Niosh Fire Fighter Investigation / Thesis

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Recommendation: The training staff must ensure all participants in a "live" fire training exercise "have received the training and opportunities to properly perform the job." And this is pivotal to safety measures for recruits: A student's first experience "in a live burn exercise should not be in an acquired structure" (IIL).

Structures and Facilities (NFPA 1403 4.2 & 4.2.2): Buildings selected for structural fire training exercise must be properly prepared -- which in this case, the row house at 145 South Calverton Road, it was not properly prepared. A previous ventilation drill, which opened several upper floor walls to the outside air (and the wind which was 20 miles per hour at that time) made the building "unsuitable" for live fire training. Adding to the mistakes made in the exercise at 145 South Calverton Road was the serious question as to whether the fire department had permission to burn that row house.

Emails passed between the Baltimore Fire Chief Saunders and the Deputy Commissioner of the Department of Housing and Community Development (DHCD) Michael Braverman. The fire department indicated that they "were not going to burn the structures" but rather would just use them for "pulling ceilings and cutting holes in the roof" (IIL). Braverman indicated that the structure in question had been condemned "as unsafe" and asked the fire department to "keep that in mind." Here is where the communication becomes sketchy. Emails went back and forth between Braverman and the fire department, and eventually Braverman gave Chief Saunders the phone number of the property manager at Claremont Development (the owners of 145 South Calverton Road). Braverman said that if the fire department intended to burn that building, the owner of 145 South Calverton would have to offer permission since Braverman and the agency simply handled the rentals but did not hold title to the property.

What happened next is an example of remarkably inept administration of executive duties and should never happen in Baltimore again under any circumstances. No follow-up emails or documentation supports that BCFD ever received permission to burn the building. The documents that Chief Hyde presented to the investigators on February 12 included a "checklist" for live fire events, including a page for permission to burn a given structure. That checklist was "blank" and the release for indicating permission to burn a dwelling "was not completed. Recommendation: The fire department in the future must document -- in advance -- that is has obtained all the paperwork verifying that it has indeed received permission to burn a building. Documents that categorically verify proper permission has been acquired must be reviewed and approved by the city's legal counsel before the burn exercise is conducted. As a further step in this particular aspect of the live burn strategy, the city should design a form specific to permission of the property owner for future training exercises. (IIL)

Recommendation II: The fire department in the future should provide a very clear description of the expected condition of the building at the end of the planned live burn exercise. The owner of the property should be required to have his or her legal counsel review the description provided by the fire department, so all parties have a thorough understanding of what is expected to take place in this exercise. That was not done in this instance.

Recommendation III: Moreover, in order to be in compliance with NFPA 1403 4.2.7, proof of insurance cancellation "or a signed statement of the absence of insurance" should be provided by the property owner prior to the fire department proceeding with the live burn exercise. That was not done in this instance.

NFPA 1403 4.2.10.4 states that prior to a live fire exercise, "holes in walls and ceilings shall be patched." But in the previous training at 145 South Calverton wallboard and ceilings had been breached, and they were not replaced during the live fire event, which allowed air from 20 miles per hour winds to fan the flames, likely contributing to the tragic outcome. Recommendation: Any holes in walls or ceilings should be blocked prior to igniting fires in a structure where training is taking place. NFPA 1403 4.2.11.1 asserts that there can be no debris left in the building prior to a live burn exercise. However when members of the NIOSH team had a walk-through on March 19, they found "obstructive" and "combustible" debris in abundance.

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Photos from that investigation show a horrendous pile of combustible debris (mattresses, etc.) in the building. Recommendation: prior to a live burn exercise the dwelling to be burned must be cleared of debris, and the fire department chiefs who are conducting the burn should verify with a written form and photographs that indeed debris was cleaned prior to the exercise.

NFPA 1403 4.2.12 / 1403.2.12.1 clearly spells out that members of the training group should know where the exits are in the building to be burned; moreover, the standard operating procedure for fire department training exercises should be reviewed and a walk through should be conducted. Recommendation: Those regulations are very clear and very helpful albeit in this instance there is no evidence that trainers were aware of the exits; important rules should be followed to the letter, and prior to a live burn training project, paperwork showing that the leadership has complied with these preliminary steps should be filed with the city. The NFPA 1403.2.17 explains that any adjacent building that could come into harm's way with a fire should be either protected or removed. In this case no effort was apparent vis-a-vis the row houses connected to the house at 145 South Calverton Road. This is particularly serious because obviously row houses are connected and fire in one can easily -- and often does -- slither into the next house. Recommendation: Avoid row house structures to be certain that there is no chance for the fire to leap into the next adjacent building.

NFPA 1403 4.2.23 & 1403 4.2.23.2 assert that the "lead instructor" should determine well in advance how the water flow will proceed, who will handle the hoses, and how much water will be needed. This was not done at 145 South Calverton Road. Recommendation: the lead trainer should include as part of his or her training program that recruits do the figuring as to how much water will be needed, how many hoses are practical and available, and where the backup source of water will be. There should always be an auxiliary source of water in case the initial source fails for any reason. This additional training will allow the cadets to get a grasp of just how many safety and strategic measures do into a live burn exercise.

Before conducting a live burn exercise, there should be at least one -- if not more than one -- briefing session involving all the cadets and veterans along with captains and chiefs. When police detectives gather their investigators and prepare them for a search for a suspect, informative meetings are held, important, key information is shared, and the officers feel like they are part of a team. Recommendation: The above-mentioned briefing should take place prior to a live burn exercise too, but in this case there was no "pre-burn" briefing. NFPA 1403 4.2.25.2 & 4.2.25.3 specifically require these informational meetings to take place, and that should be policy in Baltimore from this time forward. Worst yet, the IIR indicates that the information passed on to participants in the brief verbal discussion that took place was actually not the same strategy as was launched at the fire scene.

NFPA 1403 4.3.4 & 4.3.5 emphasize that the excelsior used to light the fire should be limited to the amount necessary to "create the desired fire size," but in this case "multiple fires were set and an excessive amount of materials were used," according to the IIR. Recommendation: There should be an independent consultant contracted by the city to verify advance compliance with all NFPA codes prior to any live burn exercise. That includes plans for where fires are to be set, how much fuel should be used in the burn, and everything else that has been mentioned previously in this report. The instructor should be so completely aware of the planning steps and the production of the exercise that if the "combustible nature of the environment represents a potential hazard" he can stop it (NFPA 1403 4.3.9).

Moreover it was found that the safety officer on the scene at 145 South Calverton Road was involved in several operational duties besides safety, in direct violation of NFPA 1403 4.4.5. Recommendation: Indeed, Chief Hyde was obliged to be aware of safety only, not of what else was going on, and he failed in that regard. Safety is so paramount.....

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