FIREFIGHTER DIES IN RESIDENTIAL ROW HOUSE STRUCTURE FIRE – BALTIMORE, MARYLAND – OCTOBER 10,2006 – NIOSH FIREFIGHTER FATALITY REPORT F2006-28

Firefighter Dies in Residential Row House Structure Fire – Baltimore, Maryland – October 10, 2006 – NIOSH Firefighter Fatality Report F2006-28

On October 10, 2006, Baltimore City Firefighter Allan Roberts was fatally injured while advancing a hoseline during a residential two-story row house fire. Arriving firefighters found heavy black smoke pouring from the front of the structure. A civilian jumped from a second story window on Side Alpha and another confused civilian was walking around on the sidewalk; both were attended to by arriving firefighters. Firefighter Roberts and two other firefighters were advancing a charged hoseline to the top of the stairs on the second floor to attack the fire. Conditions rapidly became untenable with high heat and heavy black smoke. When it became known that the fire was actually located in the basement, the firefighters attempted to retreat via the front door. In their haste to leave the building, the firefighters became jammed in the narrow hallway at the base of the stairs and the hoseline became pinched beneath the partially closed inward swinging front door. Officers and firefighters were outside trying to pull the trapped firefighters out of the building and were able to get two of them out through a partial opening of the door. Firefighter Roberts could not get out until the door was removed. Two of the firefighters were pulled out at 0232 hours and Roberts was removed at 0235 hours. Immediately, paramedics on scene attended to the two injured firefighters while Firefighter Roberts was given cardiopulmonary resuscitation and transported to the hospital where he was pronounced dead. The injured firefighters were transported to the hospital and treated for severe burns. Investigators later determined that the fire was caused by an electrical fault in a hot-water heater in the basement. The row house was receiving electricity through an illegal hookup.

The structure involved in the incident was a 1,320 square foot two-story residential middle of the row Type III Ordinary construction brick and wood joist row house without an automatic fire suppression system with the interior having been remodeled to make first and second floor apartments. The basement was accessible from the first-floor interior and an exterior alley door. The flat roof consisted of wood rafters with tar and paper over wood boards. Similar structures flanked the fire building on Exposures Bravo and Delta, and the structure was part of a row of sixteen attached units. Side Alpha was a narrow street with cars parked on both sides and Side Charlie was accessible from an alley in the rear.

Baltimore is the largest city in the State of Maryland, fourth most populous city in the Mid-Atlantic, and the 30th most populous city in the United States with a population of 585,708 according to the 2020 U.S. census. The 92.05 square mile city is about 40 miles northeast of Washington, D.C. and is located where the Patapsco River empties into the Chesapeake Bay in central Maryland. Once a predominantly industrial town with an economic base focused on steel processing, shipping, auto manufacturing, and transportation, the city experienced deindustrialization starting in the 1970s which cost residents tens of thousands of low-skills, high-wage jobs. The population has declined by more than 35 percent since the 1970 population high of 905,787 residents. At the time of the incident in 2006, the Baltimore Fire Department had 39 fire stations with a total of 1,611 career firefighters serving a population of about 651,154 residents.

Firefighter Allan M. Roberts was a career firefighter with 19 years of firefighting experience with the department. He had completed NFPA Fire Fighter Level I and II training, Field Training, Developing Fireground Expertise, Fire Fighter Survival Training and various other administrative and technical courses.

Weather conditions at the time of the incident included a temperature of 56 degrees F and a relative humidity of 90% with a north-northeast wind at 14 mph with gusts to 25 mph with heavy rain (Weather Underground). Note: Research by the National Institute of Standards and Technology (NIST) has shown wind speeds on the order of 10 to 20 mph are sufficient to create wind-driven fire conditions in a structure with an uncontrolled flow path [Madrzykowski and Kerber 2009. The windy weather conditions likely had a significant impact on fire development and the outcome of the incident.

On Monday, October 10, 2006, at 0222 hours, dispatch reported a residential two-story row house fire with possible parties trapped at 512 South Macon Street in the Greektown section of northeast Baltimore. At 0225 hours, Battalion Chief 1 was first to arrive on scene and established Command. He drove in the front of the structure then drove around the block to look down the alley to Side Charlie of the structure during size-up, due to this being a row house in the middle of the block and then returned to Side Alpha. Squad 11 then arrived, followed by Engine 41 as heavy black smoke poured out of the front of the residence. A civilian jumped from a second-story window on Side Alpha and another confused civilian was walking around on the sidewalk. Both were promptly attended to by firefighters.

