Firefighter Fatality Case Study

1
Firefighter Fatality Case Study

• Farwest Truck Auto Supply
• Coos Bay, Oregon
• November 25, 2002

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Objectives

• To analyze firefighter fatality incidents in the
  name of eliciting lessons learned to prevent
  future occurrences.
• To increase the knowledge base of firefighters,
  and in particular fire officers, in the spirit of
  making firefighting safer.

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• Those who cannot remember the past are condemned
  to repeat it.
• - George Santayana

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Community ProfileCoos Bay, Oregon

• Population 16,000
• 10.5 square miles
• Major industries
• Fishing
• Logging

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Fire Department ProfileCoos Bay, Oregon

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

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

• Personnel
• Career
• Captain - 1 Firefighter/Engineer - 2
  Administration - 3 Chief Battalion Chief
  (operation/training) Office Manager
• Cadet Firefighters (Up to 6) 

• Apparatus located at Central
• 1 - Class A Pumper
• 1 - Rapid Attack/Rescue Vehicle
• 1 - 75 ft. Quint
• 1 - Hazardous Materials Response Unit
• 1 - 19 ft. Jet boat for Water Rescue
• 1 - Command Vehicle
• 2 - Staff Vehicles for Chief and
• Operations Chief

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Coos Bay Fire Station 2 Empire Station 189 Wall
St.

• Personnel
• CareerLieutenant - 1 Firefighter/Engineer - 1
• Cadet Firefighters Up to 3

• Apparatus
• 1 - Class A Pumper
• 1 - Rapid Attack /Rescue Vehicle
• 2 - Jet Skis for water rescue

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Coos Bay Fire Station 3Eastside Station 365 D St.

• Personnel
• Career Firefighter/Engineer - 1
• Resident Volunteers Up to 3
• Industrial Fire Brigade (SOMAR)
• 7 personnel Duty Hours 7am to 4 pm

• Apparatus
• 2 - Class A Pumpers
• 1 - 3,200 gallon tender
•       Additional Equipment
• 1 - Class A Pumper
• 1 - 300 Gallon Foam Tender
• 1 - 3/4 ton Pick-Up Truck

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Farwest Truck Auto Supply

• Constructed approximately 1938
• Type IV Heavy Timber
• Numerous Modifications

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Construction Features

• Warehouse Addition
• Mezzanine
• Non-sprinklered
• 13,250 square feet
• Ceiling 8 x ¾ old growth fir ship lap with
  3/8 Furtex glued to surface.
• 2 x 10 wood ceiling joists

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Construction Features

• Sales area ceiling height 14
• Mezzanine area ceiling height 7
• Roof support structure
• 2 x 13 wood rafters
• 9 x 9 wood posts
• 9 x 13 wood beams

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The Fire(1320 hours D)

• Store employees return from lunch.
• Light haze and burning odor noted.
• Search for source begins.
• Chimney found hot to touch (on roof).
• Red glow noted in bathroom area on mezzanine.
• First aid extinguishment begins unsuccessful.
• 911 contacted at 1351 hours (D 31).

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Coos Bay FD Response(D32)

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

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Mutual Aid Response(Requested After Initial
Alarm)

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

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Operations(D33)

• Command 8111 AOS and reports nothing showing,
  assumes command.
• Property owner informs 8111 that fire is near
  chimney in bathroom on mezzanine. All occupants
  out.
• IC notes light haze at drop ceiling level.
• Ladder 8151 arrives. IC shows crew location of
  fire.

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D361356 hours

• Staff 8101 arrives. Command transferred from
  8111.
• Brown smoke visible from roof near chimney.
• 2 FFs from Ladder 8151 advance 1 ¾, 200
  pre-connect through Side A door.
• Observe fire at ceiling level 20-25 from front
  wall.
• Visible fire knocked.

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• 8111 assists Ladder 8151 with establishing supply
  line.
• IC orders 8111 to take a lap.
• Mutual aid units requested.
• Engine 8132 arrives and pulls back-up line from
  Ladder 8151.
• Initial attack line advances to mezzanine. Finds
  fully involved bathroom, light haze and little
  heat.

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• Ceiling opened, fire in rafters knocked.
• 3 firefighters from 8132 (Victim 3, Firefighters
  3 4) advance two handlines from Ladder 8151.
• Line 1 goes to sales counter.
• Line 2 goes to mezzanine.
• Grayish/brown smoke noted at ceiling level.
• Ceiling height deceptive due to suspended lights
  and drop ceiling.

