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(FFCC Notes: Below are two articles regarding the internal report on the tragic line of duty death of Cincinnati FF Oscar Armstrong. The entire report can be viewed at: http://www.cincinnati-oh.gov/cityfire/downloads/cityfire_pdf8213.pdf (PDF format) This is an EXCELLENT, well written, easy to understand and highly professional report worth the time it will take to read, that enables all FD's to be able to compare and learn, so future losses can be minimized.) Fireman's death reveals problems-Department probe finds failings in training and equipment By Jane Prendergast and Gregory Korte The Cincinnati Enquirer Tuesday, March 30, 2004 A 200-page internal investigation into a firefighter's death last year says the Cincinnati Fire Department needs more than $6.7 million in equipment upgrades and new staff. The report was commissioned by Fire Chief Robert Wright after the March 21, 2003, death of Oscar Armstrong III during a house fire in Bond Hill. His was the first on-duty fire death in Cincinnati in 22 years. While the report did not fix blame for Armstrong's death, it points out inadequacies that contributed and should be corrected to prevent other firefighters from being injured or killed. The report examined the response to the fatal fire in detail and pointed out broader concerns about department operations. Among them: Firefighters aren't consistently trained after their initial recruit training at the fire academy, even after they're promoted into new positions; firefighters' gloves are too restrictive, making it difficult for them to press buttons on their radios to call for help; and the department doesn't routinely review "close-call" incidents. The report says the Fire Department needs more than $4.4 million in equipment upgrades and $2.3 million a year in additional staffing. Itrecommends hiring 12 captains to assist district fire chiefs; four safety officers, also at the rank of captain; and eight new trainers. Two major recommended purchases: kink-resistant hose and gauges to measure water flow. Councilman David Pepper, council law committee chairman, called the report "startling." "It's incredibly thorough and impressive," he said. "It's also a wake-up call about things that need to be thought through differently. We'd be making a critical error to have this report sitting on a shelf." Wright said he needed to meet with City Manager Valerie Lemmie and City Council members today to talk about the report before discussing it publicly. Lemmie has not yet made any recommendation about how to implement any of the report's suggestions. "Clearly, they're not all going to be implemented at once," said Meg Olberding, an assistant to the city manager. "With that kind of budgetary impact, there's just no way. They've got to be prioritized." "There's nothing like a critical incident to make you sit up and look at something from every angle," she said. "The Police Department did the same thing with the Justice Department investigation." Mayor Charlie Luken said the city could look for Homeland Security grants or other funding sources. "We just don't have 6 million bucks," he said. Joe Arnold, president of the Cincinnati Fire Fighters Union Local 48, said he knows the money isn't available. "But I do think they can sit down with us and try to get a timeline of when these things can be done." Many of the recommendations are things the union has been talking about for years, he said, chiefly more and better training. "The days of robbing Peter to pay Paul have to be over," Arnold said. "It's just not working." The report lists many mistakes made in the fire on Laidlaw Avenue in Bond Hill. Armstrong, the first man on the hose line, died when the fire got so hot it flashed over, engulfing everything in the room. The fire's cause, the most common fire cause in Cincinnati from 1997 to 2001: food left on the stove. According to the report: Armstrong and two others went into the burning house holding a hose with no water. The fire apparatus operator had turned on the water, but didn't know the hose lay in kinks in the side yard. A captain went to fix it, but left his crew without a supervisor. Armstrong's uniform pants were almost 11 years old and hadn't been inspected in 35 months, six times longer than national standards suggest. His helmet, gloves, boots and hood had never been inspected. The dispatcher did not immediately report that everyone was out of the burning house. Had the firefighters on scene known that, they might not have attacked the fire so aggressively. Firefighters disobeyed an order to stay out of the house and went