Engine 41 covered Squad 11 on the hydrant per standard operating guidelines. However, Squad 11 did not stretch the first attack hoseline; instead, two Engine 41 firefighters, Firefighter Allan Roberts, who was working an overtime shift, and Firefighter #1, led a Squad 11 firefighter, Firefighter #2, into the residence with a 1.75-inch hoseline from Squad 11’s engine. Other members of Squad 11 were putting on their gear and grabbing a second back up hoseline. The first hose crew entered a narrow hallway and went through an open door at the bottom of the stairs that led to the second floor. The Engine 41 Lieutenant entered the structure and requested the building be vented due to the heat.

At 0228 hours, Battalion Chief 2 arrived on scene and was assigned per Command to Side Charlie where Truck 3 was trying to position ladders while Engines 5 and 51 were stretching hoselines from opposite ends of the rear alley. The basement was heavily involved, and fire was starting to blow out the first and second floor windows in the rear. Operations were being hindered by numerous electric lines in the rear of the fire structure. At 0231 hours, Command called for a second alarm and for the utility company to cut the power. Truck 20 positioned their aerial ladder to the roof so a firefighter could vent the roof while other crew members positioned a ground ladder to the second-floor windows on Side Alpha to vent.

Firefighter #1 and Firefighter #2 manned the hoseline at the base of the stairs while Firefighter Roberts advanced to the top of the stairs. No fire was seen by any member of the interior attack crew at this time and there appeared to be no fire impingement from the interior towards the front of the structure. The Truck 20 firefighter on the roof opened up several skylights, but the back skylight had self-vented, so the firefighter went back to Side Alpha near the first skylight to open up a hole in the roof, but fire started blowing out and he could not finish the cut.

At 0231 hours, the interior crew learned that the fire’s origin may be in the basement and started backing out. At 0232 hours, conditions became extremely hot inside the fire structure and Firefighter Roberts suddenly ran by Firefighter #1 and into Firefighter #2. Firefighter #2 fell to the floor with Roberts on top of him. They came to rest against the inward swinging metal front door, forcing it to close off the front entrance. This pinched the hoseline in the door frame, leaving a small gap between the metal door and the door frame. In addition to being pinched, the hoseline possibly got bundled up behind the door along with Robert’s body, adding to the difficulty of getting the door open. Firefighter #2 was pinned to the floor and managed to get his arm through the small gap at the door while Firefighter #1 tried to get Roberts off of Firefighter #2. At this point, Command requested a rapid intervention crew (RIC) which had not yet been established.

The Engine 41 Lieutenant and several other firefighters, who had exited the fire structure just prior to the door closing, were outside trying to pull the firefighters out of the structure and began to force open and remove the door. At 0232 hours, Firefighter #1 and Firefighter #2 were pulled out of the partially forced opened door and were attended to by paramedics. At 0235 hours, the front door was removed, and Firefighter Roberts could be seen on the floor with his mask off and hood missing. Firefighters carried Roberts to paramedics on scene who administered cardiopulmonary resuscitation and transported him to the hospital where he was pronounced dead. Firefighter #1 and Firefighter #2 were also transported to the hospital and treated for severe burns.

The coroner listed the cause of death of Firefighter Allan Roberts as smoke inhalation and thermal injuries. Soot was present in the airways. His heart blood carboxyhemoglobin saturation was 26%. Thermal injuries were present over approximately 30% of his body. Affected areas were the head, chest, hands, forearms and lower back. Firefighter #1 and Firefighter #2 received burns on both hands, wrists, and forearms with more severe third degree burns on the left side covering 3% of their bodies.

Investigators later determined that the fire was caused by an electrical fault in a hot-water heater in the basement. The house was receiving electricity through an illegal hookup.

NIOSH investigators concluded that, to minimize the risk of similar occurrences, fire departments should:

• ensure that thermal imaging cameras (TIC) are used during initial size-up.
• ensure that ventilation is coordinated with the interior attack.
• ensure that tools such as door wedges are utilized to prevent water flow and escape problems.
• ensure that a Rapid Intervention Crew (RIC) is on scene prior to an attack crew entering a hazardous environment.
• ensure that department policies and procedures are followed.

