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Texas Captain; 2010 LODD Report Issued with Lessons Learned

By Christopher J. Naum, SFPE on Jul 04, 2011 with Comments 0

Captain Thomas Araguz III

Captain Araguz, a 30 year old, 11-year veteran of the Wharton Volunteer Fire Department made Captain in 2009. He lost his life while battling a multiple alarm fire a the Maxim Egg Farm located at 3307 FM 442, Boling, Texas on July 3, 2010. The Texas State Fire Marshal’s Office issued the Fire Fighter Fatality Investigation Report, SFMO Case Number FY10-01 that provides a detailed examination of the incident, operations and yeilds findings and recommendations. A full version of the report is available at the Texas SFMO web site HERE.

On July 3, 2010, Wharton Volunteer Fire Department Captain Thomas Araguz III was fatally injured during firefighting operations at an egg production and processing facility. At 9:41 PM, Wharton County Sheriff’s Office 911 received a report of a fire at the Maxim Egg Farm located at 3307 FM 442, Boling, Texas. Boling Volunteer Fire Department and the Wharton Volunteer Fire Department responded first, arriving approximately 12 minutes after dispatch. Eventually, more than 30 departments with 100 apparatus and more than 150 personnel responded. Some departments came as far as 60 miles to assist in fighting the fire.

Aerial View

The fire involved the egg processing building, including the storage areas holding stacked pallets of foam, plastic, and cardboard egg cartons and boxes. It was a large windowless, limited access structure with large open areas totaling over 58,000 square feet. A mixed construction, it included a two-story business office, the egg processing plant, storage areas, coolers, and shipping docks. It was primarily metal frame construction with metal siding and roofing on a concrete slab foundation with some areas using wood framing for the roof structure.

Captain Araguz responded to the scene from the Wharton Fire Station, approximately 20 miles from the fire scene, arriving to the front, south side main entrance 20 minutes after dispatch. Captain Araguz, Captain Juan Cano, and Firefighter Paul Maldonado advanced a line through the main entrance and along the south, interior wall to doors leading to a storage area at the Southeast corner.

Maldonado fed hose at the entry door as Captains Araguz and Cano advanced through the processing room. Araguz and Cano became separated from the hose line and then each other. Captain Cano found an exterior wall and began kicking and hitting the wall as his air supply ran out. Firefighters cut through the exterior metal wall at the location of the knocking and pulled him out. Several attempts were made to locate Captain Araguz including entering the building through the hole and cutting an additional hole in the exterior wall where Cano believed Araguz was located. Fire conditions eventually drove the rescuers back and defensive firefighting operations were initiated.

Captain Cano was transported to the Gulf Coast Medical Center where he was treated and released. Captain Araguz was recovered at 7:40 AM, the following morning. Initially transported by ambulance to the Wharton Funeral Home then taken to the Travis County Medical Examiner’s Office in Austin, Texas for a post-mortem examination.

Site Plan of Building Complex

Building Structure and Systems

The fire incident building was located on the property of Maxim Egg Farm, located within an unincorporated area of Wharton County. The 911 address is 580 Maxim Drive, Boling, Texas 77420.

Wharton County has no adopted fire codes, or model construction codes, and no designated Fire Marshal on staff that conducts fire safety inspections within their jurisdiction.

National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2009 Edition, is adopted by the State Fire Marshal’s Office, and is the applicable standard for fire and life safety inspections in the absence of an adopted fire code within unincorporated areas of a county by an applicable authority. All references regarding evaluation of the incident building in relation to minimum life safety requirements are based on NFPA 101, Life Safety Code, 2009 Edition.

Maxim Farm property includes 23 chicken coops known as layer barns that average 300 feet long and 50 feet wide holding between 15,000 to 25,000 chickens each. These layer barns inter-connect to a central processing building by a series of enclosed conveyor belts transporting over one million eggs daily.

The property includes integrated feed silos, water tanks, and waste management facilities. Additional areas on the property include equipment barns, shipping offices, loading docks, coolers, storage areas, and business offices.