back in to get Armstrong. The report is dedicated to Armstrong, 25, who left behind two sons and a pregnant fiance. She has since had their baby girl. Without his sacrifice, the document says, it "would have taken many years to accomplish the mission of this report." Pepper said many council members - and probably most citizens - assumed that the Fire Department had the resources it needed. "It's not up to what you would think the Cincinnati Fire Department - the oldest professional fire department in the country - would have," he said. "I don't know how we got to a point where these things weren't happening, but now that it's on our watch, we need to make sure we learn from these things." The report will be presented today to City Council's Law and Public Safety Committee. Report's criticisms: Firefighters' protective equipment is not routinely inspected, cleaned or repaired, as it should be at least once every six months. Firefighters, after they graduate from drill school, don't get enough refresher training; there's no specialized training after promotions to teach new supervisors; firefighters frequently work without training in higher-level assignments. Without hose gauges that measure flow, the firefighter controlling the water can't be sure it's actually coming out. No procedures exist about engine company functions or how to perform ongoing size-ups at an incident scene. The department has no computer database listing who is trained and when; information is kept on handwritten log pages. Report's recommendations: The committee says the Fire Department needs more than $4.4 million in equipment upgrades and $2.3 million annually in additional staffing. Among the recommendations: Hire 12 captains to assist district fire chiefs. Cost: $98,556 each, totaling $1.18 million a year. Hire four incident safety officers, also at rank of captain: $98,556 each, totaling $394,000 a year. Hire eight new trainers: $662,000 a year. Buy kink-resistant hose: $1,077,020. Buy gauges to measure gallons-per-minute water flow: $183,600. Buy glow-in-the-dark exit markers for hose: $7,395. Fixes to Fire Dept. apt to take years - Staffing increases most doubtful By Jane Prendergast The Cincinnati Enquirer Wednesday, March 31, 2004 Cincinnati city and fire officials promised Tuesday they'll do what they can - within budget constraints - to make the changes to fire operations recommended in a 200-page internal investigation into a firefighter's death last year. But everyone involved says it likely will take years. And the $2 million in recommended additional personnel - particularly a dozen chiefs' aides - drew immediate doubts from officials who said the city just doesn't have the money. "It's not something we expect to be done four days from now," said Doug Stern, spokesman for firefighters' union Local 48. "We know it's going to take a long time. But we're going to stick with it and see that it's done." Fire officials spent a year investigating the March 2003 death of Oscar Armstrong III, the first Cincinnati firefighter to die on-duty in a fire in 22 years. Armstrong and two others went into the Bond Hill house fire that morning without water in their hose line, the report found. He died when the fire got so hot it flashed over, engulfing everything in the room. The report, discussed for two hours Tuesday at City Council's Law and Public Safety committee, lists mistakes from an inexperienced firefighter controlling the water to a lack of regular cleaning and inspections of firefighters' clothes and equipment. The report did not place blame. In fact, it does not name any of the firefighters who made mistakes that day. The city's objective was to focus on systemic problems, City Manager Valerie Lemmie said, not on people. "They're good people in bad systems," she said. Regardless of the mistakes, Armstrong was in an "unsurvivable environment, no matter what equipment he had on," said training District Chief Tom Lakamp. Still, Mayor Charlie Luken called it "amazing" that some of these basic problems could still happen in a professional fire department in 2004. Armstrong's mother and other family members sat in the audience but did not speak. Each council member, before asking questions, expressed sympathy. Some improvements already have been made. Among them: Firefighters use shorter hoses now to avoid the serious kinks that left Armstrong without water. Rapid assistance teams, which help rescue firefighters, are now dispatched sooner. New fire clothes, being purchased now, will have firefighters' names on them so it will be more obvious who's in the fire. Armstrong was unaccounted-for for 20 minutes.
