 6 pg. 322 Confusion over what strategy is being used can he disastrous to the IC and can result in ?re extending hoth within a building and to adjacent exposed huiidings, along with loss of the ?re huilding, victims, and eoen ?re?ghters? lines. Finding 3 Adequate supervision of personnel did not take place. The Command structure employed at the Abrams Road ?re only partially provided a framework that was appropriate for mitigation of the emergency while ensuring re- sponder safety. Initially, supervisors were in place at the Bravo, Charlie divisions and there was a designated Incident Safety Of?cer. The Incident Safety Of?cer was reassigned and the incident was without a Safety Of- ?cer for more than an hour. The newly assigned Incident Safety Of?cer was unaware that a search into the ?re building was taking place. The IC was supervising the incident, the Alpha Division, and the Delta Division. Di- vision Supervisors were not noti?ed of a change in tactics to an offensive interior search and did not allow them to communicate the potential dangers or concerns during the search assignment. These dangers included the continued flow of master streams onto the structure to be searched as well as insuf?cient drain time for the large amount of water weight placed on the weakened structure. Recommendation Use of NIMS provides communication to the Incident Commander (and the Division Supervisors) allowing for effective coordination of resources and situational awareness. References NIMS The Incident Command System (ICS) is a standardized, on-scene, ail- hazards incident management approach that: Allows for the integration of facilities, equipment, personnel, procedures and commu- nications operating within a common organizational structure. Investiqotlon Number FY 13-07 42 Enahles a coordinated response among various jurisdictions and functional agencies, hothpuhlic and private. - Estahlishes common processes ?ir planning and managing resources. All levels of sigbervision, from the Compaiyl O?icer to the Incident Commander, should he aware of their responsihiligi to supervise assigned personnel. This responsibility includes ensuring that or- ders are properhl understood and that Command is aware (yr extreme conditions that endanger safe completion of an order. Division Supervisors should he noti?ed that personnel are heing sent to operate in their Division. Incident Scy?ety O?icers should he noti?ed argztime a transition from defensive to offensive operations is considered. The Incident Scy?ety Of?cer can then perform a risk anah/sis of the operation and make recommendations to the Incident Commander and/ or the search team. NFPA 1500, 8.1.5 -At an emergency incident, the Incident Commander shall he responsihle for the overall management of the incident and the sa??g) of all memhers involved at the scene. NFPA 1561, 5.3.16 - The Incident Commander shall keep the Seyfeij/ Of?cer informed of strate- gic and tactical plans and my changing conditions. Dallas Fire Rescue Manual of Procedure 600.00 Emergency Response Proce- dures - Effective 10-15-12, 601.18 Teams - The Team Leader will notz?/ the next higher level in? supervision of imminent hazards encountered. 602. 00 Personnel Accountability Procedures Awareness - Each level of super- vision must maintain an awareness (yr the location and function of the Commanders, companies, teams, and individual steyjl and svpport memhers in their command throughout the emergency dent. 602.00 6- c) Rapid confirmation of Fire?ghter Safety - Once divisions or groups have heen estahlished, Division/ Grotto Sipervisors will serve as Accountahility O?icers hy providing direct supervision of companies. They must maintain an awareness cy? where their companies are and what they are doing. Investigation Number FY 1 3-07 43 NFPA 1561, 5. 8.1 - Risk management principles sball be employed routinely by supervisorjper- sonnel at all levels of tbe incident management system to define tbe limits of acceptable and anac- ceptable positions and functions for all responders at tbe incident scene. NFPA 1561, 5.8.5 - Supervisory personnel sball be alert to recognize conditions and actions tbat create a bazard witb tbeir spans of control NFPA 1561, 5.8.6 -All siperoisory personnel sball bane tbe aatboriij/ and responsibiligi to take immediate action to correct imminent bazards and to adoise tbeir supervisory personnel regarding action. Finding 4 There were simultaneous offensive and defensive operations. Master stream devices continued to flow while Unit 701 and the Truck 53 crew en? tered the building. Although the Dallas Fire Rescue Manual