A year after the veteran firefighter was killed in the incident, Baltimore fire officials released an investigative report that blamed the death on more than a dozen errors and safety violations – including miscommunication and possible equipment misuse. The 314-page report found 14 problems, including that fire crews in the rear of the building operated an exterior stream into the windows as Roberts and others entered the building from the front. But few of the more than two dozen recommendations in the report offer any changes to the way the department fought fires. Instead, the report repeatedly suggested that the fire might not have been fatal if procedures already in place had been followed more rigorously. “Most of the proposed solutions involve adhering to established policies and procedures regarding incident command, unit operations, personal protective equipment, communications and firefighter safety,” the report reads. Roberts’ death was the first in the line of duty for a city firefighter in more than a decade. It was followed months later by the death of a recruit, Racheal M. Wilson who was killed in a fire training exercise in February where many safety violations were discovered. As a result of these two firefighter death incidents, Baltimore fire officials pledged to improve training and adherence to existing standard operating procedures.

Firefighter Allan M. Roberts, age 40, was a 19-year member of the Baltimore Fire Department. He joined the department on April 20‚ 1987‚ when he entered the Fire Academy. He was assigned to Engine 37 until he was transferred to Truck 26 on July 13‚ 1989‚ and remained with Truck 26 until his death. During his time at Truck 26‚ he rose to the rank of Acting First Lieutenant on D shift. He received several service awards during his career. He is survived by his wife, Teresa, and their four children: Daniel, age 18 months; Jacob, age 5; Katie, age 11; and Samantha, age 13; his parents, Robert and Sandra Jarred, his grandmother, Claudine DePetris, and his in-laws, Robert and Linda Gregory.

The funeral for Firefighter Allan M. Roberts was held on October 17 at the Cathedral of Mary Our Queen in Baltimore. The casket of the fallen firefighter was carried on the back of a city fire apparatus and bagpipes played as hundreds of Baltimore firefighters, joined by thousands of firefighters from Maryland and from around the country, attended the service. Interment followed at Dulaney Valley Memorial Gardens in Timonium, Maryland.

The name of Firefighter Allan M. Roberts has been honored at the Maryland Fire-Rescue Services Memorial in the state capitol of Annapolis. The Maryland Fire-Rescue Services Foundation holds an annual remembrance ceremony at the site.

The name of Firefighter Allan M. Roberts has been inscribed on the 2006 plaque displayed at the National Fallen Firefighters Memorial on the campus of the National Fire Academy in Emmitsburg, Maryland.

Following the fire, the row house at 512 South Macon Street was repaired and is occupied today as a private residence. There is no memorial marker at the site.

Commentary:

Basic firefighting procedures matter. In this incident, the simple act of wedging the front door open upon entry of the fire attack hose crew might have avoided the death of a firefighter and burn injuries to two firefighters. The early assignment of an initial rapid intervention crew to be ready to handle fast evolving conditions is critical to firefighter safety. Conditions became untenable in this structure after fire units had been on the scene for only seven minutes. Having at a minimum a two-firefighter initial rapid intervention crew (IRIC) may help ensure that trapped or distressed firefighters will receive immediate assistance until a fully staffed (4+ firefighters) rapid intervention crew arrives at the fire scene. The NIOSH report and an internal fire department report reinforced that existing departmental policies and procedures need to be followed in order to be effective.

We have attached photos from the incident. The link to the NIOSH report is available here: https://stacks.cdc.gov/view/cdc/163650

We have attached the link to a Rapid Intervention Crew training guide developed by the New Jersey Division of Fire Safety that includes a model standard operating procedure for RIC team operations that is available here:

https://www.nj.gov/dca/dfs/pdf/Ref%20Booklets/reference_booklet_12.pdf

We have also attached an article published in FireRescue1 by Michael Lee on the concepts of two-in/two-out and initial rapid intervention crews:

https://www.firerescue1.com/firefighter-training/articles/rapid-intervention-teams-what-firefighters-should-know-R2hqmtJoSoRCtzQ6/

And we have attached the link to an article published on FireRescue1 by Chris DelBello on RIT training: Focus on simplicity and speed over complexity and gadgets: https://www.firerescue1.com/mayday-survival-guide/articles/rit-training-focus-on-simplicity-and-speed-over-complexity-and-gadgets-VKGMRLS4aYutp6XQ/

Thanks to several media sources for additional information for this article.

Honor the service of Firefighter Allan M. Roberts by reviewing and practicing your department’s rapid intervention standard operating procedures with your crew members today.

Remember Fallen Brothers.

Get Out There And Know Your Local!!!