NFPA Technical Committee on Pre-Incident Planning

NFPA Technical Committee

on Pre-Incident Planning

NFPA 1620 First Draft Meeting

AGENDA April 18th – 19th, 2018

Hilton Baltimore BWI Airport

1739 West Nursery Rd. Linthicum Heights, MD 21090

Day One: 8:00 AM – 5:00 PM (ET)

I. Chair Gregory Jakubowski calls the meeting to order on April 18th, 2018 at 8:00 AM.

II. Welcome and Opening Remarks.

III. Introduction of attendees.

IV. NFPA Process Presentation.

V. Approval of the minutes from the NFPA 1620 Pre-First Draft Meeting August 28th – 29th,

2017 (Attachment A).

VI. Review purpose of meeting and document schedules (Attachment B).

VII. Old business:

Recap on Committee training from the August 28 – 29th, 2017, Quincy, MA

meeting (Attachment C).

VIII. New business:

Review Task Group Reports/Public Inputs and develop First Revisions

(Attachment D).

Please email any revised Task Group Reports and Task Group work items

(Chapter Working Groups) to the Staff Liaison ([email protected]) by

April 2nd, 2018.

Final review of First Draft based on all developed First Revisions.

Note: Material must receive public review during the Input Stage in order

for the Committee to consider Second Revisions at the Comment Stage in

accordance with 4.4.9.2 of the NFPA Regulations.

IX. Date and location of next meeting.

X. Adjournment.

mailto:[email protected]

ATTACHMENT A

NFPA Technical Committee on

Pre-Incident Planning

Pre-First Draft

Meeting (No. 2)

August 28 – 29th, 2017

Attendees: Jakubowski, Gregory Chair Blazemark Fire Planning Associates, Inc. Blossom, David Principal Amerisure Insurance Carsillo, Michael Principal Stuart Fire Rescue Costello, Timothy Principal JENSEN HUGHES Franchuk, Darrell Principal HSB Professional Loss Control Gibson, Hugh Principal Verisk Analytics/Insurance Services Office, Graupman, David Principal Zurich Services Corporation Keith, Gary Principal FM Global Kennedy, John Principal J. W. Kennedy, LLC Kline, Scott Principal Hoodland Fire District #74 Murphy, Jack Principal Fire Safety Directors Assoc. of Greater NY Nicoll, Scott Principal Chubb Group of Insurance Companies Schmidt, Donald Principal Preparedness, LLC Welling, John Principal Bristol-Myers Squibb Company Whalen, Timothy Principal Allianz Risk Consultants, LLC Woodfin, Ronald Principal TetraTek, Inc./AES Corporation Wyse, Ryan Principal Hebron Fire Department Battalora, Raymond Alternate JENSEN HUGHES Conroy, Patrick Alternate Liberty Mutual Insurance Gunter, Bill Alternate HSB Professional Loss Control Spaziani, Michael Alternate FM Global

I. Chair Jakubowski called the meeting to order on August 28, 2017 at 8:00 AM (ET).

II. Welcome and Opening Remarks.

III. Confirmation of attendees.

IV. NFPA Process Presentation.

V. Motion to approve the minutes from the Pre-First Draft Meeting conference call on December 19, 2016 (Attachment A) with the following amendment:

Task Group on Planning Concepts deleted as an editorial correction. Members added to a single Task Group on Alignment with other NFPA Standards containing Pre-Incident Planning Concepts. Ronald W. Woodfin remains Chair

Motion - Carried

VI. Reviewed purpose of the meeting and document schedules (Attachment B).

VII. Old business.

Provided a recap on topics and Task Groups for the 2020 edition of

NFPA 1620 and reorganized members/topics:

Errors, references, extracts & other house cleaning items.

o John Welling (Chair)

o Gregory Jakubowski

o Bill M. Gunter

o Gary Keith

o Scott C. Kline

o Jack Murphy

Alignment with other NFPA Standards containing Pre-Incident

Planning Concepts

o Ronald W. Woodfin (Chair)

o Bill Gunter

o Ryan Wyse

o Walter Groden

o Michael J. Spaziani

NIOSH FF Fatality investigations.

o Ryan Wyse (Chair)

o David R. Blossom


o Jack Murphy

Marking & Numbering Scheme.

o Timothy E Whalen (Chair)

o George J. Browne


o John Welling

Vacant Building Pre-Planning.

o Scott C. Kline (Chair)

o Hugh H. Gibson

o Scott Nicoll

Educational Occupancy & Active Shooter Pre-Planning.

o Donald L. Schmidt (Chair)

o David Blossom

o Jack Murphy

o Darrell M. Franchuk

Alternative Energy Sources Pre-Planning.

o David Blossom (Chair)

o George J. Browne

o Patrick Conroy

o Walter Groden

o David J. Graupman

o Robert T. Tebbs

Highway/Interchange & Rail Line/Locomotives Pre-Planning.

o Michael E. Carsillo (Chair)


o David Blossom

o John W. Kennedy

VIII. Committee Training provided.

IX. The Task Groups had breakout sessions for work items.

It was noted Task Group Chairs can contact staff for any assistance in

the formation or submission of any Task Group Reports.

X. New business.

The following additional Task Groups were formed for the 2020

edition of NFPA 1620:

Chapter 10 Mass Gatherings.

o Jack Murphy – Chair

o Donald Schmidt

Construction, Alteration and Demolition

o Timothy Whelan – Chair

o John Welling

o Mike Carsillo

o Jack Murphy

o Timothy Costello

Updating Annex D Cards

o Jack Murphy – Chair

o Scott Kline

The following additional work items and topics were identified for

consideration in the 2020 edition of NFPA 1620:

NFPA 1620 Reorganization – John Welling (Lead)

Chapter 9 Vacant and Abandoned Structures absorbed into Chapter 5

Physical and Site Considerations – Scott Kline (Lead)

Submission of Public Input to NFPA Standards (NFPA 1, NFPA 101,

NFPA 241, 350 & 5000) to reference NFPA 1620 – Gregory

Jakubowski (Lead)

Update of case studies in Annex B – Ryan Wyse (Lead)

Moving pre-incident plan document levels (Annex A.4.5) to the main

body of the Standard – Jack Murphy (Lead) & John Welling

Impairments requiring pre-incident plan revision (Annex A.12.2.1) –

Michael Carsillo (Lead)

(Note: December 1st, 2017 is the deadline established by the

committee for Task Group reports and any work items/topics. All are

to be submitted as Public Input to the 2020 edition of NFPA 1620 once

complete. The Closing Date for Public Input on the 2020 edition of

NFPA 1620 is January 4, 2018.)

XI. Date and location of next meeting:

April 18 & 19th, 2018 Baltimore, MD.

XII. The meeting was adjourned at 1:50 pm on August 29th, 2017.

ATTACHMENT B

Fall 2019 Revision Cycle

Process Stage Process Step Dates for TCDates for TC

with CC

Public InputStage (First Draft)

Public Input Closing Date* 1/04/2018 1/04/2018

Final Date for TC First Draft Meeting 6/14/2018 3/15/2018

Posting of First Draft and TC Ballot 8/02/2018 4/26/2018

Final date for Receipt of TC First Draft ballot 8/23/2018 5/17/2018

Final date for Receipt of TC First Draft ballot - recirc 8/30/2018 5/24/2018

Posting of First Draft for CC Meeting 5/31/2018

Final date for CC First Draft Meeting 7/12/2018

Posting of First Draft and CC Ballot 8/02/2018

Final date for Receipt of CC First Draft ballot 8/23/2018

Final date for Receipt of CC First Draft ballot - recirc 8/30/2018

Post First Draft Report for Public Comment 9/06/2018 9/06/2018

Comment Stage(Second Draft)

Public Comment Closing Date* 11/15/2018 11/15/2018

Notice Published on Consent Standards (Standards that received no Comments)Note: Date varies and determined via TC ballot.

Appeal Closing Date for Consent Standards (Standards that received no Comments)

Final date for TC Second Draft Meeting 5/16/2019 2/07/2019

Posting of Second Draft and TC Ballot 6/27/2019 3/21/2019

Final date for Receipt of TC Second Draft ballot 7/18/2019 4/11/2019

Final date for receipt of TC Second Draft ballot - recirc 7/25/2019 4/18/2019

Posting of Second Draft for CC Meeting 4/25/2019

Final date for CC Second Draft Meeting 6/06/2019

Posting of Second Draft for CC Ballot 6/27/2019

Final date for Receipt of CC Second Draft ballot 7/18/2019

Final date for Receipt of CC Second Draft ballot - recirc 7/25/2019

Post Second Draft Report for NITMAM Review 8/01/2019 8/01/2019

Tech SessionPreparation (&

Issuance)

Notice of Intent to Make a Motion (NITMAM) Closing Date 8/29/2019 8/29/2019

Posting of Certified Amending Motions (CAMs) and Consent Standards 10/10/2019 10/10/2019

Appeal Closing Date for Consent Standards 10/25/2019 10/25/2019

SC Issuance Date for Consent Standards 11/04/2019 11/04/2019

Tech Session Association Meeting for Standards with CAMs 6/17/2020 6/17/2020

Appeals andIssuance

Appeal Closing Date for Standards with CAMs 7/08/2020 7/08/2020

SC Issuance Date for Standards with CAMs 8/14/2020 8/14/2020

TC = Technical Committee or PanelCC = Correlating Committee

As of 2/3/2017

™

NFPA https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-o...

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ATTACHMENT C

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NFPA® 1620 Committee TrainingCommittee Actions and the Process

[email protected] or by phone at 001-617-276-6154

August 28, 2017 | Michael Wixted, Emergency Services SpecialistElena Carroll, Project Administrator

Copyright © [2016] National Fire Protection Association

Goal

Enhance the knowledge, skills and abilities of the NFPA 1620 Technical Committee to understand the benefit of technically strong substantiated changes, and the committee’s obligations as required by NFPA Regulations.

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Objectives

• Recognize the merits of a technically strong substantiation

• Differentiate between technically strong and weak substantiations

• Generate technically strong substantiations in an efficient and timely manner

• Look at how we can work even more efficiently for the 2020 edition

AgendaSegment 1. What's a strong committee action & why have one?

Segment 2. Lets write a technically strong substantiation

Segment 3. Compare a technically strong Vs. weak substantiation

Segment 4. Follow a strong substantiation through the process

Segment 5. What this cycle, how can we work even more cohesively?

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Segment 1. What's a strong committee action & why have one?

What is a strong committee action?

Input (First Draft)

• You don’t want a change (respond to a PI)

• You do want a change (create an FR)

Comment (Second Draft)

• You don’t want a change (Reject or Reject but Hold)

• You do want a change (Accept or Reject but See)

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• What is a strong committee action to you?

Hint, it’s the same for all of these:

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What is a strong committee action?

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• What is a strong committee action to you?

One that has a technically strong substantiation

• What's in a technically strong substantiation?1. Technical reasoning

2. Scientific justification

3. Facts supporting the action

4. Data supporting the action

• Where do these come from? NFPA Regs

Why have a strong substantiation? Regs

• 3.3.6 NFPA Standards Content…It shall also base its recommendations on one or more of the following factors: fire experience, research data, engineering fundamentals, or other such information as may be available.

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NFPA Regulations, Guide for the Conduct of Participants –see NFPA Standards Directory (http://www.nfpa.org/Regs)

nfpa.org

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Regulations

• 4.3.7.3 Responding to the Public and Correlating Input … advise the submitter of flaws in the Public Input, give reasons why the TC disagreed with the Public Input, and/or provide guidance or directions as to further information or refinement that might be needed to substantiate the Public Input or gain TC support of the proposed change.

• 4.3.9.2.2 Committee Statement. For each Revision, the TC shall develop an associated Committee Statement.

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Regulations

• 4.4.8.2 Committee Statements on Comments. The TC shall develop a Committee Statement for all its Actions on Comments. Committee Statements supporting Committee Actions shall preferably be technical in nature and shall be sufficiently detailed so as to convey the Committee’s rationale for its Action. Committee Statements may consist, in whole or in part, of a cross-reference to Committee Statements on other Comments and Second Revisions.

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Guide for conduct of participants• 2. Statement of General Principles…

(c) To promote the development of codes and standards that are scientifically and technically sound, that promote creativity and innovation in the development of new methods and technologies, and that set reasonable standards intended to minimize the possibility and effects of fire and related hazards.

• 3.1 Guidelines Applicable to All Participants…(f) In all discussion, debate, and deliberation within the Standards Development Process, participants should confine their comments to the merits of the scientific, technical, and procedural issues under review.

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Segment 2. What's a strong committee action & why have one?

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• Technical & scientific reasoning

What’s in a technically strong substantiation?

There was a technical need to distinguish between falsification of the hypothesis & falsification of test results

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• No technical or scientific reasoning

What’s not a technically strong substantiation?

The revision deals with 5.3.6 HRR and changes identifying the fuel load has no bearing on the rate of growth in its pre-flashover phase

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• Based on facts or data

What’s in a technically strong substantiation?

Substantial changes based on the facts/data derived from arc mapping research that was provided and linked to

SR No. 76, ref’s on arc bead, melted globules and arc mapping

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• No real facts or data

What’s not a technically strong substantiation?

What research contradicts the PC? What facts or data derived from those studies support the current text?

PC No. 94, proposed changes to 5.6.4.6.4 Effect of Walls

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• Is it a technically strong substantiation?

An NFPA 13 substantiation

Not only based on facts/data derived from research, but points back to the exact study

FR No. 301, new sprinkler system design criteria

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• Is it a technically strong substantiation?

An NFPA 400 substantiation

Provides guidance on why the proposed change is not being supported, allows the submitter to come back with that info

PI No. 3, regulations for piping hazard materials

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Useful tips & tricks

1) The bigger the change, the greater the need for a technically strong substantiation

2) Quality vs. quantity

3) Why do it and where does it come from?

4) In essence, capturing the debate

5) Factual, the change is not substantiated (i.e. no supporting info), the section is revised based on etc.

6) Different from editorial updates, MOS, wordsmithing nfpa.org 19

Segment 2. Lets write a technically strong substantiation

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Reports

Display

NFPA 1620 TG Report Templates

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Segment 3. Compare a technically strong Vs. weak substantiation

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Benefit’s of technically strong substantiations

Statement: The addition of the words to the parenthesis in the second sentence is to distinguish the falsification of the hypothesis from the falsification of the test results, a distinction the committee believes needs to be made. Also, data may support but not prove a hypothesis.

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• Historical record

• Reflects the technical consideration of the TC

• Consideration of industry

• Gives support to the Chair and defends the TC position

• Guidance to submitters

Flaws in technically weak substantiations

Statement: The revisions add new information from recent research.

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• No real historical record

• Doesn't reflect the technical consideration/discussion of TC

• Doesn't show consideration of industry viewpoints

• Doesn’t provide information to support the Chair and anyone who wants to defend the TC position

• Doesn't offer any real guidance to submitters

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Strong Vs. weak

Statement: The addition of the words to the parenthesis in the second sentence is to distinguish the falsification of the hypothesis from the falsification of the test results, a distinction the committee believes needs to be made. Also, data may support but not prove a hypothesis.

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Statement: The revisions add new information from recent research.

Vs.

Segment 4. Follow a strong sub. through the process

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Input Stage

Public Input (PI) – First Draft Meeting – First Revision (FR) or Response to PI

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Comment Stage

Public Comment (PC) – Second Draft Meeting – Second Revision (FR) or Rejected PC

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So what can happen at the Tech Session?

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In front of the NFPA Membership

• So what does that technically strong substantiation do in front of the NFPA Membership?– That complete historical record

– Reflects the technical consideration of the TC

– Shows consideration of industry viewpoints

– Gives support to the Chair and defends the TC position

– Shows guidance was given to the submitters

• If you go up to the microphone, supports your opinion

• Remember, this could be 12 months laternfpa.org 33

Appealed before the Standards Council

1.6 Appeals to the Standards Council.

1.6.1 General. Anyone can appeal to the Standards Council concerning procedural or substantive matters related to the development, content, or issuance of any NFPA Standard of the NFPA or on matters within the purview of the authority of the Standards Council, as established by the Bylaws and as determined by the Board of Directors. Such appeals shall be in written form and filed with the Standards Council Secretary in accordance with 1.6.3.

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What is the Standards Council looking at?• Everything, the complete record

• Has the TC met its obligations in accordance with NFPA Regs? (Remember our Reg slides at the beginning)

• How can we show that?

• A technically strong substantiation that shows:– The complete historical record

– The technical consideration of the TC

– Consideration of industry viewpoints

– Gives support to the Chair and defends the TC position

– Shows guidance was given to the submittersnfpa.org 35

Segment 5. What about next cycle, how can we work even more cohesively?

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Reports

NFPA 1620 TG Report Templates

nfpa.org 37

Our report layouts

• What do we think?– Essentially adapted the NEC/921 model

• Is there a better way?

• We can change the format, but always need to have three things?1) Text changes legislatively shown

2) Substantiation

3) Relationship between Public Inputs & Public Comments

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Questions

40

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Thank You

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[email protected] or by phone at 617-276-6154

ATTACHMENT D

Public Input No. 21-NFPA 1620-2016 [ Global Input ]

Where NFPA 1620 refers to "This document" change the terminology to "This standard."

Statement of Problem and Substantiation for Public Input

There are numerous locations in NFPA 1620 that refer to "This document" and there are other location that refer to "This standard." It appear the "This document" references is left over from when NFPA 1620 was a recommended practice. Now that NFPA 1620 is a standard, it is appropriate that the terminology reference "This standard" and language be consistent throughout the standard.

Submitter Information Verification

Submitter Full Name: Anthony Apfelbeck

Organization: Altamonte Springs Building/Fire Safety Division

Street Address:

City:

State:

Zip:

Submittal Date: Wed Dec 14 15:13:40 EST 2016

National Fire Protection Association Report https://submittals.nfpa.org/TerraViewWeb/ContentFetcher?commentPar...

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Suggest the Technical Committee develop a NFPA Fire Protection Research Foundation "CodeFund" project request to determine what information Incident Commanders require and utilize aspart of a Pre-Incident Plan in a sampling of jurisdictions.


