NIOSH Report Issue: Seven Career Fire Fighters Injured at a Metal Recycling Facility Fire – California
NIOSH Exective Summary
On July 13, 2010, seven career fire fighters were injured while fighting a fire at a large commercial structure containing recyclable combustible metals. At 2345 hours, 3 engines, 2 trucks, 2 rescue ambulances, an emergency medical service (EMS) officer and a battalion chief responded to a large commercial structure with heavy fire showing. Within minutes, a division chief, 2 battalion chiefs, 3 engines, 3 trucks, 4 rescue ambulances, 2 EMS officers and an urban search and rescue team were also dispatched.
An offensive fire attack was initially implemented but because of rapidly deteriorating conditions, operations switched to a defensive attack after about 12 minutes on scene. Ladder pipe operations were established on the 3 street accessible sides of the structure. Approximately 40 minutes into the incident, a large explosion propelled burning shrapnel into the air, causing small fires north and south of structure, injuring 7 fire fighters, and damaging apparatus and equipment. Realizing that combustible metals may be present, the incident commander ordered fire fighters to fight the fire with unmanned ladder pipes while directing the water away from burning metals. Approximately 2 ½ hours later, two small concentrated areas remained burning and a second explosion occurred when water contacted the burning combustible metals. This time no fire fighters were injured.
- Unrecognized presence of combustible metals
- Unknown building contents
- Unrecognized presence of combustible metals
- Use of traditional fire suppression tactics
- Ensure that pre-incident plans are updated and available to responding fire crews
- Ensure that fire fighters are rigorously trained in combustible metal fire recognition and tactics
- Ensure that policies are updated for the proper handling of fires involving combustible metals
- Ensure that first arriving personnel and fire officers look for occupancy hazard placards on commercial structures during size-up
- Ensure that all fire fighters communicate fireground observations to incident command
- Ensure that fire fighters wear all personal protective equipment when operating in an immediately dangerous to life and health environment
- Ensure that an Incident Safety Officer is dispatched on the first alarm of commercial structure fires
- Ensure that collapse/hazards zones are established on the fireground.
The fire department had a comprehensive list of SOGs and policies. However, the policy for the extinguishment of combustible metal fires was out dated. This policy called for copious amounts of water to be put on the combustible metal fire. The SOG for pre-incident planning was followed at this incident. However, due to the constantly changing business environment, the company had submitted a business plan that identified hazards to the city but this information did not get updated in the computer-aided dispatching (CAD) database for the fire department or dispatch.
A month prior to this incident on June 11, 2010, at 11:00 a.m., the same business owner’s metal processing facility located diagonally across the street from this incident, had several small explosions and fire. This incident required 36 fire department companies, 16 rescue ambulances, 1 USAR team, 2 hazardous material teams, 7 BCs, 1 DC, and a DDC, totaling 248 fire department personnel, in addition to mutual aid. Approximately 2 ½ hours of fire suppression operations with water brought the fire under control, which encompassed a 150′ x 100′ area of combustible metal shavings.
The company had metal –X (a brand of combustible metal fire extinguishing agent) available, but not enough of it to be effective. No fire fighters were injured. However, a civilian worker was critically injured and a police officer received minor injuries.
NIOSH REPORT 2010-30 Direct Link HERE
Fom the LAFD Press Release on July 15, 2010
On Tuesday, July 13th, 2010 at 11:43 PM, 41 Companies of Los Angeles Firefighters, 21 LAFD Rescue Ambulances, 3 Arson Units, 1 Urban Search and Rescue Unit, 1 Rehab Unit, 1 Hazardous Materials Team, 3 EMS Battalion Captains, 8 Battalion Chief Officer Command Teams, 1 Division Chief Officer Command Team and 2 Bulldozers under the direction of Deputy Chief Mario Rueda responded to a Major Emergency Structure Fire at 761 East Slauson Avenue in South Los Angeles (CA).
More than 200 Los Angeles Firefighters were requested over the course of the incident to help battle a blaze at a large two-story commercial structure that encompassed six occupancies over an entire city block. Firefighters quickly arrived at United Alloys and Metals to find heavy fire at an industrial facility known for processing titanium and super alloy scrap.
