The Texas State FM’s Office LODD Report* on Firefighter Scott Deem has been released. While many factors including the fact that this was an arson fire lead to the death of FF Deem and the injuries of other Firefighters, operationally, the report identifies the fact that his death was preventable.
On the evening of Thursday, May 18, 2017 the SAFD responded to a fire in a strip mall. Responding companies encountered heavy smoke and fire conditions upon arrival, and a second alarm was requested.
RESPONSE AND MAYDAY:
Firefighter Scott Deem and fellow Firefighter Brad Phipps were ordered to conduct search and rescue operations in the Spartan Cross Fit Gym. They entered the gym and immediately began a right hand search of the structure.
As they were conducting their search, conditions began to deteriorate very rapidly. A mayday call was sounded, and the Incident Commander was unable to make radio contact with Scott. Rapid Intervention Teams (RIT) were immediately sent in to conduct search and rescue, but they were unable to find him. The Incident Commander was forced to abandon the search for Scott due to extreme fire conditions, and his body was not recovered until after the fire had been brought under control.
FINDINGS
The following is a summary of the ten findings from the final SFMO report, as well as the actions the SAFD has already taken or has planned to address the findings:
Finding 1
The SFMO determined that while the first officer in command recognized the potential of fire to later develop beyond the initially involved business, the fire suppression efforts appeared to be similar to tactics used on a residential fire. Wind factors were taken into consideration late into fire suppression.
Finding 2
The SFMO determined there was improper or ineffective use of ventilation and Positive Pressure Ventilation (PPV) fan usage. The fan was placed early in the fire development without adequate ventilation causing the gases to be disturbed and spread toward the only opening/egress.
Finding 3
The SFMO determined that command requested a search of the business when the doors were locked and the lights appeared to be off. The Incident Commander made this decision based on the possibility that an employee may be inside after hours working in an office. Some firefighters interviewed stated “on opening doors, heavy dark black smoke under pressure came out the doors.”
Note: The first arriving fire officer makes decisions on how to managing the fire scene based on the conditions seen and his or her experience. Firefighters did not know that the fire had been intentionally set or if everyone had escaped from the building. There were signs that people may still be in the building – parked cars and the time of day.
Finding 4
The SFMO determined that Firefighters initiated the search without a tag line or hose-line and advanced past the suppression crew with the hose-line. The search crew saw what they believed to be fire in the attic and took actions outside of their assignment and changed from search to attack and began pulling ceiling without a hose-line readily available and unknown to Command. These actions are commonly referred to as “Freelancing.”
Note: At this incident, firefighters assigned to search the building for people trapped by the fire began to search for the fire. Firefighters assigned to search the building saw fire in the attic and used tools to pull down the ceiling to expose the fire. As the fire was exposed, a fire hose was not in place to put it out.
The SAFD has incident management procedures in place, such as Staging and Incident Command, which manage the actions taken by firefighters on the fire scene and minimize the occurrence of freelancing.
Finding 5
The SFMO determined that the accountability system utilized was ineffective. After the interviews, it was unclear what system was in place other than Officers and Command manually keeping track of the crews. Crew integrity was not maintained, resulting in confusion when Firefighter Vasquez was found because the crew had reported a Personnel Accountability Report (PAR).
Note: The SAFD uses a manual system to keep track of the location of firefighters at an emergency scene. The SAFD also has electronic systems to keep track of firefighters, such as a roster of who is assigned to each fire truck and a system that is part of the firefighter’s air tank. These systems were not used until later in the incident.
“Crew integrity” is when firefighters who are assigned to a unit, such as an engine company, work together on a task and watch out for one another. At this incident, crews were split up and this led to confusion when firefighters became lost.
Finding 6
The SFMO determined that when a MAYDAY was called several units continued to operate on the channel being used for the MAYDAY. The PAR was conducted on the same channel as the MAYDAY. Firefighter Vasquez became separated from his crew and received a low air alarm on his self-contained breathing apparatus (SCBA). He performed a hot bottle change out from the RIT bag and never thought to call for a MAYDAY, stating he never thought he was in trouble.
Finding 7
The SFMO determined that no Pre-Fire plans were available for the involved structure(s).
Finding 8
The SFMO determined that the Spartan Gym and Computer Repair Plus, two of the businesses involved in the fire, did not have approved inspections on file with the City of San Antonio. The last inspection was April 2017 for both businesses. Computer Repair Plus passed the fire inspection but failed the building inspection. The Spartan Gym failed the fire inspection. Neither business had been issued a Certificate of Occupancy (COO) by the city.
Note: Both the Spartan Gym and Computer Repair Plus had failed parts of recent fire inspections and/or Certificate of Occupancy (COO) inspections. Both occupancies should have repaired each deficiency then called for re-inspection. Once the re-inspection had passed, a COO would have been issued and they would have been allowed to be open for business.
The Computer Repair Plus Store failed both plumbing and mechanical inspections due to no one being on-site when the inspectors arrived.
The Spartan Gym failed its inspection due to a battery problem with the emergency exit light and failure to mount the fire extinguisher. It is up to the owner to schedule re-inspections, and they are usually completed within a few days. Spartan Gym did not call for re-inspections.
Finding 9
The SFMO determined that there is a significant time difference for the updates shown of the Standard Operating Guidelines/Standard Operating Procedures (SOGs/SOPs) reviewed for this incident. According to staff the SOGs/SOPs had been updated in the online database but the actual records provided did not show the correct date. SAFD members stated the database “SharePoint” is difficult to access, navigate and retrieving the most recent record is difficult. SOPs/SOGs need to be updated regularly.
Note: SAFD operational procedures can be accessed by any SAFD member thru an on-line database (SharePoint). All SAFD operational procedures have been reviewed and updated within the last two years and are posted on the SharePoint site. When the SAFD provided copies of procedures to the SFMO, some outdated procedures were provided in error.
Finding 10
While San Antonio Fire Department has many good policies and procedures in place, there remain pockets of members who are resistant to change. The SAFD would benefit from a culture of continuous improvement.
Finding 11
A review was completed of training records for Firefighter Deem was used as an indicator to evaluate training overall in the department. The document forwarded to the SFMO consisted of training completed at the SAFD Fire Academy to present. Other than initial training when Firefighter Deem was hired, the majority of the recent training appears to be on-line courses required by SAFD. The SFMO inquired if any other training is documented in the department beyond this mandated on-line training and was informed that other in-service training is documented in a station log book. In order to identify the specific training conducted while on duty, it would require the SAFD to review Firefighter Deem’s schedule and then go to each station he worked at and review the log book for specific information to validate fire station training took place. Unfortunately, the other findings in this line-of-duty death investigation suggest training enhancements are needed to minimize risk exposure for SAFD firefighters.
Once again-lots we can all learn from to honor FF Deem and the other members who were injured.
*The final report can be found on the State Fire Marshal’s Office website:
https://www.tdi.texas.gov/reports/fire/documents/fffsadeem.pdf
