Noonday Texas Fire Department LODD Report Issued with Crucial Lessons Learned

Executive Summary
On August 3, 2007, two Noonday Volunteer Fire Department (VFD) Texas firefighters lost their lives during fire fighting operations at a house fire. At 1:36 AM the Smith County 911 dispatcher received a report of a house fire near the town of Bullard. The Flint-Gresham VFD was dispatched and responded to the house fire, reporting flames visible when they arrived. The Noonday VFD responded to the house fire in accordance with their mutual aid agreement with Smith County Fire Department.

The Flint-Gresham VFD was in the process of an interior attack of the house fire when Noonday VFD arrived to the scene. Forty-two-year-old Kevin Williams, a five year veteran of the Noonday department, and 19-year-old Austin Cheek, who had served less than a year with the department, relieved the Flint-Gresham VFD interior attack team and continued the interior attack operations.

During the next 15 to 25 minutes of firefighting operations, which included several attempts to adequately ventilate the structure, Captain Williams and Firefighter Cheek were overcome by the fire conditions. Rapid Intervention Crews located and rescued the two firefighters, who were then transported to the East Texas Medical Center where emergency room staff continued efforts to resuscitate them.

Firefighter Cheek was pronounced dead at 03:17 AM. Captain Williams was pronounced dead at 03:34 AM. The cause of death for both firefighters was smoke inhalation and thermal injuries.

More than 90 firefighters, representing 14 departments from the Smith County area, contributed to activities associated with this incident

TEXAS STATE FIRE MARSHAL'S OFFICE , Firefighter Fatality Investigation
Recommendations
These recommendations were formed through a review of the fatality report and timeline. Recommendations are based upon nationally recognized consensus standards and safety practices for the fire service and the Standard Operating Guidelines (SOG) of the Flint-Gresham, Noonday, and Bullard Fire Departments. 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.

FINDINGS: 1 A stationary command post was not set up and the Incident Commander remained mobile throughout the incident.
Recommendations: Fire departments should familiarize themselves with National Fire Protection Association Standard (NFPA) 1561 “Emergency Services Incident Management System” and train in the use of the National Incident Management System (NIMS).

NFPA 1561, 5.3.7.1 A stationary command post should be established to plan, organize, and account for all aspects of the operation.

PA 1561, 5.3.7.2 Following the initial stages of an incident, the Incident Commander shall establish a stationary command post. In establishing a command post, the Incident Commander shall ensure the following:

The command post is located in or tied to a vehicle to establish presence and visibility.

The command post includes radio capability to monitor and communicate with the assigned tactical, command, and designated emergency traffic channels for that incident.

The location of the command post is communicated to the communications center.
The Incident Commander, or his or her designee, is present at the command post.

5) The CP shall be located in the cold zone of an incident.
The Incident Commander should establish the command post in a tactically advantageous area where overall scene operations can be monitored, post security maintained, and communication systems monitored. NFPA 1561, 5.3.7.2


FINDINGS: 2 Although a RIC was established during operations, the RIC was not dedicated for immediate deployment.
This is acceptable under the recommendations of NFPA only if at least one person is readily available and capable of performing rescue operations if needed. At this incident both members of RIC 1 were performing other duties and were not ready for immediate deployment. RIC was called by the IC, with a delay in response and deployment.

Recommendations: Fire departments must familiarize themselves with, and train on, the use of Rapid Intervention Crews. RIC should be formed once a fire has progressed beyond the incipient stage, and when personnel work inside of an Immediate Danger to Life and Health (IDLH) atmosphere. Once a RIC is formed, they must actively monitor and report changes in fire conditions to the Incident Commander and not take on 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.

Occupational Safety and Health Administration, 29 CFR Section 1910.134 (g) (4)
NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8
NFPA 1720 Standard on Organization and Deployment Fire Suppression Operations,
Standards for Accountability, SOP100, Smith County Firemen’s Association


FINDINGS: 3. The Incident Commander did not ensure that a personnel accountability system was immediately utilized.
Recommendations: An Incident Safety Officer or Accountability Officer, independent from the Incident Commander, should be appointed and on scene early in the incident to assure that accountability is accomplished, a rapid intervention crew is established, and hazard zones are monitored.

The Incident Safety Officer (ISO) is defined by NFPA 1521 as "an individual appointed to respond to or assigned at an incident scene by the incident commander to perform the duties and responsibilities specified in this standard. This individual can be the health and safety officer or it can be a separate function.”

NFPA 1720, Chapter 4 paragraph 4.5.1.3 regarding accountability;
Standards for Accountability, SOP100, Smith County Firemen’s Association;
NFPA 1521, Section 2, paragraph 1.4.1 states that "an incident safety officer shall be appointed when activities, size, or need occurs."

FINDINGS: 4 Initial crews failed to perform a 360-degree scene size-up and did not secure the utlities before operations began.
Although scene size-up was partially completed it was conducted after the interior attack commenced. There was no indication that the south side, side “B,” was visually inspected by any of the responders during the initial stages of the response.