The 73 year-old structures between Paloma Avenue and Mckinley Avenue, were quickly engulfed in flames and forced firefighters into a defensive attack early during this huge fire fight. Shortly after midnight the decision was made to pull all Firefighters out of the structure and attack the flames from the exterior.
Approximately 20 minutes following this decision a partial wall collapse, roof collapse, and a total of three explosions took place. These massive blasts rained down debris of concrete and titanium on Firefighters and even shattered windows of emergency vehicles.
From this point forward it became a heavy stream operation with ladder pipes and portable monitors that provided huge volumes of water against the intense flames. Despite the challenges of extinguishing burning titanium and the devastating explosions, the blaze was controlled in just five hours. Exhausted Firefighters were relieved the next morning by their colleagues who continued the extended overhaul and detailed salvage procedure. Link HERE
LAFD News and Information Web Site; HERE
The at the time of the fire LAFD stated damage was estimated at $5,000,000 ($4,000,000 structure & $1,000,000 contents).
The LAFD battled a similar blaze at 900 East Slauson Avenue on Friday, June 11th in 2010.
Fire Scene Photo from LAFD News HERE
The incident involved a 45,000 square foot multiple business commercial structure that measured approximately 300′ x 150′ and was built in 1939. The commercial structure was divided into 3 sections with both Type III and Type V (metal clad) construction. The A-side (west) of the structure measured 60′ x 100′ under a heavy timber bowstring truss roof and exterior block walls covered with a stucco finish. This section of the structure contained denim fabric altering machinery.
The larger 210′ x 150′ open warehouse middle section of the structure was under a metal sawtooth roof (a roof composed of a series of small parallel roofs of triangular cross section, usually asymmetrical with the vertical slope glazed or windowed to allow for light) with concrete reinforced metal beam exterior walls covered with an exterior stucco finish. This section of the structure contained bins, bales, and piles of recyclable metals. The C-side of the structure was an office area that measured approximately 30′ x 150′. It was comprised of two stories with a conventional flat roof, wood framed interior walls, and concrete reinforced metal beam exterior walls covered with an exterior stucco finish.
Occupancy hazard placards existed at the A and C/D corner of the structure. The placards had a 3 health rating (a serious hazard) in the blue quadrant, a 4 flammability rating (flammable gases, violate liquids, pyrophoric materials) in the red quadrant, a 2 instability rating (a violent chemical change possible at elevated temperatures and pressure) in the yellow quadrant, and an OX (material is an oxidizer) in the white quadrant.
The commercial structure had been recently acquired, within the past year or two, by a local metal recycling company. The company had submitted the annual business plan to the city, which identified potential hazards, but this information had not been updated in the computer-aided dispatch (CAD) database for the dispatch center or fire department. The construction features of the occupancy such as the bowstring trusses, presence of combustible metals, and access restrictions would have been critical information to the fire department for fighting a fire at this location. The fire department had pre-planned the structure prior to the metal recycling company acquiring the commercial structure.
BC11 left the command post and was walking towards T10 and T66 when an upper section of wall on the D-side near the C/D corner collapsed followed by a larger upper midsection of wall on the D-side. BC11 recalled seeing white hot metal and was about to instruct the trucks to direct water away from the white burning metals. Seconds later, approximately 40 minutes into the incident, at 0026 hours, a large explosion propelled burning shrapnel into the air and caused small fires north and south of the structure. T33 and E66′s hoseline crews were blown backwards by the blast. T10 and mutual aid E9 were hit with flaming debris which broke through E9′s driver-side door window and ignited the seat.
T10 received several large dents and wooden ground ladders were ignited. Approximately 10 feet away, T10′s hoseline crew was blown approximately 20′ back and off the 2 ½” hoseline by the explosion. T10′s captain was backing up the nozzleman and was hit with burning debris causing serious burns on his hand and ear. T66′s captain jumped on the hoseline to stop it from whipping around. T10′s fire fighter operating the ladderpipe had seen 2 white flashes and greenish plumes just prior to explosion. When the explosion occurred he turned his head to the left causing pain and ringing in his right ear as white hot debris went all around him. Multiple hose beds and hoses on the ground were burned through. The explosion was reported to have been broadcast up and out in all directions .
