Firefighter safety: June 18, 2007
By Richard Schulte
Schulte & Associates, Evanston, Ill.
Each July, the National Fire Protection Association (NFPA) publishes a report on firefighter fatalities in the United States during the previous year. A few excerpts from NFPA's report on firefighter fatalities for 2007 are as follows:
"In 2007, a total of 102 on-duty firefighter deaths occurred in the U.S. This is a sharp increase over the 89 firefighter fatalities that occurred in 2006, but returns to the long-term trend of close to 100 on-duty deaths annually."
"Of the 102 firefighters who died while on duty in 2007, 53 were volunteer firefighters, 42 were career firefighters. ..."
"Fire ground operations accounted for 36 deaths. ... Twenty-two of the victims were career firefighters and twelve were volunteer firefighters."
"The average number of career firefighter deaths on the fire ground over the past 10 years is 13 per year."
"There were 30 fatalities while responding to or returning from alarms."
"Thirteen deaths occurred during training activities."
"Seven firefighters were killed at non-fire emergencies."
"The remaining 16 firefighters died while involved in a variety of non-emergency-related on-duty activities. These activities included normal administrative or station duties (11 deaths), preparations for community fire prevention events (two deaths), preparing for a parade (one death), returning to base from a prescribed burn (one death) and flagging at a fire line construction project (one death)."
"Deaths resulting from exertion, stress and other, often medical, issues made up the largest category of fatalities. Of the 40 deaths in this category, 38 were classified as sudden cardiac deaths, usually heart attacks, and two were due to strokes."
"Of the 38 victims of sudden cardiac events in 2007, post mortem medical documentation showed that 10 had severe arteriosclerotic heart disease, five were hypertensive, four were reported to have had prior heart problems, such as previous heart attacks, bypass surgery or angioplasty/stent placement, and three were diabetic. Some of the victims had more than one condition."
"Over the past 25 years, post mortem information or other details on the victims' medical histories have been available for 720 of the 1,155 sudden cardiac death victims. Of those 720 victims, 663, or 92.1 percent, had suffered prior heart attacks, had severe arteriosclerotic heart disease, had undergone bypass surgery or angioplasty/stent placement, or were diabetic or hypertensive."
"Blood pressure screenings from 2005 through 2007 found that 6.2 percent of the tested firefighters had Stage 2 hypertension; 28.9 percent had Stage 1 hypertension and 48 percent were prehypertensive. Only 16.9 percent had normal blood pressure readings."
"Body fat was only tested in 2005, but of the almost 2,000 firefighters tested that year, 44.7 percent were found to be obese. Obesity is defined as 25 percent or more of body fat for men and 32 percent or more for women."
Note: The statistic on the percentage of firefighters who are obese appears to merit some additional research. By a commonly used measure of obesity (BMI), many athletes, particularly athletes who have utilized weight-training, are considered to be obese who obviously are not overweight (i.e., Governor Arnold Schwarzenegger).
"More than half of the firefighters over age 40 and almost two-thirds of those over age 50 who died in 2007 died of heart attacks or other cardiac events."
"Of the 36 fire ground deaths, 21 were due to asphyxiation, 7 were due to sudden cardiac death, 4 were due to internal trauma, 3 were due to burns and 1 was due to electrocution. This very high number of asphyxiation deaths includes the nine fire ground deaths in Charleston.
"Seventeen of the 32 firefighter deaths at structure fires occurred in residential properties. Fires in single-family dwellings killed 13 firefighters, and fires in apartment buildings killed four firefighters. There were nine deaths in the furniture store in Charleston. ...Two firefighters were killed in a restaurant fire, and two were killed in a building undergoing demolition. There was also one death in a fire in a farm shed and one death at a fire in a detached dwelling garage."
