NIOSH Findings Reported on Bridgeport (CT) Double LODD Fire; Failed to Respond to Maydays

 

2 Bridgeport firefighters die in line of duty: wtnh.com

Fire vented through the roof. Note: NIOSH investigators believe this photo shows conditions very close to the time that the Mayday was called for Victim #2 by FF4. Wind was pushing the smoke plume from right to left. (Photo courtesy of Keith Muratori.)

Bridgeport (CT) fire officials’ failure on nearly ever level led to the line-of-duty deaths of two firefighters battling a fire in a residential occupancy in Bridgeport, CT on July 24, 2010. 

Among the findings of the National Institute for Occupational Safety and Health (NIOSH) released Wednesday:

  • the deputy fire chief and his assistant at the scene of the Elmwood Street fire were having a discussion about whether they heard a mayday call from the two fallen firefighters instead of taking immediate action to rescue them.
  • The report also stated firefighters failed to immediately treat one of the firefighters who managed to make it to relative safety before collapsing.
  • Officials also did not properly managed firefighters’ air supplies — both firefighter’s air cylinders were empty when they were found, the report stated.
  • The department’s incident safety officer, who is required to be on scene for assistance in a fire also did not arrive more than 20 minutes after the initial dispatch.

Lt. Steven Velasquez and Firefighter Michel Baik were on the third-floor of the wood-frame home at 41 Elmwood Ave. checking for hot spots and making sure there were no people in the smoldering blaze. Then trouble hit. The two sent mayday signals back to dispatch. Within minutes, the fire department’s rapid intervention team found the pair on the floor, unconscious, and gave them CPR. The two men could not be revived.

Full NIOSH Report F2010- 18 FINAL CT F2010-18

NIOSH Executive Summary

On July 24, 2010, a 40-year-old male career fire lieutenant and a 49-year-old male career fire fighter were found unresponsive at a residential structure fire. The victims and two additional crew members were tasked with conducting a primary search for civilians and fire extension on the 3rd floor of a multifamily residential structure. The fire had been extinguished on the 2nd floor upon their entry into the structure.

While pulling walls and the ceiling on the 3rd floor, smoke and heat conditions changed rapidly. The first firefighter transmitted a Mayday (audibly under duress) that was not acknowledged or acted upon. Minutes later the incident commander ordered an evacuation of the 3rd floor. As a fire fighter exited the 3rd floor, the lieutenant was discovered unconscious and not breathing, sitting on the stairs to the 3rd floor.

Approximately 7 minutes later, the second firefighter  was discovered on the 3rd floor in thick, black smoke conditions. Both victims were removed by the rapid intervention team (RIT) and other fire fighters who assisted them. Both victims were pronounced dead at local hospitals.

Contributing Factors

  • Failure to effectively monitor and respond to Mayday transmissions
  • Less than effective Mayday procedures and training
  • Inadequate air management
  • Removal and/or dislodgement of self-contained breathing apparatus (SCBA) facepiece
  • Incident safety officer (ISO) and rapid intervention team (RIT) not readily available on scene
  • Possible underlying medical condition(s) (coronary artery disease)
  • Command, control, and accountability.

Aerial View of House and Exposures

 
 

Key Recommendations

  • Ensure that radio transmissions are effectively monitored and quickly acted upon, especially when a Mayday is called
  • Ensure that Mayday training program(s) and department procedures adequately prepare fire fighters to call a Mayday
  • Train fire fighters in air management techniques to ensure they receive the maximum benefit from their SCBA
  • Ensure that fire fighters use their SCBA during all stages of a fire and are trained in SCBA emergency procedures
  • Ensure that a separate incident safety officer (ISO), independent from the incident commander, is appointed at each structure fire with the initial dispatch
  • Ensure that a rapid intervention team (RIT) is readily available and prepared to respond to fire fighter emergencies
  • Consider adopting a comprehensive wellness and fitness program, provide annual medical evaluations consistent with NFPA standards, and perform annual physical performance (physical ability) evaluations for all fire fighters.

Timeline

This timeline is provided to set out, to the extent possible, the sequence of events according to recorded and intelligible radio transmissions. Two channels were used during this incident: the main dispatch channel and channel 2 (fireground). Times are approximate and were obtained from review of the dispatch records, witness interviews, photographs of the scene, and other available information. Times have been rounded to the nearest minute. NIOSH investigators have attempted to include all intelligible radio transmissions, but some may be missing. This timeline is not intended, nor should it be used, as a formal record of events.