The IC called for a personnel accountability report (PAR) which accounted for all personnel and indentified 2 injured fire fighters and a captain. Note: The other 4 fire fighters injuries were not made apparent until after the incident. Minutes later, the Division C chief (BC13) reported to the IC that he identified a National Fire Protection Association 704 placard above the entrance door on the C/D corner of the structure.
BC13 relayed to command the placard classifications of Health – 3, Flammability – 4, Reactivity – 2, and Special Hazards – OXIDIZER. The command team discussed the current fire department policy of using copious amounts of water on combustible metals and decided to alter the tactical plan based on information learned through the 704 placard and the fire conditions. The IC called for aerial ladderpipe personnel to move from the tip of the aerial to the aerial turntable. Note: When the decision is made to go defensive, ladderpipe personnel should be removed from the tip of the aerial to minimize any risk associated with being at an elevated height, such as explosions or falling. On Division C, two monitors and a 2 ½” hoseline were directed on the office area of the structure.
Recommendation #1: Fire departments should ensure that pre-incident plans are updated and available to responding fire crews.
Discussion: NFPA 1620 Standard for Pre-Incident Planning, states “The purpose of this document shall be to develop pre-incident plans to assist responding personnel in effectively managing emergencies for the protection of occupants, responding personnel, property, and the environment.” A pre-incident plan identifies deviations from normal operations and can be complex and formal, or simply a notation about a particular problem such as the presence of flammable liquids, explosive hazards, modifications to structural building components, or structural damage from a previous fire.
Building characteristics including type (or more importantly risk) of construction, materials used, occupancy, fuel load, roof and floor design, and unusual or distinguishing characteristics should be recorded, shared with other departments who provide mutual aid, and if possible, entered into the dispatcher’s computer so that the information is readily available if an incident is reported at the noted address.
Since many fire departments have thousands to hundreds of thousands of structures within their jurisdiction, it is a challenge to establish an effective preplanning system that addresses all structures and hazards. Priority should be given to those locations having elevated or unusual fire hazards and life safety considerations.
Written SOGs enable individual fire department members an opportunity to read and maintain a level of assumed understanding of operational procedures. Conversely, fire departments can suffer when there is an absence of well developed SOGs. The NIOSH Alert: “Preventing Injuries and Deaths of Fire Fighters” identifies the need to establish and follow fire fighting policies and procedures. Guidelines and procedures should be developed, fully implemented and enforced to be effective. Periodic refresher training should also be provided to ensure fire fighters know and understand departmental guidelines and procedures.
One tool for fire departments to use in assessing their risks for structures within their jurisdictions is the mnemonic, BECOME SAFE:
- Operational hazards
- Manage time and elements
- Situational awareness
- Assessment and risk analysis
- Fire behavior and effects
- Evaluate and execute 7
A pre-planning process should integrate the BECOME SAFE concepts and include updated information from the annually submitted business plans and any other pertinent fire safety information needs to be developed by involving fire department personnel, dispatch center personnel, and building and fire code officials. NFPA 1, Fire Code, Annex Q, Fire Fighter Safety Building Marking System, makes direct reference to potential resolution towards identifying structures and contents.
It contains a standard symbol that integrates information about building construction features, content hazards, life safety systems and NFPA 704 placards into one placard. High hazard and life safety considerations for the storage, handling, and manufacturing of chemicals should be indicators to prioritize processing of the information and expediting it to the CAD system.
Current and correct information is needed to adequately address risk management issues and to comply with NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, Annex A, Section 8, that addresses guidelines for the IC to consider when evaluating risk versus gain.
In this incident, the construction features of the occupancy, such as the bowstring trusses, presence of combustible metals, and access restrictions, would have been critical information to the fire department for fighting a fire at this location. A more complete pre-planning process and/or business plan updating process, involving fire department personnel, dispatch center personnel, and building code officials could have noted this information which may have aided the IC in developing a safer and more effective offensive or defensive strategy. In order to facilitate open communication, fire department personnel, dispatch center personnel, and building and fire code officials should develop a process to effectively update building information and to share this information in a timely manner. The relay of this information could be used to facilitate dynamic risk management and enhanced command and control. (Note: The fire department did a business survey following this incident and found 68 business sites that had combustible metals.)
Recommendation #2: Fire departments should ensure that fire fighters are rigorously trained in combustible metal fire recognition and tactics.
