The Day The Impossible Happened

1
The Day The Impossible Happened

• The tragic death of Captain Bob Gallardy during
  training.

2
Sunday October 23, 2005

• On a mild October afternoon during the last
  training evolution of the day, a veteran state
  instructor was critically burned in the basement
  of the Pennsylvania State Fire Academy
  residential burn building. Two days later,
  Captain Bob Gallardy of the Altoona Fire
  Department died from those burns. Here is the
  story of that tragedy and the changes that have
  occurred since that day.

3
WHO WE ARE
4
The Pennsylvania State Fire Academy

• Located in Borough of Lewistown -Mifflin County,
  PA
• Facility opened in 1955
• Only facility owned and operated by Commonwealth
  of PA

PSFA
5
The Pennsylvania State Fire Academy

• Managed by the Office Of The State Fire
  Commissioner (OSFC)
• Supported by the PA Emergency Management Agency
  (PEMA)

6
The Pennsylvania State Fire Academy

• Current class A burn buildings opened in May
  1993
• Buildings lined with High Temperature Lining
  (HTL) in 2001

7
The Pennsylvania State Fire Academy

• Four (4) main program areas
• Certification Program
• Resident (on campus) classes
• Academy On The Road classes
• Local-Level (field delivery) classes

• Fourteen (14) full-time employees
• 2 are Resident Instructors
• 140 Adjunct Instructors
• 1500 Local-Level Instructors
• Suppression
• Non-Suppression

8
The Suppression Instructor Development Program
(ZFID)
9
ZFID Attendance Requirements

• 8 years experience in fire service
• 3 letters of recommendations
• Attend 150 hours structural track training
• Attend educational methodology class

• Must be certified Firefighter II, Fire
  Instructor I
• Attend NFA ISO class

10
Suppression Instructor Development Program (ZFID)

• Started in 2000 for the purpose of evaluating
  instructor candidates
• This 40-hour program contains
• specific PSFA policies including the intent of
  NFPA 1403
• presentations by instructor candidates,
• tour of PSFA facilities including walk-through of
  burn building
• wet-line drills
• live fire evolutions
• Candidates act as Students, Ignition Officers,
  ISO, IC, and Instructors

11
Suppression Instructor Development Program (ZFID)

• Program is presented by 8 Adjunct Instructors
• A lead and co-lead spend first 20 hours with
  candidates
• 6 additional Adjuncts assist during next 20 hours
• Act as evaluators during live-fire exercises
• Shadow instructor candidates during all evolutions

12
Live Fire Evolutions during ZFID class

• Instructor candidates are shown safest methods of
  stacking pallets, spreading Excelsior, and
  starting fire
• Fires occur in basement and Division 2 of
  residential structure

13
Live Fire Evolutions during ZFID class

• ZFID Candidates will act as the
• Incident Commander
• Incident Safety Officer
• Instructor Up
• Instructor Down
• Students
• Each position is
• shadowed and evaluated by an adjunct instructor

14
Live Fire Evolutions during ZFID class

• Fire Suppression
• 2-person hose team assigned to the basement
• 2-person hose team assigned to Division 2
• RIT
• 4-person team stands by on Side A with wet-line
• Radios
• One assigned to every team
• Assigned to all Staff involved in the evolution

15
Live Fire Evolutions during ZFID class

• Resident Instructors
• Operate engine
• Provide other support as required
• Can perform duties of an adjunct instructor if
  necessary
• Field Supervisor
• Monitors drills
• Monitors candidates progress and counsels them
  as needed

16
Live Fire Evolutions during ZFID class

• 2-person EMS crew with BLS ambulance on scene
  (may have medic aboard)
• Ladder in place on Side D for secondary egress
• Engine has additional water supply

17
Live Fire Evolutions during ZFID class

• First 4 evolutions
• Wet-lines only , no live fires
• Live-fires for 12 evolutions
• Each evolution is slow and methodical as the IC,
  ISO and Instructors verify with each other, each
  team and each level of building are ready to
  start the evolution

18
Live Fire Evolutions during ZFID class

• Fire sets are smaller and fires are less intense
  than those in Resident structural firefighting
  classes
• Candidates have previously proven their skills as
  interior firefighters

19
Live Fire Evolutions during ZFID class

• Simulated emergencies may be staged in later
  evolutions. They may include one of eight. Such
  as
• a burst hose line
• a PASS device sounding somewhere (not on a person
  but by itself)
• a portable radio that quits working
• a separated crew member
• These are scripted and staff are informed prior
  to evolution starting

20
WHAT HAPPENED THAT DAY
21
Suppression Instructor Development Program (ZFID)

• Sunday October 23, 2005 was the final day of the
  class
• Last of the 16 normally scheduled evolutions

22
Live Fire Evolutions during ZFID class

• Because of an issue with one candidate the
  Curriculum Specialist was monitoring evolution
  16 basement fire
• This meant one additional staff member was
  evaluating the candidates going to the basement

23
Live Fire Evolutions during ZFID class

• Evolution 16
• Fire sets were built by adjunct staff which were
  equivalent in size to a Resident Program
• Why?
• Motivate candidates
• Create a condition that if seen in an acquired
  structure would be cause for concern (Go/No-Go)

24
Live Fire Evolutions during ZFID class

• Evolution 16
• Started and proceeded
• Candidate Safety Officer recognized and reported
  a smoke condition different from previous
  evolutions
• Crews entered assigned areas after all radio
  checks were verified
• A radio transmission stated firefighter down
• Confusion among outside staff
• Is this a staged emergency?