These last two excerpts from the NFPA report on firefighter fatalities in 2007 bring us to the topic of this column, the fire at the Sofa Super Store in Charleston, South Carolina, on the evening of June 18, 2007. Following are excerpts from the Phase II report by the Post Incident Assessment and Review Team commissioned by the City of Charleston:
“On the evening of June 18, 2007, units from the Charleston Fire Department responded to a fire at the Sofa Super Store, a large retail furniture outlet in the West Ashley district of the city. Within less than 40 minutes, the fire claimed the lives of nine firefighters and changed the lives of countless others." (page 21)
"The fire originated in discarded furniture and materials that had been placed outside the loading dock. The suspected cause of the fire was careless disposal of smoking materials." (page 21)
"The business occupied a complex of interconnected structures that had been constructed in several phases. The showroom building, facing Savannah Highway, was actually an assembly of three separate structures." (page 26)
"The main showroom was originally constructed as a grocery store, probably during the 1950s or 60s. The original building was approximately 125 feet in width and 130 feet deep, with a rectangular extension in the southwest corner (right-rear facing the building from Savannah Highway). The front wall was brick construction with large storefront windows, while the side and rear walls were constructed of concrete block. The original structure had a flat metal deck roof, supported by lightweight steel bar joists (trusses), spanning from east to west across the store. The side walls supported the ends of the bar joists, while two rows of steel beams and columns provided intermediate support. A suspended ceiling was installed below the roof trusses." (page 26)
"After the property was converted to a furniture store, two pre-engineered metal buildings were added on to the original structure to expand the showroom area. Each showroom addition was approximately 60 feet in width and 120 feet deep." (page 27)
"City of Charleston records indicate that the original structure was the only building on the site when the property was annexed into the city in 1990. Building permits were issued for the construction of the three pre-engineered structures in 1993, 1995 and 1996. The building permit files indicate that the original building and the three additions were considered as four separate structures for building code purposes. The concrete block side walls of the original structure were designated as fire walls and roll-down fire doors were installed in the six large (8' X 8') openings that connected the showrooms. A seventh roll-down fire door was installed at the point where the corridor leading to the warehouse was connected to the rear wall of the original building. All of the fire doors had fusible link release mechanisms." (page 29)
"The division of the property into four separate structures allowed the additions to be constructed without automatic sprinklers. The floor area of each individual building was below the threshold that would have required automatic sprinklers to be installed." (page 29)
"On June 18, 2007, there were no effective fire walls or physical separations to stop a fire that originated in the loading dock area from spreading into the three adjoining areas. The fire could spread directly into the rear of the original building through an open doorway. The fire could also spread to the warehouse and to the west showroom through sheet metal walls that offered no fire resistance." (page 34)
"Examination of the premises after the fire determined that three of the required exits had been compromised by the non-permitted additions and modifications and that all of the exits, with the exception of the main entrance/exit doors, were obstructed and/or locked at the time the fire occurred." (page 34)
"Photographs that were taken after the fire indicate that all of the exit doors from the showroom buildings and the warehouse were secured by padlocks and hasps or by slider mechanisms. One of the exits from the warehouse was also physically obstructed by a large shipping container. The main entrance and exit doors at the front of the showroom building were unlocked." (page 35)
"The annual fire inspection program for commercial occupancies was discontinued after the 1998 inspection was conducted. The City of Charleston Code was amended in 2001 to remove a mandatory requirement for annual fire inspections in mercantile occupancies." (page 37)
"The Fire Department had conducted pre-fire planning and familiarization visits during the intervening years. These visits did not involve code enforcement activities." (page 37)
"The City of Charleston occupies an area of almost 110 square miles, with a total estimated population of 121,247." (page 47)
"In 2007, the Charleston Fire Department included 19 fire companies, operating out of 14 fire stations. The Department employed 246 sworn members and 14 civilians with an operating budget of 14.9 million dollars." (page 47)
"The fire at the Sofa Super Store originated at approximately 19:00 hours (7:00 p.m.) on Monday, June 18, 2007. The store was open for business at the time, although no customers were present. There were five employees working in the showroom area and one in the workshop at the rear when the fire was discovered." (page 53)