In reading through NFPA 1620 and the associated Annex material, especially Annex C, the document appears to still be written almost as a "Recommended Practice" rather than a "Standard." Some of this problem appears to be from the difficulties of wanting to collect enough information but not wanting to collect too much. Because of these concerns, the document is very vague and nonspecific in much of the data collection specifications. The Annex C material also seems to be out of place and appears as if it is left over material from the "Recommended Practice" looking for a home. Annex C should really be incorporated into either Annex A or the core text. An NFPA Fire Protection Research Foundation "Code Fund" project would appear to be a valuable course of action by the TC to help determine what exactly an IC needs in an Pre-Incident Plan based on a sampling of jurisdictions and creating core text. This information could then be utilized by the TC make the complete transition from "Recommended Practice" to a "Standard" with some confidence that the information specified as being a needed data collection field is truly a necessary collection field from the end user standpoint.




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Transportation Issues

Highway / Interchange

Preplans for highways, interchanges, road tunnels and bridges shall be developed in

accordance with NFPA 502, The Standard for Road Tunnels, Bridges, and Limited

Access Highways, Annex F. (Emergency Response Plan Outline)

Rail Line/Locomotives, Trains

Preplans for rail lines, locomotives and trains shall be developed in accordance with

NFPA 130, The Standard for Fixed Guideway Transit and Passenger Rail Systems,

Chapter 9. (Emergency Procedures)

Airports

Preplans for airports shall be developed in accordance with NFPA 424, The Standard

for Airport / Community Planning.


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Ports

Preplans for ports shall be developed in accordance with NFPA 303, The Standard for

Fire Protection Standard for Marinas and Boatyards.

Bakken Crude Oil Response and Emergencies

Preplans for bakken crude oil response and emergencies shall be developed in

accordance with The Pipeline and Hazardous Materials Safety Administration (PHMSA)

Safety Alert, International Association of Fire Chiefs Association (IAFC)

Flammable Liquid Spills and Fires

Preplans for flammable liquid spills and fires shall be developed in accordance with

NFPA 472, The Standard for Professional Competence of Responders to Hazardous

Materials Incidents.


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Type your content here ...


The Transportation sub-committee (D. Blossom, J. Kennedy, and M. Carsillo) were tasked with providing additional suggestions related to transportation issues for the future edition of NFPA 1620, The Standard for Pre-Incident Planning. The targeted areas included highway / interchange; rail line / locomotives and trains; airports; bakken crude oil response and emergencies; flammable liquid rail spills and fires. During theTechnical Committee Meeting of August 28-29, 2017, at NFPA headquarters in Quincy, other Technical Committee members, suggested using existing NFPA standards in assisting with this task.


Submitter Full Name: Michael Carsillo

Organization: Stuart Fire Rescue

Affilliation: NFPA 1620 Technical Commitee Member

Street Address:

City:

State:

Zip:

Submittal Date: Mon Oct 23 07:48:04 EDT 2017


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A.12.2.1*

Pre-incident plans shall be updated or revised whenever significant changes occur. Thesesignificant changes could include impairments to fire protection systems and devices. Examplesinclude fire hydrants, fire sprinkler systems, fire alarm systems, smoke management systems whenthey are taken out of service for repairs or maintenance. Some repairs or maintenance could occurfor a short period of time or may involve many days or weeks depending on the scope of themaintenance or repairs and parts availability. Pre-Incident plans shall be updated to reflect theseabnormalities to ensure that the correct information is available to emergency service deliveryproviders and stakeholders. Incorrect data may lead to incorrect assumptions and actions duringan emergency or planning of a special event.


Provides additional information to users of the document on when existing pre-incident plans shall be updated or revised. Impairments of life safety systems or devices could impact existing pre-incident plans.


Submitter Full Name: Michael Carsillo

Organization: Stuart Fire Rescue

Affilliation: NFPA 1620 Technical Committee

Street Address:

City:

State:

Zip:

Submittal Date: Wed Nov 08 06:11:35 EST 2017


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Public Input No. 33-NFPA 1620-2017 [ Section No. 1.1.1 ]

1.1.1

This document is not intended for pre-incident planning related to construction, alteration, and demolition.( See NFPA 241 ).

A.1.1.1 NFPA 241, Safeguarding Construction, Alteration, and Demolition Operations should be consultedwhen developing pre-incident plans related to structures undergoing constuction, alteration, anddemolition.


The pointer to NFPA 241 is more appropriate in the annex text then the core text as it is a non-mandatory reference.




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Submittal Date: Mon Apr 17 09:09:25 EDT 2017


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A. 1.1.2

Annex A, Explanatory Material; Annex B, Case Histories; Annex C, Special or Unique Characteristics ofOccupancy Classifications; and Annex D, Sample Pre-Incident Plan Field Collection Card and Facility DataRecord forms provide information to the users of this document.


This section is informational only and is more appropriate for the annex then the core text of a Standard.




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Public Input No. 17-NFPA 1620-2016 [ New Section after 1.3.5 ]

Insert a new section:

1.4 Units and Formulas

1.4.1 SI Units. Metric. Units of measurement in this Standard are in accordance with the modernized metricsystem known as the International System of Units (SI).

1.4.2 Primary Values. The inch-pound value for a measurement, and the SI value given in parentheses,shall each be acceptable for use as the primary value units for satisfying the requirements of this standard.


Insert the standard NFPA "Units and Formulas" administrative language.




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Submittal Date: Tue Dec 13 16:23:30 EST 2016


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Add a new section:

1.4 Technical Assistance. The AHJ is authorized to require a pre-incident plan be completed by anapproved independent third party with expertise in plan development.


If responding personnel typically complete pre-incident plans there are a number of valid reasons that they may not be able to for some properties. These include, time/workload constraints, lack of technical expertise and complexity of the property. This PI authorizes the AHJ to require a third party individual, with technical expertise in pre-incident plan development, to be directed to complete a pre-incident plan by the AHJ.




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1.4 Code Violations

1.4.1 Individuals conducting pre-incident plans shall be obvervant for code violations that pose an imminentdanger to occupants and first responders.

A.1.4.1 Types of violations that can pose an imminent danger to occupants and first responders include butare not limited to:

(1) Blocked or locked exit doors

(2) Fire Sprinklers Systems that are out of service with closed valves or no pressure indicated on thesystems

(3) Fire Alarm Systems that are out of service with no power

(4) A Change of Occupancy has occured without a new certificate of occupancy being issued

(5) Vacant or abandon buildings that are unsecured

(6) Other conditions that could be expected to result in serious injuries or deaths if a fire was to occur

1.4.2 Individuals observing imminent dangers while conducting a pre-incident plan shall report suchconditions to the AHJ.

3.x.x.x.Imminent Danger. (Extract the definition of imminent danger from NFPA 1 Fire Code)


Individuals conducting pre-incident plans should be observant for significant life safety hazards. Such hazards should be identified to the AHJ for correction action to be initiated. Basic hazard identification is goal of pre-incident planning, a JPR of NFPA 1001 FFII and NFPA 1021 Fire Officer I. Therefore, these types of issues should already be identified as part of a pre-incident plan and the individuals conducting such plans have the skill set to do so. (If an individual cannot identify these basic types of life safety hazards, I would argue they should not be conducting a pre-incident plan in the first place.) Section 4.1.9 already requires that "Potential life safety hazard, including emergency responder safety" should be considered as part of establishing a pre-incident plan program. This PI just calls out the basic responsibility to report such significant violations to an AHJ for appropriate follow-up. It would be unconscionable to have a pre-fire plan conducted with these types of life safety issues and those issues not being passed along to an AHJ. The standard should not allow that as the model best practice for conducting a pre-incident plan.




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Submittal Date: Mon Dec 12 15:17:11 EST 2016


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1.3.6 The AHJ shall ensure individuals conducting pre-incident plans are trained to this standard and properproceedures for conducting pre-incident plans.

A.1.3.6 In order to conduct pre-incident plans, individuals conducting such plans should be trained on howto conduct such plans in accordance with this standard and the AHJ's proceedures. As part of that training,such individuals conducting pre-incident plans should receive training on interpersonnal skill, 4thAmendment/Right of Entry provisons and conduct during such inspections.


Proper training to conduct pre-incident plans is essential in order to identify conditions, hazards systems and potential impacts on fire ground operations. In addition, conducting pre-incident plans involves a significant amount of interaction with the customer and legal access questions. Training staff on interpersonal skills and legal responsibilities resulting from this activity is a must to ensure issues do not arise between the customer and those conducting pre-incident plans. As a model standard, NFPA 1620 should ensure best practices are incorporated into the documents. Training on how to conduct such plans is clearly a practice that should part of that best practice in the standard.




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Add a new definition:

3.X.XX Mass Gathering Event: An event that is expected to generate a crowd exceeding 500 individuals atany one time.


Chapter 10 addresses "Mass Gathering Events." However, no definition or guidance is provided to the AHJ as to what constitutes a "Mass Gathering Event." In accordance with the Manual of Style, section 2.5.2 Word Clarity, "Words and terms used in NFPA documents shall be selected for specificity and clarity in meaning...." Clearly, "Mass Gathering Event" in itself provides no specificity or clarity in means. This PI establishes a definition for the term which provides specificity and clarity as to the application. The threshold proposed is reasonable based on when such events should be considered as a "Mass Gathering Event." If the TC wishes to substitute another threshold or definition, this proposer would not object.




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4.1.2 *

The pre-incident plan developer shall be competent and familiar to utilize this standard, familiar with thebasic information to be collected and included in the final pre-incident plan.


Stating an individual should be competent without indicating what competent means with any guidance does not really provide sufficient direction to the AHJ, owner or occupant. "Competency" should be defined in some manner. Providing a reference back to this standard, as the standard for conducting pre-incident plans, will at least indicate what the one conducting the pre-incident plans should be competent on.




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4.1.3.1 Prior to conducting an on-site survey of a property to perform a pre-incident plan, the individualconducting the pre-incident plan shall receive authorization from the property owner or occupant, or otherlegal authority, to enter the premises.


The standard should recognize the basic 4th amendment constitutional protections that are in place against illegal searches. Receiving permission from the property owner or occupant to go on-site and conduct a pre-incident plan is a legal requirement, good customer service and should be specified in the model document on pre-incident planning. (The TC might want to consider this as a new section 4.2.2.1 in lieu of the location proposed in this PI.)




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4.4.3 The most recent fire inpsection record of the facility's compliance with the jurisdition'sadopted fire prevention code shall be consulted.

4.4.3.1 If the most recenf fire inspection record details code violations that have the potential tosignifiantly impact the first responder's ability to mitigate an incident, those violations shall bedocumented on the pre-incident plan.

A.4.4.3.1 Types of violations the may sinifiantly impact the first respnder's ability to mitigate anincident may include blocked means of egress, illegal occupancy, fire protection systems/firehydrants/fire alarm systems that are out of service or hazardous material storage that is in violationof the fire code.


Since the purpose of the standard is to assist personnel in effectively managing incidents for the protection of occupants, responding personnel, property and the environment, any significant code violation that are in place at the facility should be recorded as part the pre-incident plan. This includes readily obvious code violations that are observed during the pre-incident planning process walk-thru of the building (covered in another PI) and violations that may not be obvious during a walk-thru but have been documented as part of the most recent fire inspection of the facility. Obviously, violations of the fire code can have a significant impact on the ability of responding personnel to manage incidents for the protection of occupants, responding personnel, property and the environment. If significant known fire code violations are not documented on the pre-incident plan, then the responding personnel will have no awareness of the hazards or, worse, it will be inferred that there are no significant fire code violations because they have not been documented.




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Public Input No. 1-NFPA 1620-2016 [ Section No. 4.8 ]

4.8* Training.

The pre-incident planning process shall include a provision for additonal advanced training and educationin those portions of the pre-incident plan that involve unique or unusual operations.


by adding advanced training to the sentence it would advocate training more advanced for special hazards.


Submitter Full Name: Brian Keene

Organization: Lincoln Park Fire Dept

Affilliation: Lincoln Park Fire Department

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Submittal Date: Mon Oct 17 08:54:33 EDT 2016


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Public Input No. 25-NFPA 1620-2017 [ Sections 5.3.2.3, 5.3.2.4 ]

Sections

5.3.2.3

, 5.3.2.4

* Emergency Power.

5.3.2.3

* Emergency Power

.

1 The location and duration of emergency power components shall be recorded in the pre-incident plan.

5.3.2.

4

3.2 Emergency power systems requiring manual action shall be recorded in the pre-incidentplan.

5.3.2.3.3.The location of the disconnecting means for emergency power systems shall berecorded in the pre-incident plan.

(Renumber remaining sections)

Additional Proposed Changes

File Name Description Approved

Public_Input_No._25-NFPA_1620-2017.docx Word file of the PI in proper format.


Note: Terraview's presentation of this change is flawed. The staff liaison has a copy of the correct format and language. I have also attached a word file to reflect the changes for added clarity.

This PI accomplishes two items:

1. Reformats the section numbering so that the current two sections, and the proposed new section, are under one broad topic of Emergency Power. This provides for better readability. 2. Add a new section that specifics the location of disconnecting means for emergency power needs to be specified on the pre-incident plan. Emergency responders need to know where to secure power when it is provided from an emergency source. There are circumstances where the emergency power system needs to be disconnected.




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Submittal Date: Fri Apr 14 09:48:45 EDT 2017


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Public Input No. 25‐NFPA 1620‐2017

Recommend Text:

5.3.2.3* Emergency Power.

5.3.2.3.1 The location and duration of emergency power components shall be recorded in the

pre‐incident plan

A.5.3.2.3 A.5.3.2.3.1 The location and duration of emergency power sources that should be

recorded include those of generators, fuel supplies, batteries, uninterruptible power supply

systems, and stored energy, as well as the equipment that remains powered when normal

power is lost.

5.3.2.4 5.3.2.3.2 Emergency power systems requiring manual action shall be recorded in the

pre‐incident plan.

5.3.2.3.3 The location of the disconnecting means for emergency power systems shall be

recorded in the pre‐incident plan

Substantiation:

This PI accomplishes two items:

1) Reformats the section numbering so that the current two sections, and the proposed

new section, are under one broad topic of Emergency Power. This provides for better

readability.

2) Adds a new section that specifics the location of disconnecting means for emergency

power needs to be specified on the pre‐incident plan. Emergency responders need to

know where to secure power when it is provided from an emergency source. There are

circumstances where the emergency power system needs to be disconnected.

Public Input No. 24-NFPA 1620-2017 [ New Section after 5.3.2.4 ]

Insert a new 5.3.2.5 and renumber the remaining

5.3.2.5 Electrical Service Disconecting Means

The location of all building service disconnecting means, and the buildings controlled by the servicedisconnecting means, shall be recorded in the pre-incident plan.

(Also...extract the definition of service and disconnecting means from NFPA 70 into Chapter 3)


Where to turn the electrical power off to a building from the utility is a key piece of information that is important to any emergency responder that is dealing with an emergency incident in a building. In addition to knowing where to turn off the power, what the disconnect actually controls is important information to communicate in the pre-incident plan.




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Insert a new 5.2.3.5 and renumber the remaining

5.2.3.5 Energy Storage Systems and Photovaultaic Systems

5.2.3.5.1 The location of all energy storage systems and photovoltaic systems shall be recorded in the pre-incident plan.

5.2.3.5.2 The location all disconnecting means for energy storage systems and photovoltaic systems shallbe recorded in the pre-incident plan.


With the proliferation of energy storage systems and PV system and environments where emergency responders will encounter such systems, the standard should ensure that responders are aware of these systems via the pre-incident plan and they are aware of how to mitigate the hazard of these systems via a disconnecting means.




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5.4.1.2 The proper method to access secure portions of the site shall be recorded on the pre-incident plan.


How to access secure portions of the site is the critical information that emergency responders require. This could be one of numerous methods including key codes, key boxes, electronic opening devices, combination or contact numbers to gain access.




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Public Input No. 50-NFPA 1620-2018 [ New Section after 5.5 ]

5.5.1 Surveillance Systems

1. Site plan showing exterior camera locations and angles of view

2. Floor plan showing interior camera locations and angles of view

3. Locations where surveillance camera images can be viewed

4. Remote and wireless access to surveillance systems including URL/IP address and login credentials

5.5.2 Location of and access to keys, fobs, and RFID cards to enter locked buildings.

5.5.3 Document capability of access control system if primary power is lost.


The Task Group on Educational Occupancy & Active Shooter Pre-Planning recommends adding the preceding text to existing chapters 5 and 6 to address the unique needs of education occupancies. The new text addresses the significant and sometimes unique life safety needs of the K-12 and higher education environment; use of technology increasingly common within educational institutions; and the emergency planning for educational institutions for acts of violence. The goal of this text is to make users of the standard aware of these considerations so they can make use of systems, equipment, and technologies found in schools, effectively communicate with and within schools, utilize systems and equipment for situation analysis; and attain a common understanding of terminology used in school emergency planning.


Submitter FullName:

Donald Schmidt

Organization: Preparedness, LLC

Affilliation:Leader, NFPA 1620 Task Group on Educational Occupancy & ActiveShooter Pre-Planning

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Submittal Date: Thu Jan 04 12:15:46 EST 2018


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5.7 * Security Animals.

The use and number of security animals shall be noted in the pre-incident plan.


The number of security animal could vary dramatically on a property. By placing a number in the pre-incident plan, that implies that the number of security animal is a fix amount that can be relied on by emergency responders. We can easily picture the scenario of an responder saying "Well the pre-incident plan only says there are two attack dogs and the two are isolated so we are good to go in now" and they get a nasty surprise turning the next corner when a third was added a month ago. The key here is not the number but the use of them.