25
EMERGENCY HAS OCCURRED

• Discussions among outside staff in an attempt to
  clarify radio message
• This resulted in delaying assistance
• EMS crew is advised of possible firefighter
  down

26
EMERGENCY HAS OCCURRED

• RIT team sent to basement after several minutes
• Basement crew exited via exterior stairwell with
  victim
• Emergency evacuation/PAR conducted
• Patient care started immediately by the ambulance
  crew along with EMTs and Paramedics who were
  students or staff

27
EMERGENCY HAS OCCURRED

• Full-time staff members begin emergency
  notification process and site security measures
• Victim is transported to Lewistown ER after
  helicopter is put on stand-by
• All persons directed to write statement of
  incident immediately

28
EMERGENCY HAS OCCURRED

• Contacts made
• State Fire Commissioner
• State EOC
• PSFA Administrator
• Altoona FD Chief
• CISM team is requested
• All students and staff held at facility (guests)

29
EMERGENCY HAS OCCURRED

• Captain Gallardy is transferred from Lewistown ER
  via helicopter to Lehigh Valley Burn Center at
  Allentown with burns over 50 of his body
• The Gallardy family notified by the Altoona Fire
  Department

30
EMERGENCY HAS OCCURRED

• CISM Team meets with entire group then splits
  into staff, student and guest groups for
  defusing
• After defusing all persons stay for light meal
  and well-being check before traveling home
• A graduation and informal critique of the ZFID
  program was conducted in an attempt to conclude
  the day on a positive note

31
EMERGENCY HAS OCCURRED

• State Fire Commissioner Mann calls NIOSH twice
  and leaves message requesting an investigation
• All persons depart PSFA promising to check on one
  another and stay in close contact
• Billy Goldfeder is notified for national
  distribution of incident

32
TRAGEDY STRIKES

• Captain Gallardy spends 2 bad nights in burn unit
• Family and friends surround him at Allentown
• Bob passes away late Tuesday morning

• NFFF, State EOC, participants from Sundays class
  are notified
• Altoona Fire Department and Fire Commissioner
  Mann agree to allow Altoona to hold LODD Funeral
  in Altoona

33
NIOSH Arrives

• Tuesday October 25, 2005
• NIOSH Investigator Steve Berardinelli arrives to
  begin investigation
• Full cooperation is promised by Fire Commissioner
  Mann
• Fire Commissioner Mann pledges to tell the
  world when the NIOSH report is released

34
NIOSH Investigation

• Investigator Berardinelli takes 3 days to
  complete work at Lewistown
• interviews persons
• reads statements
• takes pictures
• closely examines burn building
• fire training grounds
• victims PPE and SCBA

• Works closely with PSFA staff and displays
  professionalism while explaining as much as
  possible

35
WHERE WE ARE TODAY
36
What is the solution?

• State Fire Commissioner, PSFA management and
  staff discuss possible causes, changes, and
  remedies
• March 2006 test burns are conducted by NIST with
  staff and NIOSH investigator present

37
Live Burn Policy Changes since October 2005

• Operating alone anywhere in the building is
  strictly prohibited
• Two instructors are now required for ignition and
  stoking of fires
• One person must remain outside of burn room in
  visual contact when the other person is in burn
  room
• Fires on multiple floors require multiple
  ignition teams
• Additional charged safety lines are added to live
  burn training sessions

38
Live Burn Policy Changes since October 2005

• Stand-by ambulance MUST be BLS during live burns
  in acquired structures ALS is highly recommended
• Use of any combustible liquid is prohibited
• All live fire evolutions are conducted in
  accordance with NFPA 1403

39
Live Burn Policy Changes since October 2005

• Rapid Intervention Team
• Must be six people
• plus a RIT Officer who is a suppression
  instructor
• two of those must be ready for immediate
  deployment
• could be a RIT not associated with the class
• A suggested list of tools
• Charged hoseline

40
Resident Course Specific Changes

• Increased number of adjunct instructors
• Two ignition officers plus safety officer
• Additional charged hoselines
• A formal gear inspection required for all
  resident programs
• Baseline vitals taken prior to live fire
  activities
• Vitals required for staff and students after
  exiting live fire during rehab

41
Resident Course Specific Changes

• ALS Ambulance on-site during live fires
• Simulated emergencies during the ZFID program
  removed because they were not producing the
  intended result
• A redundant accountability system
• Maximum fuel load is more clearly defined

42
Information Sharing

• NIOSH investigation findings have yet to be
  released
• NIST is currently compiling data from the test
  burns.
• Upon completion two presentations are scheduled
• Fire Academy Staff and Adjunct Instructors
• Local-level instructors

43
Closing Comments and Questions
44
Contact Information

• PA State Fire Academy
• 1150 Riverside Dr.
• Lewistown, PA 17044
• 717 248-1115
• 800 459-4096(In PA)
• Tim Dunkle Fire Academy Administrator
• TDunkle_at_state.pa.us