In analyzing and recording these events, the Investigation Team acknowledges and respects that members confronted a challenging situation. On?scene personnel reacted quickly to the changing conditions at this incident. We request that every person who reads this report show respect, appreciation and consideration for all personnel who responded to this incident.
As is a common industry practice, for this report Lieutenant Vincent Perez was referred to as Victim 1 and Firefighter Paramedic Anthony Valerio was referred to as Victim 2, with the exception of the Rescue Events Section.
Excerpt from Chief of Department’s Letter
“On Thursday, June 2, 2011 at 10:45 a.m., the San Francisco Fire Department responded to Box 8155, at 133 Berkeley Way. What was seemingly a routine working fire in a single family residence quickly transformed into a fierce and unrelenting incident with ultimately tragic results.
When we answered the call to a career in the Fire Service and took our Oath of Allegiance, we were aware of the inherent danger of our occupation. Despite this awareness, we do not expect to encounter a line of duty death of a brother or sister, especially not in our very own Department. The profound loss of Lieutenant Vincent Perez and Firefighter/Paramedic Anthony Valerio has left an indelible impression in our hearts and will forever be remembered in the annals of SFFD history.
Even as we mourned our fallen brothers in the early days after the tragedy, our Department began the painful and difficult, but necessary, steps of a Line of Duty Death investigation. We were resolute in understanding what occurred during those fateful minutes and compelled to uncover any recommendations for improvement that may arise to future operations so that their passing will not have been in vain. For over six months, the Investigative Team worked tirelessly, scrutinizing every piece of evidence in order to produce a comprehensive report.”
Chief of Department
Executive Summary and Report Excerpt
On June 2, 2011 at 10:45 hours, the San Francisco Fire Department was dispatched to a report of a fire in the building at 133 Berkeley Way in the City’s Diamond Heights neighborhood. The first unit arriving on the scene, Engine 26, observed light smoke showing from the garage of the 4 story (2 above grade, 2 below grade) wood framed building, detached on the Bravo side.
An aggressive interior fire attack was initiated through the front door, which is on a level between the ground level and second floor. After investigating the garage (ground level), Engine 24, the second Engine on the scene, led a small line through the garage to the interior door to back up the first Company. Battalion 9 was assigned Fire Attack by Battalion 6, who had assumed Command. Battalion 9 entered the fire building and, after conferring face to face with Engine 26 on the first floor (ground level), concluded that the fire was below them.
Battalion 9 exited the building and proceeded to the Bravo side to check for an entrance leading directly to the fire floor. Engine 11 led a large line wye to the driveway with the intention of leading a 1 ¾ inch line through the garage. They were redirected by Battalion 6 to make their lead down the Bravo side of the building to Sublevel 1 (one floor below grade) to assist Battalion 9. The Division Chief, upon arrival, assumed Command. He assigned Battalion 6 to Division 3 (ground floor).
Truck 15 was assigned Roof Division. Truck 11 split their crew, two members to the roof and three members to search and ventilate the top floor of the fire building. The Rescue Squad was ordered to conduct a search. Two members initially attempted to make entry through the garage but, due to extreme heat conditions, redeployed and entered through Sublevel 1 on the Bravo side.
The other two members of the Rescue Squad made entry through the front door, were pushed back by the heat and then made a successful second effort and conducted a search of the top floor.
In the course of fireground operations, members of several Companies came upon the stricken members on the first level and removed them from the building. All possible efforts were employed to revive the members and they were transported to San Francisco General Hospital (SFGH). One member (Victim 1) succumbed to his injuries that day and the second member (Victim 2) succumbed to his injuries two days later. Two other Firefighters were treated at SFGH for various injuries and released that day.
The Medical Examiner determined the cause of death for both members was due to complications from external and internal thermal injuries. Both victims suffered burns to 40% of their body surface. This fire was determined to be accidental by the SFFD Fire Investigative Unit. The fire originated on Sublevel 1, on the West side of the family room, near the large floor to ceiling windows. The ignition was a non?specific electrical sequence in the electrical wiring or appliance (handheld vacuum cleaner) in this area.
There was a delay in reporting the fire due to the occupants’ attempting to extinguish it on their own. (SFFD Fire Investigation Report 11?0500532)
The investigation identified that the failing of the window on Sublevel 1, located near the seat of the fire and directly across the stairwell leading to the ground floor, led to the extreme fire behavior which ultimately caused the death of two Firefighters. This fire was in a stage of deprived oxygen when the window failed, causing a rapid extreme high heat event to occur. The extreme heat followed the natural flow path up the interior stairs where Victims 1 and 2 were located.
The Safety Investigation Team found no conclusive evidence that the members were exposed to direct flame impingement during this rapid extreme heat event. However,
Victims 1 and 2 received varying degree of burns up to 40% of their body. The investigation concluded that this was caused by the rapid extreme heat conditions that radiated through their Personal Protective Equipment (PPE) to their bodies. These temperatures exceed the ability for human survival regardless of PPE.
The PPE was inspected and evaluated by NIOSH and the manufacturer. Both reviewing parties concluded that the PPE performed to its specifications and design. The manufacturer concluded that the PPE was exposed to temperatures in the range of 550? 700°F. These extreme temperatures were short in duration which caused limited damage to the outer shell of the PPE.