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5.10.1.1

1. Access points, coverage, capabilities, and limitations of systems and equipment for alerting,notification, warning, and communications including wired, wireless, and VOIP (voice over IP)telephones, public address, intercom, duress (panic) buttons, paging, mass notification systems,electronic mail, smart boards, and computer-based and smartphone applications

2. Procedures and credentials for access and use of mass notification systems and smartphonemessaging apps including SMS communications between faculty, staff, and others within theeducation occupancy

3. Interoperability of two-way radios with public safety communications




Submitter FullName:

Donald Schmidt


Affilliation:Leader NFPA 1620 Task Group on Educational Occupancy & ActiveShooter Pre-Planning

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6.2.1.2 Building Information

1. Floor plan with room numbers and occupancy and use of each room

2. Locations of assembly occupancies including auditoriums, lecture halls, and athletic facilities(interior and exterior)

3. Number and locations of individuals with disabilities or functional needs that will requireassistance with protective action (evacuation, shelter-in-place, or lockdown)




Submitter FullName:

Donald Schmidt



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Public Input No. 12-NFPA 1620-2016 [ Section No. 6.2.1.2 ]

6.2.1.2

The following information shall be noted in the pre-incident plan:

(1)

(2)

(3)

(4)

(5)


Before assistance needs to be considered, the ability to take their own self-preservation actions should be assessed and documented. This is an exceedingly important piece of information for the IC. Responding to a single story unsprinklered assisted living facility where the occupants are incapable of self-preservation will provide an entirely different assessment than to a single story apartment building. In addition, assistance will not only be required to the disabled but may be required to individuals that are not awake, are incarcerated or are taking egress paths that are not normally utilized (High-rise).




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* Hours of operation

* Occupant load

* Occupant accountability

* Assistance for people with disabilities Capablity of occupants to self evacuateand potential Assistance required for individuals that are incapable of self evacuation

* Strategies for protecting facility occupants, other than evacuation


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6.2.1.2

The following information shall be noted in the pre-incident plan:

(1)

(2)

(3)

(4)

(5)

(6)


A basic item that should be communicated in any pre-incident plan is the type of occupancy that is occurring in the building. This information is the basis for any IC decisions in dealing with an incident.




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*Type of occupancies in the building

Hours of operation

* Occupant load

* Occupant accountability

* Assistance for people with disabilities

* Strategies for protecting facility occupants, other than evacuation


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1. Room [interior door] locking system




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Donald Schmidt



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6.3.1* Facility Emergency Action Plan.

If a facility has an emergency action plan, it shall be obtained for reference during an emergency.

Add:

1. Terminology for protective actions (e.g., evacuation, shelter-in-place, lockdown, run, hide, fight/counter)

2. Procedures for response to security threats inside, outside, and off-campus but in the vicinity of theschool

3. Off-site shelter locations and travel paths

4. Accountability database and procedures




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Donald Schmidt



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7.1.1 Water supplies and fire protection systems that are obviously impaired shall be noted on thepre-incident plan.

(Extract the definition of Impaired from NFPA 25 into Chapter 3.)


During the course of a pre-incident plan, the Pre-Incident Plan Developer may come across fire protection systems or water supplies that are obviously impaired. Those impairments should be recorded on the pre-incident plan for consideration by emergency responders prior to and during an incident. A prime example might be a fire hydrant that is marked OOS. Leaving that fire hydrant on the pre-incident plan without marking it as impaired falsely implies to the fire department that the fire hydrant is usable during an emergency incident.




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Public Input No. 35-NFPA 1620-2017 [ Sections 7.2.4, 7.2.5, 7.2.6 ]

Sections 7.2.4, 7.2.5, 7.2.6

7.2.4 Static Water Supply Sources.

Static water sources, such as ponds, lakes, rivers, tanks, and cisterns, shall be recorded in the pre-incidentplan.

7.2.

5 * Water Storage Tanks.

7.2.5.1

Where a water storage tank is used as a source of water, the water storage capacity 4.1

When static water supply sources are subject seasonal variation or seasonal access, such informationshall be recorded in the pre-incident plan.

7.2.

5

4 .2

*

The method of obtaining water drafting from the static water storage tank supply source shall berecorded in the pre-incident plan.

7.2. 6 5 * Bodies of Water Storage Tanks .

7.2. 6 5 .1 *

The Where a water storage tank is used as a source of water, the water storage capacity shall be recordedin the pre-incident plan shall include seasonal variation information for bodies of water .

7.2. 6 5 .2 *

The method of drafting obtaining water from the water source storage tank shall be recorded in the pre-incident plan.


TerraView completely butchered this change...sorry. However, the intent is that section 7.2.6 "Bodies of Water" be moved to two new sections under 7.2.4.1 and 7.2.4.2 "Static Water Supply Sources." "Bodies of Water" really is a type of "Static Water Supply Sources." Currently, it is somewhat disconnected as 7.2.4 and 7.2.6 are separated by 7.2.5 water storage tanks. This PI puts all of the static source language together and revised the wording somewhat for better readability and content regarding seasonal access and use.




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9.1.1 Where vacant or abandon structures are not secured against entry, the AHJ shall be notifiedimmediately by the pre-incident plan developer.


Vacant and abandon structures are a significant threat to the lives of illegal occupants and responders. When these structures are not secured, they become an attractive nuisance and the hazard is increased exponentially. When vacant or abandon structures are found to be unsecured, they should be immediately reported to the AHJ so the AHJ is aware of the condition and can take appropriate action to mitigate the hazard.




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9.4 Potential Hazards.

The following potential hazards shall be considered as part of the pre-incident plan for vacant andabandoned structures:

(1) Unstable structure

(2) Fall and trip hazards

(3) Standing water in basement

(4) Vermin

(5) Unauthorized occupancy

(6) Ongoing criminal activity

(7) Rapid fire growth potential

(8) Status of utilities (e.g. active, inactive, unknown)

(9) Illegal occupancy


Abandon or vacant structures have the very likely potential to be occupied by transients, homeless or other illegal use. This is different from the "ongoing criminal activity" in (6) above. If there is evidence of this use, it should be documented in the pre-incident plan to make fire responders aware of the added life safety risk that might exist.




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9.6 Additional Hazards.

Additional hazards to responders include, but are not limited to, the following:

(1) Holes and penetrations in floors, walls, and roofs

(2) Fire escape access

(3) Open shafts/pits

(4) Structural degradation due to weather and vandalism

(5) Exposed structural members

(6) Maze-like configuration

(7) Blocked, damaged, or missing stairs

(8) Previous fires in building

(9) Structure is unsecured allowing access by trespassers


If an abandon or vacant structure is unsecured, this creates an attractive nuisance to trespassers and increases the hazards to first responders as they might have to consider the need for rescue operations. This information is very valuable to a first responder as a factor of consideration. Therefore, the existence of an unsecured structure should be documented as a condition on a pre-incident plan.




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10.3 Pre-Planning.

Where the authority having jurisdiction has determined that a pre-incident plan is required for massgatherings, the following items shall be included in the pre-incident plan and coordinated with otherapplicable agencies:

(1) Access and ingress/egress

(2) Evacuation

(3) Weather

(4) Emergency medical services (e.g., routine and mass casualties)

(5) Security

(6) Traffic

(7) Crowd management

(8) Fire protection

(9) Food operations

(10) Pyrotechnics

(11) Aeronautical operations

(12) Communications

(13) Fuels (cooking equipment, internal combustion engines, hot air balloons, etc.)

(14) Safety data sheets (SDS) as determined by the authority having jurisdiction

(15) Contingency plans

(16) Special operations (e.g. technical rescue, hazardous material)

(17) Temporary structures

(18) Unified command post

(19) Other items as identified by the AHJ or mass gathering event organizer that are necessary for aneffective pre-incident plan


The list should have an open ended option for the AHJ and event organizer to substitute some level of judgment as to other items that might be necessary as part of a pre-incident plan. The document cannot be expected to be inclusive of all possible items in a singular list.




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11.3.1.1 The pre-incident plan developer shall consider the capabilites of initial response publicemergency respons resources to effectively managing emergencies for the protection ofoccupancts, responding personnel, property and the environment as part of developing a pre-incident plan

A.11.3.1.1. The pre-incident plan should not be developed without some basic understanding of thepublic emergency response resouces that would probably be engaged in mitigating an on-siteincident. The capabilities of those responders can have a significant impact on the pre-incidentplan assumptions and content. A pre-incident plan developed for a hazardous materials facilitywhere a fully staffed Type I Haz Mat team is a public resources available within 10 minutes of aincident will probably look significantly differnt than a pre-incident plan for that same facility in avery rural area where the closest Haz Mat team is four hours away from the facility.


The pre-incident plan should not be developed without some basic understanding of the public emergency response resouces that would probably be engaged in mitigating an on-site incident. The capabilities of those responders can have a significant impact on the pre-incident plan assumptions and content. A pre-incident plan developed for a hazardous materials facility where a fully staffed Type I Haz Mat team is a public resources available within 10 minutes of a incident will probably look significantly differnt than a pre-incident plan for that same facility in a very rural area where the closest Haz Mat team is four hours away from the facility.




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11.3.4.1

The liaison and entity represented shall be identified by name or , job title with emergency contact phonenumbers and included in the pre-incident plan. The AHJ may require multiple contact individuals based onthe nature of the facility.

11.3.4.1.1

Such contact information shall be recorded into the responding jurisdiction's computer aided dispatchsystem when required by the AHJ.


An individual's name or job title is insufficient information. The key is being able to contact someone after-hours in an emergency condition when such individual may not be available on-site. This information should also be available in the CAD, when required by the AHJ, to ensure expedient access to a responder.

Related Public Inputs for This Document

Related Input Relationship

Public Input No. 18-NFPA 1620-2016 [Section No. 12.2.3.2] Similar Issue




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Public Input No. 31-NFPA 1620-2017 [ Chapter 12 ]

Chapter 12 Pre-Incident Plan Testing and Maintenance

12.1 General.

12.1.1 *

The roles, responsibilities, and authority to act of responding agencies shall be identified in the pre-incidentplan.

12. 1. 2

The person or agency responsible for testing of the pre-incident plan shall be determined at the time of pre-incident plan development.

12.2 Pre-Incident Plan Update.

12.2.1 *

Where conditions indicate that a change in a pre-incident plan is warranted, the pre-incident plan shall beupdated and distributed in accordance with Section 4.7.

12.2.2

Prior editions of the pre-incident plan shall be archived or destroyed in accordance with local policy.

12.2.3 Pre-Incident Liaison.

The list of all pre-incident plan recipients maintained by the pre-incident plan developer shall be used fordistribution of pre-incident plan updates.

12.2.3.1 *

Where technical expertise from outside agencies, building occupants, or persons representing facilitymanagement is vital to successfully conduct emergency operations, the person(s) shall be considered aliaison to the IC.

12.2.3.2

The liaison shall be identified in the pre-incident plan by name or job title, and who they represent, andincluded in the pre-incident plan.

12.3 * Pre-Incident Plan Resources.

Response to incidents that require additional agencies or organizations for statutory purposes(investigation, public health/safety, etc.) shall be included in the pre-incident plan.


The title of Chapter 12 and the contents of Section 12.3.2 both use the term "testing." However, there is no guidance provided in the document as to how "testing" is to be accomplished, what "testing" is to encompass or the frequency that "testing" is supposed to occur. Without such guidance, the designation of a person to do "testing" and the title of chapter 12 with "testing" included is useless. Now, if the TC wishes to include guidance in the First Revision as to what exactly defines "testing", the frequency of "testing" or the mandatory development of a "testing" plan with appropriate scope, then the current language in Chapter 12 could remain and be modified. Otherwise, the vague language implying "testing" should be removed. However, if the TC does an FR with expanded "testing" language, the TC should keep in mind that not all pre-incident plans require some form of "testing" so any newly developed language would need to be mandated only at the judgment of pre-incident plan developer or AHJ.





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12.2.1.1 Prefire plans shall be updated via a site visit at least once every three (3) years in order to confirmconditions have not changed or to make modifications to the existing plan.


Out of date pre-fire plans can create a risk greater than having no pre-fire plan. The standard should establish a minimum update cycle to ensure the content does not become void based on changing site condition. As a model standard, this document should establish what best practice is for updates of pre-fire plans. If a jurisdiction wishes to revise the standard due to justified local concerns, they can do so. A 3 year cycle may not be perfect in all situations but, it at least sets forth a model standard expectation of best practice which is what a standard should do.

(If the TC wishes to change the three years to another frequency, the submitter would support that change. The key issue with this proposal is to establish a minimum schedule.)




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Submittal Date: Mon Dec 12 14:08:13 EST 2016


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12.2.3.2

The liaison shall be identified in the pre-incident plan by name or , job title, and who they represent, andwith emergency contact phone numbers and included in the pre-incident plan. The AHJ may requiremultiple contact individuals based on the nature of the facility.

12.2.3.2.1 Such contact information shall be recorded into the respeonding jurisdiction's computer aideddispatch system when required by the AHJ.


An individual's name or job title is insufficient information. The key is being able to contact someone after-hours in an emergency condition when such individual may not be available on-site. This information should also be available in the CAD, when required by the AHJ, to ensure expedient access to a responder.

Related Public Inputs for This Document

Related Input Relationship

Public Input No. 14-NFPA 1620-2016 [Section No. 11.3.4.1]




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12 11 .3 .6 * Pre-Incident Plan Resources.

Response to incidents that require additional agencies or organizations for statutory purposes(investigation, public health/safety, etc.) shall be included in the pre-incident plan.


Relocate this section to 11.3.6. "Pre-incident Planning Resources" and the content of 12.3 is not germane to the title of Chapter 12. It is more appropriate to Chapter 11.




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Public Input No. 49-NFPA 1620-2018 [ Chapter A [Excluding any Sub-Sections] ]

Annex A is not a part of the requirements of this NFPA document but is included for informational purposesonly. This annex contains explanatory material, numbered to correspond with the applicable textparagraphs.

A.1.1 Any term used for representing Pre-Incident Planning as referenced and defined by NFPA 1620, Pre-Incident Planning, can include, but not limited to, the following terms:

(1)Pre-Incident

(2)Pre-Plan,

(3)Pre-fire

(4)Pre-Fire Planning,

(5)Pre-Fire Plan

(6)Pre-Emergency,

(7)Preplanning

(8)Preplanned,

(9)Prefire Plan,

(10)Prefire Planning,

(11)Preplan,

(12)Preplans,

(13)Fire Plan,

(14)Fire Control Plan,

(15)Emergency Action Plan

(16)Emergency Procedure Plan

(17)Emergency Planning

(18)Fire Emergency Plan



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There are 69 Codes that reference Pre-Incident Planning “like” terms; • Of the 69 Codes only 11 Codes referenced NFPA 1620; • Of the 69 Codes only 17 Codes referenced the term Pre-Incident Planning as it is presented in NFPA 1620;• Of the 69 Codes only 12 Codes referenced the term Pre-Incident Planning in their document, as it is presented in NFPA 1620; There are 18 identified PIP “like” Terms throughout the 69 Codes and there are several hundred phrases using the 18 identified PIP ‘like” terms. In an effort to consolidate various terms referencing “Pre-Incident Planning” throughout the NFPA codes, the above text is being proposed as an addition to the Annex. This will assist users of the document in applying pre-incident planning concepts, especially when slightly different terminology is being deployed throughout different NFPA Standards. It will be especially useful when using NFPA 1620 in conjunction with another NFPA code or standard.


Submitter Full Name: Ronald Woodfin

Organization: TetraTek, Inc./AES Corporation

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Submittal Date: Wed Jan 03 14:55:18 EST 2018


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Public Input No. 7-NFPA 1620-2016 [ Section No. A.7.2.1 ]

A.7.2.1

The following factors should be considered when evaluating the water required:

(1) Volume of water required for fire protection, including the following:

(2) Automatic sprinkler system demand (see NFPA 13)

(3) Standpipe system requirements (see NFPA 14)

(4) Outside hose line requirements for manual fire suppression efforts (see NFPA 1, NFPA 1142,NFPA 13) and local fire department requirements

(5) Other aqueous-based extinguishing system demands (see NFPA 11 and NFPA 16)

(6) Volume of water needed for processes that cannot be interrupted

Additional factors that could affect the quantity of water required or the duration of time that the water mustbe available include the following:

(1) Combustibility of construction

(2) Combustibility of contents

(3) Presence of hazardous processes and materials

(4) Exposures

Additional resources that could provide information on the quantity or duration of water that should beavailable include the following:

(1) Local fire department requirements

(2) Requirements in applicable fire protection standards, including the following:

(3) NFPA 1, Fire Code

(4) NFPA 13, Standard for the Installation of Sprinkler Systems

(5) NFPA 14, Standard for the Installation of Standpipe and Hose Systems

(6) NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection

(7) NFPA 16, Standard for the Installation of Foam-Water Sprinkler and Foam-Water SpraySystems

(8) NFPA 30, Flammable and Combustible Liquids Code

(9) NFPA 30B, Code for the Manufacture and Storage of Aerosol Products

(10) NFPA 1142, Standard on Water Supplies for Suburban and Rural Fire Fighting

(11) International Fire Code, Appendix B

(12) ISO Guide for Detemining Needed Fire Flow


TerraView did not fully reflect the changes made to this section via this PI. For clarification, the following changes were made:1. Under (1) (c) "for manual fire suppression efforts" and references to "NFPA 1" and "NFPA 1142" were included.2. Under (2) (a) "NFPA 1, Fire Code" was added3. Under (2) (I) "International fire Code, Appendix B" was added


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4. Under (2) (j) "ISO Guide for Determining Needed Fire Flow" was added

The addition of "for manual fire suppression efforts" clarifies the intent of the reference to for the purpose of outside hose streams. They are for manual fire suppression effort. NFPA 1 and NFPA 1142 are included as those two documents are NFPA's documents for determining how fire flow for manual fire suppression is developed and required. NFPA 1, IFC and ISO references are added to (2) as those are applicable fire protection standards for water supply requirements that are used to evaluate water supply for fire suppression efforts.




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A.7.2.2

The available water supply should be determined by conducting a water supply test in accordance withNFPA 291.

The results of the water supply test should be reported in the pre-incident plan, including the following:

(1) Static pressure

(2) Residual pressure and flow rate

(3) Flow rate available at 140 kPa (20 psi) residul (Unless the water supply source is developed from adraft. Then the flow rate is the rate developed at the draft.)