"At this point in the operation, approximately 19:25, all of the firefighters who were inside the showrooms were operating in zero visibility conditions." (page 65)
"At 19:38:09, the Fire Chief broadcast "Everyone abandon the building." Captain 11 sounded the air horn on Engine 11 as a signal to abandon the building at approximately the same time. Firefighters SA1 and SA2 noted that the air horn was blowing as they were crawling back toward the front door. They were the last firefighters to escape from the building." (page 77)
"All of the deceased firefighters died from a combination of smoke inhalation and/or thermal burns." (page 81)
“The evidence indicates that the structural collapse of the roof occurred after the firefighters were incapacitated or deceased. The roof of the main showroom did not collapse until almost 20 minutes after the interior became fully involved in fire. The roof collapse did not cause their deaths." (page 81)
"The loading dock was approximately 2,200 square feet in area and contained a substantial quantity of furniture and other fuels, including containers of flammable liquids. The dock was constructed of wood, and the structure built to enclose it was wood frame covered by sheet metal. The fire had immediate access to all of this fuel." (page 84)
"The hot fire gases were probably flowing into and accumulating within the void spaces above the ceilings in both showroom areas by the time the first hose lines were being advanced into the building. The heated fire gases had access to the void spaces on both sides of the wall that divided the main and west showrooms, which caused the wall to be ineffective in limiting the spread of the fire." (page 86)
"It is impossible to determine the exact sequence of events that occurred, although the critical time was close to 19:27. The radio transmissions from firefighters in distress began at 19:27 and continued until approximately 19:35. Engineer 6 encountered the three lost firefighters in the rear section of the middle showroom at approximately 19:30." (page 88)
"At 19:26:17, Engineer 16 radioed Engineer 11 to advise that he was charging the supply line. At 19:29:02 Engineer 11 transmitted a message indicating that 'water's coming right now,' which suggests that he was charging the 2-1/2 inch line at that time. The first radio transmissions indicating that firefighters were in distress inside the building were recorded at approximately 19:28." (page 91)
"All three fire doors in the wall between the main and west showrooms failed to close, although the fusible links operated and caused the mechanisms to release." (page 92)
"The firefighters who were attempting to attack the fire from the front of the building were approximately 200 feet inside a complex building when the situation became untenable, forcing them to abandon their attack. Nine firefighters lost their lives because they were too deep inside a highly combustible smoke-filled building and could not find their way back to the entrance or locate alternative exits before they ran out of air or were overwhelmed by the fire." (page 97)
"WHEN THERE IS NO POTENTIAL TO SAVE LIVES, FIREFIGHTERS SHALL NOT BE COMMITTED TO OPERATIONS THAT PRESENT AN ELEVATED LEVEL OF RISK." (page 99)
"No building or property is worth the life of a firefighter." (page 100)
"All interior fire fighting involves an inherent risk." (page 100)
"The Charleston Fire Department did not have the resources, training, or leadership that would have been required to conduct an operation of this size and complexity in the limited time that was available." (page 102)
"In addition to the familiarization and planning aspects of pre-fire planning, the process of visiting properties and gathering information often identifies fire hazards, unusual risks and situations that require special attention. The appropriate action can vary from providing information or recommendations to the business or property owner to referring a situation for follow-up by code enforcement personnel." (page 106)
"Analysis of the recorded radio traffic indicates that the deceased members did not attempt to call for assistance until they were in critical distress. All of the recorded messages indicate that the firefighters are lost, disoriented, and either running out of air or already out of air. The firefighters were already in imminent danger, deep inside the building, when they began to call for assistance." (page 115)
"Firefighter 15A had exhausted his air supply when he exited at 19:33. He had been using his SCBA for approximately 13 minutes." (page 119)
"Captain 6 had run out of air when he exited at 19:35, approximately 12 minutes after he entered the showroom." (page 119)
"If the firefighters waited until the low pressure alarms on their SCBA activated, they would have had only 3 to 4 minutes to find an exit from the depths of the Sofa Super Store before their air supplies were exhausted. A firefighter who was disoriented or had lost contact with the hose line would have been unlikely to find a way out of the building within the limited available time." (page 120)