Discussion: Fire departments often respond to complex or unique hazards which require specialized/advanced knowledge and/or training in dealing with that hazard. Combustible metal fires present unique and dangerous hazards to fire fighters which are not commonly encountered in conventional structure fire fighting operations. The temperatures encountered in a combustible metal fire far exceed those of a structure fire.A block wall near the first explosion had an appearance of brown and black glass, suggesting that temperatures exceeded 3000 degrees F
The National Fire Protection Association (NFPA) 484, Standard for Combustible Metals, states that it is extremely important to conduct a good size-up by identifying the combustible metals involved, the physical state of the metals (e.g., shavings, chips, fine dust, etc.), the location relative to other combustible materials, and the quantity of the product involved. NFPA 484, A.188.8.131.52.3, states that the application of a wet extinguishing agent (particularly water hose streams) accelerates a combustible metal fire and could result in an explosion.
This is due to the water reacting with the combustible metal and giving off highly flammable hydrogen gas and oxygen. This conversion of water into hydrogen has a heat value (British Thermal Units per pound (Btu/lb)) of about 2.8 times that of gasoline, assuming 100 percent conversion of the hydrogen in the water. This equates to flowing 42.8 gallons per minute (gpm) of gasoline on the fire for every 100 gpm of water. NFPA 484, A.184.108.40.206, states that the following agents shall not be used as extinguishing agents on a combustible metal fire because of adverse reactions or ineffectiveness: water, foams, halon, carbon dioxide, nitrogen (except on iron, steel, and alkali metals, excluding lithium), and halon replacement agents.
Thus, in lieu of using a wet extinguishing agent, primarily water, it is recommended that a bulk dry extinguishing agent compatible with the product involved, such as dry sand, dry soda ash, or dry sodium chloride, be used. In most cases for large fires beyond the incipient stage, the application of a dry agent is not feasible. In these cases the best approach is to isolate the material as much as possible, protect exposures, and allow the fire to burn out naturally. Thorough training is a must to properly identify and handle these unique fires. Businesses that manufacture, use or store combustible metals, and fire departments with combustible metals in their jurisdiction, should review Chapter 13 of the National Fire Protection Association (NFPA) 484: Standard on Combustible Metals.12
Combustible metal fire training should only occur in the classroom since combustible metals are not a practical substance to use for live exercises. The excessive temperatures and the unstable nature of combustible metals when burning would put fire fighters in an unnecessary and dangerous situation, if used in live exercises.
In this incident, several fire fighters noticed the unusually bright white hot fire, white sparks, bluish green hues of the fire, and white smoke but did not recognize that this could be indicative of burning combustible metals. The fire department did not suspect that combustible metals were present until after the first explosion and the discovery of the placard indicating oxidizers were in the structure. Once identified, command directed water away from areas of suspected burning combustible metals. Later in the incident, a few concentrated areas remained burning, and copious amounts of water were directed on these areas to extinguish them. This caused a second explosion, in which no one was hurt. The titanium that was involved in the second explosion had developed a protective crust during the fire which was over 2 feet thick and contributed to the shaped charge effect when the molten metal under the protective crust came in contact with the water being applied by the ladderpipes and exploded. The development of the protective crust is a normal occurrence in combustible metal fires which actually limits open burning of the combustible metal and will result in control and extinguishment of the fire, if no actions are taken which disturb the protective crust.
In June, an incident had occurred diagonally across the street at different structure, owned by the same company, where the fire department had a combustible metal fire and was informed by employees not to use water. The fire department updated their training bulletin addressing tactics for combustible metals and removed the use of copious amounts of water.
Recommendation #3: Fire departments should ensure that policies are updated for the proper handling of fires involving combustible metals.