Overall Building Description

The main processing structure was an irregularly shaped mixed construction of metal, concrete block, and wood framing on a concrete slab foundation with approximately 58,000 square feet of space. Three dry-storage rooms connected by a wide hallway lined the east side of the plant. A concrete block (CMU) wall separated the egg processing area from the East Hallway and storage rooms. Coolers were located north of the processing room with the loading docks along the west side of the structure. The loading docks were accessible from the processing room, Cooler 3, and Cooler 2. Cooler 1 was located at the north end of Dry Storage 2. A two-story building housing the business office was attached to the main processing plant at the southwest corner.

Construction Features

The building construction was classified as an NFPA 220, Type II-000 construction with an occupancy classification by the Life Safety Code as Industrial with sub-classification as special-purpose use. The Life Safety Code imposes no minimum construction requirements for this type of occupancy.

The predominant use of the building was to process and package fresh eggs for shipment after arriving by automated conveyor directly from a laying house adjacent to the building. The general floor plan of the building consisted of a large egg processing room, with surrounding areas used for storage of packing materials and two large drive-in coolers for holding packaged eggs prior to shipping.

Building construction consisted of a combination of steel and wood framing with a sheet metal exterior siding and roofing over a low-pitch roof on a concrete slab foundation. Structural elements within the interior of the building were exposed and unprotected with no fire-resistance rated materials applied. The load bearing structural elements consisted of steel beams, and steel pipe columns, with steel open web trusses supporting the roof structure.

Wood components were also used as part of the load bearing elements and wall framing.
Perimeter walls of the cooler compartments were constructed of concrete masonry units (CMU).
The building was not separated between other areas of use by fire-resistance rated assemblies.
Ancillary facilities located within the building used for administrative offices and other incidental spaces were constructed of wood framing with a gypsum wallboard finish.

Detailed Construction Features

The front of the structure faced to the south where the main entrance to the processing room and business offices was located approximately 4 feet above the parking lot grade level and accessed by a series of steps. The business office was a two-story wood frame construction with a vinyl exterior siding under a metal roof on a concrete slab foundation. Additional separate, single-story, wood frame structures with offices located to the west of the main business office connected by covered walkways.

Processing Room

The egg processing room was 141 feet along the east and west walls and approximately 100 feet along the north and south walls. The processing room received the eggs transported from the layer barns on the conveyer belt system. The room contained the processing equipment and conveyor systems where eggs were cleaned, graded, packaged and moved to large coolers to await shipment. The construction of the processing room was sheet metal panels embedded into the concrete slab foundation supported by 8-inch wide metal studs. Sheet metal panels lined the exterior and interior sides of the south and west walls with fiberglass insulation sandwiched between.

Main Processing Area

The north wall separated the processing room from Cooler 3 and consisted mainly of interlocking insulated metal panels embedded into the slab locked at the top in metal channels. Their interior surface was polyurethane laminate.

The east wall was mainly of concrete block (CMU) construction. A USDA office and a mechanics room were accessed through doors in the east wall of the processing room. The northeast corner of the processing room extended into the north end of the east hallway, forming an 18 feet by 18 feet area with wood frame construction on a concrete stem wall with fiber cement board (Hardy board) and metal panel siding. A 6-feet wide opening between the processing and dry-storage areas with a vinyl strip door allowed unrestricted access.

Along the south wall of the processing room, a walkway between the processing equipment and exterior wall led to swinging double doors at the southeast corner to enter into Dry Storage 3. Conveyors carried the eggs from the north and south layer barns through openings in the walls of the extension of the processing room. The conveyors from the north and south layer barns entered the building suspended overhead. As the conveyors approached the entrance to the main processing room, they gradually descended to 3.5 feet above floor level and were supported by metal brackets attached to the floor. Electric drive motors attached to the conveyors at several points along their lengths to power their movement.