"The Charleston Fire Department did not have an established policy to apply the '2-in/2-out' rule for the initial phase of interior fire fighting operations nor to assign Rapid Intervention Teams during fire incidents. The OSHA Respiratory Protection Standard (29CFR1910.134) and NFPA 1500 Section 8.5 both require the assignment of at least one Rapid Intervention Team (or crew) whenever firefighters are operating in an IDLH environment. (page 121)
"It is important to recognize the limitations of a Rapid Intervention Team. Rapid intervention procedures are generally directed toward providing the ability to locate and rescue a single firefighter. It is highly unlikely that a single RIT could have entered the showroom, located and then rescued the number of firefighters who were in distress deep inside the smoke-filled building F." (page 122)
"Charleston Fire Department members routinely entered and operated in IDLH atmospheres alone. In many cases the company officer operated a hose line while the other crew members operated semi-independently. Company officers frequently lost track of their assigned crew members. Firefighters who lost track of their assigned company officers took direction from any other officer who was present or became involved in whatever task caught their attention. Members who had expended their air supplies went outside individually, obtained replacement SCBA cylinders and returned to conduct interior operations." (page 123)
"Water supply issues played a very significant role at the Sofa Super Store fire and contributed to the loss of the nine firefighters." (page 124)
"The Charleston Fire Department did not use large diameter hose for supply lines; the standard hose load on engine companies provided only a single bed of 2-1/2 inch hose that could be used as a supply line. This arrangement severely limited the volume of water that was available for fire attack." (page 124)
"The standard attack lines were configured to deliver very limited flows. The nozzles on the 1-1/2 inch preconnected lines were set to deliver 60 gallons per minute. The nozzle operator had the option of resetting the nozzle to a higher flow, if necessary, and advising the pump operator to increase the pressure to provide the higher flow rate. Larger (2-1/2 inch) attack lines were rarely used inside structures. Engine companies were not equipped with pre-piped master stream devices." (page 125)
"Conducting an offensive fire attack with two engines supplying the attack lines with tank water and no supply lines connected to hydrants is a very high risk situation under any circumstances. The risk was even greater when the particular circumstances of the Sofa Super Store are considered - a very large building with a heavy fuel load requiring firefighters to operate deep inside the structure." (page 126)
"Delays were encountered in charging both of the hose lines that were taken through the showrooms to attack the fire in the loading dock. The delays and subsequent flow interruptions placed crews in extremely dangerous situations inside the building." (page 128)
"Several other problems and interruptions in water flow were reported. The problems began during the early stages of the incident and increased as the incident grew in magnitude and complexity. The water problems became even more severe when the showrooms and the warehouse became involved and the demand for additional hose lines increased in proportion to the magnitude of the fire." (page 128)
"Most of the water problems were related to inadequate supply lines and inexperienced pump operators. The single 2-1/2 inch supply lines that were used by the Charleston Fire Department could not deliver the flows that were required to conduct an effective fire attack, even if fire hydrants had been closer to the scene." (page 129)
"Engine 11 is a 1500 gpm pumper. The maximum flow, with the 2-1/2 inch line charged, would have been approximately 350 gpm. The supply line from Engine 16 to Engine 11 was incapable of delivering more than 250 gpm." (page 129)
"The code violations would have been discovered if the City of Charleston had conducted regular fire inspections and if firefighters had been trained to identify code violations during pre-fire planning visits and report them to the Inspections Department." (page 134)
"The fire suppression operations that were conducted by the Charleston Fire Department at the Sofa Super Store did not comply with federal occupational health and safety regulations, with NFPA consensus standards or with modern fire service expectations. These deviations from standard operational and safety practices exposed firefighters to excessive risks and failed to remove the nine deceased firefighters from a critically dangerous situation." (page 134)
"The Charleston Fire Department was inadequately staffed, inadequately trained, insufficiently equipped and organizationally unprepared to conduct an operation of this complexity in a large commercial occupancy. The Department attempted to compensate for the limited resources and organizational inadequacies by engaging in dangerously aggressive and uncoordinated fire fighting operations. This placed the firefighters deep inside a large building without the systems that should have been in place to ensure their safety and to provide for the removal of all firefighters when the situation became critical." (page 134)