  • 1544 Hours E3 and L5 dispatched to a report of an elevator rescue.
  • 1546 Hours While en route, E3 contacted the dispatcher on the main dispatch channel and advised them they needed to redirect all companies to a possible house fire.
  • 1547 Hours L5 copied E3‘s transmission on the main dispatch channel and redirected to the possible house fire. E3 advised the dispatcher, on the main dispatch channel, that they had a fire on the 2nd floor and that they did not have a hydrant. Note: It is unclear whether E3 established command, but L5 arrived just after E3 and established command.
  • 1548 Hours E3, E4, E1, E7 as RIT, L11, L5, R5, and B1 were dispatched on the main dispatch channel to the house fire.
  • 1549 Hours L5 arrived on scene and their officer stated over the main dispatch channel, ―2½-story wood frame with heavy fire coming from the 2nd floor, Alpha/Bravo side, L5 is now command.‖
  • 1550 Hours E7 en route.
  • 1551-1552 Hours E4 arrived on scene and laid a supply line in from the hydrant. Over the main dispatch channel, L5 officer (initial arriving IC) advised the dispatcher that the bulk of the fire was knocked down by E3 and the primary search was in progress. Over the main dispatch channel, the dispatcher advised L11 and E7 which way they should approach the scene. Over the main dispatch channel, L5 officer requested an ambulance for an injured fire fighter (ankle injury). Over the main dispatch channel, B1 advised the dispatcher that he was on scene, and he confirmed the first report of heavy fire with the bulk of the fire knocked down. B1 then took command of the incident.
  • 1553 Hours L11 arrived on scene. E1 took an additional hydrant. A7116 dispatched to the incident for an injured fire fighter. Note: Dispatch of A7116 was not part of the initial fire assignment. The 9-1-1 center contacted the EMS dispatch center via landline to request an ambulance for the injured fire fighter on scene after the request from the L5 officer.
  • 1554 Hours Over the main dispatch channel, the BA advised the dispatcher that the command post would be in front of the fire building and tag collection would be at the command post. On channel 2, E4 officer asked E3 to charge the second hoseline. E7 (RIT) arrived on scene.
  • 1555 Hours On channel 2, E4 officer asked E3 again to charge the second hoseline. Over the main dispatch channel, the IC requested the dispatcher to have the safety officer respond to the incident. IC checked on the status of the ambulance. Fire dispatch advised the IC that the ambulance was en route.
  • 1556 Hours E3 advised the IC (on the main dispatch channel) that he needed hooks on the 2nd floor in the room of origin; the IC acknowledged the request. Over the main dispatch channel, IC advised all companies, ―Channel 2 fireground, channel 2 fireground.‖ Note: Up to this point, companies on scene were operating on the main dispatch and channel 2. Fire dispatch assigned fireground operations to channel 2 for the incident.
  • 1557-1558 Hours IC called L11 on channel 2. IC (on the main dispatch channel) confirmed with the dispatcher who was RIT (which was E7) on scene and advised them that their equipment was available at the command post. Victim#1 acknowledged the IC‘s request for L11 on channel 2, but the IC did not respond. E3 officer, who incorrectly identified himself as ―E4,‖ called command on channel 2 and stated they had a slight extension into the A/B corner. Note: He was working overtime the day of the incident at the station that houses E3 and E4, which is also his normal duty station. The IC copied the E3 officer‘s transmission on channel 2 and asked him if he had enough hooks available; the E3 officer stated he did. A7116 arrived on scene.
  • 1559 Hours E3 officer on channel 2 advised the IC that they needed a hoseline to the 3rd floor because they could not reach it (fire extension) from the 2nd floor. The IC acknowledged the E3 officer‘s transmission on channel 2. The IC, on channel 2, advised Victim #1 that E1 was bringing a hoseline to the 3rd floor. Victim #1 acknowledged the IC‘s transmission on channel 2 and advised, ―A primary is in progress, which is negative; and, they are still checking for extension.‖ The IC acknowledged Victim #1‘s transmission.
  • 1600 Hours Over the main dispatch channel, the ISO advised the dispatcher that he was responding (from home). A7116 contacted EMS dispatch requesting a single ambulance to standby at the incident per the IC. A7110 dispatched and en route to fire to standby. On channel 2, the IC (at the command post) advised the E4 officer that he could see fire extending up the A/B corner. Note: NIOSH investigators were not sure if this transmission was meant for the E4 officer or the officer from E3 who identified himself as E4. At 1559 hours, the E3 officer advised the IC of the extension to the 3rd floor. On channel 2, the E4 officer advised the IC that he was working on getting a line up to the 3rd floor.
  • 1601 Hours Over the main dispatch channel, the dispatcher advised the IC that the ISO and DC were responding. On channel 2, the L5 officer contacted ―L5-Alpha‖ (believed to be L5‘s aerial ladder) to assist in the bucket; L5-Alpha acknowledged the transmission.