The roof consisted of steel columns and girders with metal panel roofing attached to metal purlins supported by steel rafters. Wire mesh supported fiberglass insulation under the roof deck. The roof gable was oriented north to south.

Dry Storage

The plant included three dry-storage rooms along the eastern side of the building connected by an east hallway. Dry Storage 1 and Dry Storage 2 were located in the northeast corner of the plant under a common sloping metal roof. The dry-storage rooms held pallets of containers including polystyrene egg crates, foam egg cartons, pulp egg cartons, and cardboard boxes.

Dry Storage 1 was approximately 123 feet long and 50 feet wide and was 4 feet below the grade of the rest of the plant. It was added to the east side of Dry Storage 2 in 2008. Dry Storage 1 was a concrete slab and 4-feet high concrete half wall topped with wood framing and metal siding. The metal roof sloped from 11 feet high above the west side to 10 feet high above the east wall. The roof attached to 2 inch x 8 inch wood joists supported by two rows of steel support columns and steel girders. The two rows of seven columns were oriented in a north-south direction.

A concrete ramp at the south end facilitated access to the East Hallway and Dry Storage 2 and the main level of the processing room. A concrete ramp at the northeast corner of Dry Storage 1 provided access to the rear loading dock. The rear dock was secured on the interior at the top of the ramp by a wood frame and metal double door with a wooden cross member and a chain and padlock. An additional wood frame and screened double door secured on the interior.

The conveyor belt from the north layer barns ran the length of the west side of Dry Storage 1 where it turned to the west, crossing Dry Storage 2 and the East Hallway into the main processing room.

Dry Storage 1 contained 29 rows of pallets, seven to eight pallets deep, of mainly Styrofoam egg crates stacked between 7 and 10 feet high, depending on their location. Corridors between the rows were maintained to provide access to the pallets with an electric forklift. Fluorescent light fixtures attached to the wood rafters in rows north to south with their conductors in PVC conduit. Skylights spaced evenly above the west side allowed for natural light. Pallets of stock material were single stacked below the locations of the light fixtures to keep clearance and prevent damage.

Dry Storage 2, located west of and 4 feet above Dry Storage 1, stored pallets of flattened cardboard box stock. The room was approximately 81 feet long and 40 feet wide. The south wall was the processing room extension and was approximately 25 feet long. The east side of the room was open to Dry Storage 1 with 4 inch x 4 inch unprotected wood studs spaced unevenly from 4 feet to 9 feet, supporting the metal roof. The west wall was CMU construction and was the exterior wall of Cooler 3. The metal roof sloped from the top of the west wall approximately 12 feet high to approximately 11 feet above the east side.

The room was accessed from the south end at the top of the ramp leading down into Dry Storage 1. Pallets of folded cardboard boxes were stacked along the entire length of the west wall extending 16 to 20 feet to the east. The rows of pallets were without spacing for corridors. One row of six fluorescent light fixtures attached to wood rafters near the north-south centerline.

The East Hallway was approximately 118 feet long and 37 feet wide running along the length of the east side of the processing room. The East Hallway connected Dry Storages 1 and 2 with Dry Storage 3 by a corridor at the south end. The East Hallway allowed access between the storage room areas and into utility rooms including the Boiler Room at the north end and a mechanics room and small utility closet. Pallets of polystyrene egg crates were stored along the east wall in rows of three pallets each. Seven pallets of polystyrene egg crates were stored along the conveyors.

The west wall was concrete block construction (CMU) until it connected to the extension of the processing area constructed of wood frame covered by Hardy board and sheet metal. The east wall was sheet metal embedded in the concrete slab supported by 2 inch x 4 inch wood studs with Hardy board interior. The metal roof sloped from a height at 12 feet at the west wall to 10 feet high at the east wall, supported by 4 inch x 6 inch wood columns and 2 inch x 8 inch wood joists.