The Safety Investigation Team noticed severe heat damage to the portable radios remote speaker/microphones on Victims 1 and 2 and had the radios tested. The testing indicated that the remote speaker/microphones failed to operate correctly due to heat damage. The Safety Investigation Team was not able to determine, after testing, exactly when the remote speaker/microphones failed. The investigation has shown that multiple attempts were made to contact Engine 26 with no response.
The investigation also found that no radio transmissions of distress were received from Victims 1 or 2. Command and Control of any incident in the San Francisco Fire Department is acquired and maintained through the use of the Incident Command System (ICS).
The Incident Command System provides the tools for clear objectives, a single action plan, clear and acknowledged communications, and accountability for all members assigned to an incident. At this incident, some of the components of Incident Command System that were not followed include:
- Single action plan
- Fireground Accountability
From these findings, this report makes recommendations for several areas of the Department, including:
- Policy Development
- Policy Enforcement
The Safety Investigation Team gathered and analyzed many facts and conducted interviews of members directly involved in this incident. The Team identified several factors that occurred that contributed to the deaths at this incident.
These factors include:
- Extreme heat conditions accelerated by the failure of a window on the fire floor.
- Layout of building
- Excessive live fuel load which contributed to the growth of the fire
This incident appeared from the onset to be a routine “room and contents” fire that the SFFD encounters on a regular basis. As the Companies were performing standard fireground operations, the incident rapidly deteriorated due to a hostile fire event. The failure of a window in the fire room allowed fresh oxygen to enter the room, providing a fire that was deprived of one of the key elements of combustion to rapidly intensify.
Due to the growth of the fire, the room flashed, causing extreme and rapid heat conditions which traveled up the interior stairs (the flow path) to the location which our members were operating. Our members were caught in this high heat, causing the injuries that ultimately claimed their lives.
Due to this fire event, other Companies attempting to conduct fireground support operations were prevented from making entry into the structure from street level (through garage) to back up Engine 26. These Companies were forced to regroup and find an alternate point of entry. In the process of doing so, crews made entry from the Bravo side directly into the fire room and extinguished the fire. This allowed members to make entry from above which led to the discovery and rescue of our members.
These events happened in a time frame of less than fourteen minutes.
During the course of this investigation, the Safety Investigation Team recognized that no matter how experienced or properly prepared we are, we must always approach all incidents with the utmost awareness.
This incident showed that a simple failure of a piece of glass/window caused unforeseeable and fatal consequences.
We, as a Department, need to gain further knowledge and understanding of the following:
- Having Situational Awareness prior to taking action, this would include the ongoing process when conditions change
- How Risk Management must be used when making all decisions
- Limitations of the PPE (turnouts, SCBA, and equipment)
- Building construction, including layout and how fire/smoke will
- move within the structure
- Ventilation practices and how they affect fire conditions
- Importance of Communications for all members operating on the scene
- Companies must use strict discipline when assigned task/locations
Previous Coverage on CommandSafety.com below:
- 2nd San Francisco Firefighter Dies After Diamond Heights Fire
- San Francisco FD: The Diamond Heights Fire Updates
- Flags at the NFFF Memorial; SFFD LODD
San Francisco Chronical; S.F. firefighter dies, second fighting for life; Article and Photos HERE
SFFD Report PDF, HERE
SFFD Web Link, HERE
The mission of the Fire Department is to protect the lives and property of the people of San Francisco from fires, natural disasters, and hazardous materials incidents; to save lives by providing emergency medical services; to prevent fires through prevention and education programs; and to provide a work environment that values health, wellness and cultural diversity and is free of harassment and discrimination.
Site overview: Steep downhill slope adjacent to Glen Canyon
Date of Construction: 1975
- Attached garage located in the front of the house. Main structure is 2 stories above grade and 2 stories below grade
Type of Construction:
- Four story, Type 5 wood framed, single family home, detached on three sides
- Approximate square footage: 4,000 sq ft.
- Four stories of living space
- First Floor (Ground floor): garage, 3 bedrooms, 2 bathrooms
- Second floor: dining room, living room, kitchen, bathroom and family room
- Sublevel 1: large family room (origin of fire), mechanical room, bathroom, bedroom, balcony, side entrance on Bravo side
- Sublevel 2: enclosed finished storage area, bathroom (no windows)
- Roof type: Flat roof, bitumen roofing membrane, normal dimensional lumber
- Exterior: siding T1-11 plywood, 5/8”
- Interior: drywall over normal insulated framing
- Note: Fire origin room had decorative plywood veneer panels over drywall
- Steel I beams wrapped in drywall were used as structural supports
- Note: Fire origin room had a steel I beam that spanned horizontally from Bravo to Delta side
- Rear of structure had extensive use of glass to capture views, including windows and sliding doors
- Second floor and Sublevel 1 (fire origin) had large balconies
- Flooring consisted of tile, carpet and sheet vinyl throughout the house
- Dual glazed windows throughout, installed in 2003
- Ground level had a two car garage with access to residence
- Note: Two large vehicles occupying garage at time of fire
- Main entrance was accessed by ascending a flight of stairs adjacent to the garage
- Note: Main entrance stairs led to an interior landing which allowed access to top floor (5 stairs up) or grade level (7 stairs down)
- Sublevel 1 had an access door from the exterior Bravo side along with access from interior stairs
- Sublevel 2 had access door from exterior Bravo side. (no interior access)
- Note: Access through the Bravo side was difficult due to unfinished terrain and poor housekeeping