Discussion: The fire department had an outdated policy on the handling of combustible metal fires which primarily called for copious amounts of water to be put on a metal fire. The policy had been based on a training scenario in which burning magnesium Volkswagen engine blocks, when hit with water, would spark, but the water cooled the large mass of magnesium enough to put the fire out. Numerous fire departments across the country remember this training scenario and have not kept up with the increasing and varied uses of combustible metals in everyday products. Manufacturing and recycling facilities for these combustible metal products have been on the rise. This poses a new and different hazard for fire fighters. Combustible metals in smaller pieces and particle sizes burn at much higher temperatures, 5000 degrees F for magnesium to 8500 degrees F for zirconium, and present an explosion hazard when water comes into contact with these burning metals. When applied to burning combustible metals, water and carbon dioxide will disassociate into their base chemical elements. For example, water disassociates into hydrogen and oxygen. The added fuel and oxygen increases burning and causes extreme reactions, such as explosions. An example standard operating procedure (SOP) for the proper handling of combustible metal fires that reflects modern day hazards is provided in
Recommendation #4: Fire departments should ensure that first arriving personnel and fire officers look for occupancy hazard placards on commercial structures during size-up.
Discussion: NFPA 704, Identification of the Hazards of Materials for Emergency Response, states that all buildings or areas storing, using, or handling hazardous materials should be marked by use of a standardized placard system. The placard system identifies hazard categories for health, flammability, reactivity and special hazards, including water reactivity and oxidizers.
When conducting a size-up at commercial structures, fire officers should look for such placards. Placard locations should be located at or near entrances and unobstructed by landscaping, fencing, etc.
In this incident, placards existed at the A and C/D corner of the structure. However, they were not identified until after the explosion. The late night hour, poor lighting, angled corners of structure, and fire attack from doorways other than the front entrance may have contributed to first arriving personnel and fire officers not seeing and acting upon the information on the placard.
Recommendation #5: Fire departments should ensure that all fire fighters communicate fireground observations to incident command.
Discussion: National Fire Protection Association (NFPA) 1561, Standard on Emergency Services Incident Management System, Section 6.3 Emergency Traffic states: To enable responders to be notified of an emergency condition or situation when they are assigned to an area designated as immediately dangerous to life or health (IDLH), at least one responder on each crew or company shall be equipped with a portable radio and each responder on the crew or company shall be equipped with either a portable radio or another means of electronic communication.The U.S. Fire Administration report, Voice Radio Communications Guide for the Fire Service, provides an overview of radio communication issues involving the fire service. Effective fireground radio communication is an important tool to ensure fireground command and control as well as helping to enhance fire fighter safety and health. It is every fire fighter and company officer’s responsibility to ensure radios are properly used. Ensuring appropriate radio use involves both taking personal responsibility (to have your radio, having it on, and on the correct channel) and a crew-based responsibility to ensure that the other members of your crew (subordinates, peers, and supervisor) are doing so as well.
Receiving interior/exterior status updates is critical to the safety of fire fighters on the incident, rescue/recovery efforts, and overall control of the incident. The decision to commit interior fire fighting personnel or establishing a collapse/hazard zone for exterior fire fighting personnel should be made on a case-by-case basis with proper risk-benefit decisions being made by the incident commander.
The fireground is very dynamic, and conditions can either improve or deteriorate based on fire suppression activities, and available resources, and most importantly assessments/size-ups of the incident are necessary to detect a change on the fireground.
In this incident, several fire fighters noticed the unusually bright white hot fire, white sparks, bluish green hues of the fire, and white smoke (all potential signs of combustible metal involvement), but did not communicate it to command.
Recommendation #6: Fire departments should ensure that fire fighters wear all personal protective equipment when operating in an immediately dangerous to life and health environment.
Discussion: NFPA 1500 Standard on Fire Department Occupational Safety and Health Program states, “the fire department shall provide each member with protective clothing and protective equipment that is designed to provide protection from the hazards to which the member is likely to be exposed and is suitable for the tasks that the member is expected to perform…protective clothing and protective equipment shall be used whenever a member is exposed or potentially exposed to the hazards for which the protective clothing (and equipment) is provided.”
NFPA 1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting has established minimum requirements for structural fire fighting protective ensembles and ensemble elements designed to provide fire fighting personnel limited protection from thermal, physical, environmental, and bloodborne pathogen hazards encountered during structural fire fighting operations.
These requirements will assist in protecting firefighters, but only if they wear the PPE as recommended by the manufacturer. The potential for injury at all incidents exists when fire fighters do not wear the full PPE ensemble, including gloves.
In this incident, numerous fire fighters did not don their facepiece and/or wear hoods or gloves. The potential for unknown toxic gases and flying debris as evidenced by the 2 explosions makes wearing full PPE critical for protecting fire fighters from immediate and chronic hazards. If gloves and hoods had been worn, the hand and ear burn injuries would have been less severe or perhaps totally eliminated.