  • 1602-1603 Hours On channel 2, the IC contacted the L5 officer to verify whether he thought he could make the roof with L5. On channel 2, the L5 officer stated that he was sending the driver down to talk to him. R5 officer advised the IC on channel 2 that the primary was negative on the 2nd floor. E4 attempted to contact L5 on channel 2, but was walked-on by R5-Alpha attempting to contact the R5 officer twice. E3 officer advised L5 on channel 2 that they needed to overhaul the porch on the 2nd floor, but he did not think L5 could get to it. L5 officer acknowledged E3 engineer‘s transmission on channel 2.
  • 1604 Hours DC en route to the incident. Over channel 2, R5 called the IC three times (no response). Over channel 2, the E4 officer called the E3 pump operator twice to shut the fog nozzle hoseline down; the E3 pump operator acknowledged. Victim #1 called the IC twice on channel 2 (no response).
  • 1605 Hours Over the main dispatch channel, the IC requested another RIT from the dispatcher. On channel 2, R5Alpha advised the R5 officer that the primary above the fire floor (2nd floor) was complete. On channel 2, the R5 officer attempted to contact the IC (no response). E4 officer advised the E3 pump operator to recharge the fog nozzle hoseline; the E3 pump operator acknowledged.
  • 1606-1607 Hours A7110 arrived on scene. E12 dispatched and responded as the RIT. Note: At 1604 hours, E12 was en route to the elevator rescue. On channel 2, the IC advised Victim #1 that he was getting a second hoseline to the 3rd floor for him. The IC asked Victim #1, ―What‘s the situation up there?‖ Victim #1 stated, ―We got the line in place, it‘s charged, we have extension into the attic space…‖ The IC then asked for Victim #1 to verify ―if‖ he already had a line in place, but there was no response. A member of E4 advised the IC that they had, ―…line in operation on the number three floor.‖ A7116 en route to hospital with injured fire fighter.
  • 1608 Hours R5 contacted the IC on channel 2 and advised him that they had one line in operation and he recommended that the roof be opened. Note: A Vibralert® could be heard alarming during his transmission. IC advised R5 that they were preparing ground ladders to access the roof.
  • On channel 2, the L5 officer stated that he was sending the driver down to talk to him. R5 officer advised the IC on channel 2 that the primary was negative on the 2nd floor. E4 attempted to contact L5 on channel 2, but was walked-on by R5-Alpha attempting to contact the R5 officer twice. E3 officer advised L5 on channel 2 that they needed to overhaul the porch on the 2nd floor, but he did not think L5 could get to it. L5 officer acknowledged E3 engineer‘s transmission on channel 2.
  • 1604 Hours DC en route to the incident. Over channel 2, R5 called the IC three times (no response). Over channel 2, the E4 officer called the E3 pump operator twice to shut the fog nozzle hoseline down; the E3 pump operator acknowledged. Victim #1 called the IC twice on channel 2 (no response).
  • 1605 Hours Over the main dispatch channel, the IC requested another RIT from the dispatcher. On channel 2, R5Alpha advised the R5 officer that the primary above the fire floor (2nd floor) was complete. On channel 2, the R5 officer attempted to contact the IC (no response). E4 officer advised the E3 pump operator to recharge the fog nozzle hoseline; the E3 pump operator acknowledged.
  • 1606-1607 Hours A7110 arrived on scene. E12 dispatched and responded as the RIT. Note: At 1604 hours, E12 was en route to the elevator rescue. On channel 2, the IC advised Victim #1 that he was getting a second hoseline to the 3rd floor for him. The IC asked Victim #1, ―What‘s the situation up there?‖ Victim #1 stated, ―We got the line in place, it‘s charged, we have extension into the attic space…‖ The IC then asked for Victim #1 to verify ―if‖ he already had a line in place, but there was no response. A member of E4 advised the IC that they had, line in operation on the number three floor.‖ A7116 en route to hospital with injured fire fighter.
  • 1608 Hours R5 contacted the IC on channel 2 and advised him that they had one line in operation and he recommended that the roof be opened. Note: A Vibralert® could be heard alarming during his transmission. IC advised R5 that they were preparing ground ladders to access the roof.
  • The IC called the L11 officer (Victim #1) on channel 2 (no response).
  • 1615 Hours On channel 2, the IC stated, ―Command to all companies on the 3rd floor, vacate the 3rd floor; I repeat, command to L11 and E1, vacate the 3rd floor.‖