Care should be exercised in interpreting the test results, as only the available water supply in the watermains is determined. The actual flow from the hydrant will be less than the test results, depending on thesize and length of the hydrant lateral, the type of hydrant, and the outlet that is used. The 140 kPa (20 psi)should be available at the hydrant outlet as a minimum. The available flow and pressure at the pump intakeof the fire engine should be determined.

The fire protection system demands, including required fire flow, sprinkler system, standpipe system, waterspray system, and foam water system should be obtained.


Clarifies that the 20 psi is the residual pressure and provides a caveat that the 20 psi is not applicable if operating from a draft.




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A.7.2.2

The available water supply should be determined by conducting a water supply test in accordance withNFPA 291.

The results of the water supply test should be reported in the pre-incident plan, including the following:

(1) Static pressure

(2) Residual pressure and flow rate

(3) Flow rate available at 140 kPa (20 psi)

Care should be exercised in interpreting the test results, as only the available water supply in the watermains is determined. The actual flow from the hydrant will be less than the test results, depending on thesize and length of the hydrant lateral, the type of hydrant, and the outlet that is used. The 140 kPa (20 psi)should be available at the hydrant outlet as a minimum. The available flow and pressure at the pump intakeof the fire engine should be determined.

The manual fire protection system demands, including required fire flow, sprinkler system, standpipesystem, water spray system, and foam water system fire flow demand should be obtained.


It is highly unrealistic that most individuals conducting a pre-incident plan would obtain the fire sprinkler system demands, standpipe demands and other built-in fire protection system demands. Nor is that information exceedingly valuable as part of a pre-incident plan. It is difficult to develop a fire scenario where an incident commander is looking at a pre-fire plan outside of a building and wondering what the demand is for the fire sprinkler system. That is just not going to occur nor is that information necessary. The basic goal of knowing what the manual fire flow demand is, that the building has a protection system and that the building FDC is located at X is about the limits of what we should expect from individuals conducting pre-incident plans.




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Public Input No. 10-NFPA 1620-2016 [ Section No. A.7.2.2.2 ]

A.7.2.2.2

A deficient water supply might be mitigated by any combination of the following:

(1) Supply from an adjacent water distribution system pressure zone

(2) Mutual aid

(3) Tankers or water tenders

(4) Drafting from static water sources, such as lakes, streams, and swimming pools

(5) A further investigation by responsible parties to see if valves are closed or if the water supply hasbeen adversely impacted due to lack of inspection, testing and maintence (If such conditions arelocated, corrective action should occur to mitigate the deficient condition.)


Deficient water supplies are frequently caused by closed valves or a lack of ITM on the water supply source. Acceptance of such conditions should not just be a given. The standard should identify that mitigation of a deficient condition may involve further investigation to see if the deficient condition can easily be corrected without accepting it as a given. The standard should expect that basic level of critical thinking in developing pre-incident plan.




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Public Input No. 45-NFPA 1620-2018 [ Section No. B.2 ]


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B.2

Paper ProductsWarehouse Fire ,

Connecticut, 1991.

The warehouse was 124 m × 118 m × 23 m (408 ft × 388 ft × 75 ft) high and of light noncombustibleconstruction. The storage racks supported the roof of the warehouse and contained 11 tiers of gift andgreeting card products. Ceiling sprinklers and eight levels of in-rack sprinklers were provided.

During an overnight shift, employees working on an automatic stacker crane in the warehouse heard a loudnoise and saw sparks at the ceiling. Power was lost to the warehouse and the remainder of the facility. Thefire department and the plant emergency organization were alerted as the fire developed at the top of therack. The plant emergency organization members met and directed the fire department to the fire area.

The fire department connected to a yard hydrant and advanced two 44 mm (1¾ in.) hose lines into thewarehouse. Fire fighters used a ladder on the stack crane to access the fire, which was 23 m (75 ft) abovethe floor. The fire was extinguished in less than 30 minutes and prior to the operation of the automaticsprinklers.

Fire and water damage was limited to three pallet loads of stock. The operation of the warehouse waspartially interrupted for 3 days while repairs were made to the electrical system. Total damage from the firewas less than $10,000

West Virginia, 2017

Shortly after midnight on October 21 st , 2017, a fire broke out in an unknown location of a warehouseresponsible for storing various materials used in the manufacturing of plastics. The warehouse wasapproximately 420,000 square feet that was constructed from combining a conglomerate of many smallerwarehouses, both new and old. Many portions of the warehouse were nothing more than two smallerbuildings with the space separating the two closed up. The thick, black smoke covering the area began toimpact the local communities almost immediately and could be smelt more than 100 miles away. Localresidents were instructed to shut down their HVAC systems, close all windows & doors, and shelter-in-place for fear of potential health risks associated with the smoke and falling particles. This resulted in theclosing of schools, the cancelation of community events, and even sparked a local valet services to handout free filtration masks to the public. The amount of calls from concerned citizens reporting a smell ofsmoke forced 911 dispatchers to require a caller to actually see flames before they would dispatch any fireunits.

Firefighters were met with problems early on, such as access restrictions from outside storage, aninsufficient water supply to control the large volume of fire, and a lack of knowledge for what thewarehouse contained. There were also questions as to whether the buildings fire suppression systemsoperated correctly. SDS sheets were provided to firefighters by company representatives, but they wereout dated and did not provide an accurate picture of what was inside. The company was required tosubmit an annual Tier II hazardous materials inventory list to multiple government agencies, one being thelocal fire department, but the company was not in compliance with this law. As a result, all documents thataccurately reflected the building's inventory and their specifics at the time of the incident were lost in thefire. Though the fire was controlled within the first day, the fire burned overall for eight days and wasdeclared an emergency disaster by the West Virginia Governor.

The last reported fire inspection conducted by the West Virginia Fire Department of Military Affairs andPublic Safety was conducted in 2008, almost a decade previous to this incident, after two local volunteerfire chief’s filed letters of concern to the State Fire Marshal addressing concerns about the facility. Theirletter addressed concerns surrounding such things as the lack of an adequate water supply, lack of accessto portions of the building and fire protection equipment, lack of adequate sprinkler protection in variousportions of the building, and the arrangement of storage that could jeopardize the safety of firefighters.

The lack of established building codes and poor fire code enforcement resulted in a devastating fire thatimpacted the entire community, and cost local and state governments millions. The lack of pre-incidentplanning information such as accurate SDS sheets and a plan for accessing alternative water sourcesforced firefighters from over 30 different fire departments to control and extinguish a fire they were notprepared for fight .



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Submitting on behalf of the task group for this section.


Submitter Full Name: Ryan Wyse

Organization: Hebron Fire Department

Affilliation: NFPA 1620 Technical Review Committee (PIP-AAA)

Street Address:

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Submittal Date: Tue Jan 02 19:07:33 EST 2018


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B.3 Two Fire Fighter 10 Firefighter Fatalities at Auto Parts Store, Virginia, 1996.

The building involved was approximately 12 years old. Two of the building’s exterior bearing walls wereconstructed with unprotected steel frames, and two were constructed with masonry block. Lightweight woodtrusses with a clear span of 15.2 m (50 ft) supported the building’s roof.

The building contained a wide variety of combustible and noncombustible materials, flammable auto paints(liquid and aerosol), and other flammable and combustible liquids. During construction of this building,several roof trusses had collapsed while plywood roof sheathing was being installed, injuring threeconstruction workers. Fire officers and fire fighters on the fire scene were unaware that the roof of thebuilding was constructed with lightweight wood trusses.

The fire occurred when a utility worker damaged the electrical service drop conductors on the outside of thebuilding. Electrical arcing inside the store ignited fires that quickly involved the wood trusses supporting theroof and ignited a fire in the area of an electric hot water heater. Though some of the fire was visible toanyone in the occupied area of the building, much of the fire was hidden in the concealed space above thebuilding’s ceiling, and the fire was able to spread in that area.

The fire department was dispatched at 11:29 a.m. Two fire fighters entered the building and located a smallfire at the rear of the building. The fire fighters extinguished the fire and called for second crew and pikepole. Approximately 20 minutes after arrival, the roof of the building collapsed, and the two fire fighters weretrapped inside. The fire fighters both died of burns, with smoke inhalation being a contributing factor.

The Chesapeake Fire Department has a comprehensive, company level, commercial building inspectionprogram. The building had a pre-fire plan that had last been reviewed in April 1994. The pre-fire plan haddiagrams showing the building’s location and a plan showing the interior arrangement of the building andthe location of utilities. The pre-fire plan also showed the location, distance, and flow of the three closestfire hydrants. It is unclear if the pre-fire plan was referenced during the fire attack

Fertilizer Plant, TX, 2013

On April 17, 2013, 10 firefighters and five civilians were killed when a fertilizer plant exploded. In addition tothose killed, five firefighters were also injured in the blast. The incident involved a 12,000 square feetfacility that was originally built in the 1960’s and had received multiple additions to the building throughoutthe years. The building was primarily constructed of wood and metal silos that stored, mixed, and soldvarious agricultural products used by the farming community. The structure did not have any form of firesuppression. The facility also stored a large amount of hazardous materials, both raw and mixed, that wereused to enhance a farmer’s crops such as anhydrous ammonia and ammonium nitrate. As it was theplanting season, the company maintained an inventory of these hazardous materials in the thousands.

Initial 911 calls of smoke being visible from the structure began coming into the county’s 911 center around19:29, with the first fire department unit arriving on the scene 10 minutes later. Firefighters found flamesthat were visible from the sliding doors of the seed room. Crews immediately initiated fire suppressionoperations as additional personnel were arriving on scene in other fire apparatus and personally ownedvehicles. Despite their efforts, firefighters quickly realized that the fire was gaining in intensity, possibly dueto becoming a wind driven fire. They also did not have a water supply established yet, so their fire attack

efforts were being supplied solely by tank water. The 2 nd arriving engine company had dropped a 4-inchsupply line from the closest hydrant, but they did not have enough hose to stretch the 1,600 feet from thehydrant to the attack engine. This resulted in firefighting having to halt their suppression operations in aneffort to establish a water supply through the use of the supply hose from their attack engine.

It was reported that during the incident, a discussion was held between the fire chief, assistant chief, and afirefighter who also worked as a manager of the facility. The chiefs raised concern that the ammoniumnitrate stored inside the building may explode and that firefighters may need to be pulled back further fromthe structure. However, the firefighter advised them that the burning fertilizer would not explode. Approximately 12 minutes after the arrival of the first arriving engine company, the 40-60 tons of ammoniumnitrate stored next to the seed room exploded. The explosion decimated the building, left a crater thatmeasured 93 feet in diameter and 10 feet deep, and registered as a small-scale earthquake on the Richterscale. Investigators were unable to determine the cause of the fire.

Many factors contributed to this tragedy, such as the fire department not having a formal pre-incidentplanning program established at the time of the explosion, nor had they performed any formal training onhow to respond to incidents involving ammonium nitrate. The lack of an adequate water supply within closeproximity to the structure was also an immediate problem. Having a pre-incident plan in place that helpedorganize fireground efforts and facilitate the laying of supply lines early into the incident may have helpedfirefighters identify the hazards that they were faced with and establish a water supply sooner .


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Submitting on behalf of the Technical Committee Task Group



Organization: NFPA 1620 Technical Review Committee

Affilliation: Task Group for Appendix B

Street Address:

City:

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B.4 Four Fire Fighter Nine Firefighter Fatalities, Warehouse Furniture Store , Washington SouthCarolina , 1995.

The building in which the fire occurred was originally constructed in 1909 with a structural support system ofheavy timber. Over the years, however, the warehouse had been modified a number of times. One of thesemodifications was a cripple wall (a short section of wall used to support a larger wall) that had beeninstalled to support the joists of the floor assembly between the upper and lower levels. Unfortunately, thiscripple wall was more susceptible to fire than the building’s other structural support mechanisms, and, whenit failed, it caused the floor to fail, creating the opening into which the four fire fighters fell.

From the outside, each face of the building presented a significantly different image. From the west side, itlooked like a two-story structure constructed of various materials. When viewed from the north, a steepgrade partially obscured the details of the building, and the structure appeared to have two stories, althoughonly one level was accessible from the east side. From the east, it appeared to be a one-story building withno lower level. From the south, heavy vegetation obscured the building, so that only one floor was visibleuntil one approached the parking lot at the southwest corner.

The layout of the building, the adjacent structures, and the sloping grades made it impossible to drivearound the structure to size it up. However, it was possible, with some difficulty, to walk around the building.

Probably the most significant factor contributing to this fatal incident was the fact that the building had twolevels. Members of the crew that attacked the fire from the east thought that they were working in a one-story structure without a basement. Members of the crew working on the west side of the building knew thatthe building had two floors but thought that the interior crew was fighting the same body of fire they wereconfronting.

This confusion over the number of levels and the level where the main body of fire was located allowed thecrews working on the fire to operate longer than they possibly should have. They thought they were makingheadway on the fire and were hitting spot fires, while the main body of fire was actually working below them

2007

On June 18, 2007, nine firefighters were killed in the line of duty after being overrun by a rapidlyprogressing fire that produced an enormous amount of heat. The original 125 FT x 130 FT building wasconstructed in the 1960’s as a grocery store, but over time, eventually became a furniture store. Thestructure consisted of masonry walls with a flat metal roof supported by steel bar joists. Large glasswindows lined the storefront.

Throughout the years, the showroom of the main building was expanded through the addition of a 60 FT x120 FT pre-engineered metal building to each end, a 120 FT x 130 FT warehouse in the rear, and a 2,200-square foot loading dock area that connected the warehouse to the main building. The buildings originallydid not meet the requirements for it to be sprinklered. However, the construction of additions to the loadingdock area without permits, along with the installation of unprotected openings and separation walls thatwere not fire rated, changed this. Since permits were never obtained for these changes, the requirementfor sprinklers was never enforced.

The fire started as a trash fire on the exterior of the loading dock. The flames then traveled up the wall andinto the loading dock’s attic space. An employee attempted to extinguish the fire, but stopped once thesmoke conditions intensified and he heard one of the roll-up fire doors close. As the fire intensified, initialinvestigations into the store’s showroom revealed no signs of any smoke or flame. That changed whenfirefighters opened the doors leading to the loading dock. The massive rush of fresh air leaving theshowroom area sucked the door out of the hands of the firefighter, but was quickly closed by anotherfirefighter. Firefighters began taking defensive positions inside the showroom at the doorway and believedthat they were protected by a masonry block fire wall. What they were unaware of were the penetrationsthat were made through this wall over the years, which allows the smoke and heat to travel throughout thevoid space overhead between the acoustical ceiling and roof. This heat was intensified significantly by theburning furniture in the loading dock area that eventually began to bank down into the showroom. Firefighters began to become disoriented and visibility was zero. Firefighters attempted to transmit distresssignals over the radio, but the heat was too intense for firefighters outside to make a rescue.

A pre-incident plan of this building had been conducted multiple times throughout the years. However, itwas not referred to until late into the incident. The magnitude of the fire load and the dangers that lied inthe building’s construction were also not communicated adequately within the document. Thoughwalkthroughs were being conducted by fire crews over the years, no code enforcement had beenperformed since 1998. The proper enforcement of fire codes could have prevented this tragedy fromoccurring .


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Additional Proposed Changes

File Name Description Approved

Charleston_9.pdf

Super_Sofa_Fire_Charleston_SC.pdf


Submitted on behalf of the Annex B Task Group.




Affilliation: Annex B Task Group

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Fire Fighter Fatality Investigation and Prevention Program

A summary of a NIOSH fire fighter fatality investigation

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In fiscal year 1998, the Congress appropriated funds to NIOSH to conduct a fire fighter initiative. NIOSH initiated the Fire Fighter Fatality Investigation and Prevention Program to examine deaths of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim. To request additional copies of this report (specify the case number shown in the shield above), for other fatality investigation reports, or further information, visit the Program Website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

February 11, 2009

2007 18

Death in the line of duty…

Nine Career Fire Fighters Die in Rapid Fire Progression at Commercial Furniture Showroom – South Carolina SUMMARY On June 18, 2007, nine career fire fighters (all males, ages 27 – 56) died when they became disoriented and ran out of air in rapidly deteriorating conditions inside a burning commercial furniture showroom and warehouse facility. The first arriving engine company found a rapidly growing fire at the enclosed loading dock connecting the showroom to the warehouse. The Assistant Chief entered the main showroom entrance at the front of the structure but did not find any signs of fire or smoke in the main showroom. He observed fire inside the structure when a door connecting the rear of the right showroom addition to the loading dock was opened. Within minutes, the fire rapidly spread into and above the main showroom, the right showroom addition, and the warehouse. The burning furniture quickly generated a huge amount of toxic and highly flammable gases along with soot and products of incomplete combustion that added to the fuel load. The fire overwhelmed the interior attack and the interior crews became disoriented when thick black smoke filled the showrooms from ceiling to floor. The interior fire fighters realized they were in trouble and began to radio for assistance as the heat intensified. One fire fighter activated the emergency button on his radio. The front showroom windows were knocked out and fire fighters, including a crew from a mutual-aid department, were sent inside to search for the missing fire fighters. Soon after, the flammable mixture of combustion by-products ignited, and fire raced through the main showroom. Interior fire fighters were caught in the rapid fire progression and nine fire fighters from the first-responding fire department died. At least nine other fire fighters, including two mutual-aid fire fighters, barely escaped serious injury.

Incident Scene (Photo courtesy of Alexander Fox, Associated Press.)