Two conveyors entered the south end of the east hallway from Dry Storage 3. The conveyors ran parallel for approximately 80 feet along the west wall and entered the processing room through openings in the extension at the north end of the east hallway. They were 6 feet from the west wall and gradually descended from a height of 9 feet at the south end to 3.5 feet at the north. Each conveyor was 31 inches wide and combined was approximately 7 feet wide. Two compressor machines and a pressure washer were located along the west wall near the south end.

The Boiler Room, located at the northeast corner of the East Hall, housed two propane fired boilers, a water treatment system and two vacuum pumps. It was wood frame construction with metal siding under a metal roof on a combination concrete slab and concrete pier and wood beam foundation. A small utility room with service panels was constructed of concrete block on a concrete slab under a metal roof and was also located along the west wall of the East Hallway. An approximately 10 feet wide corridor connected the East Hallway to Dry Storage 3.

Dry Storage 3 extended south from the main processing room and East Hallway to the south dock area where tractor-trailers parked to unload the pallets of supplies. Two parallel conveyors suspended 9 feet overhead from the roof extended along the length of the east wall where it passed through the south wall toward the south layer houses.

The plant’s main power conductors entered the west wall of Dry Storage 3 from load centers and transformers mounted to the slab outside approximately 15 feet south of the main processing room exterior wall. Stacks of wood pallets were stored in Dry Storage 3. Corridors wide enough for forklifts provided access to the south cargo dock area.

Fire Ground Operations and Tactics

Note: The following sequence of events was developed from radio transmissions and firefighter witness statements. Those events with known times are identified. Events without known times are approximated in the sequence of the events based on firefighter statements regarding their actions and/or observations. A detailed timeline of radio transmissions is included in the appendix.

On July 3, 2010, at 21:41:10, Wharton County Sheriff’s Office 911 received a report of a fire at the Maxim Egg Farm located on County Road 442, south of the city of Boling, Texas. The caller, immediately transferred to the Wharton Police Department Dispatch, advised there was a “big fire” in the warehouse where egg cartons were stored. Boling Volunteer Fire Department was dispatched and immediately requested aid from the Wharton Volunteer Fire Department. Wharton VFD became Command as is the usual practice for this county.

Wharton Assistant Chief Stewart (1102) was returning to the station having been out on a response to a vehicle accident assisting the Boling Volunteer Fire Department when the call came in for the fire. He responded immediately and at 21:50 reported seeing “heavy fire” coming from the roof at the northeast corner of the building as he approached the plant from the east on County Road 442. When he arrived he was eventually directed to the east side of the building (D side) to the rear loading dock. Asst. Chief Stewart worked for several minutes with facility employees to gain access to the fire building before being led to the northeast loading dock.

An employee directed him on the narrow caliche drive behind the layer barns and between the waste ponds to the loading dock. Wharton Engine 1134 followed 1102 to the east side and backed into the drive leading to the loading dock. Asst. Chief Stewart’s immediate actions included assessing the extent of the fire on the interior of the building by looking through the doors at the loading dock to Dry Storage 1. Unable to see the fire through the smoke at the doors of the loading dock, an attack was eventually accomplished by removing a metal panel from the east exterior wall of Dry Storage 1 and using one 1¾”-inch cross lay. After a few minutes, the deck gun on Engine 1134 was utilized, directing water to the roof above the seat of the fire near the south end of Dry Storage 1.

Water supply became an immediate concern and 1102 made efforts to get resources for resupply. Requests for mutual aid to provide water tankers were made to area communities. During the incident, re-supplying tankers included a gravity re-fill from the on-site water supply storage tanks and from fire hydrants in the City of Boling, 3 miles from the scene and the City of Wharton, nearly 11 miles. The City of Boling water tower was nearly emptied during the incident.

The radio recording indicates there were difficulties accessing the location of the fire as apparatus were led around the complex by multiple employees. Heavy rains during the previous week left many roadways muddy and partially covered with water, which added to problems with apparatus access. In addition, fire crews were not familiar with the layout of the facility and there are no records of pre-fire plans. Asst. Chief Stewart worked for several minutes with facility employees to gain access to the fire building before being led to the northeast loading dock.