"The volume of fire could not be controlled by the limited flow from small hose lines. Firefighters were operating deep inside the building without the capability to control the fire and without the support systems that should have been in place to protect them. The strategy and tactics attempted by Department members were inappropriate for the situation and exposed the firefighters to extreme and unnecessary risks." (page 135)
"Fire fighting is not an exact science, and it is unrealistic to expect that every firefighter will perform flawlessly in every situation. Fire fighting is inherently dangerous and firefighters are human beings who can make mistakes. The final analysis of this incident does not suggest that any of the firefighters who lost their lives, or any of the surviving members of the Charleston Fire Department, failed to perform their duties as they had been trained or as expected by their organization. The analysis indicates that the Charleston Fire Department failed to adequately prepare its members for the situation they encountered at the Sofa Super Store Fire." (page 135)
"Fire fighting involves inherent dangers and hazardous situations that must be anticipated, recognized, evaluated and properly managed to produce positive outcomes. The mission of a fire department is to protect lives and property from those hazards, and firefighters must be prepared to perform their duties in the face of those inherent risks. The health and safety of firefighters are directly related to the ability of the fire department to skillfully and effectively perform every aspect of that mission." (page 136)
"The determination of the appropriate strategy - either offensive or defensive - is the key factor that controls firefighter safety. The determination of appropriate strategy must be based on an appropriate size-up of the situation, a realistic evaluation of the resources and capabilities that are available to conduct operations and the application of risk management principles." (page 138)
"Offensive strategy can only be effective when the fire department has the capability to conduct an interior attack that delivers a sufficient quantity of extinguishing agent by firefighters to suppress the fire. Attempting an offensive attack without the resources that are required to suppress the fire places firefighters in needless jeopardy. If an offensive attack cannot be accomplished safely and effectively with the resources at hand, it should not be attempted." (page 138)
"A successful offensive strategy requires effective action at the tactical level and coordination among actions. If the Incident Commander lacks the resources to execute the plan or the tactics are not adequately executed and coordinated, the operation cannot be accomplished safely or effectively." (page 138)
"Firefighters operating in IDLH conditions must work in teams of 2 or more, remaining in direct contact with each other at all times. The members of each team (or full company) enter, work and leave the IDLH area together." (page 139)
"Rapid Intervention Crew(s)/Team(s) must be assigned at all appropriate emergency incidents. These teams must be trained, equipped and prepared to provide assistance to firefighters in distress." (page 139)
"All Charleston Fire Department members must be trained to recognize hazardous conditions and situations, such as lightweight construction and unusual fire loads and to react appropriately." (page 139)
"Mitigation programs to reduce or eliminate excessive risk levels should be encouraged and supported. Measures that mandate or provide incentives to encourage the installation of automatic sprinklers or support alternative fire protection measures should be adopted as public policy. The City of Charleston should continue to encourage actions at the state level that will support these efforts." (page 143)
"All Charleston firefighters should be trained and should have a specific responsibility to recognize fire hazards and code violations and to initiate appropriate corrective actions." (page 143)
"The City of Charleston should also work closely with the Water System to ensure that sprinkler system connections are provided at the least possible cost." (page 144)
"Coordination with the Charleston Department of Public Service, Building Inspections Division to assure that fire safety concerns observed by firefighters are corrected, to assure that code compliance inspections of commercial occupancies are conducted on a regular basis, and to assure that buildings are constructed utilizing fire safe practices." (page 144)
"The building was last inspected by a City of Charleston fire inspector on March 30, 1998." (page G-4)
"Charleston Fire Department personnel visited the store on multiple occasions between 1998 and 2007 for pre-fire planning purposes. A Sofa Super Store employee noted that they made some safety and prevention suggestions during their visits." (page G-4)
"Roll-down fire doors in required fire separations did not operate properly." (page G-5)
Discussion
A meeting to address the issue of firefighter life safety, referred to as a Firefighter Life Safety Summit, took place in Tampa, Florida, in March 2004. The following are excerpts from the report on the Summit:
"An unprecedented gathering of the leadership of the American fire service occurred on March 10th and 11th, 2004, when more than 200 individuals assembled in Tampa to focus on the troubling question of how to prevent line-of-duty deaths."