  • 1616-1619 Hours (2nd Mayday Call) The IC attempted to contact L11 again on channel 2 (no response). The IC, on channel 2, then stated, ―Command to E1.‖ (1616.50 hours) On channel 2, FF2 stated, ―Mayday, Mayday…Rescue 5 Bravo command we have a downed fire fighter rear steps. Mayday-Mayday-Mayday fire fighter down rear steps, 2nd floor.‖ IC called L11 again on channel 2 (no response). FF4 on channel 2 stated, ―Ladder 11 irons to Ladder 11‖ (no response). Note: An apparatus air horn is heard sounding in the background of this transmission. FF2 on channel 2 stated, ―Rescue 5 Bravo command, Rescue 5 Bravo command we need help 2nd floor, send the RIT, we need fresh bodies.‖ Note: No audio transmissions or emergency tones are heard on channel 2 or the main dispatch channel advising that the Mayday call had been acknowledged. DC contacted the IC on channel 2 to have him send the RIT to the rear stairs; the IC acknowledged. Note: The RIT may have already been advancing up the rear stairs, but they ran into difficulty accessing the 2nd floor landing off the rear stairs because a charged hoseline was against the closed door. Dispatch attempted to contact command on channel 2 (no response). The IC called L11 again on channel 2 (no response). The DC contacted the IC requesting the ambulance on scene to come to the rear of the house. Victim #1 was extricated out the rear of the house.
  • 1620 Hours A7110 began medical care for the downed fire fighter (Victim #1). Over the main dispatch channel, the BA requested an advanced life support ambulance to the fire scene. A7126 was dispatched to intercept A7110 at the fire scene to provide advanced life support. (~1620.35 Hours) The following transmission is heard on channel 2, ―…Ladder 11 ‗mayday‘ (very quick transmission)…Ladder 11 (unintelligible word(s)).‖ Note: The dispatch caller ID for this radio is designated as “L-11 FF3,” which was assigned to the fire fighter (designated as FF4 for this report) who later finds Victim #2 (see below 1624 hours). FF4 had not found Victim #2 at the time of this transmission. On channel 2, FF4 stated, ―Ladder 11 irons to Ladder 11 can‖ (no response). Note: “Ladder 11 can” was Victim #2’s designation that shift.
  • 1621 Hours A7126 en route to fire scene.
  • 1622 Hours On channel 2, the ISO advised the IC that the fire fighter (Victim #1) was removed and they needed to do a roll call for everyone on scene. On channel 2, the IC advised all company officers that the ―incident is taking a PAR‖ (personnel accountability report). Officers began calling in their respective PARs.
  • 1624 Hours (3rd and 4th Mayday Calls) FF4 on channel 2 stated, ―Mayday-Mayday, I have a fire fighter trapped on the 3rd floor, Mayday-Mayday-Mayday 3rd floor.‖ Note: This Mayday is for Victim #2. A PASS device is heard alarming during FF4‘s transmission. On channel 2, the IC stated, ―This is command to all companies, vacate the building, I report, command to all companies, vacate the building.‖ FF4 on channel 2 stated again, ―Mayday-Mayday-Mayday, I‘ve got another fire fighter down, another one, 3rd floor, hurry!‖
  • 1625 Hours Over channel 2, the dispatcher stated, ―For a Mayday,‖ and activated the emergency evacuation tones. Note: It is unknown why the evacuation tones were sounded instead of the Mayday tones. Their evacuation tone is an alternating, high-low sound, similar to a European siren. Their Mayday tone is a rapid, high to low pitch, chirping sound. This was dispatch’s first acknowledgement of a Mayday over the radio. No further radio traffic regarding the Mayday was provided by the dispatcher following the tone activation on channel 2. Over the main dispatch channel, the dispatcher stated, ―For a Mayday,‖ and activated the emergency evacuation tones as well. No further radio traffic regarding the Mayday was provided by the dispatcher following the tone activation on the main dispatch channel.
  • 1626 Hours The IC contacted the DC on channel 2. DC acknowledged with no further traffic from the IC. The IC on channel 2 again advised all companies to vacate the building. The dispatcher then activated the emergency tones on channel 2 and the main dispatch channel, and stated, ―All companies per command vacate the building, all companies vacate the building.‖
  • 1627 Hours The ISO contacted the IC on channel 2 and stated, ―We need to make contact with that Mayday, we need more information, we have not heard from them since the initial call.‖ On channel 2, the IC stated, ―Command to company declaring a Mayday; I repeat, command to the company declaring a Mayday sound off, sound off.‖ A fire fighter from the RIT advised the IC on channel 2 that they were moving the fire fighter off the 3rd floor. On channel 2, the dispatcher advised the IC that the Mayday call was for the 3rd floor. A7126 arrived at the fire scene.
  • 1628 Hours RIT advised the IC that they have the fire fighter (Victim #2) on the 3rd floor and will be bringing him down the rear stairs from the 3rd floor.
  • 1630 Hours A7110 en route to the hospital with Victim #1 without assistance from A7126.
  • 1632 Hours ISO asked for a progress report from the RIT on the Mayday. RIT replied, ―Coming down…3rd floor.‖ ISO asked RIT to repeat their traffic. A radio was keyed, but there was no transmission.
  • 1634 Hours RIT personnel advised the IC that they had the fire fighter (Victim #2) down to the 2nd floor landing.
  • 1640 Hours A7110 arrived at local hospital with Victim #1.
  • 1643 Hours A7126 began medical care on second downed fire fighter (Victim #2). Note: This time was taken from Victim #2’s patient care report and may not be accurate.
  • 1703 Hours A7126 arrived at local hospital with Victim #2.