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Nine Career Fire Fighters Die in Rapid Fire Progression at Commercial Furniture Showroom – South Carolina

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Fatality Assessment and Control Evaluation Investigation Report # F2007-18

2007

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

• develop, implement and enforce written standard operating procedures (SOPs) for an occupational safety and health program in accordance with NFPA 1500

• develop, implement, and enforce a written Incident Management System to be followed at

all emergency incident operations • develop, implement, and enforce written SOPs that identify incident management training

standards and requirements for members expected to serve in command roles

• ensure that the Incident Commander is clearly identified as the only individual with overall authority and responsibility for management of all activities at an incident

• ensure that the Incident Commander conducts an initial size-up and risk assessment of the

incident scene before beginning interior fire fighting operations

• train fire fighters to communicate interior conditions to the Incident Commander as soon as possible and to provide regular updates

• ensure that the Incident Commander establishes a stationary command post, maintains the

role of director of fireground operations, and does not become involved in fire-fighting efforts

• ensure the early implementation of division / group command into the Incident Command

System

• ensure that the Incident Commander continuously evaluates the risk versus gain when determining whether the fire suppression operation will be offensive or defensive

• ensure that the Incident Commander maintains close accountability for all personnel

operating on the fireground

• ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed at each structure fire

• ensure that crew integrity is maintained during fire suppression operations

• ensure that a rapid intervention crew (RIC) / rapid intervention team (RIT) is established

and available to immediately respond to emergency rescue incidents



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2007

• ensure that adequate numbers of staff are available to immediately respond to emergency incidents

• ensure that ventilation to release heat and smoke is closely coordinated with interior fire

suppression operations

• conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics

• consider establishing and enforcing standardized resource deployment approaches and

utilize dispatch entities to move resources to fill service gaps • develop and coordinate pre-incident planning protocols with mutual aid departments • ensure that any offensive attack is conducted using adequate fire streams based on

characteristics of the structure and fuel load present

• ensure that an adequate water supply is established and maintained • consider using exit locators such as high intensity floodlights, flashing strobe lights, hose

markings, or safety ropes to guide lost or disoriented fire fighters to the exit

• ensure that Mayday transmissions are received and prioritized by the Incident Commander

• train fire fighters on actions to take if they become trapped or disoriented inside a burning structure

• ensure that all fire fighters and line officers receive fundamental and annual refresher

training according to NFPA 1001 and NFPA 1021

• implement joint training on response protocols with mutual aid departments • ensure apparatus operators are properly trained and familiar with their apparatus

• protect stretched hose lines from vehicular traffic and work with law enforcement or other

appropriate agencies to provide traffic control

• ensure that fire fighters wear a full array of turnout clothing and personal protective equipment appropriate for the assigned task while participating in fire suppression and overhaul activities

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conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics

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develop and coordinate pre-incident planning protocols with mutual aid departments



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• ensure that fire fighters are trained in air management techniques to ensure they receive the maximum benefit from their self-contained breathing apparatus (SCBA)

• develop, implement and enforce written SOPS to ensure that SCBA cylinders are fully

charged and ready for use

• use thermal imaging cameras (TICs) during the initial size-up and search phases of a fire • develop, implement and enforce written SOPs and provide fire fighters with training on the

hazards of truss construction

• establish a system to facilitate the reporting of unsafe conditions or code violations to the appropriate authorities

• ensure that fire fighters and emergency responders are provided with effective incident

rehabilitation

• provide fire fighters with station / work uniforms (e.g., pants and shirts) that are compliant with NFPA 1975 and ensure the use and proper care of these garments.

Additionally, federal and state occupational safety and health administrations should:

• consider developing additional regulations to improve the safety of fire fighters, including adopting National Fire Protection Association (NFPA) consensus standards.

Additionally, manufacturers, equipment designers, and researchers should:

• continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communication in conjunction with properly worn SCBA

• conduct research into refining existing and developing new technology to track the

movement of fire fighters inside structures.

Additionally, code setting organizations and municipalities should: • require the use of sprinkler systems in commercial structures, especially ones having high

fuel loads and other unique life-safety hazards, and establish retroactive requirements for the installation of fire sprinkler systems when additions to commercial buildings increase the fire and life safety hazards

• require the use of automatic ventilation systems in large commercial structures, especially

ones having high fuel loads and other unique life-safety hazards.



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Additionally, municipalities and local authorities having jurisdiction should:

• coordinate the collection of building information and the sharing of information between building authorities and fire departments

• consider establishing one central dispatch center to coordinate and communicate activities

involving units from multiple jurisdictions

• ensure that fire departments responding to mutual aid incidents are equipped with mobile and portable communications equipment that are capable of handling the volume of radio traffic and allow communications among all responding companies within their jurisdiction.

INTRODUCTION On June 18, 2007, nine male career fire fighters (the victims), aged 27 to 56, died when they became disoriented in rapidly deteriorating conditions inside a burning commercial furniture showroom and warehouse facility. At least seven other municipal fire fighters and two mutual aid fire fighters barely escaped serious injury. The National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research, Fire Fighter Fatality Investigation and Prevention Program, learned of the incident on June 19, 2007 through the national news media. On June 19, 2007, the U.S. Fire Administration (USFA) notified NIOSH of the fatalities. That same day, a Safety Engineer and a General Engineer from NIOSH traveled to South Carolina to initiate an investigation of the incident. The NIOSH investigators traveled to the incident site and met with representatives of the Bureau of Alcohol, Tobacco and Firearms (ATF), National Institute of Standards and Technology (NIST), South Carolina State Law Enforcement Division (SLED), and South Carolina Occupational Safety and Health Administration (SC-OSHA). The NIOSH investigators were on-site June 20-22, and the NIOSH General Engineer returned June 24th to work with representatives of NIST to collect data related to the structure’s constructiona for the NIOSH investigation and for a comprehensive fire reconstruction model. Note: The NIST Building and Fire Research Laboratory is developing a computerized fire model to aid in reconstructing the events of the fire. When completed, this model will be available at the NIST website: http://www.bfrl.nist.gov/. On July 9, 2007, three NIOSH investigators (Safety Engineer, General Engineer, and Safety and Occupational Health Specialist), along with representatives of NIST, returned to South Carolina. Meetings were conducted with the Fire Chief; Assistant Chief; the city’s Director, Safety Management Division; and the city’s Workers’ Compensation administrator.

a The fire completely destroyed the structure and the sheet metal roof was removed at the direction of ATF before NIOSH

and NIST were allowed access to the structure. Consequently, detailed information on the construction was not available and NIOSH and NIST frequently relied on photographs of the structure after the fire.



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During the weeks of July 9-13, July 16-20, and August 27-31, 2007, interviews were conducted with officers and fire fighters who were on-duty and dispatched to the incident scene, as well as fire fighters who were off-duty and came to the scene to offer assistance. Fire fighters from two mutual aid departments were also interviewed during these times. NIST representatives participated in many of the NIOSH interviews to collect information for their computerized fire model. During the course of the ensuing investigation, the NIOSH investigators met with chief officers and fire fighters from the initial responding department, two local mutual aid departments, NIST staff, the county coroner, the county emergency response dispatch center staff, city building inspectors, city water system officials, representatives of the International Association of Fire Fighters (IAFF) labor union, U.S. Fire Administration staff, ATF, and representatives of the city’s Fire Review Team (FRT). NIOSH investigators reviewed some departmental standard operating procedures,b the victims’ training records, chief officers’ training records, and floor plans and photographs of the structure. Photographs were obtained from a number of sources including NIOSH, NIST, the city police department, the FRT and national media.c NIOSH investigators visited the city’s fire training academy, met with the training officer, and reviewed the training schedule (see Appendix I). The department’s maintenance and repair facility (for in-house maintenance and repair of fire apparatus, equipment, and self-contained breathing apparatus (SCBA)) was visited and maintenance records were reviewed. An independent inspection report for one of the apparatus involved in the incident, that had been contracted for by the city, was reviewed (see Appendix II). The city’s fire and police dispatch center was visited as well as the dispatch center for the first responding mutual aid department. Other sources of information used in this investigation include state and federal OSHA regulations, NFPA standards, fire department pre-plan information (see Appendix III), coroner’s reports, copies of the fireground radio transmissions provided by the city legal department, a transcript of the dispatch audio records provided by the FRT, and the FRT Phase I and Phase II reports.1,2 NIOSH contracted with a leading expert in personal protective clothing to evaluate the clothing and personal protective equipment worn by the victims (see Appendix IV). This evaluation took place on August 29, 2007. The evaluation site and handling of the evidence materials was coordinated with the assistance of the county coroner’s office and the city police department. The PPE evaluation was witnessed by representatives of NIOSH, NIST, the FRT, the county coroner’s office, the city police department, and the state fire marshal’s office. The lead NIOSH investigator participated in a meeting convened by the U.S. Fire Administration on September 20, 2007 to discuss the status of ongoing investigations and share information not of a

b NIOSH investigators reviewed two Standard Operating Procedures (SOPs) provided to NIOSH: “Standard Operating

Procedures Engine Company 2” (undated) and “Fire Department Policies and Procedures Manual” dated July 25, 2005. The city reported that there were additional SOPs in place at the time of the incident.

c Some photographs used in this NIOSH report have been altered to remove names, faces and other identifiers.



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confidential nature. This meeting consisted of representatives of the U.S. Fire Administration, ATF, the FRT, the county coroner, NIST and NIOSH. The lead NIOSH investigator participated in a similar meeting convened by the FRT on December 18, 2007. This meeting consisted of representatives of the FRT, ATF, the county coroner, NIST, and NIOSH. Safety and Health Regulations South Carolina is one of 26 states and territories which administers its own occupational safety and health program through an agreement with the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). The South Carolina Occupational Safety and Health Administration (SC-OSHA) has jurisdiction over private and public sector employers and employees within the state. The state occupational safety and health act requires employers to provide their employees with a safe and healthy worksite which is free of hazards which may cause injuries and illnesses to workers. South Carolina has adopted the federal OSHA Standards verbatim, with a few exceptions.3 Most notably, South Carolina OSHA has revised the federal OSHA Respiratory Protection Standard paragraph 1910.134(g)(4)(ii), commonly known in the fire service as the “two in – two out” rule, to allow fire fighters to enter immediately-dangerous-to-life-or-health (IDLH) atmospheres with only one fire fighter located outside the IDLH atmosphere until additional fire fighters arrive, provided certain conditions are met. Following the fatal fire, SC-OSHA cited the fire department for several alleged violations and assessed penalties.4 The fire department and city contested these findings and SC-OSHA and the city reached a settlement in which the fire department was cited for two violations, an inadequate fire department incident command system and failure to ensure use of personal protective equipment by some fire fighters at the incident.5 SC-OSHA also cited the furniture store employer for locked exit doors, fire doors not operating properly, and not implementing an emergency action plan at the store.4 Fire Department At the time of the incident, the career fire department was an ISOd Class I rated department with 19 fire companies located throughout the city. The fire department serves a population of approximately 106,000 in a geographic area of about 91 square miles. In June 2007 the fire department consisted of

d ISO is an independent commercial enterprise which helps customers identify and mitigate risk. ISO can provide communities with information on fire protection, water systems, other critical infrastructure, building codes, and natural and man-made catastrophes. Virtually all U.S. insurers of homes and business properties use ISO’s Public Protection Classifications (PPC) to calculate premiums. In general, the price of fire insurance in a community with a good PPC is substantially lower than in a community with a poor PPC, assuming all factors are equal. ISO’s PPC program evaluates communities according to a uniform set of criteria known as the Fire Suppression Rating Schedule (FSRS). The FSRS has three main parts – fire alarm and communications (10%), the fire department (50%), and water supply (40%). The FSRS references nationally recognized standards developed by the National Fire Protection Association (NFPA) and the American Water Works Association. Rated fire departments are classified 1 through 10 with Class 1 being the best rating a fire department can receive. More information about ISO and their Fire Suppression Rating Schedule can be found at the website http://www.isogov.com/about/.



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approximately 240 uniformed fire fighters and fire officers. The department operated 16 engine companies and 3 ladder truck companies at 14 stations in the city. Each apparatus was staffed with four fire fighters but routinely operated with three fire fighters per apparatus (a captain, engineer, and fire fighter), depending on the staffing available each shift. The standard work shift was 24 hours on-duty and 48 hours off-duty, with fire fighters assigned to one of three rotating shifts. Each shift was supervised by an Assistant Chief. On the day of the incident, the department had 61 fire fighters, 4 Battalion Chiefs and an Assistant Chief working on-duty. Note: At the time of the incident, the fire department did not have a safety officer position and a safety officer was not designated at the incident. Since then, the fire department has hired a full-time permanent safety officer. The fire department utilized the 911 dispatch center operated by the municipal police department (PD). The local county also maintains an emergency communications / dispatch center and provides communications for two small fire departments. Some mutual aid fire departments within the county maintain their own dispatch centers. The first mutual aid department to respond to the scene was a career department that employs 60 fire fighters and officers. It maintains four stations and serves a population of approximately 24,000 residents in an area of approximately 30 square miles. Jurisdictional boundaries between this mutual aid department and the municipal department were intermingled. Adjoining properties in the same block could be in different jurisdictions. This led to incidents where a department would be the first to arrive at a working fire outside its jurisdiction. The second mutual aid department to respond to the scene was a combination department with 44 fire fighters that serves a rural population of 14,000. Training In South Carolina, it is up to the local fire chief to decide what level of training is required for fire department personnel to obtain in order to meet SC-OSHA training requirements. At the time of the incident, this municipal fire department required fire fighters to receive basic training to at least Fire Fighter I certification from the South Carolina Fire Academy or some other source. While the South Carolina Fire Academy is accredited by the International Fire Service Accreditation Congress to provide a number of NFPA level courses, at the time of the incident, the fire department recognized training from sources other than the South Carolina Fire Academy as meeting their basic certification requirements. Note: Basic fire fighter certification required by the fire department at the time of the incident did not meet NFPA 1001, Standard for Firefighter Professional Qualifications. 6 Once hired, the recruits were assigned to the department’s training center for 10 days of hands-on training after which the new fire fighters were assigned to companies throughout the city. The department’s training focused on equipment use, SCBA use, ladder drills, hydrant hookup, hose lays, hose pulls, rescue drills, and live-burn exercises (see training schedule – Appendix I). A training officer supervised the recruit training and oversaw the department’s training program. Individual companies normally trained from 0930 to 1130 hours each day with each company’s captain responsible for the training. Training on hydrant location and hook-up was done once per month.



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Driver / operator training was mainly on-the-job hands-on training. Individual fire fighters could request to receive driver / operator training. The request would then be reviewed and approved through the department’s chain of command. Training records provided by the city for the nine victims consisted of verification of the weekly in-station training, certificates indicating training on subjects such as National Incident Management System (NIMS), weapons of mass destruction (WMD) and emergency medical services – medical first responder. SCBA facepiece fit test records were also provided. Training records for the chief officers were provided, consisting mainly of copies of National Incident Management System (NIMS) training certificates. Victims Note: Throughout this report, the 9 victims are identified by the order in which they were located at the scene, identified by the County Coroner, removed from the structure and transported. The following table provides information on each victim.

Victims (Order located)

Rank Apparatus Age Experience (yrs)

1 Engineer Engine 19 37 9 2 Fire fighter Engine 19 56 32 3 Fire fighter Engine 16 46 2 4 Assistant Engineer Ladder 5 27 1.5 5 Captain Engine 16 49 29 6 Captain Engine 19 48 30 7 Acting Captain Ladder 5 40 12.5 8 Captain Engine 15 34 11.5 9 Fire fighter Ladder 5 27 4

Equipment and Personnel The municipal fire department initially responded to the alarm with 3 apparatus and 9 fire fighters including Engine 11 (E-11 acting captain, acting engineer and fire fighter), Engine 10 (E-10 captain, acting engineer and fire fighter), Ladder 5 ( L-5 acting captain, engineer (assistant engineer), and fire fighter), a battalion chief (BC-4) and an Assistant Chief (AC). Note: Fire department procedures stated that where structures were 5 stories or less in height, the first alarm assignment would be 2 engines, 1 ladder truck, and a Battalion Chief. For structures over 5 stories in height, the first alarm assignment would be 3 engines, 1 ladder truck, a Battalion Chief and the Assistant Chief. Once on-scene, the Incident Commander could request additional resources as deemed necessary. Procedures also stated that a confirmed report of “smoke showing” would automatically send an additional engine. When a ranking officer arrived on-scene, that officer automatically became Incident Commander.