Wharton Fire Chief Bobby Barnett (1101) arrived on scene at 21:56:14, and ordered incoming apparatus to stage until he could establish an area of operations at the front, south side of the plant (A side). Chief Barnett directed Engine 1130 to position approximately 50 feet from the front main entrance of the plant. At 22:09:16, Chief Barnett (1101) established a command post on A side and became the Incident Commander; 1101 directed radio communications for the fireground to be TAC 2 and called for mutual aid from the Hungerford and El Campo Fire Departments. Chief Barnett described the conditions on side A as smoky with no fire showing. Light winds were from the east, side D, pushing the smoke toward the area of the processing room, and the front, side A, of the building.

Maxim Egg Farm Manager David Copeland, a former Wharton VFD Chief, advised Command and firefighters that the fire was in the area of the Boiler Room and should be accessed by breaching an exterior wall in the employee break area. Chief Barnett ordered Wharton crews to the breach attempt. Captain Thomas Araguz III, Captain John Cano and Firefighter Paul Maldonado were involved with this operation. The crews working in this area were in full structural personnel protective clothing and SCBA.

At 22:10, Command ordered Engine 1130 and Tanker 1160 to set up at the front entrance using Tanker 1160 for portable dump tank operations for water re-supply.

On D side, difficulty accessing the fire from the exterior of the building was reported by Asst. Chief Stewart and the crews. Heavy doors, locked loading dock doors and steel exterior paneling, required the crews to spend extra time forcing entry.

At 22:17:23, Wharton County Chief Deputy Bill Copeland (3122), once a Wharton FD volunteer firefighter, notified Command that the fire was now through the roof over Dry Storage 1.

Chief Barnett noticed smoke conditions improving at the main plant doorway and ordered crews to advance lines into the processor room. Chief Barnett stated he assigned Captain Araguz, Captain Cano and Firefighter Maldonado because they were the most experienced and senior crews available.

Positive Pressure Ventilation (PPV) was in place at the main entry door when Captain Cano, Captain Araguz and Firefighter Maldonado entered the structure into the processing room. There are no radio transmissions to verify exact entry times.

Captain Cano stated that an employee had to assist fire crews with entry into the main plant through a door with keypad access. Captain Cano reported the door to processing was held open by a three-ring binder that he jammed under the door after entry. Cano stated there was low visibility and moderate heat overhead. Captain Cano and Captain Araguz made entry on a right-hand wall working their way around numerous obstacles. The line was not yet charged and they returned to the doorway and waited for water. Wharton Engine 1130’s driver reported in his interview that he had difficulty establishing a draft from the portable tank later determined to be a linkage failure on the priming pump. 1160 connected directly to 1130 and drafted from the folding tank.

As the crew entered into the structure through the main entry door, several plant employees began entering into the administration offices through the area of the main entry door to remove files and records. This was reported to Command at 22:23 and after several minutes Chief Barnett ordered employees to stay out of the building and requested assistance from the Sheriff’s Office to maintain scene security.

At 22:31, once the line was charged, the two captains continued into the processor on the right wall leaving Maldonado at the doorway to feed hose. Captain Cano was first with the nozzle and described making it 20 feet into the building.

Cano states in his interview that he advised Command over the radio that there was high heat and low visibility, although the transmission is not recorded. Cano also reported in his interview, he could not walk through the area and had to use a modified duck walk. Cano projected short streams of water towards the ceiling in a “penciling” motion and noted no change in heat or smoke conditions. They advanced until the heat became too great and they retreated towards the center of the processor. Cano stated that they discussed their next tactic and decided to try a left-handed advance.

At 22:33, Chief Barnett advised, “advancing hose streams in main building to try to block it.”

Captain Araguz took the nozzle and Captain Cano advanced with him holding onto Araguz’ bunker gear. The crew advanced along the south wall of the processing room toward the double doors to Dry Storage 3 and lost contact with the hose line.