Actions at fatal fire faulted - Gloucester City Fire (article link) Never Forgotten - Gloucester City (Photos of the fire) State Fire Report (Adobe PDF) Communication lapses cited in Glo. City tragedy By JASON NARK and JASON LAUGHLIN Courier-Post Staff GLOUCESTER CITY Wednesday, May 28, 2003 A state investigation into the July 4 fire here reveals a combination of poor communications, inadequate training and a meltdown of the command structure played a role in a tragedy that left three firefighters and three children dead. It describes firefighters showing up in their own cars with no one to report to and some unable to communicate with one another. It depicts a fire chief who misinterpreted a warning the building could collapse. And it illustrates a search for children in the burning duplex that turned into an increasingly chaotic effort to recover firemen trapped or killed in the structure's rubble. The May 21 report from the Office of Public Employees Occupational Safety and Health doesn't attribute the deaths directly to the violations investigators discovered, but said the findings could prevent a similar tragedy in the future. The investigation resulted in the state filing more than a dozen violations against the city's fire department, which was in command. "We'll fix it. We'll change it. We'll do whatever we have to so it won't be a violation," said Fire Chief William Glassman, the incident commander during the pre-dawn blaze. Two months ago, Camden County Prosecutor Vincent P. Sarubbi issued a report indicating a carelessly discarded cigarette likely started the fire that trapped three children, Alexandra Slack, 5, and twins Claudia and Colletta Slack, 3, in the North Broadway duplex. Mount Ephraim Fire Chief James Sylvester, Gloucester City firefighter Thomas Stewart III and Camden County Deputy Fire Marshal John West, also a Mount Ephraim firefighter, were searching for the girls when the home collapsed. They died as the blazing structure toppled, leaving behind two wives, a fiancee and their children. Among the most serious violations cited by the state: * Gloucester City and other responding fire departments had lapses in communication with Camden firefighters at the scene. * Some firefighters lacked documentation proving they received proper training. * A command hierarchy, which should have been established as the fire escalated and more departments arrived, was not formed. * The men killed were either not wearing or did not have functioning Personal Alert Safety Systems, which sound when the wearer stops moving. * Most disturbingly, a fireman's warning that the second floor was unstable went unheeded by Glassman. The chief's explanation of his response to the warning is a tale of misunderstandings and a missed opportunity to prevent a tragedy: A young officer searching the duplex for survivors noticed the second floor was giving way about 1:57 a.m., and reported it by radio. The call came within seconds of another call reporting a firefighter missing. Glassman ordered an evacuation to account for everyone. The chief acknowledged the report of instability. But because of a communications confusion, the chief thought he was talking to a different firefighter, Bobby Williams. During the roll call, Glassman, Williams, Sylvester and West stood side by side before the flaming building, and Glassman got the impression from Williams nothing was wrong with the building's stability. So he ordered firefighters back inside after everyone was accounted for, and the young firefighter who reported the instability never mentioned it again, thinking it wasn't important, Glassman said. Minutes later, about 2:10 a.m., the duplex collapsed. The state did not levy fines against the city for the violations. Mayor Robert Gorman said the report unfairly points the finger at his city's fire department and its chief for issues beyond their control. "One of the write-ups is about the communications problem, but how are we going to control the other departments that come in? The entire communications system needs to be fixed," Gorman said. Gorman also defended the chief's actions. "Our fire department is one of the best in the state under Chief Glassman's leadership," he said. John McNutt, a district vice president for the New Jersey State Firemen's Mutual Benevolent Association, also backed Glassman. "While he is named as the person who violated the rules, it doesn't mean he's wrong. It just means the buck stops with him," said McNutt, also a Gloucester City firefighter. Glassman attributes the problems cited in the report to some of his firefighters not showing up for training. This problem prompted him to suspend about 20 volunteer firefighters last week after the Department of Health and Senior Services found the volunteers did not have proper training in how to handle bloodborne pathogens. Stewart's family backed the state report's findings. "We feel that the PEOSH report reflects many of the facts that came to light in the days immediately following the fire; facts that became masked by opinions, altered by emotions, and maybe even jaded by the fears of liability or accountability," a family statement said. The wives of Sylvester and West said they had not been informed about the report. Glassman continues to struggle with his role as chief during the disaster. He alternates between blaming himself and trying to find other reasons why his friends were killed. He plays out in his mind the happier endings that could have been when the sun rose on that steamy Independence Day. He said: "If the building didn't fall down we would have been the greatest fire department in the country that day."
First-Floor Collapse During Residential Basement Fire Claims the Life of Two Fire Fighters (Career and Volunteer) and Injures a Career Fire Fighter Captain - New York
Saturday, January 7, 2006 Rapid Intervention Isn't RAPID By Steve Kreis, Asst. Chief, Phoenix Fire Dept.