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Engine 16 (E-16 captain, engineer, and fire fighter) was dispatched after BC-4 (the initial Incident Commander (IC)) radioed dispatch to confirm smoke was showing at the incident site as per department procedures. E-16 was designated as the third-due engine responding to all structure fires in the western district (where the incident occurred) if not assigned on the initial dispatch. Chief Officers requested Engine 15 (E-15), Engine 12 (E-12), Engine 19 (E-19), Engine 6 (E-6), Engine 3 (E-3), Engine 13 (E-13), Engine 9 (E-9), and Ladder 4 (L-4) as the incident escalated. Additional responders included the Battalion Chief from the neighboring district (BC-5) and the Battalion Chief of training (BC-T). A large number of off-duty officers and fire fighters also responded to the incident scene. Some of the off-duty fire fighters responded with turnout gear, others did not. Only the units directly involved in the operations preceding the fatal event are discussed in this report. The activities of the additional mutual aid departments that were dispatched after the structure collapsed are not addressed by this report. Timeline Note: This timeline is provided to set out, to the extent possible, the sequence of events as the fire departments responded. The times are approximate and were obtained from review of the dispatch audio records, witness interviews, photographs of the scene and other available information. In some cases the times may be rounded to the nearest minute, and some events may not have been included. The timeline is not intended, nor should it be used, as a formal record of events. The response, listed in order of arrival (time approximate) and events, include:

• 1907 hours Dispatch for possible fire behind furniture store

• 1909 hours BC-4, E-10, E-11, L-5 enroute BC-4 confirms smoke showing while enroute E-10, L-5, E-16 acknowledge hearing BC-4 confirm fire AC enroute

• 1910 hours E-16 enroute as third-due engine E-15 relocates to western district BC-4 arrives on scene and reports trash fire at side of building. BC-4 radios for E-10 to come down side of building

• 1911 hours Assistant Chief (AC) on scene E-10 and E-11 on scene

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• 1912 hours AC radios for E-16 to come inside building when they arrive on-scene. (Showroom clear with no fire/smoke showing) Ladder 5 on scene Fire Chief (enroute) radios E-15 to relocate to Station 11 AC radios dispatch to send Engine 12 BC-4 radios Car 2 and says he knows fire is inside building Engine 12 dispatched to scene

• 1913 hours

BC-4 radios E-12 that he needs E-12 to lay a supply line to E-10 E-11 acting captain radios “I need an 1 ½” inside this building” (Door connecting showroom to loading dock was opened by AC showing heavy fire in loading dock) AC radios E-15 to “come on” AC radios E-15 and says to bring 1 ½” hose line inside to right rear of building E-6 begins relocating to the west side

• 1914 hours AC radios BC-4 and says fire is inside the rear of the building and moving towards the showroom AC radios dispatch to send E-6 E-6 dispatched to scene Fire Chief radios dispatch to send E-19 and have E-6 relocate to Station 11

• 1915 hours AC radios E-16 to bring 2 ½” hose line in front door E-16 radios AC to confirm assignment E-16 on-scene

• 1916 hours L-5 engineer and L-5 fire fighter both radio E-11 to charge line (1 ½” line pulled by L-5 / E-11 crews) E-19 enroute L-5 again requests E-11 to charge hose line Fire Chief on scene

• 1917 hours E-12 on scene - assigned to lay supply line to E-10 E-15 on scene

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• 1919 hours Fire Chief radios E-6 and tells them to come to scene and come in front door E-6 responds they are enroute Fire Chief radios dispatch to call the power company E-16 captain radios “charge that 2 ½”

• 1920 hours E-11 engineer radios the E-11 acting captain to see if he wants the 2 ½” hose line charged. AC replies “not until the supply line is charged” E-19 on scene E-12 radios E-10 … “water coming 10” E-12 engineer radios dispatch that the police department is needed because cars are running over hoses. Dispatch replies that the police department is enroute

• 1921 hours AC radios E-16 engineer - “16, what about that supply line?” E-16 engineer replies he is looking for a hydrant. E-6 on scene

• 1922 hours E-11 engineer radios E-16 that tank water is down to half-full E-16 engineer replies he is looking for hydrant

• 1924 hours (see Photo #1) Battalion Chief 5 (BC-5) on scene Fire Chief radios E-12 to boost water pressure on supply line by 50 pounds E-12 acknowledges AC radios.. “We need that 2 ½” (referring to 2 ½” hoseline off E-11) E-3 is relocated to Station 16/19 Mutual aid department # 1 on-scene

• 1925 hours E-10 radios that tank water is down to one-quarter full Fire Chief radios E-12 to boost supply water pressure to E-10 by 50 more pounds E-12 acknowledges Mutual aid department # 1 radios the fire department with no response

• 1926 hours E-16 engineer radios that “water coming” Dispatch radios Fire Chief and informs him that dispatch has received a phone call from a civilian saying he is trapped at the rear of the building Fire Chief acknowledges

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• 1927 hours Inaudible radio traffic – possibly “lost inside” or “trapped inside” Fire Chief radios AC and says that the warehouse door has been opened and a 2 ½” hose line is in operation. Fire Chief also asks about the rescue attempt of the trapped civilian and tells AC to do what he can do. Dispatch radios AC to inform him that the trapped civilian is banging on exterior wall with a hammer

• 1928 hours AC radios for E-11 and gets no response. Note: This may be when the AC is looking for fire fighters to assist with rescue of the civilian and mutual aid fire fighters are pressed into action.

• 1929 hours Broken radio traffic of fire fighter in distress asking “which way out” then “everyone out”

• 1930 hours (see Photo #2) E-11 radios that 2 ½” hose line is charged Several different fire fighters in distress radio “need some help out,” “need help getting out,” also “lost connection with the hose” AC radios Fire Chief that they are attempting to free civilian trapped in warehouse

• 1931 hours – 1934 hours (see Photo #3) More broken radio traffic from fire fighters in distress L-5 repositioned to D-side by off-duty fire fighters Fire Chief asks for E-3 to come to scene and lay supply line to L-5 BC-5 reports civilian is out of building E-16 engineer radios dispatch that police department is needed to prevent traffic from running over supply line. FF calls Mayday Fire Chief asks AC “is everyone out?” AC responds the civilian is out Fire Chief radios AC to make sure his people are accounted for. E-15 FF exits building (out of air) – reports he didn’t call the Mayday Fire Chief radios “who called Mayday” Fire Chief radios “…we need to vacate the building” Dispatch tells Fire Chief that the L-5 engineer emergency button (on radio) has been activated Fire Chief radios for E-15 captain with no response E-15 FF changes air cylinder and goes back inside

• 1935 hours – 1936 hours (see Photos # 4, # 5, and # 6) Front windows knocked out E-6 crew (captain, engineer, and FF) along with E-15 engineer and FF exit showroom

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Fire Chief orders mutual aid crew to search for missing fire fighters Fire Chief continues to radio for E-15 captain and crew with no response Fire Chief instructs everyone else to stay off radio Conditions at front of showroom change dramatically – turbulent thick dark smoke rolls out windows

• 1937 hours Fire Chief continues to radio for E-15 captain and crew with no response E-13 is dispatched to scene E-7 relocates to Station 13 Fire rolls out windows at front of showroom

• 1938 hours (see Photos # 7 and # 8) Mutual aid crew exits building Fire Chief continues to radio for E-15 captain and crew with no response Fire Chief radios for everyone to abandon the building Training Chief (BC-T) radios for E-15 captain BC-T radios E-16 engineer to boost water supply pressure to E-11.

• 1939 hours AC radios E-16 to “give me some more water” BC-T also radios E-16 for more water pressure E-16 engineer acknowledges and water pressure is boosted to 200 psi

• 1940 hours E-3 on scene Mutual Aid Department # 2 enroute to lay water supply line to L-5

• 1942 hours BC-T continues to radio for E-15 captain (no response) Fire Chief radios that no one is to go inside E-13 on scene

• 1943 hours

Fire Chief asks if everyone is out of front BC-T radios E-16 engineer that he needs more water pressure. Engineer responds that the entire hose bed has been stretched out plus two sections of 3” hose. Additional radio communications about civilian vehicle traffic driving over the supply line. BC-T radios E-16 engineer and says “I need all you can give me!”

• 1944 hours AC radios dispatch to call the city water department to increase water pressure in the area.



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Fire Chief radios for E-15 captain E-3 engineer radios that water is coming (water supply established to L-5)

Additional crews continued to arrive on-scene and contributed to the fire suppression efforts. Engine 13 began laying a supply line to L-5 at 1947 hours. The Fire Chief radioed dispatch to send Ladder 4 to the scene at 1948 hours. The Fire Chief radioed dispatch and requested that the Mayor be notified at 1950 hours. A portion of the roof over the right side of the showroom collapsed causing the front façade to begin collapsing at 1951 hours. Eventually, almost the entire roof over the main showroom and the right side addition collapsed. Ladder 4 was put into operation in the front parking lot at approximately 2005 hours. The fire was brought under control after 2200 hours. Recovery operations continued until after 0400 hours the next morning. Personal Protective Equipment The fire department issued each fire fighter a full set of black turnout gear and station uniforms when they were hired and sent to the recruit training class. The department issued helmets, hoods, gloves, and boots. The Chief Officers (Battalion Chief rank and higher) wore a set of brown turnout gear from a different manufacturer. At the time of the incident, each fire fighter was allowed to purchase and wear his own turnout gear, or bring their gear from other departments they served in, if they desired, so long as it met the requirements of the department. Following the incident, the personal protective equipment (PPE – turnout clothing, SCBA, radio, hand tools, etc) worn by each of the nine victims was secured by the city police department. On August 29, 2007, the PPE was examined in detail by a personal protective clothing expert contracted by NIOSH. The PPE was examined, documented and photographed through a systematic process. The county coroner’s office coordinated the PPE examination at the request of NIOSH. Representatives of NIOSH, NIST, the FRT, the county coroner’s office, the city police department, and the state fire marshal’s office were present during the examination. Each victim’s PPE was severely damaged by fire and heat exposure due to the length of time it took to locate and recover the victims. The evaluation indicated melting of polyester station uniforms (non-NFPA 19757 compliant) in the areas where the turnout clothing was degraded by the fire exposure. The PPE examination also identified examples where turnout gear was not being properly worn such as turnout coat collars not fully extended upward and helmet ear flaps not deployed. A summary of the complete PPE inspection is contained in Appendix IV. A copy of the complete PPE inspection report is available upon request from the NIOSH Fire Fighter Fatality Investigation and Prevention Program. The city fire and police departments utilized a type-2 trunked radio system (computer-aided) that automatically assigned radio frequencies as needed to different “talk groups.” Each apparatus riding position was assigned a radio so that each on-duty fire fighter had access to a radio. Each radio contained an emergency notification button that, when activated, would send a signal to the dispatch center with the radio’s identity. On the day of the incident, radios were available, but at least one fire fighter did not carry his assigned radio. The county in which this incident occurred maintained its own dispatch center for emergency medical services (EMS) and the smaller outlying volunteer fire departments. Some smaller fire departments operated as public service districts (PSDs) and operated

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their own dispatch centers. Thus not all fire departments who were on scene could communicate directly with the city fire department due to the multiple radio systems in place. Apparatus and Equipment Maintenance The fire department operated a maintenance and repair facility at one of the stations, where in-house maintenance was performed on all fire apparatus, equipment and SCBA. Annual pump flow testing was conducted and recorded. During the NIOSH investigation, interviewed fire fighters reported a number of recurring maintenance problems on apparatus and power equipment to the NIOSH investigators. During the NIOSH investigation, fire fighters reported during interviews that Engine 11 (E-11) required specific procedures to engage the pump. When interviewed by NIOSH investigators, the maintenance supervisor reported that E-11 had a hydraulic transmission and a non-electric pump, and if the engine was not throttled to full throttle before the pump was engaged, the pump would not discharge at full capacity. The city reported that there were no records or reports of operational issues with E-11 prior to this event, and that daily equipment checks were performed. In December 2008, the city contracted with a nationally recognized company to conduct independent testing and evaluation of E-11. The city indicated that no changes had been made to Engine 11 since the fire. A copy of the December 16, 2008 inspection report was provided to NIOSH for review (Appendix II). The results of this testing and evaluation indicated that Engine 11 was generally in good acceptable working order with 3 maintenance findings that were corrected during the inspection, and 8 findings needing corrective action. In addition, the report highlighted findings of the Engine 11 pump inspection. The report reads, “When shifting the [pump] lever downward from top position, proper operation calls for a pause in center (neutral) position momentarily before bringing the lever to the complete downward position. Failure to pause at the center (neutral) position can cause a long excessive delay in engaging of pump. There is an expected delay even in proper operation of this pump. Please check with manufacturer for exact acceptable delay time line.”

During the NIOSH investigation, fire fighters reported to NIOSH investigators that the fire department’s procedure was to refill cylinders when the pressure dropped to 1500 psi which is well below the required 90% level found in the OSHA Respirator Standard8 and NFPA 18529 (1500 psi is 68% of full cylinder pressure or 2216 psi). NIOSH investigators examined a small number of SCBA cylinders in service on city fire apparatus and did find some with cylinder pressures below 2000 psi. Structure The structure involved in this incident was a one-story, commercial furniture showroom and warehouse facility totaling over 51,500 square feet that incorporated mixed-construction types. The structure was non-sprinklered. The facility had been renovated and expanded a number of times over the past 15 years. The original structure was constructed in the 1960’s as a 17,500 square foot grocery store with concrete block walls and lightweight metal bar joists (metal roof trusses) supporting the roof to create an open floor plan. After being converted to a furniture retail store, the original structure was expanded by adding a 6,970 square foot addition on the right side (D-side) in 1994 and

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a 7,020 square foot addition to the left (B-side) in 1995. Both additions were attached to the original exterior walls and consisted of steel beams supporting the walls and roof. To provide access between the original structure and the two additions, the exterior walls on the B and D sides of the original structure were each penetrated in 3 locations to form six 8’ X 8’ openings that were equipped with metal roll-up fire doors. These fire doors were equipped with fusible links designed to automatically close the doors in the event of a fire. In 1996, a 15,600 square foot warehouse was added to the rear of the main showroom. The main showroom and the warehouse were connected by an enclosed wood-framed loading dock of approximately 2,250 square feet. Double metal doors connected the rear of the right-side addition to the loading dock area. These metal doors swung outward (opened into the loading dock). Additional access to the loading dock area was available from the rear of the original structure. (See Diagram 1) At the time of the incident, the showroom included painted sheet-metal siding on the B and D side exterior walls with a combination of sheet metal and concrete block in the rear (C-side) and a front masonry and block façade (at the A-side). The roof over the main showroom (original structure) was constructed of sheet-metal roof decking covered by foam insulation and a weather membrane. Both right and left showroom additions included roofs constructed of sheet metal roof decking over fiber glass insulation. The fire caused extensive damage to the roof structure, making an analysis of the roof construction difficult. The warehouse was a free-standing, clear-span structure with sheet-metal walls and roof. Both structures contained concrete floors. The main showroom measured 9 feet from the floor to a suspended drop ceiling and approximately 14 feet to the roof, creating almost 5 feet of void space above the suspended ceiling. The warehouse measured 29 feet from the floor to the roof. The warehouse contained rows of metal storage shelving that contained a variety of furniture items including couches, chairs, mattresses, etc. (see Photo 9 showing storage racks in warehouse). The roofs over the main showroom, the showroom additions on both the B and D sides of the structure, and the warehouse contained limited penetrations (ventilation ductwork, utilities, etc.). Thus there were limited openings for smoke and hot gases to escape naturally in the event of a fire. According to city building officials, the property was annexed into the city in 1990. The original structure and the 3 additions were considered as 4 separate structures for code enforcement purposes. Separate permits were issued for the construction of the left and right side additions and the warehouse. City building officials indicated to NIOSH investigators that after the fire, the furniture store property was determined to be “non-code compliant” (not in compliance with applicable codes). Work had been performed on the loading dock area and the maintenance shop without permits between 1996 and 2005. Other code violations included the accumulation of trash outside the loading dock, large quantities of flammable liquids, solvents, and thinners in the loading dock area, and storage of furniture and flammable materials in non-permitted areas. At the time of the incident, city ordinances required commercial structures over 15,000 square feet to be equipped with a sprinkler system. The original structure was grandfathered (exempt from this

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requirement) while the left and right additions (at the B and D-sides) did not meet the threshold requirement. Thus, since the store was considered as 4 separate structures, the facility had been exempt from sprinkler system requirements. The structure had been inspected by the fire department on a number of occasions. In 1987, fire inspection duties were transferred from the fire department to the city with the last documented fire code inspection by the city in 1998. The fire department continued to perform periodic pre-plan inspections. A building pre-plan form obtained from the fire department dated April 26, 2006 noted that store contents were “household furniture and office equipment” and that the rear warehouse contained racks approximately 30 feet high (see Appendix III). The pre-plan form did not mention the large volume of furniture and flammable materials (fuel load) contained in the structure. It was reported to NIOSH investigators by fire fighters during interviews that trash from the furniture business, including packing materials, cardboard, broken furniture and other flammable materials, were routinely stored against the building near the loading dock on the west (D) side of the structure (see Diagram 2). Weather At the time of the incident, the temperature was approximately 86 degrees Fahrenheit (F) with a dew point of 72 degrees F and a relative humidity of 63 percent. The sky was partly cloudy with light winds blowing from the south up to 11 miles per hour.10 INVESTIGATION The furniture store fire on June 18, 2007, was originally dispatched as a possible fire behind a commercial retail furniture store. The initial Incident Commander radioed dispatch that the fire was a “bunch of trash free-burning against the side of the structure.” The fire very rapidly grew into an incident of major proportions. (A computerized fire model will be available in the future from NIST at http://www.bfrl.nist.gov/). Summary of Initial Sequence of Events On June 18, 2007, at approximately 1907 hours, the fire department was dispatched to a possible fire behind a large commercial retail furniture store. Two engines (Engine 11 and Engine 10), one ladder truck (Ladder 5), and the Battalion Chief (BC-4) were dispatched per department procedures. The on-duty Assistant Chief (AC) was at Station 11 and responded to the scene. While enroute, BC-4 observed heavy dark smoke rising into the air and radioed dispatch that smoke was coming from the direction of the store. Per department procedures, this initiated the response of the third-due engine (Engine 16) to the scene. BC-4 arrived on scene driving east to west, pulled past the store and drove down the alley to the loading dock located on the D-side of the structure. BC-4 observed fire burning from ground level to over the roofline outside of the covered loading dock. Note: The covered loading dock connects the front showroom area to the rear 15,600-square foot warehouse facility. BC-4 radioed dispatch that the fire was a “bunch of trash free-burning against the side of the structure.” The dispatcher asked

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the responding units if they heard BC-4’s report on the fire conditions. E-10, L-5, and E-16 acknowledged. When the AC arrived on-scene, he parked in the parking lot in front of the main showroom right addition. The AC and BC-4 briefly discussed their observations and directed Engine 10 to back down the alley to the loading dock area. The AC entered the store through the main entrance located in the center of the front of the structure (A-side). The AC walked down the center of the showroom to the rear (in the original structure) then went back outside. He did not observe any smoke or fire in the main showroom. BC-4 drove his car to the front of the showroom and observed the AC coming out of the showroom’s main entrance. The AC remained at the front of the store while BC-4 returned to the D-side. Note: Departmental policy was that the highest ranking officer on-scene was the Incident Commander. Incident Command (IC) was never formally announced at this incident. While the E-11 crew looked for a hydrant to establish water supply, the AC and the E-11 acting captain re-entered the main showroom. The AC radioed E-16 to come inside the front door when they arrived on scene. E-16 acknowledged. Ladder 5 (L-5) arrived on-scene at 1912 hours and pulled into the parking lot in front of the furniture store, facing east. BC-4 radioed the AC and informed him that the fire was now inside the structure. The AC radioed Dispatch and requested that Engine 12 (E-12) be sent to the scene. The Fire Chief advised the dispatcher to relocate Engine 15 (E-15) to Station 11. BC-4 radioed E-12 and instructed them to lay a supply line to E-10. E-12 acknowledged. The Assistant Chief detected fire when he opened a door connecting the rear of the right showroom addition to the loading dock area. The E-11 acting captain radioed that he needed a 1 ½” hand line inside the building. When E-15 radioed that they had relocated to the west-side, the AC instructed E-15 to come to the scene. The AC also instructed E-15 to bring a 1 ½” hand line inside to the rear right-side of the structure. The AC radioed that the fire was inside the rear of the structure and was moving towards the showroom. The E-11 acting captain went outside and met the L-5 crew pulling a 1 ½” hand line off E-11. The AC radioed dispatch and requested that Engine 6 (E-6) be sent to the scene. E-6 was dispatched at 1914 hours. The Fire Chief (enroute) radioed dispatch to change the assignment to have Engine 19 dispatched to the scene and have E-6 relocate to Station 11. E-16 radioed the AC to ask if they were to go to the rear of the building. The AC instructed E-16 to come to the front door and bring a 2 ½” hand line inside. The Fire Chief arrived on-scene at 1916 hours. Note: Beginning at approximately 1916 hours, the L-5 engineer is heard over the radio asking for the 1 ½” hose line from E-11 to be charged. Diagram 2 shows the location of Engine 10 and Engine 11 in relation to the structure and how the attack lines were deployed during offensive operations. A mutual aid department noticed heavy black smoke in the area and self-dispatched to the scene. The fire had already spread to the warehouse when the mutual aid department arrived on-scene. After some discussion with the Fire Chief, the mutual aid department was assigned to the rear of the warehouse (C-side) to begin fire suppression.