The investigation found the couplings between the first and second sections of the hose lodged against a threaded floor anchor (see photo) preventing further advancement of the line. How the team lost the hose line remains uncertain.

Captain Cano stated in his interview that Captain Araguz told him to call a Mayday. Captain Cano stated that he was at first confused by the request, but after some time it became apparent they lost the hose line. Captain Cano reported calling Mayday on the radio but never received a reply. Captain Cano now believes he may have inadvertently switched channels at his previous transmission reporting interior conditions. Captain Araguz had a radio but it was too damaged to determine operability. There are no recorded transmissions from Captain Araguz.

At 22:37, Deputy Chief Copeland advised Command that the fire had breached a brick wall and was entering the main packing plant. Command responded that there was a hose team inside.

At 22:42:50, Command radioed “Command to hose team 1, Cano.” This was the first of several attempts to contact Captain Cano and Captain Araguz. At 22:47:17, Command ordered Engine 1130 to sound the evacuation horn. At 22:50:44, Command announced Mayday over the radio, stating “unlocated fireman in the building.”

Captain Cano stated in his interview that they made several large circles in an attempt to locate the fire hose.
Cano became entangled in wiring, requiring him to doff his SCBA.
After re-donning his SCBA, Captain Cano noted he lost his radio, but found a flash light. He remembered that his low air warning was sounding as he and Araguz searched for the hose. Cano stated that they made it to an exterior wall and decided to attempt to breach the wall. Working in near zero visibility,
Captain Cano reported losing contact with Captain Araguz while working on breaching the wall.
Shortly after he lost contact, Captain Cano ran out of air and removed his mask. Captain Cano continued working to breach the exterior wall until he was exhausted.

At 22:54, crews working on the exterior of the building near the employee break area reported hearing tapping on the wall in the area of the employee break room.

Crews mustered tools and began to cut additional holes through the building exterior.
After making two openings, Captain Cano was located and removed from the building.
Captain Cano reported that Captain Araguz was approximately 15 feet inside of the building ahead of him.
Firefighters made entry through the exterior hole but were unsuccessful in locating Captain Araguz. Cano was escorted to the folding water tank and got into the tank to cool down.

Rapid Intervention Crews (RIC) were established using mutual aid members from the Hungerford and El Campo Fire Departments. The first entry made was at the main entry door where Firefighter Maldonado was located. Maldonado was relieved and escorted to the ambulance for rehab. An evacuation horn sounded and the first RIC abandoned the interior search and exited the building.

A rescue entry by a second RIC was through the breached wall of Dry Storage 3. After several minutes inside, the evacuation signal sounded due to the rapidly spreading fire and deteriorating conditions. Two additional RICs entered the structure through the loading dock doors of Dry Storage 3. Chief Barnett states that there were a total of four RICs that made entry after the Mayday. After approximately 45 minutes, all rescue attempts ceased.

As the fire extended south toward Dry Storage 3, smoke conditions became so debilitating that Chief Barnett ordered all crews staged near the front of the building on side A to move back and apparatus to relocate. Command assigned Chief Hafer of the Richmond Fire Department to “A” side operations and defensive operations were established. Captain Cano and Firefighter Maldonado were transported to Gulf Coast Medical Center and treated for smoke inhalation.

Fire ground operations continued through the night. Captain Araguz was recovered at approximately

07:40 AM. Command transferred to the Richmond Fire Department Chief Hafer at approximately

07:56 AM as 1101 and the Wharton units escorted Captain Araguz from the scene. All Wharton units cleared the scene at 08:02 AM.

Captain Araguz was transported to the Travis County Medical Examiner’s Office for autopsy. The Travis County Medical Examiner’s Office performed post mortem examinations on July 4, 2010. Captain Araguz died from thermal injuries and smoke inhalation.

Findings and Recommendations

Recommendations are based upon nationally recognized consensus standards and safety practices for the fire service.
All fire department personnel should know and understand nationally recognized consensus standards, and all fire departments should create and maintain SOGs and SOPs to ensure effective, efficient, and safe firefighting operations.