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• Crews reach mezzanine and begin pulling
  walls/ceilings and extinguishing fire.
• Firefighter 5 and Victim 2 enter and follow
  handlines to mezzanine.
• Victim 1 enters and proceeds to mezzanine.
• 8 firefighters in building operating 2 handlines
  and pulling ceilings and walls.
• Victim 1 requests (via radio) roof ventilation
  and PPV on Side A.

20
D481408 hours

• Mutual aid Engine 8306 arrives. 5 members to roof
  for ventilation.
• Staff 8301 arrives. Assigned Division C.
• Staff 8302 arrives. Assigned Safety.
• Engine 8306 arrives.
• Roof reports small flame visible near chimney.
• Firefighters pull handlines from Engine 8306 and
  begin attacking fire through Side C doors.

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8306
FARWEST AUTO AND TRUCK SUPPLY 11/25/2002 1408
HOURS (D48)
8151
8132
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1408 (D48)

• Crews lose water momentarily.
• Firefighters 1, 2 4 low on air - exit.
• Firefighter 3 calls for more manpower.
• Firefighter 4 passes line to Victim 3.
• Firefighter 4 runs into Victim 1 while exiting
  and gives briefing.
• Visibility zero, heat relatively mild.

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1408 D48

• Operating inside
• Victim 1
• Victim 2
• Victim 3
• Firefighter 3
• Firefighter 5
• V2 V3 - handlines
• V1, F3, F5 - hooking

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1408 (D48)

• Skylights broken out by roof vent crew.
• First skylight initially yields no smoke. Then
  heavy, dark, gray smoke pours out.
• Second skylight yields heavy smoke immediately.
• IC ( Staff 8101) passes command back to 8111 to
  check on roof ops.
• Senior firefighter on roof notes spongy
  feeling.

25

• Senior firefighter orders crew roof.
• Staff 8101 reaches roof and notes bubbling tar,
  heavy smoke pushing from skylights, soft and
  spongy feel near Side A wall.
• Staff 8101 orders building evacuation.

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• Firefighters 3 5 exit the building due to low
  air.
• Major ceiling collapse ensues knocking
  Firefighter 5 down stairs. Firefighter
  at bottom of stairs forced to exit.
• Victim 3 trapped at top of stairs or knocked
  over railing.
• Victim 1 Victim 2 buried under full force of
  collapse.
• Firefighter 5 calls out. No replies. Turns to
  see mezzanine fully involved. Runs out of air
  and exits building.

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D48

• As Staff 8101 exits roof he sees skylights drop
  into building. Deep red flame and heavy black
  smoke begin blowing out of hole.
• Firefighter 5 exits and tells ISO that
  firefighters are trapped.
• ISO other officers call
• missing on radios.
• No response.

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• Staff 8101 resumes command.
• Orders Roof team to RIT.
• Additional handlines pulled to protect Side A
  entrances.
• Division C enters building on Side C and hears
  PASS alarms sounding overhead on mezzanine.
• RIT enters Side A.
• Driven back by high heat, and rolling flame
  front.

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D55

• Firefighter 1 reports hearing PASS alarm while
  operating 2 ½ handline on Side A.
• Firefighters 1 5 enter structure and recover
  Victim 3.
• Victim 3 Full PPE on, including SCBA, found
  near front counter.
• Apparently followed hoseline before collapsing.

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1608(D175)

• Defensive operations in effect.
• Victim 1 Victim 2 recovered and pronounced
  dead approximately 1708 (D235).

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NIOSH Recommendations

• FDs should ensure that
• firefighters provide the IC with interior size up
  reports.
• firefighters open concealed spaces to determine
  if a fire has spread.
• Pre-emergency planning is completed for
  mercantile and business occupancies.
• RIT teams are established and in position.

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NIOSH Recommendations

• FDs should consider the use of thermal imagers
  to assist with interior size-up.
• FDs should ensure that local citizens call the
  fire department immediately when they smell smoke
  or feel heat.

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NIOSH Recommendations

• FDs should always maintain good accountability.
• (Not a factor in this incident)
• Building owners should ensure that building
  permits are obtained local codes are followed.
• Chimney was improperly installed.

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Coos Bay Fire and Rescue
Lt. Randall Carpenter 46 YO, 20 years
Firefighter Jeffrey Common 30 YO, 8 years
Firefighter Robert Hanner 33 YO, 13 years
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Sources

• NIOSH Firefighter Fatality Investigation and
  Prevention Program
• Report 2002-50

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• Firehouse.com
• Roof Collapse Takes Three Oregon Firefighters
• Community in Shock Over Deaths of Three
  Firefighters
• Oregon Firefighters Leave Legacy of Bravery,
  Fellowship
• Coos Bay Tragedy The Victims and Memorial
  Information
• Investigators Hidden Fire Likely Burned for
  Hours