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The burning furniture quickly generated large volumes of smoke, toxic gases and soot that added to the fuel load. At approximately 1926 hours, a store employee called the city’s 911 Dispatch center and reported that he was trapped inside the back of the building. Note: The employee was actually working near the front of the warehouse opposite the covered loading dock (see Diagram 3.) The employee stated he was banging on the exterior wall with a hammer. The dispatcher told the employee to continue banging on the wall and to stay calm and stay as low to the floor as he could. The dispatcher radioed the Fire Chief and informed him of the situation. This information was also relayed to the city police dispatcher and a police officer on-scene verbally informed some fire fighters of the situation. The city Assistant Fire Chief and a Battalion Chief (BC-5) quickly instructed a crew of four fire fighters from the mutual aid department to initiate the rescue attempt on the B-side of the warehouse. This crew quickly located the point where the trapped civilian was banging on the exterior wall. They were able to cut through the exterior wall (metal siding) using a Haligan bar and axe. The fire fighters were able to safely extricate the civilian at approximately 1933 hours. The civilian employee rescue was announced over the radio. The mutual aid fire fighters assisted the employee to the front parking lot where he was checked by EMTs. As the civilian was being rescued, the fire was extending into the main showroom. The fire quickly outgrew the available suppression water supply. The interior fire attack crews could not contain the spread of the fire. Note: At this point, three hose lines were inside the main showroom – the initial 1½ inch hose line, a 2½ inch hose line and a 1 inch booster line. All three hose lines were pulled off Engine 11 which was being supplied by Engine 16 through a single 2 ½ inch supply line approximately 1,850 feet long. Water supply from Engine 16 to Engine 11 was established at approximately 1926 hours. The interior crews from Engine 11, Ladder 5, Engine 16, Engine 15, Engine 19, and Engine 6 became disoriented as the heat rapidly intensified and visibility dropped to zero as the thick black smoke filled the showroom from ceiling to floor. The interior fire fighters realized they were in trouble and began to radio for assistance. At least one Mayday was called. Another fire fighter radioed that he had lost contact with the hose line and needed help. One fire fighter activated the emergency button on his radio. Note: During this incident fire fighters experienced intermittent radio communication problems and interruptions. Audio transcripts of the fireground channel recorded multiple instances where fire fighters inside the structure (including some of the victims) transmitted over the radio but the transmissions were not heard or not understood. The first recorded transmission of a fire fighter requesting assistance occurred at approximately 1927 hours and transmissions requesting “we need help,” “lost connection with the hose,” and “Mayday” continued until at least 1934 hours. The first “Mayday” was recorded at approximately 1932 hours. The first recorded transmissions indicating chief officers were aware of the fire fighters calling for assistance was at approximately 1933 hours. The Engine 6 crew and three fire fighters from E-15 were able to find the front door and exit the showroom. The front showroom windows were knocked out to improve visibility. Fire fighters, including two fire fighters from the mutual aid crew who extricated the trapped civilian, were sent inside to search for the missing fire fighters at approximately 1936 hours. The two mutual aid fire fighters made brief contact with two disoriented fire fighters just as the flammable mixture of gases



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and combustion by-products in the showroom ignited, filling the showroom with flames. The two mutual aid fire fighters lost contact with the two disoriented fire fighters and were driven outside by the intense heat and flames (see Photo 7). One of the rescuers received second degree burns on his face, neck, hands, and arms. An off-duty Battalion Chief and the Engine 6 engineer also entered the structure for a rescue attempt. They also were driven out by the rapid fire spread. While fire fighters were known to be trapped inside, the number and their identities were not known. Interior fire fighters were caught in the rapid fire progression and nine fire fighters from the first-responding fire department were killed. The operational details of each responding apparatus company are listed below. Per department procedures, chief officers requested additional apparatus as the need was identified. Engine 10 The E-10 crew (consisting of a captain, engineer, and fire fighter) was in-transit returning to quarters when the fire dispatch came in. The crew could see smoke billowing from the incident scene as they pulled onto the highway and they heard BC-4 report over the radio a trash fire on the side of the structure. Note: E-10 and Ladder 5 are quartered at the same station. The fire fighters on E-10 and L-5 had switched positions so that another fire fighter could train on pumping E-10. The AC and BC-4 were already on-scene when Engine 10 arrived. The AC directed E-10 to back down the alley parallel to the D-side of the store toward the loading dock. The crew observed smoke and flames inside the loading dock area and coming out an exhaust fan in the D-side wall. The E-10 captain pulled a booster line (1” red hose) and knocked down the outside trash fire while the E-10 fire fighter pulled a 1 ½” pre-connected hand line to the loading dock. BC-4 returned to the loading dock after meeting with the AC and observed fire burning inside the structure so he radioed dispatch to report that the fire was now inside the building. The E-10 captain decided to use the 1 ½” hand line for the interior attack. The E-10 engineer charged the 1 ½” hand line from the engine’s tank-water supply. Fire was readily visible inside the loading dock area as the E-10 fire fighter and captain advanced the hoseline inside the loading dock about 20 to 25 feet. At their furthest point of entry, the E-10 crew could just see the door connecting the enclosed loading dock to the showroom right-side addition. This area became fully involved in flames as the E-10 crew directed water onto the fire. The 60 gallons per minute (gpm) flow from their 1 ½” handline was insufficient to control the fire. According to the fire fighters interviewed by NIOSH, the flames appeared to float in the air and burned floor to ceiling. The water didn’t appear to have any effect on the fire so the crew started to retreat. Note: The E-10 crew told NIOSH investigators that the water pattern produced by their fog nozzle just pushed the flames around the room as they attempted to extinguish the fire. After the fire, at least 28 one-gallon cans of extremely flammable solvents were found inside the loading dock suggesting that at some point a vapor fire was burning inside the loading dock. As they were backing out, the hose either burst or was burned through by the fire. Water spraying from the ruptured hose aided the fire fighters (improved visibility and provided a protective water curtain) in locating the door and moving outside.



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The E-10 engineer pulled some sections of 2 ½” supply line from E-10 out to the street to meet E-12 which had been assigned to provide a water supply line. When the E-10 attack crew exited the loading dock, they asked fire fighters from Engine 12 (E-12), just arriving on-scene, to repair the damaged 1 ½” hand line. The E-10 captain and fire fighter got the 1” booster line that they had previously pulled off E-10 and advanced the booster line to the loading dock door. The booster line did not have any effect on the fire so they backed the line out, switched back to the 1 ½” hand line (that had been repaired by the E-12 crew) and moved back inside the loading dock. By this time the Fire Chief was on scene. The Fire Chief came to the loading dock and yelled inside to tell the E-10 captain not to advance any further. A few seconds later, the Fire Chief ordered the E-10 crew to back outside and operate from the doorway. Note: The E-10 crew was inside the loading dock 3 times for a total of approximately 15 minutes. BC-4 observed that the fire had extended into the warehouse. BC-4 returned to the front of the building and asked the manager if he had keys for the warehouse at the rear of the loading dock. The manager said “no,” so BC-4 returned to the loading dock and directed the E-12 crew and off-duty fire fighters who had responded to the scene to cut through the warehouse’s roll-up door with a power saw. The crews experienced trouble with getting the saw to run properly and used axes and Haligan bars to open the warehouse doors. BC-4 also directed the E-10 crew to assist with opening up the warehouse. BC-4 then directed the E-10 crew to get a 2 ½” hand line with a stack-tipped nozzle from E-10 and pull it to the warehouse door. By this time, the warehouse was becoming well involved. A second 2 ½” hose line was later pulled from E-10 and put into operation. BC-4 was able to look inside the warehouse and he observed a large amount of fire inside. BC-4 went back to the front of the building and directed 2 off-duty fire fighters to move Ladder 5 to the D-side and set it up for aerial water pipe operation. BC-4 also met with an off-duty captain and asked him to take over getting L-5 set up for operation. Note: This off-duty captain is also an Assistant Chief at a neighboring mutual aid fire department located about 20 miles away. A crew from the mutual aid department responded and the captain used this mutual aid crew to assist with establishing water supply to L-5 by supplying it with tank water and then stretching supply lines to Engine 12. Per department procedures, off-duty fire fighters are allowed to respond to working fires and become involved in fire suppression activities. Off-duty fire fighters are supposed to check in with the IC, give the IC their ID card or driver’s license, and get an assignment. The civilian owner of a small yellow frame building located next to the D-side of the furniture warehouse advised BC-4 that his building was full of vehicles, gasoline, oil, and other flammables (see Diagram # 2). BC-4 talked to the deputy chief of the first mutual aid department about the building and asked him to get a hand line to protect the yellow building. Once L-5 was put into operation at approximately 1944 hours, it also was used to protect this building. Engine 11 The Engine 11 (E-11) crew (acting captain, acting engineer, and fire fighter) was in quarters at Station 11 and the engine was being washed when the fire dispatch was initiated. The AC and BC-4 were also at station 11. E-11 was the first due engine but Engine 10 was in the vicinity and arrived on-scene first. While enroute to the scene, the E-11 crew heard BC-4 radio that smoke was coming from the location of the furniture store. The original fire dispatch stated that the fire was at the rear,



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so E-11 turned left off the highway onto a side street and drove behind the building. The AC radioed for E-11 to come back to the front of the store and pull into the second entrance to the parking lot. E-11 circled around and turned right into the parking lot in front of the store just as E-10 backed down the alley on the D side. E-11 got on scene at 1911 hours just before BC-4 radioed that the fire was inside the structure. The acting captain on E-11 directed the E-11 acting engineer and fire fighter to lay a supply line to E-10. The E-11 fire fighter (suction man) started walking down the street looking for a hydrant. The E-11 fire fighter returned to E-11 before making a hydrant connection when Ladder 5 (L-5) arrived on-scene. The E-11 acting engineer was directed by the L-5 acting captain to reposition E-11 near the front door facing northeast. The E-11 acting captain entered the main showroom doors and walked down the center aisle to the rear of the main showroom. The showroom was clear with no smoke visible inside. The AC had preceded the E-11 acting captain inside the showroom and the two walked into the right addition and walked to the rear of the right showroom addition. They both observed a small wisp of light smoke visible at ceiling level in this area. They were not immediately alarmed by this smoke and the AC opened the double door leading to the loading dock. They reported seeing lots of fire and smoke beyond the door. The AC attempted to pull the door shut but he could not shut the door due to the air rushing from the showroom toward the fire. The E-11 acting captain helped pull the door shut and the AC told the acting captain to get a 1 ½” hand line. At 1913 hours, the E-11 acting captain radioed that he “needed an inch-and-a-half inside the building.” The E-11 acting captain then went outside and met the acting captain from Ladder 5 (L-5) pulling a 1 ½” preconnected hand line off E-11. They both pulled the 1 ½” pre-connected hand line through the center doors and down the center aisle. The hand line just reached the rear of the center showroom. The E-11 acting captain told the L-5 acting captain he was going to go outside to add in another section of hose. The E-11 acting captain added 5 more sections of 1 ½” hose (the second pre-connected hose line on E-11) and dragged it inside. The L-5 acting captain and L-5 fire fighter were at the nozzle at this time. The L-5 crew pulled the nozzle toward the rear of the right side addition (the line was still not charged at this point). The E-11 fire fighter entered the main showroom flaking more slack in the hose line. The E-11 acting captain asked him to go find out why they did not yet have water pressure on the 1 ½” hose. After waiting a short time for water pressure, the E-11 acting captain went outside to find out why they still didn’t have water pressure. The E-11 acting captain and engineer were able to get the pump in operation by cycling the engine transmission to get the pump in gear. Note: Fire fighters interviewed by NIOSH stated that E-11 required specific procedures to engage the pump; an independent inspection of the apparatus confirmed these findings. On the day of the incident, the E-11 engineer was serving as the acting captain so E-11 was driven and operated by a fire fighter less experienced in its operation. The E-11 acting captain then re-entered the structure. He had to don his facepiece and go on air because gray-colored smoke was starting to accumulate in the center of the showroom. Fire was still not visible in the showroom at this point.



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The Engine 16 (E-16) captain and fire fighter entered the showroom with a 2 ½” hose line that was uncharged at this point. The E-11 acting captain told the E-16 captain he would go find out why the 2 ½” hose line was still uncharged. As he started to exit the showroom, the inside conditions changed very rapidly. The smoke turned very thick and grayish black. The E-11 acting captain had to find the 1 ½” hose and follow it outside. E-11 was still without a water supply at this point. After talking with the E-11 acting engineer about the water supply situation, the E-11 acting captain walked around to the loading dock area to look for the E-11 fire fighter. While at the D-side, BC-4 asked the E-11 acting captain to help with setting up a 2 ½” hose line to the warehouse. Note: This 2 ½” hose line was pulled from E-10. The E-11 acting captain was just stepping up to the warehouse door when the Fire Chief ordered everyone out of the warehouse. The E-11 acting captain observed that the other fire fighters in this area had things under control so he went back to the A-side. When the E-11 acting captain returned to the front, fire was blowing out the front windows. He heard the Fire Chief give an order to evacuate. The E-11 acting captain got into the E-11 cab and sounded the airhorn 3 times for an evacuation signal. Ladder 5 Ladder 5 (L-5) was the third apparatus to arrive on-scene and initially positioned in the parking lot in front of the furniture store just west of E-11. The L-5 crew included an acting captain (Victim # 7), an assistant engineer (Victim # 4) and a fire fighter (Victim # 9 - who had switched assignments with the E-10 fire fighter). Note: This fire department typically dispatches ladder trucks as extra manpower, and not for ventilation activities. The ladder trucks do not have their own pumps and must be supplied by an engine in order to flow a master stream. The L-5 acting captain directed the E-11 acting engineer to reposition E-11 near the front door of the main showroom. It is assumed that the L-5 acting captain heard the E-11 acting captain radio for a hand line inside the structure so the L-5 crew started to pull a 1 ½” preconnected hand line off of E-11. When the L-5 crew took this hand line inside, they met the E-11 acting captain coming outside to get a hose line. The L-5 crew took the 1 ½” hose line to the rear of the right-side addition (after the E-11 acting captain added additional sections to the hose line) and after some delay in getting water, advanced into the loading dock through the double doors connecting the showroom to the loading dock. This was the last confirmed location of the L-5 crew. Between approximately 1932 and 1934 hours, L-5 was repositioned from the front of the showroom to the D-side by off-duty fire fighters who had responded to the scene. Fire fighters from a mutual aid department along with off-duty fire fighters worked to establish water supply to L-5. Engine 3 arrived on scene at approximately 1940 hours and also worked to get a water supply established to L-5. Water supply was established at approximately 1944 hours. Engine 16 At the time of the incident, Engine 16 (E-16) was designated as the 3rd due engine on all confirmed structure fires in the department’s western district if not assigned on the initial dispatch. Note: NIOSH investigators were told that the 3rd due engine is designated as the “Safety Team” and should



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have been held on stand-by at the scene. However, the crew was instructed to engage in fire suppression activities before they arrived on-scene. The crew was in quarters when the fire dispatch was initiated. The E-16 crew consisted of a captain (Victim # 5), an engineer, and a fire fighter (Victim # 3). E-16 started to move toward the scene when BC-4 reported smoke in the area. At approximately 1915 hours, the AC radioed E-16 to bring a 2 ½” hose line in the front door. E-16 arrived on scene driving west to east. The E-16 captain and fire fighter dismounted the engine and went to talk to the AC. They took a 2 ½” hose line with a stacked-tip nozzle (uncharged) into the main showroom and advanced it to the double doors leading to the loading dock and met up with the acting captain from E-11. This was the last confirmed location of the E-16 crew. The E-16 engineer was instructed to lay a supply line for E-11 so he drove east on the highway toward where a hydrant had been previously located. This hydrant had been removed in 2004 because it had received damage from heavy truck traffic in the immediate area. He continued east to the next hydrant located approximately 1,200 feet away. Note: 1,850 feet of a single 2 ½” supply line was stretched from E-11 to the hydrant. The E-16 engineer reported hearing the radio traffic about the civilian worker being trapped in the rear of the building just as he was pulling up to the hydrant. (see Diagram # 2) At approximately 1919 hours, the E-16 captain radioed to charge the 2 ½” hoseline (inside the building). The E-11 engineer radioed the E-11 acting captain to ask if he wanted the 2 ½” hoseline charged. The AC responded to not charge the 2 ½” hoseline until the supply line from E-16 to E-11 was charged. Note: Water supply from E-16 to E-11 was not yet established at this point. Water supply from E-16 to E-11 was established at approximately 1926 hours. After the hose was stretched out, traffic on the highway began to drive over the supply line from E-16 to E-11. The E-16 engineer radioed dispatch that the city police were needed for traffic control. As crews attempted to battle the escalating fire, water supply became an issue. Later, during the time period from 1937 hours to 1941 hours, chief officers in front of the showroom repeatedly called the E-16 engineer to boost water pressure to E-11 as the fire escalated out of control. At approximately 1941 hours, the E-16 engineer was instructed to switch to another radio channel to clear up the main channel for rescue purposes. Engine 12 The Engine 12 (E-12) crew, consisting of an acting captain, assistant engineer, and two fire fighters were in quarters at the time of the initial dispatch. At approximately 1912 hours, the AC radioed dispatch to send E-12 to the scene. While enroute, BC-4 radioed E-12 and instructed them to lay a supply line down the alley on the D-side of the building to E-10. Engine 12 acknowledged this assignment. The Fire Chief also radioed the same instructions. Engine 12 arrived on-scene at approximately 1917 hours and hooked up a 2 ½” supply line to E-10, then drove across the highway and down a side street to a hydrant, laying out 15 sections of supply line. The E-12 engineer hooked up to the hydrant and operated the pumps supplying E-10 throughout