There were several factors that, when combined, may have contributed to the death of Captain Araguz. It is important that we honor him by learning from the incident.

Water supply became an immediate concern.
Although there are two water storage tanks on the facility with the combined capacity of nearly 44,000 gallons, refilling operations to tankers were slow, accomplished by gravity fill through a 5-inch connection.
A fire department connection attached to the plant’s main water supply pump and plant personnel familiar with the system could have sped up the refilling process at the plant.
Most tankers were sent to hydrants in the City of Boling 3 miles away, which in turn quickly depleted the city water supply.
Other tanker refilling was accomplished at hydrants on the City of Wharton water system, as far as 15 miles away.

Fire protection systems are not required by National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2009 Edition for this classification of facility. Fire sprinkler and smoke control systems may have contained the fire to one area, preventing the spread of fire throughout the plant.

Findings and recommendations from this investigation include:

FINDING 1:

There were no lives to save in the building. An inadequate water supply, lack of fire protection systems in the structure to assist in controlling the spread of the smoke and fire, and the heavy fire near the windward side facilitated smoke and fire spread further into the interior and toward “A” side operations. Along with the size of the building, the large fuel load, and the time period from fire discovery, interior firefighters were at increased risk.

Recommendation: Fire departments should develop Standard Operating Guidelines and conduct training involving risk management and risk benefit analysis during an incident according to Incident Management principles required by NFPA 1500 and 1561.

The concept of risk management shall be utilized on the basis of the following principles:

(a) Activities that present a significant risk to the safety of personnel shall be limited to situations where there is a potential to save endangered lives

(b) Activities that are routinely employed to protect property shall be recognized as inherent risks to the safety of personnel, and actions shall be taken to reduce or avoid these risks.

(c) No risk to the safety of personnel shall be acceptable where there is no possibility to save lives or property.

(d) In situations where the risk to fire department members is excessive, activities shall be limited to defensive operations. NFPA 1500 Chapter 8, 8.3.2

NFPA 1500 ‘Standard on Fire Department Occupational Safety and Health Program’, 2007 ed., and NFPA 1561’Standard on Emergency Services Incident Management System’, 2008 ed. Texas Commission on Fire Protection Standards Manual, Chapter 435, Section 435.15

(b) The Standard operating procedure shall:

(1) Specify an adequate number of personnel to safely conduct emergency scene operations;

(2) limit operations to those that can be safely performed by personnel at the scene;

FINDING 2:

Initial crews failed to perform a 360-degree scene size-up and did not secure the utilities before operations began.

Recommendation: Fire departments should develop Standard Operating Guidelines that require crews to perform a complete scene size-up before beginning operations. A thorough size up will provide a good base for deciding tactics and operations. It provides the IC and on-scene personnel with a general understanding of fire conditions, building construction, and other special considerations such as weather, utilities, and exposures. Without a complete and accurate scene size-up, departments will have difficulty coordinating firefighting efforts.

Fireground Support Operations 1st Edition, IFSTA, Chapter 10 Fundamentals of Firefighting Skills,

NFPA/IAFC, 2004, Chapter 2

FINDING 3

The Incident Commander failed to maintain an adequate span of control for the type of incident. Safety, personnel accountability, staging of resources, and firefighting operations require additional supervision for the scope of incident. Radio recordings and interview statements indicate the IC performing several functions including: Command, Safety, Staging, Division A Operations, Interior Operations and Scene Security.

Recommendation: Incident Commanders should maintain an appropriate span of control and assign additional personnel to the command structure as needed. Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision. In ICS, the span of control of any individual with incident management supervisory responsibility should range from three to seven subordinates, with five being optimal. The type of incident, nature of the tasks, hazards and safety factors, and distances between personnel and resources all influence span-of-control considerations.

U.S. Department of Homeland Security – Federal Emergency Management Agency Incident Command Systems http://www.fema.gov/emergency/nims/ICSpopup.htm#item5 NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed.

