Thesis: Niosh Fire Fighter Investigation and Prevention Program

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NIOSH Fire Fighter Investigation / Prevention

When errors in judgment occur and correct firefighter safety practices are violated, accidents, injuries, and even deaths can result. In the case of the February 9, 2007 fire training exercise on South Calverton Road, many National Fire Protection Agency (NFPA) guidelines were ignored or violated, resulting in the death of recruit Racheal Wilson. Though tragic and heartbreaking -- not just for the colleagues of Wilson but for her family, her two children, her friends and loved ones -- incidents like these can be used as a tool for better safety practices in the future. Indeed, so that Wilson's death will not have been in vain, this report reviews and analyses the facts of the case based on BCFD regulations and on proper procedures for training exercises laid out thoroughly in the National Fire Prevention Association's NFPA 1403 -- "Standard on Live Fire Training Evolutions, 2002 Edition."

What we now know went wrong, why it went wrong, who was in charge, why standard safety procedures were not followed -- and what changes need to be made for safe future live fire training exercises -- are presented in this paper. It should be stated at the outset of this report that among the failings of the leadership involved in this tragedy, paper documentation having to do with the structure in question, and its NFPA approved preparation were not produced prior to the live fire event. In addition proper documentation of the event (by those in leadership positions) was not provided in a timely manner during the investigations that followed. The failure of fire department management to produce these documents sheds light on one aspect of the BCFD that needs to be addressed, and that relates to the need to follow basic procedural steps.

However, since the employee culture at the bottom of the chain of command tends to reflect the level of competency, consistency and adherence to structure carried forward at the top of the chain of command, an organization is generally a reflection of those in leadership positions. And when management eschews important policy steps it offers a very bad example to those in lower positions on the chain. Learning from tactical and strategic errors, and errors of omission, can be useful in terms of correcting those errors. A sober but honest assessment is far more germane to this discussion than retributions and uninformed finger pointing. This paper is presented with the positive philosophy that making errors is human and understandable, but when those errors result in the loss of life, a careful reconstruction of the facts -- along with recommendations for future mitigation of errors -- must be part of the process. That process is what motivated this report, and hopefully positive results will be realized in the future.

The sequence and details from the training exercise

According to the report presented by the Baltimore City Fire Department (BCFD) ("Preliminary Investigation into the Line of Duty Death of Recruit Racheal M. Wilson") 24 members of the FPA Class 19 were involved in this training exercise.

Three fires were set at 145 South Calverton Road at 1135 hours. The vacant building was a three-story "end-of-group" row house owned by the Housing Authority of Baltimore City. Weeks earlier this same row house was used for a training exercise but at that time no fire was set in the building. Four minutes after the three fires were set a "simulated dispatch of units" began "suppression activities."

The hoses were not "charged" (containing high pressure water) when Wilson and others entered the front door of the building. On the second floor Wilson and others "encountered fire" in the hallway and when Wilson opened the nozzle she "…was knocked backwards by the pressure of the water that was now flowing." PM Stephanie Cisneros then helped Wilson to her feet; meantime, EVD Ryan Wenger put out the hallway fire. The rest of the 2nd floor fire was left burning, according to the BCFD report.

Wilson is again given the "pipe" (hose) and they advance to the 3rd floor. Wilson begins to put out a fire directly to her right and Wenger is within 3 feet of Wilson. Cisneros is on the "upper level of the split-level stairs" and "begins to receive burns to her left leg from heat coming from the fire in the second floor rear room" (BCFD. In fact the fire from the 2nd floor is burning through the wall into the stairwell. Cisneros goes to the top of the steps and sees Wegner sitting on the windowsill; Cisneros tells Wegner she is rushing to get out of the building. Wegner gets out first through the window (onto the roof of the 2nd floor) and helps Cisneros in getting out.

Wegner looks back through the 3rd floor window to check on Wilson, who appears to have all "protective gear" in place but Wilson has dropped the hose line. Wilson tries hard to escape through that 3rd floor window "but was unable to do so because of the unusual height of the windowsill [41 inches from the floor]." Wilson "ended up lying on the windowsill at chest level. Wenger attempted to pull her up and out of the window but was unsuccessful" (BCFD). While help is arriving from team members on the roof of the 3rd floor, Wilson "momentarily slipped off the windowsill" back into the building. She tried to climb back up and at that time her face piece had fallen off, her helmet "was hanging to the side of her head by the neck strap, but her hood was still on." Wenger "at this point" witnessed Wilson's face "starting to burn."

The next attempt to get Wilson out through the window fails. Wilson's left foot is apparently "entangled in wire mesh" exposed through the wall just below the window. Wilson soon "goes limp and loses consciousness," according to BCFD report. Wilson is helped through the window and CPR is administered on the 2nd floor roof while other team members use the hose Wilson abandoned to put out the fire on the 3rd floor. Wilson is missing her left boot; she is placed on a backboard "and into a stokes basket" and lowered to the ground by an aerial ladder. CPR is continually administered at this point and is rushed to the Shock Trauma Center. Dr. Thomas Scalia pronounced Racheal Wilson dead at 1250 hours (BCFD).

Besides a wealth of data and changes that will be instituted in the BCFD, the "Independent Investigation Report" (IIR) that was presented to Baltimore Mayor Sheila Dixon adds an important footnote to the incident. Led by R. Chris Shimer, Deputy Chief of Howard County Department of Fire and Rescue Services (HCDFRS), the IIR noted that the temperature that day at the Baltimore Washington Thurgood Marshall International Airport was 26 degrees. The wind was gusting up to 25.3 miles per hour, and was otherwise steady out of the Northwest at 17.3 miles per hour. Reports from the live fire incident indicate that the wind was out of the southwest blowing at 20 miles per hour. That twenty-mile-per-hour wind could well have "contributed significantly to the fire growth and propagation"; the wind, if the BCFD report is accurate, could have pushed the smoke and heat to the "rear" of the structure, hastening the growth of the three fires that were set.

Did the Wilson death impact how BCFD conducts its business?

As of November 2009, no ordinances and no legislation have been passed by local, state, or federal lawmakers as regards the aftermath of the February 9 incident, which resulted in the death of Racheal Wilson. In the Independent Investigation Report (IIR), which had the assistance of Gregory Grant, Special Agent in Charge of the Baltimore Division of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), a number of serious violations of NFPA 1403 were identified and "Recommendations" were offered. This paper will include those recommendations and add a deeper interpretation when it is appropriate, in order that the city and the fire department avoid future tragedies and keep the image of the BCFD free of corruption and/or incompetence. The list of "recommendations" is lengthy, but given the lack of proper planning and slipshod execution of this live burn experience, all recommendations should be considered hard and fast rules to be adhered to. The city must provide oversight in this matter, and that oversight should have been in place prior to the tragedy.

The IIR recommendations began with NFPA 1403 4.1, Student Prerequisites. There were members of Wilson's class (Class 19) who "did not appear to have been adequately prepared" to perform the duties required during live fire training evolutions (IIR). Paramedic Stephanie Cisneros explained later that she had been involved in a "good-natured, competitive discussion" with Racheal Wilson regarding who would operate the fire hose nozzle on February 9. This discussion took place because neither of them had ever operated a nozzle in a live fire situation and both were "eager to… [END OF PREVIEW]

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