identi?es this is an op? tional procedure, Unit 701 and Truck 53 were tasked to complete a search of the ?rst floor of the ?re building which was in the same geographical area as the defen? sive operations. There was no coordination by Command with the Division Supervi? sors and the Incident Safety Of?cer was unaware of the search operation in the ?re building. Recommendation Simultaneous offensive and defensive operations in the same geographic area of a ?re structure are extremely dangerous. If considered, these simultaneous operations must only be conducted after a thorough review of the risk analysis and discussion with the Division Supervisors and Incident Safety Officer. Investigation Number FY 13-07 44 Reference Dallas Fire Rescue Manual of Procedure 600.00 Emergency Response Proce- dures - Effective 10-15-12 - 601.0 #3 Incident Strategy - Combination strategies are activities involving simultaneous cyfensive and defensive strategies occurring in dzj?ferentgeograpliical areas. Simultaneous of?insive and defensive operations must be coordinated by the incident com? mander and/ or Division Seabervisors. Finding 5 ?The IC was directly supervising up to 18 personnel. Information from interviews indicates that the IC was actively supervising four divi? sion chiefs, the USAR, Truck 19, Truck 37, the ISO, BC701, Truck 53, Engine 48 and four command technicians. Recommendation Incident Commanders should maintain an appropriate span of control and assign additional personnel to the command structure as needed. Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision. In ICS, the span of control of any individual with incident management supervisory responsibility should range from three to seven subordinates, with five being optimal. The type of incident, nature of the tasks, hazards and safety factors, and distances between personnel and resources all in?uence span?of?control considerations. References NFPA 1561, Chapter 8, 8.2, Span of Control Tloe command structure for eacli incident shall maintain an effective supervisory span of control at each level of tlse organization. US. Department of Homeland Securig/ - Federal Emergency Management/lgency Incident Com- mand Systems http:[ emergency nims ICSpopup.htm#item5 NFPA l500'5tandard on Fire Department Occupational Safegl and Healtn Program, Clyapter 8, 2007 ed. Investigation Number FY 13-07 45 Finding 6 The plan and command to conduct a primary was not altered although a search was completed earlier. The IC, Division Supervisors and Team Leaders did not alter the Action Plan to con? duct a primary search nor did the Supervisors or Team Leaders advise the 1C to alter the Action Plan to conduct a search of the ?rst floor even though a search had been accomplished earlier. During interviews ?re?ghters stated that they queStioned the value and safety of conducting a search of the ?rst floor after defensive operations had commenced and master streams were operating. Ultimately the Incident Command has responsibility for the operation and safety at the incident scene. NFPA 1500, 8.1.5 - At an emergency incident, the Incident Commander shall be re? sponsible for the overall management of the incident and the safety of all members involved at the scene. Recommendation All ?re?ghters and personnel operating on the ?re ground should be empowered to prevent unsafe actions. Four of the 16 Life Safety Initiatives state: (1) De?ne and advocate the need for a cultural change the ?re service relating to safety; incorporating leadership, management, supervision, ac- countability and personal responsibility. (2) Enhance the personal and organizational accountability for health and safety throughout the ?re service. (3) Focus greater attention on the integration of risk management with incident management at all levels, including strategic, tactical, and planning responsi? bilities. (4) All ?re?ghters must be empowered to stop unsafe practices. The full 16 Life Safety Initiatives can be found at http:[ Investigation Number FY 1 3-07 46 Participating in the ?Courage to be Safe? (CTBS) program that emphasizes the mes- sage ?Everyone Goes Home?.? Information on the CTBS program is available online at http:/ Additional Recommendation The following recommendation may have no direct relations/n}; to the factors contributing to tire deat/a of PF Wilson, however they should be considered to ensure the safey of all personnel on t/ie?re ground. Communication issues Fire personnel at this incident reported dif?culty hearing or understanding radio traf? ?c during the incident. The simplex radio channel that Dallas FR utilizes for incident