All,
Some highlights:
ENTER OR NOT ENTER?
Seconds later Laird called a Mayday, reporting that he had fallen into the basement. Seventeen times while he was in the basement, Laird attempted radio transmissions that were rejected due to other radio traffic. He had not activated the emergency button radio that would have given his transmissions priority over other traffic.
POOR RADIO DISCIPLINE, COMMAND, CONTROL.
INCOMPLETE 360
No 360 was conducted that looked at all sides of the building, which significantly meant that no one had identified the fire in the basement or the presence of a basement. In addition, no one was initially aware of stairs entering into the basement, which were eventually used to extricate Captain Laird. In addition, even after it was clear there was fire in the basement fire crews proceeded attacking the fire as if it were a first-floor fire.
MOST THERMAL IMAGERS NOT USED, FIREFIGHTING BASICS IGNORED, CREW INTEGRITY MISSING.
Most officers on the fireground had thermal imagers, but almost none turned them on or used them in the fire. In addition, many firefighters did not follow basic procedures such as getting low to the ground in a smoky environment and remaining with their crew.
INEFFECTIVE TRANSFER OF COMMAND, COMMUNICATION.
Four minutes after his arrival, Captain Laird, who was the officer in command initially, transferred command to a chief who had arrived. However, the arriving chief did not receive, nor seek, a complete breakdown of where all people and apparatus were deployed, making it difficult for him to effectively manage the fire.
COMMAND & CONTROL.
The report notes that when the Mayday was transmitted, the chief in command did not have a good knowledge of where his resources were and what they were doing.
MAYDAY PROCEDURES NOT FOLLOWED, FREELANCING, FIRE CONTROL NOT MAINTAINED.
Many of the Mayday policies were not followed, including a failure to rebroadcast the Mayday alert, so many of the firefighters at the scene and responding to the call were not initially aware of it. A formal command structure was never put in place for the Rapid Intervention Team efforts, which resulted in freelancing and uncoordinated efforts to rescue Laird. In addition, no one was assigned to maintain fire control operations.
INEFFECTIVE COMMAND STRUCTURE DUE TO CAREER & VOLUNTEER DISPARITIES
Their dual system of career and volunteer firefighters creates an inadequate system of assigning command and other responsibilities during fires. The report recommended that the county establish a clear and unambiguous command structure that relies not on rank, but rather on the training individuals have received since the standards for career and volunteer firefighters vary significantly.
Captain Laird (who was posthumously promoted to battalion chief) was pulled from the fire and transported to the hospital. The cause of his death was smoke inhalation. When he was found in the basement, his facemask and helmet had been removed and his PASS device had been activated and was sounding.
His final transmission, nine minutes after calling Mayday, was “Tell my family I love them.”