Lairdsville Tragedy
Apparant Flashover at House Burn
Saturday, January 7, 2006 http://www.state.nj.us/dca/dfs/Verga report calls for trainingChief sees lessons for all in Verga reporthttp://www.southjerseynews.com/issues/december/m121703i.htm
Wednesday, September 14, 2005 By KAREEM FAHIM Published: September 14, 2005 A Fire Department analysis of a fire in a Bronx building last January in which six firefighters were forced to jump from the fourth floor - killing two of them - has found that mistakes, communication failure and unfamiliarity with new equipment may have contributed to the tragedy, say fire officials briefed on its contents. The report and another one, on a second fire that same day in Brooklyn in which a firefighter was killed - making it the department's deadliest day since 9/11 - will be released today, the Fire Department said. The department will also release audio recordings of radio transmissions between firefighters and fire officers from the Bronx fire. The report on the first fire, details of which appeared yesterday in The New York Post, concluded that the mistakes hampered the firefighting as several companies attempted to douse a blaze on the third floor of the Bronx apartment house on Jan. 23, the officials said. Lt. Curtis W. Meyran, 46, and Firefighter John G. Bellew, 37, died in the Bronx, while Firefighter Richard T. Sclafani, 37, died in the fire in Brooklyn after he was trapped in a basement looking for survivors. Recommendations touch on the failures that undercut the rescue effort, and the authors - a panel of five fire chiefs - suggest a number of steps, including improved evacuation training, the use of personal escape ropes, better discipline, better preparation to deal with water loss and putting weather forecasts on daily fire schedules. In the Bronx blaze, the firefighters who jumped from the building had gone above the fire, to the fourth floor, to look for people who might have been trapped, as firefighters from Engine Company 75 covered them.Downstairs, Engine Company 42 attacked the fire in the third-floor apartment. At some point, the hose to the third floor began to sputter, and the company mistakenly believed the line had burst, the investigators found. In fact, the line had more likely become kinked, the investigation concluded, but the consequences were the same. Its water cut off, Engine Company 42, on the third floor pulled back from the fire, and Engine Company 75 came downstairs to replace the firefighters. At that point, the investigators concluded, the six men from Ladder Company 27 and Rescue Company 3, operating on the fourth floor, should have been pulled back, too, since they were no longer covered. The flames burst through the ceiling into the fourth-floor apartment, keeping the firefighters from leaving by the door and forcing them out the window. Two died when they jumped, and the other four were critically injured. Engine Company 42, which had lost pressure, tried too late to return to the fourth floor. Officials said that one of the engine companies may have been unfamiliar with a new pumper truck that was used to relay water. In most cases, pumper trucks simply hook up to a hydrant outside a fire. But that day, the closest hydrant had become frozen, so firefighters set up a relay from a hydrant farther down the streets, using two fire trucks. The investigation concluded that firefighters might not have understood how the new equipment worked when used in relay. The fire focused attention on personal safety ropes, which the department began to phase out in 1996 but continued to issue to some. Two firefighters that day used a single rope to escape. The investigators found that all would have been better off if they had had ropes. The department has said that next month it would begin supplying all firefighters with a rope escape system designed to allow them to descend safely from windows during a fire. A Fire Department official said that the families had received copies of the fact-finding report yesterday. Reached at his home, Firefighter Joseph DiBernardo, who was injured in the Bronx fire, said of the report: "We did what we had to do. Hopefully, firefighters around the country can learn from it." He said that he had heard tapes of the events that day that will be released along with the reports, and added that he believed things he had said over the radio were not included in those tapes. Investigators found that communication difficulties that day had not been caused by equipment failure but by incorrectly relayed information. They also found that firefighters on the fourth floor, knowing that the company providing water cover was withdrawing, determined that conditions did not warrant their leaving their floor. While critical of the mistakes, the report, like other operational analyses, does not recommend discipline for anyone, the officials said. Fernanda Santos contributed reporting for this article.
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