scene communications appears to have been negatively impacted by the physiCal structure of the ?re building. Additionally, use of the simplex radio channel prevents the Dispatch Center from monitoring or recording ?re ground transmissions. Recommendation Consideration should be given to monitoring and recording ?re ground activity. Monitored ?re ground channels can offer a greater degree of safety. A third party can effectively monitor/ clarify sometimes hectic incident scene communications. The use of recorded tactical channels allows for improved post?incident analysis and facilitates better reconstruction of potentially critical events. Reference NFPA 1221-16, 7.6.1? Communications centers shall have a logging ooice recorder wit/9 one c/Janne/jor each of t/oefol/owing: (1) Each transmitted or received radio channel or talkgroup. Investigation Number FY 1 3-07 47 Appendix 1: Timeline . 1 May 20, 2013 02:51:22 911 call received from the ?re alarm monitoring ?rm. 02:52:40 Dispatch of T57 and E57 to Alarm Activation at 12363 Abrams Road. 02:54:54 E57 replaced with E29 due to proximity to incident. Unknown T57 arrived at complex and upgraded to a BOX Alarm due to ?re visible from roadway. 02:58:42 Box alarm was dispatched: E57, E28, T37, BC4, BC2 and R57. 02:59 T57 observed ?re at north end of building at the roof level and requested a second alarm because of signi?cant amount of ?re and the requirement for rescuing civilians. Advanced to third floor (by stairs at southern end of ?re building and by elevated aerial ladder) to rescue civilians on balconies. De- ployed stinger line to assist with defensive operations. 03:00:11 Engine 29 arrived on scene. 03:00:23 Second alarm was dispatched: E22, E37, E20, T20, T56, R19, E19, T19, BC7, BC3, R29, 806, 829, 896, 685, 684, 782 and 820. 03:01:37 Engine 57 arrived on scene. 03:02:19 R57 arrived on scene. 03:03:51 E28 arrived on scene. 03:05:06 BC4 (?rst Chief Of?cer) arrived on scene, assumed Command and positioned himself on the west?side of the ?re building. Command Tech positioned Command Post on the east?side of the ?re building. 03:07:08 R29 arrived on scene. I 03:08:28 T37 arrived on scene. Rescued female from balcony of living unit 533. Investigation Number FY 1 3-07 48 03:09:14 03:10:36 03:10:45 03:11:06 03:12:41 03:12:47 03:13:23 03:13:44 03:15:16 03:20 03:21:37 03:21:39 03:27 03:27:57 03:28:02 03:30 03:31:17 03:33 03:33:57 03:36:48 03:38 03:38:11 E22 arrived on scene. 806 arrived on scene. Chief assumed Command. Command Tech assisted with organizaiion of Command Post. Command Post and Staging locations an? nounced. Fire ground divisions established (Command Post on east side was Alpha Division). E37 arrived on scene. Deployed stinger line at Bravo/ Charlie corner once de? fensive operations were ordered. E20 arrived on scene. Assisted with evacuation of civilians from living unit 514. Went to second ?oor, but thermal imaging camera revealed signi?cant amount of ?re in walls and overhead. BC2 arrived on scene. Assigned as initial Incident Safety Of?cer. R19 arrived on scene. T56 arrived on scene. BC3 arrived on scene. BC assigned to floors 2 and 3 at Bravo end of ?re building. Command Tech assisted at the Command Post with organization of Command Board. Monitored Dispatch Channel (Channel 1). T20 arrived on scene. Assisted with efforts to cut off ?re from exposure buildings. BC2 reassigned to supervise efforts to cut off ?re from the exposure build? ings (buildings 4 and 6). E19 arrived on scene. T19 arrived on scene. Crews of T19, E19 and R19 assembled to form Rapid Intervention Team Engine 20 and Engine 37 completed primary search of ?rst and second floors. USAR19 arrived on scene. BC7 arrived on scene. Chief assigned to Bravo division. Civilian rescue from third-floor balcony on Alpha side by Truck 37. R28 added to the incident. Third alarm requested. Third alarm was dispatched: E39, E55, E56, T39, 825, 784 and 881. R28 arrived on scene. Transition to defensive began. E39 arrived on scene. Investigation Number FY 1 3-07 49 03:40:40 T39 arrived on scene. 03:41:46 E55 arrived on scene. Assisted with efforts to cut off ?re from exposure buildings. 03:43:00 Dispatch noti?ed the IC that they were receiving calls from citizens concerned about embers being generated by the ?re. 03:45 BC2 reassigned to supervise efforts to cut off ?re from the exposure build? ings (buildings 4 and 6). 03:48:35 E56 arrived on scene. 04:03:50 Fourth alarm was dispatched: E48, E31, E2, T53 and 802. 04:07:30 T41 added to the incident. 04:11:31 T53 arrived on scene. 04:13:24 E48 arrived on scene. 04:17:36 E31 arrived on scene. 