Recommendations: 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

FINDINGS: 5 Perimeter designations were inconsistent between responding departments.
The Incident Commander and responding mutual aid department chiefs related different designators for the exterior perimeter while conducting scene size-up. This may have led to confusion about the conditions of the structure and the improper placement of ventilation operations. location and perimeter designations. Perimeter designators are recommended to follow a clockwise rotation.

Fire Department Company Officer, Chapter 21, IFSTA, 3rd ed.
Fire Officer Principles and Practice, Chapter 15, NFPA/IAFC, 2008

FINDINGS: 6 Ventilation operations were not closely coordinated with interior fire attack placing the crew between the fire and the point of ventilation.
Initial crews reported to Command that the fire was on their left (south, towards side “B”) and ventilation was performed on side “D.” The placement of ventilation openings caused the interior firefighters to be placed between the fire and the ventilation opening. Without a viable ventilation opening, coordination with the interior attack team, and the injection of fresh air by the PPV fan, interior conditions deteriorated to the point of flashover.

Recommendations: Fire departments should familiarize themselves and train on the proper techniques for vertical and horizontal ventilation. Ventilation is the systematic removal of smoke, heat and particles of combustion thereby improving life safety, increasing firefighter visibility, and reducing the chances of flashover. Horizontal ventilation openings should be made as close as possible to the seat of the fire. Vertical ventilation should be performed as directly over the fire and as high as possible.

According to the Essentials of Fire Fighting 4th ed. “If forced ventilation (positive pressure) is misapplied or improperly controlled, it can cause a great deal of harm” (p. 367). “Positive-pressure ventilation requires good fireground discipline, coordination, and tactics” (p. 369). To perform effective positive pressure ventilation the building must not be pressurized until a correctly placed ventilation opening is made, otherwise the introduction of such large volumes of air will cause the fire to intensify and spread.

Essentials of Fire Fighting 4th Edition, IFSTA, Chapter 10;
Structural Firefighting Strategy and Tactics, NFPA, Chapter 4

FINDINGS: 7 The Incident Commander failed to establish good communications with interior crews and did not take immediate actions when his request for updates went unanswered.
The noise on-scene by the PPV fan, apparatus pumps, and ventilation crews impaired the ability of the personnel to hear and respond to radio traffic. Command should remain in communication (including, but not limited to, radio) with interior personnel at all times. Any failure in communications should result in an immediate evacuation order and the accountability of members verified with a Personnel Accountability Report (PAR.)

Recommendations: Fire departments should develop written policies and procedures for effective fire ground communications and should make sure there are adequate numbers of portable radios for use by crews. Departments should develop a policy for dealing with communications breakdowns, such as calling an immediate evacuation, a Mayday, or deploying a RIC.

NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 8;
Fundamentals of Firefighter Skills–NFPA/IAFC, 2004, Chapter 2, pg. 27

FINDINGS: 8 . As fire conditions progressed changes were not made to the fireground operations.
Recommendations: Incident Commanders must continually monitor fire-ground conditions and make changes to the Incident Action Plan as needed. Incident Commanders or their designee must maintain communications with interior crews and request updates on fire ground conditions.

NFPA 1561, 5.3.17 The Incident Commander shall evaluate the risk to responders with
respect to purpose and potential results of their actions in each situation.

NFPA 1561, 5.3.18 In situations where the risk to emergency service responders is excessive activities shall be limited to defensive operations.
NFPA 1561, 5.3.8 The Incident Commander shall continually conduct a thorough situation evaluation.

NFPA 1561, Standard on Fire Department Incident Management System; 2008
Fire Department Company Officer, NFPA 3rd ed., Chapter 20

Recommendation 9. The initial attack crew did not advance to the seat of the fire and reported to the second attack team that the fire was under control with only mop up operations needed.
The initial attack crew failed to recognize rollover coming from the area of origin. It is extremely important to recognize indications of rollover early in operations because it is usually a precursor to flashover. They used a “penciling” technique to extinguish the flames above them and continued application of small amounts of water toward the ceiling, causing the fire to retreat into the area of origin and disrupt the thermal layer. This caused a decrease in visibility along with raised heat intensity. The interior crew did not advance toward the area of origin and search for the seat of the fire. Interior crews also failed to call for ventilation and relay this information to the Incident Commander.

Recommendations: Fire departments should familiarize themselves with conditions such as flashover and rollover. Training programs in fire science/fire behavior should be a part of regular departmental training.
Departments should implement a policy regarding, in detail, how to deal with these occurrences using proper fire streams based on what interior crews observe. Penciling techniques should only be used to delay flashover for emergency evacuation of firefighters and not as a primary fire stream for fire attack or to permit advancement into the area of the seat of the fire.

Essentials of Fire Fighting 4th Edition, IFSTA
Structural Firefighting Strategy and Tactics, NFPA