FINDING 4

The interior fire team advanced into the building prior to the establishment of a rapid intervention crew (RIC).

Recommendation: Fire Departments should develop written procedures that comply with the Occupational Safety and Health Administration’s Final Rule, 29 CFR Section 1910.134 (g) (4) requiring at least two fire protection personnel to remain located outside the IDLH (Immediate Danger to Life or Health) atmosphere to perform rescue of the fire protection personnel inside the IDLH atmosphere. One of the outside fire protection personnel must actively monitor the status of the inside fire protection personnel and not be assigned other duties. NFPA 1500 8.8.7 At least one dedicated RIC shall be standing by with equipment to provide for the rescue of members that are performing special operations or for members that are in positions that present an immediate danger of injury in the event of equipment failure or collapse.

U.S. Occupational Safety and Health Administration Respiratory Protection Standard, CFR 1910.134 (g) (4); Texas Commission on Fire Protection Standards §435.17 – Procedures for Interior Structure Fire Fighting (2-in/2-out rule) NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed. NFPA 1720 Standard on Organization and Deployment Fire Suppression Operations by Volunteer Fire Departments, 2004 ed.

FINDING 5

The interior team and Incident Commander did not verify the correct operation of communications equipment before entering the IDLH atmosphere and subsequently did not maintain communications between the interior crew and Command. Although Chief Barnett stated he communicated with Captain Cano, there was no contact with Captain Araguz.

Recommendation: Fire Departments should develop written policies requiring the verification of the correct operations of communications equipment of each firefighter before crews enter an IDLH atmosphere. Fire Departments should also include training for their members on the operation of communications equipment in zero visibility conditions.

U.S. Occupational Safety and Health Administration Respiratory Protection Standard, CFR 1910.134(g)(3)(ii) NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8, 2007 ed.

FINDING 6

The interior operating crew did not practice effective air management techniques for the size and complexity of the structure. Interviews indicate the crew expended breathing air while attempting to breach an exterior wall for approximately 10 minutes, then advanced a hose line into a 15,000 square feet room without monitoring their air supply. During interviews Captain Cano estimated his consumption limit at 15 – 20 minutes on a 45 minute SCBA.

Recommendation: Crews operating in IDLH atmospheres must monitor their air consumption rates and allot for sufficient evacuation time. Known as the point of no return, it is that time at which the remaining operation time of the SCBA is equal to the time necessary to return safely to a non-hazardous atmosphere. The three basic elements to effective air management are:

Know your point of no return (beyond 50 percent of the air supply of the team member with the lowest gauge reading).
Know how much air you have at all times.
Make a conscious decision to stay or leave when your air is down to 50 percent.

IFSTA [2008]. Essentials of Fire Fighting and Fire Department Operations, 5th ed., Chapter 5, Air Management, page 189 Fundamentals of Firefighter Skills, 2^ndedition, NFPA and International Association of Fire Chiefs, Chapter 17, Fire Fighter Survival.

Finding 7

Captains Araguz and Cano became separated from their hoseline. While it is unclear as to the reason they became separated from the hose line, interviews with Captain Cano indicate that while he was finding an exterior wall and took actions to alert the exterior by banging and kicking the wall, he lost contact with Captain Araguz.

**Captain Cano credits his survival to the actions he learned from recent Mayday, Firefighter Safety training.

Recommendation: Maintaining contact with the hose line is critical. Losing contact with the hose line meant leaving the only lifeline and pathway to safety. Team integrity provides an increased chance for survival. All firefighters should become familiar with and receive training on techniques for survival and self-rescue.

United States Fire Administration’s National Fire Academy training course “Firefighter Safety: Calling the Mayday” Fundamentals of Firefighter Skills, 2^ndedition, NFPA and International Association of Fire Chiefs, Chapter 17, Fire Fighter Survival.

Additional References Related to Surviving the Mayday and RIT operations from 2011 Safety Week at CommandSafety.com;