04:20:35 IC noti?ed Dispatch that the incident had transitioned to defensive opera? tions. Three ladder nozzles, a ground monitor and a stinger line were in opera? tion on the ?re building. 04:21 :46 E2 arrived on scene. 04:22 T53 assigned to search building adjacent to ?re building (Building 4). 04:23:53 T41 arrived on scene. T41 Captain was assigned to relieve BC2 as Incident Safety Of?cer. 04:31:36 701 arrived on scene; instructed to put on structural gear. Unknown 1C requested RIT (T17) Captain to evaluate the stability of the ?re structure to determine the viability of conducting a primary search. Unknown IC ordered 701 to have a company search the ground floor of ?re building. Unknown Based on information from BC4, RIT Captain advised IC that primary search had been completed on floors 1 and 3 and approximately 2/3 of floor 2. Unknown 701 and T53 crew entered ?re building at south (Bravo) end. 04:48 Balcony of living unit 534 collapsed onto balcony of unit 524. 04:50 Mayday transmitted by T53 Captain. 04:51:10 Fifth alarm was dispatched: E41, E3, E11 and 800. Unknown All master streams were shut down. 04:56:58 E41 arrived on scene. 04:58:53 E3 arrived on scene. 04:59:58 E11 arrived on scene. Investigation Number FY 1 3-07 50 05:09:08 R22 added to the incident. 05:12:10 R33, T33 and E33 added to the incident to establish replacement Rapid Inter? vention Team. 05:16:00 Trapped T53 FF rescued by USAR19. 05:18:30 R22 arrived on scene. 05:22:45 Sixth alarm was dispatched: E7, E8, E15, 803 and 848. 05:28:03 E8 arrived on scene. 05:30:48 R33 arrived on scene. 05:33:05 E15 arrived on scene. 05:33:55 T33 arrived on scene. 05:36:15 E33 arrived on scene. 05:37:44 USAR33 arrived on scene. 05:50:11 E7 arrived on scene. Investigation Number FY 13-07 5] Appendix 2: Dallas Fire-Rescue Department Statistics The Dallas Fire?Rescue Department consists of 1750 members at 57 ?re stations serving a population of more than 1.2 million people in an area of approximately 370 square miles. Four ?re?ghters respond on each ?re engine and aerial ladder truck company. The 57 ?re stations house 56 ?re engines, 22 aerial ladder trucks, 5 aircraft rescue ?re?ghting appara? tus, 9 booster pumpers, 1 haz?mat unit, 40 front line rescue trucks and 3 peak demand res? CUCS. Dallas Fire-Rescue is an ISO Class 2 department. Investigation Number FY 3-07 52 Appendix 3: National Response Framework, Second Edition Executive Summary The National Response Framework is a guide to how the Nation responds to all types of disasters and emergencies. It is built on scalable, ?exible, and adaptable concepts identi?ed in the National Incident Management System to align key roles and responsibilities across the Nation. This Framework describes speci?c authorities and best practices for managing incidents that range from the serious but purely local to large?scale terrorist attacks or catas? trophic natural disasters. The National Response Framework describes the principles, roles and responsibilities, and coordinating structures for delivering the core capabilities required to respond to an incident and further describes how response efforts integrate with those of the other mission areas. This Framework is always in effect, and elements can be implemented at any time . . . Relationship to NIMS (Page 3) The response protocols and structures described in the NRF align with NIMS. NIMS pro? vides the incident management basis for the NRF and defines standard command and man? agement structures. Standardizing national response doctrine on NIMS provides a consis? tent, nationwide template to enable the whole community to work together to prevent, pro? tect against, mitigate, respond to, and recover from the effects of incidents regardless of cause, size, location, or complexity. All of the components of the NIMS?including preparedness, communications and infor- mation management, resource management, and command and management?support re- sponse. The NIMS concepts of multi?agency coordination and uni?ed command are de? scribed in the commzind and management component of NIMS. These two concepts are essential to effective response operations because they address the importance of: Investigation Number FY 1 3-07 53 (1) developing a single set of objectives; (2) using a collective, strategic approach; (3) improving information flow and coordination; (4) creating a common understanding of joint priorities and limitations; (5) ensuring that no agency?s legal authorities are compromised or neglected; and (6) optimizing the combined efforts of all participants under a single plan. Investigation Number FY 1 3-07 54