Recommendation #7: Fire departments should ensure that an Incident Safety Officer is dispatched on first alarm of commercial structure fires.
Discussion: According to NFPA 1561 Standard on Emergency Services Incident Management System, “The incident commander shall have overall authority for management of the incident and the incident commander shall ensure that adequate safety measures are in place.” This shall include overall responsibility for the safety and health of all personnel and for other persons operating within the incident management system. While the incident commander is in overall command at the scene, certain functions must be delegated to ensure adequate scene management is accomplished.According to NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, “as incidents escalate in size and complexity, the incident commander shall divide the incident into tactical-level management units and assign an incident safety officer (ISO) to assess the incident scene for hazards or potential hazards.” These standards indicate that the incident commander is in overall command at the scene, but acknowledge that oversight of all operations is difficult. On-scene fire fighter health and safety is best preserved by delegating the function of safety and health oversight to the ISO. Additionally, the incident commander relies upon fire fighters and the ISO to relay feedback on fireground conditions in order to make timely, informed decisions regarding risk versus gain and offensive-versus-defensive operations. The safety of all personnel on the fireground is directly impacted by clear, concise, and timely communications among mutual aid fire departments, sector command, the ISO, and the incident commander. NFPA 1521 Standard for Fire Department Safety Officer defines the role of the ISO at an incident scene and identifies duties such as recon of the fireground and reporting pertinent information back to the incident commander; ensuring the department’s accountability system is in place and operational; monitoring radio transmissions and identifying barriers to effective communications; and ensuring established safety zones, collapse zones, hot zones, and other designated hazard areas are communicated to all members on scene.
Larger fire departments may assign one or more full-time staff officers as incident safety officers who respond to working fires. In smaller departments, every officer should be prepared to function as the ISO when assigned by the incident commander. The presence of an incident safety officer does not diminish the responsibility of individual fire fighters and fire officers for their own safety and the safety of others. The ISO adds a higher level of attention and expertise to help the fire fighters and fire officers. The ISO must have particular expertise in analyzing safety hazards and must know the particular uses and limitations of protective equipment.
In this incident, for the size of the fire department and responsible coverage area, there is an insufficient number of incident safety officers (ISO) and/or qualified personnel (certified to NFPA 1521) to act as an ISO. The ISO should be of a rank worthy of the significant responsibility.
Recommendation #8: Fire departments should ensure that collapse/hazard zones are established on the fireground.
Discussion: During fire operations, two rules exist about structural collapse: (1) the potential for structural failure always exists during and after a fire, and (2) a collapse danger zone must be established.
A collapse zone is an area around and away from a structure in which debris might land if a structure fails. The collapse zone area should be at least 1½ times the height of the building—the height of the building plus an additional allowance for debris scatter. For example, if the wall was 20 feet high, the collapse zone would be established at least 30 feet away from the wall. In this incident, the structure was approximately 18 feet high at the top of the parapet wall, and the collapse zone extended at least 27 feet from the structure.
Fire fighters must recognize the dangers and take immediate safety precautions if factors indicate the potential for a building collapse. An external load—such as a parapet wall, steeple, overhanging porch, awning, sign, or large electrical service connections—reacting on a wall weakened by fire conditions may cause the wall to collapse. Other factors include fuel loads, building damage, renovation work, pre-existing deterioration as well as deterioration caused by the fire, support systems, and truss construction.
Whenever these contributing factors are identified, all persons operating inside the structure must be evacuated immediately and a collapse zone should be established around the perimeter. Once a collapse zone has been established, the area should be clearly marked and monitored to make certain that no fire fighters enter the danger zone. Positioning companies at the corners of the building is usually safer than a frontal attack. In this incident, a collapse zone should have been established given the age of the structure and deteriorating fire conditions.
Recommendation #9: Vendors/Training Organizations should develop and offer a training program on combustible metal fires.
Discussion: There are a limited amount of training materials/programs that exist on combustible metal fires. There have been a small number of presentations and workshops conducted at fire conferences over the years but nothing offered by outside training organizations that pertains to what the fire service needs to know. Programs should be developed to highlight the characteristics of a combustible metal fire, tactics, and strategies for handling them.