"The Summit marks a significant milestone, because it is the first time that a major gathering has been organized to unite all segments of the fire service behind the common goal of reducing firefighter deaths."
"This is the first step along a path that will require a huge commitment of energy and resources over several years. Some of the initiatives that were agreed upon will involve radical changes for the fire service."
"The essence of professionalism in the fire service is the ability to function safely and effectively within that dangerous environment. We will never be able to eliminate all of the risks, but we can be very well prepared to face most of them."
"The willingness of firefighters to risk their own lives to save others must never be used as an excuse to take unnecessary risks. Firefighters are highly respected for being willing to risk their own lives to save others, but that cannot justify taking unnecessary risks in situations where there is no one to save and nothing to be gained. In too many cases firefighters lose their lives while trying to save property that is already lost or to rescue victims who are already dead. While these efforts are valiant, they are also futile. Individual firefighters who take unnecessary risks, or fail to follow standard safety practices, endanger their own lives as well as the lives of other firefighters who are depending on them or who might have to try to rescue them."
In a nutshell, this last excerpt summarizes the investigation report on the fire at the Sofa Super Store. While the report on the Sofa Super Store fire specifically addresses the operations of the Charleston Fire Department, the observations and recommendations contained in the report are really applicable to every fire department in the United States.
It is interesting to note the similarities in the operations of the Charleston Fire Department at the Super Store fire and the operations of the Chicago Fire Department at the fire at the Cook Country Administration Building on October 17, 2003. Like the Chicago Fire Department at the County Administration Building, the chief officers of the Charleston Fire Department failed to take control of the fire companies working the fire. It's apparent that the Charleston Fire Department didn't learn much from the investigation into the Cook County Administration Building fire. (Perhaps that's because the two investigation reports on the fire in downtown Chicago were so poorly written, despite the outrageous cost to the taxpayers of the State of Illinois for these reports.) From my perspective as a building code consultant, what I found most interesting in the Super Store investigation report were the comments regarding building code compliance and how the lack of inspections and code enforcement directly impacted firefighter safety at the fire. As has been previously stated in this column, the inspection of existing buildings for continued code compliance by the fire service is just as much part of the job of a firefighter as is actual fire fighting. Unfortunately, it cost the Charleston Fire Department the lives of nine firefighters to find out that this statement is true.
A little more than twenty-five years ago (1980 - 1982), I worked as the fire protection engineer for the San Jose (California) Fire Department, reviewing architectural drawings for code compliance and performing field inspections of new high-rise buildings and hospital construction. It was clear to me back then that few of the firefighters in the department of 600 had any interest in or respect for the activities of the fire prevention bureau. Few firefighters showed any appreciation of the fire prevention bureau's efforts. The report on the Charleston Fire Department confirms that the fire service's attitude toward fire prevention activities hasn't changed all that much in the last quarter century.
Will the fire service's attitude toward fire prevention change now? It's hard to say, but I certainly have my doubts.
Conclusion
Just one final comment regarding the Super Store investigation report. The authors of the report, J. Gordon Routley, Michael D. Chiaramonte, Brian A. Crawford, Peter A. Piringer, Kevin M. Roche and Timothy E. Sendelbach, have done a fine job with their report and deserve a standing ovation. The report is clear and concise and the writing is excellent.
One of the questions that remain is whether the observations and recommendations contained in the report will be implemented, not only by the City of Charleston Fire Department, but, even more importantly, by the rest of the fire service. Firefighters or civilians (as was the case at the Cook County Administration Building) shouldn't have to die in order for the fire service to begin to realize that there is more to fire fighting than simply putting the "wet stuff on the hot stuff."
Richard Schulte is a 1976 graduate of the fire protection engineering program at the Illinois Institute of Technology. After working in various positions within the fire protection field, he formed Schulte & Associates in 1988. His consulting experience includes work on the Sears Tower and numerous other notable structures. He has also acted as an expert witness in the litigation involving the fire at the New Orleans Distribution Center. He can be contacted by sending e-mail to rschulte@plumbingengineer.com.