 

Fire Behavior

The room and contents fire was determined to have originated in a bedroom on the 2nd floor, A/B corner; it was quickly knocked down by E3 (see Photo 2). It is believed that the fire got into the eves when it was lapping out the A/B corner windows, and then spread within the large void spaces in the ceiling and walls of the 3rd floor. The fire was situated toward the A/B corner of the 3rd floor, but the open void areas allowed smoke to accumulate within the ceilings and walls before they were opened.

Operating on the 3rd floor at varying times were members from L5, R5, L11, E4, and E7. Initially, light-to-moderate smoke conditions were observed on the 3rd floor, depending on how close fire fighters were to the A-side of the 3rd floor. Fire fighters recalled the 3rd floor being very hot. TICs used by different individuals on the 3rd floor showed the room to be hot on the A-side and ceiling. Windows on the A-, B-, and D-sides were opened, allowing most of the smoke to self ventilate. Light smoke remained within the 3rd floor, with good visibility.

Extension was checked around A- and B-side baseboards. Some fire fighters recall Victim #1 telling them the fire was in the ceiling and possibly the walls, and to not open those areas until a hoseline was in place. Even after providing horizontal ventilation on the 3rd floor, smoke conditions worsened, banking down to fire fighters‘ chin levels and becoming denser.

While waiting for the hoseline, L5 members were reassigned by the IC to ventilate the roof to provide additional relief to the 3rd floor. The IC reported to NIOSH investigators that he ordered the roof vented because he saw smoke pushing out the B-side windows. Personnel from E4 advanced the charged hoseline to the 3rd floor, allowing the ceilings and walls to be opened. A mixture of thick, brown/black smoke quickly filled the room, reducing visibility.

  

Initial conditions observed when the BC arrived on scene at approximately 1551 hours. Note: Fire was under control on the 2nd floor and fire fighters were checking for extension. White-to-gray smoke can be seen flowing in the direction of right to left from the gables. The A-side window on the 3rd floor had been opened for ventilation (unsure at what stage of the fire or by whom).

  

  

Structure

Built in the early 1900s, the two-and-half-story house (see Photo 1) was purchased approximately 4 years prior to the incident as a multifamily rental occupancy. One family lived in the 1st floor apartment (approx. 1,300 sq. ft.); a second family lived in the 2nd floor apartment (approx. 1,300 sq. ft.) and the owner occupied the finished half-story or attic space (approx. 700 sq. ft.).  The house also contained an unfinished basement (approx. 1,300 sq. ft.).

The common front entrance contained access to the 1st floor apartment and a private stairwell, located at the A/D corner of the house, which provided access to the 2nd floor apartment. The house also had a single rear-entry door that provided access to a stairwell that led up to the owner‘s apartment and had landings to access all the apartments from the rear. According to the owner of the house, smoke detectors were installed within the house about a year prior to the incident. These smoke detectors were installed in every bedroom, in each hallway, and in the stairwells.

The house did not have an installed sprinkler system and had been inspected in accordance with Department of Housing and Urban Development Section 8a guidelines, according to the homeowner. The house was Type V wood frame construction, but, during the initial stages of the fire, was presumed by arriving fire fighters to be balloon-framed due to the era when it was constructed. State fire investigators were able to confirm Type V construction after closer inspection.

The Office of the State Fire Marshal‘s building code compliance inspection showed that the house did not meet certain Connecticut Fire Safety Code requirements for this type of structure. NIOSH investigators do not believe that these non-compliance issues contributed to the deaths of the two fire fighters.

  

Typical Ballon Framing Construction

 

 LINKS

 

2 Bridgeport firefighters die in line of duty: wtnh.com

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