“… An available thermal-imaging camera was not used by rescue teams that made multiple attempts to locate Fierro once it was realized he was missing…”
By Jeff Lehr
Globe Staff Writer
One of the two Diamond firefighters who were with Carthage firefighter Steve Fierro just before he met his death in February inside a smoke-filled bar and restaurant did not even think he was still with them. That’s one of the findings of three specialists from the National Institute of Occupational Safety and Health who investigated the Feb. 18 fire at Bronc Busters Lounge and Restaurant near Diamond. A report by the investigators from NIOSH’s federally funded Fire Fighter Fatality Investigation and Prevention Program was made public Thursday. The report points out several flaws in firefighting safety involved in the fire that took the life of 40-year-old Fierro, a 12-year veteran of the Carthage Fire Department, and makes 11 recommendations for minimizing the risk of similar occurrences. Bruce Oerter, one of the specialists involved in the investigation, said the report is not intended to place the blame for the fatality on a particular department or individual. “Our main goal is to keep injuries and deaths from happening in the future,” Oerter said. But the report does reveal for the first time a number of things that went wrong in the Bronc Busters fire: Diamond firefighter Zack Testerman told investigators that he, Diamond firefighter Steve Watkins and Fierro had checked out the north side of the interior of the building and were passing back by the front entrance on their way to checking out the south side of the building. Testerman said he saw Carthage firefighter Josh Anderson, who had been feeding them hose at the door, leave the building and mistook him for Fierro. That mistaken impression later caused Testerman to believe he had been left alone when something tugged the air mask off Watkins, causing him to inhale smoke and forcing him to drop the hose and leave the building. Testerman followed Watkins out, not realizing Fierro was still inside. Watkins told investigators that he does not know what tugged his mask off. He said that when he left the building, he was under the impression that both Testerman and Fierro had gotten out as well. Because Watkins had inhaled smoke, he took some time to recover once he was outside. Someone subsequently pulled the hose that Watkins and Testerman were manning back out of the building before it was realized that Fierro was still inside. As a consequence, it was not realized that Fierro was missing until minutes later, when the Diamond fire chief, Mark Garbet, ordered the building evacuated and fire-crew head counts to be made. Because of limited ground frequencies, Garbet – who served as the incident commander at the fire while operating the pump panel on the Diamond fire engine’s truck at the front of the building – had no radio communications with the Carthage engine’s truck at the back of the building or with Fierro. Garbet also never received any reports on interior conditions of the fire from any crews. An available thermal-imaging camera was not used by rescue teams that made multiple attempts to locate Fierro once it was realized he was missing. Fierro’s body was found almost an hour after he had entered the building, and after firefighters finally got the fire knocked down. He was found in a face-down position about 25 feet south of the main entrance, along the east wall of the building. He was found with his face mask partially removed, the hose from his air pack to his face mask tangled around the legs of a barstool, and a dent in his helmet. The cable on the thermal-imaging camera he was wearing was entangled in the legs of the chair. Exactly what happened to Fierro remains uncertain. The report states: “It appears that the entanglement with the chair would have inhibited exit but not trapped the victim.” It further states that the dent in his helmet “appears to have been caused by a ceiling-mounted television that had fallen post-mortem.” Oerter said the dent on the helmet was “a clean spot” on an otherwise charred helmet, suggesting that the television set had fallen on Fierro after he had succumbed to the smoke and hot gases of the fire and was most likely not the reason he did not get out. The Newton County coroner ruled the cause of Fierro’s death to be smoke inhalation. Coroner Mark Bridges said an autopsy found no trauma to Fierro’s scalp that would be consistent with a blow to the head being the cause of death. The NIOSH report states that toxicology tests found the level of carbon monoxide in Fierro’s blood to be at 51 percent saturation, a lethal level. As reported by the Globe on Feb. 22, Fierro had failed to activate a personal alert safety system, or PASS, on his coat that sounds off when a firefighter stops moving. The report states that the PASS on his coat was field-tested and did sound off even in its semi-melted condition. A second PASS integrated with Fierro’s self-contained breathing apparatus was not sounding when his body was discovered, “possibly due to the charred and melted condition of the unit,” according to the report. But the investigators found that the device had gone off while Fierro was on the truck on the way to the fire, and that he had been observed silencing it and resetting it. “It’s likely it was on and operating,” Oerter said. “If the air was on, it was activated.” But whether it ever sounded off when Fierro was overcome remains unknown, Oerter said. No one reported hearing a PASS go off. Carthage fire Chief John Cooper said it is possible that the unit did sound at some point. “But that doesn’t mean you could hear it with two or three diesel trucks running outside,” Cooper said. Oerter said Fierro’s air pack and integrated PASS were never tested, and it remains unknown whether there was air in his tank. He said the reason is that the laboratory testing involved is expensive and seemed impractical to the Carthage Fire Department because it would not have been able to determine when the tank had run out of air. Oerter said the tank was most likely empty because it operates on positive pressure, and Fierro’s body was not discovered until almost an hour after he first entered the building. Most of the report’s recommendations focus on problems the investigators saw with incident command, pre-entry analysis of the fire, the ordering of emergency evacuation procedures, the conducting of a firefighter head count known as personnel accountability reports, and the organization and equipping of rapid intervention teams to try to find Fierro once it was realized he was missing. The report does not state how long it took other firefighters to realize Fierro was still inside. But Oerter said that once it was realized, multiple entries were attempted. But the first attempt was made from the rear of the building and not the front entrance through which Fierro had entered, and near which he was located. Oerter said the teams also did not use another thermal-imaging camera that was available at the fire. Oerter also said removal of a fire hose before a head count is conducted is a mistake. “That’s not a good thing to do,” he said. “That’s one of the ways a firefighter finds his way back out of a building. It’s unknown who dragged the hose out.” Garbet defended the orders he gave as the incident commander and said the time it took to execute them was reasonable, given the conditions of the fire. “The (evacuation) order was given, and when it was given, everybody backed out,” he said. He said “all-outs” are prone to cause some initial panic and confusion, but he did not think what confusion there was had caused any significant delays. Many of the problems cited by the report, Garbet said, stem from fire departments not having enough money and personnel to follow the recommended procedures. He said he, himself, was running a pump handle in addition to serving as the incident commander. Garbet also defended the head count he ordered and the rapid intervention team efforts that were made. “It was discovered as quickly as it c
ould be,” Garbet said of Fierro being inside. He said the conditions inside the building had grown so dangerous by that time that he eventually had to order the rapid intervention teams to desist before the body could be found. Cooper said that overall, he found little in the report that was not already known. He said most of its recommendations do not apply to his department. “Almost to the number, in this department and in this district, we already do them,” Cooper said. He said the first recommendation – that inspections of buildings be conducted to ensure pre-incident knowledge of structures – would not apply to his department in this case because the Bronc Busters building was not in his jurisdiction. “We do the pre-planning they recommend,” Cooper said of buildings in his district.