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the incident. Water supply to E-10 was established at approximately 1920 hours. The E-12 acting captain and fire fighters assisted the E-10 crew by repairing the 1 ½” hoseline that had burst, then forced open the walk-thru door at the front of the warehouse and advanced a 2 ½” hoseline inside the warehouse about 10 feet before being ordered to withdraw. The 2 ½” hoseline was then operated through the doorway into the warehouse. The fire was reported to be burning so hot that the water immediately turned to steam and did little good in suppressing the fire. Note: The E-12 crew reported that while forcing open the warehouse door, they experienced problems with a gasoline powered saw that had the wrong type of blade (for cutting plywood, not metal). Crews had to use axes to cut through the metal siding. The E-12 crew also cut holes in the metal siding along the D-side walls for ventilation and to direct water streams inside the building (see Photo 10). Later in the incident, additional supply lines were stretched to E-12 so that E-12 could pump to E-11 and L-5 and L-4. Chief Officers radioed E-12 to boost the water pressure to E-10 at least 3 times during the incident. The E-12 engineer also radioed dispatch to have the city police department stop traffic on the highway from running over the supply lines. Engine 15 The Engine 15 crew was in quarters when the first alarm crews were dispatched. The E-15 crew consisted of a captain (Victim # 8), engineer, and two fire fighters. One of the E-15 fire fighters ( fire fighter # 2) was newly hired and was responding to his first working structure fire with the department. Per department procedures, E-15 began to relocate from downtown to the west side. The E-15 crew reported that smoke was visible from a couple of miles away as they relocated so they began running hot (Code 3 - lights and sirens on). At approximately 1912 hours, the Fire Chief radioed dispatch to have Engine 15 relocate to Station 11. Almost immediately, the AC radioed for E-15 to come to the scene. Then the AC radioed E-15 to bring a 1 ½” hose line to the right rear of the building. Engine 15 arrived on-scene at approximately 1917 hours just as Engine 16 began dropping a supply line for Engine 11. The E-15 captain instructed the E-15 engineer to get dressed to go inside the building. Note: During the NIOSH interviews, numerous fire fighters reported that most fire fighters responding after the first alarm would be expected to enter a structure fire for additional interior support. Coordinated ventilation and ladder truck operations reportedly were seldom initiated. The E-15 captain and two fire fighters donned their SCBA and proceeded to Engine 11. One fire fighter took a pike pole and Haligan bar while the other fire fighter took an axe. They briefly talked with the E-11 engineer. They observed two hose lines going through the front entrance and followed the hose lines (one 1 ½” and one 2 ½”) inside. Visibility at the front of showroom was still good at this time and the crew did not go on air until they were about 10 feet inside the door. As the E-15 crew advanced further, the visibility decreased. They were aware of other crews working to their right. The E-15 captain discussed with his crew that he wanted to work a hose line to the center and



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left rear of the main showroom to cut the fire off from spreading in that direction (contain fire to the right rear corner). The E-15 captain instructed fire fighter # 2 to go outside and get a hose line. Fire fighter # 2 went outside and pulled a booster line (1” red hose) as far as he could down the center walkway through the main showroom. By this point, the visibility had decreased to where it was difficult to distinguish other fire fighters moving nearby. Fire fighter # 2 moved as far as he could and then began to flow water from the booster line toward a red glow overhead. He ran low on air and followed the hoseline toward the front entrance. Once outside he changed his air cylinder, then followed the hoseline back inside. He heard airhorns sounding (evacuation signal) and followed the hoseline back outside. The E15 engineer donned his PPE and went to the front door where he assisted fire fighter # 2 in pulling the booster line through the front door. The E15 engineer advanced inside the showroom about 10 feet where he encountered thick black smoke from ceiling to floor. He could see a red glow at the rear of the showroom but no distinct flames. He ran low on air and went outside and changed his SCBA cylinder then re-entered the main showroom. It was noticeably hotter inside the showroom as the E15 engineer entered the second time. The engineer heard three airhorn blasts then heard radio traffic about evacuating the building so he followed the hose line outside. After the E-15 captain (Victim # 8) and fire fighter # 1 moved deeper into the showroom, the E-15 captain instructed fire fighter # 1 to go get another hose line. Note: This was the last confirmed location of the E-15 captain. Fire fighter # 1 found a charged booster hose and dragged this hose as far as he could in the direction of where he had last seen the E-15 captain. Fire fighter # 1 did not encounter the E-15 captain or his other crew members when he returned to the rear of the showroom. Fire fighter # 1 opened the hose line nozzle a couple of times but couldn’t see much fire. Fire fighter # 1 noticed that it was starting to get really hot and the thickening smoke was reducing visibility to near zero. His low air alarm began to go off so he started to follow the hose line outside. He came to a point where the hose line ran underneath furniture and he couldn’t follow the hose line any further so he jumped over the furniture. Once on the other side of the furniture, he searched for the hose line but could not locate it. As he searched for hose lines, he saw the bright flashing light of a PASS device and moved toward the light. He encountered the engineer from Engine 6 who was looking for his crew. The E-6 engineer guided the E-15 fire fighter to the front of the showroom and when they got close enough to the front entrance to hear the sound of Engine 11 running outside, the E-15 fire fighter bolted through the door (shortly after 1931 hours). The E-15 fire fighter went to Engine 11 and asked the E-11 engineer to switch out his SCBA cylinder. At approximately 1934 hours, while changing his cylinder, the E-15 fire fighter was asked if he had radioed a Mayday and he reported that he had not. While changing cylinders, the E-15 fire fighter heard that fire fighters were missing inside the building. Note: During the timeframe of approximately 1935 to 1936 hours, fire fighters outside the main entrance knocked out the showroom windows to improve visibility inside the building. After changing cylinders, he followed the hose lines back inside the main showroom to search for his crew. He advanced about 50 feet into the showroom and encountered intense heat and could see fire



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burning everywhere around him. He met the E-6 crew (captain, engineer, and fire fighter) following the hoseline to exit the showroom. The E-6 engineer told the E-15 fire fighter he couldn’t go any further and he needed to get out. These four fire fighters exited the showroom with the E-15 fire fighter jumping through a showroom window to the right of the doorway. The E-15 engineer and fire fighter # 2 also exited the main entrance at approximately the same time. The E-15 captain did not exit the building. Engine 19 The Engine 19 crew was in quarters when the fire dispatch was initiated. The Engine 19 crew consisted of a captain (Victim # 6), engineer (Victim # 1), and one fire fighter (Victim # 2). Engine 6 had just been dispatched to the scene when, at approximately 1914 hours, the Fire Chief radioed dispatch to send Engine 19 to the scene and to have Engine 6 relocate to Station 11. Engine 19 arrived on scene at approximately 1920 hours and parked in the middle of the highway in front of the furniture store. The E-19 crew entered the main showroom through the front entrance. There are few details about their activities after this point. Engine 6 The Engine 6 crew, consisting of a captain, engineer, and one fire fighter were in quarters when they heard the initial fire dispatch. Engine 6 is the second engine to relocate to the western district per fire department procedures. At approximately 1914 hours, the AC radioed dispatch to send Engine 6 to the scene. When Engine 6 was dispatched, the Fire Chief radioed for Engine 6 to relocate to Station 11 and for Engine 19 to come to the scene. At approximately 1919 hours, the Fire Chief radioed for Engine 6 to come to the scene and to come in the front door. Engine 6 was already enroute (relocating to the west side) and acknowledged that they were enroute. Engine 6 arrived on scene at approximately 1921 hours. The E-6 captain and E-6 fire fighter went to the front door and donned their SCBA masks. They followed the 1 ½” hose line into the building. The E-6 captain observed light smoke coming out the front door and also at the connection of the main showroom and the right side addition (exterior wall). Visibility was initially about 5 to 10 feet but visibility was reduced as they advanced into the showroom interior. There was little heat and the E-6 captain and fire fighter were able to walk into the showroom standing upright as they followed the hose line to the rear of the main showroom then into the right side addition. The E-6 engineer entered the showroom a couple of minutes later after donning his turnout gear, SCBA, and grabbing a pike pole from E-6. He reported the smoke at the front of the showroom was intensifying and beginning to bank down. He followed the 1 ½” hose line to the rear of the main showroom. A booster line reached only to the right rear side of the main showroom. He could hear other fire fighters talking in the direction the 1 ½” hose line was running (into the right addition) and began opening up sheetrock walls and pushing up ceiling tiles to look for fire extension. The E-6 captain and fire fighter met other crews near the double doors to the loading dock. The other fire fighters stated they were going to get another hose line so the E-6 captain worked the nozzle of the 1 ½” hand line for approximately 5-6 minutes while the E-6 fire fighter attempted to pull slack in



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the line so they could advance closer to the fire in the loading dock area. The water pressure on the 1½” hose line fluctuated and at one point water pressure dropped to near zero. The E-6 captain attempted to radio outside to ask what happened to the water pressure but the on-off button on his radio had broken off during his entry so he couldn’t turn on his radio. The E-6 crew noticed that the interior conditions suddenly deteriorated very rapidly with visibility decreasing and in less than 30 seconds, the heat became unbearable. As the E-6 engineer was opening the walls and ceiling at the rear of the main showroom, three or four unidentified fire fighters approached him and frantically stated that they were running out of air and couldn’t find the way outside. The E-6 engineer heard their low-air alarms sounding as they bumped into him then pulled away from him and disappeared into the smoke. This happened in a matter of seconds. During the short contact with the other fire fighters, the E-6 engineer was turned around several times and became separated from the hoseline. He moved in short circles until he found the hose line and began following it. Almost immediately, the E-6 engineer encountered another fire fighter (later identified as the E-15 fire fighter # 1) who also stated he was out of air and couldn’t find his way outside. The E-6 engineer led the E-15 fire fighter along the hose line (at one point having to reverse directions) until they got within a few feet of the front door. They could hear the sound of Engine 11 running outside and the E-15 fire fighter ran outside, followed by the E-6 engineer. After checking on the condition of the E-15 fire fighter, the E-6 engineer re-entered the main showroom. As the E-6 fire fighter was pulling slack in the 1 ½” hose line, another fire fighter, searching for the way out, ran into him and momentarily knocked him off the hose line. As the E-6 fire fighter regained the hose and stood up, water pressure in the hose was lost. At this point, the heat began to intensify and the E-6 fire fighter decided it was time to retreat. At the same time, he began hearing radio traffic of the Mayday followed by attempts by the Fire Chief and the dispatcher to identify who was calling Mayday and who had activated their emergency button. As the heat rapidly intensified, the E-6 captain began following the hoseline outside. His low air alarm started to sound and he burned his hands feeling for the hose line. His facepiece began to pull down onto his face as he exhausted his remaining air supply. He encountered the E-6 fire fighter who told the E-6 captain he had the hose line and they began moving toward the front of the building. By this time, the E-6 captain was almost completely out of air and he bolted toward the front of the building. The E-6 engineer was following the hoseline back into the showroom looking for his crew and encountered the E-6 captain who was now out of air and becoming disoriented. The engineer grabbed his captain and guided him toward the front door until they could hear the sound of Engine 11 running outside. They made their way outside followed seconds later by the E-6 fire fighter and the E-15 fire fighter # 1. The front showroom windows were just being knocked out when the E-6 crew exited the showroom (see Photo 4). Engine 9 The Engine 9 (E-9) crew, consisting of a captain, engineer, and fire fighter were in quarters at Station 9 when they heard the fire dispatch. The crew monitored the fireground radio traffic and knew that a serious situation was developing. They heard the Fire Chief calling for additional resources and



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Engine 9 was dispatched to relocate to Station 10 and arrived at 1946 hours. At 1951 hours, E-9 was directed to drive past the incident site and stretch a 2 ½” supply line from the hydrant west of the site back to the site to Engine 13 to supply Ladder 4 before it arrived. After stretching the supply line, the E-9 crew worked on the D-side of the structure supporting fire suppression activities. Engine 13 The Engine 13 (E-13) crew consisting of a captain, engineer, and fire fighter were in quarters when they heard the fire dispatch. E-13 was dispatched to the scene at approximately 1937 hours and arrived on-scene at 1942 hours. The E-13 crew worked to help establish water supply to Ladder 5 by stretching a 2 ½” supply line from E-12 to L-5. The E-13 crew then assisted with fire suppression activities. Engine 3 The Engine 3 (E-3) crew consisting of a captain, engineer and fire fighter was out of service at a special event several miles outside of the city when they heard radio traffic about the fire. When they heard the incident was a confirmed structure fire, they began moving back to the city. At approximately 1924 hours, E-3 was directed to relocate to cover Station 16/19. At approximately 1931 hours, the Fire Chief called dispatch and requested the next closest engine company. E-3 was still enroute to Station 16/19 so the Fire Chief requested that E-3 come to the scene and lay a supply line to Ladder 5. At approximately the same time, L-5 was repositioned from in front of the structure to the D-side by off-duty fire fighters who had arrived at the scene. E-3 arrived on-scene at 1940 hours. The E-3 suction man (fire fighter) took their 5” adaptor to connect to the hydrant, but E-19 (driven by the acting captain of E-11) arrived at the hydrant first. E-3 stretched a 2 1/2” supply line from E-19 (the next hydrant west of the structure) to L-5 and water supply was established at 1944 hours. After establishing water supply, the E-3 engineer stayed at the engine and the rest of the E-3 crew worked on the D-side of the structure operating a 2 ½” hand line. Fire fighters cut holes into the sheet metal siding and at one point, the E-3 fire fighter and an off-duty fire fighter attempted to advance a hoseline inside the showroom by crawling under the metal shelving located along the D-side wall. They were only able to advance 5 or 6 feet and had to withdraw because of the intense fire and heat inside the burning showroom. Ladder 4 The Ladder 4 crew consisting of an acting captain, engineer, and fire fighter were in-quarters at the time of the initial dispatch. The crew monitored the radio traffic and knew things were escalating. The Fire Chief radioed dispatch at approximately 1948 hours and requested that Ladder 4 be dispatched to the scene. At approximately 1952 hours, the Fire Chief radioed dispatch and requested Engine 9 be sent from Station 10 to lay supply line for L-4. Ladder 4 was on scene at approximately 1956 hours and BC-4 directed the crew on where to position in the front parking lot. Portions of the showroom roof had already collapsed when L-4 got set up. Engine 19 began supplying water to L-4 at approximately 2002 hours through one 2 ½” supply line. At approximately 2006 hours, L-4 radioed the Fire Chief and requested another supply line be set up



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to L-4 so that both nozzles on the bucket could be put into operation. The mutual aid department laid a 4” supply hose to L-4. L-4 initially operated with 300 gpm flowing through one nozzle. L-4 operated at 750 gpm when the second supply line was set up. Mutual Aid Jurisdictional boundaries separating the municipal fire department from surrounding fire departments were irregular and often intermingled. As commercial areas were annexed into the city, jurisdictional boundaries often split blocks. For example, the furniture store involved in this incident was within the city’s jurisdiction. Residential structures directly behind the furniture store property that were within the same block were in the jurisdiction of a mutual aid fire department that operates as a public service district (PSD). This mutual aid fire department had 60 fire fighters operating from 4 stations and served a population of approximately 24,000 in an area of approximately 30 square miles. Note: This fire department operated its own dispatch system. This fire department routinely used positive pressure fans for ventilation purposes and routinely deployed thermal imaging cameras at structure fires. Two crews from the mutual aid department were in close vicinity to the incident scene for a special event and noticed heavy smoke. The acting battalion chief (BC) for the mutual aid department (who was at the special event with the crews) radioed his dispatch and said the mutual aid crews were going to the scene. The dispatcher reported that the municipal fire department was already on scene. The acting battalion chief (BC), Engine 2 (E-2) with a crew consisting of an acting captain and an engineer / fire fighter, and Rescue 1 (R1) with a crew of an engineer and a fire fighter, proceeded to the scene and arrived at approximately 1924 hours. The BC radioed dispatch that they were on-scene and also requested that Engine 1 (E-1) be dispatched. The BC immediately went to the D-side of the furniture showroom and talked with the city Fire Chief. The BC informed the Fire Chief he had two crews on scene and another crew on the way. The BC also offered the use of their thermal imaging camera and their large diameter (4”) supply hose (LDH). According to the acting battalion chief, the city Fire Chief initially told him that the mutual aid department’s assistance would not be needed. The BC asked the Fire Chief if he wanted the mutual aid department to cover the rear of the warehouse and the Fire Chief said “yes.” At approximately 1925 hours, the BC directed E-1 to drive down the street at the rear of the warehouse and set up operations there. The BC also radioed dispatch to send Truck 1 (T-1). E-1 arrived on scene at approximately 1926 hours with a captain, engineer, and two fire fighters. E-1 connected to a hydrant located just east of the warehouse. The E-1 captain and fire fighters advanced a 1 ¾” preconnected hand line inside the warehouse through a door located on the B-side at the rear near the B-C corner at approximately 1930 hours. Engine 2 (E-2) and Rescue 1 (R-1) parked in the middle of the highway in front of the main showroom. The two crews (two fire fighters on each apparatus) donned their turnout gear and proceeded to the D-side of the showroom to join up with their BC when a city police officer stopped them and said a male employee was trapped in the rear of the structure and had telephoned 911 for



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assistance. They proceeded to the front of the showroom and were directed by the city AC and BC-5 to assist them in rescuing the trapped employee. They radioed their dispatch at approximately 1928 hours that the city fire department wanted them to assist in rescuing the employee, then proceeded around the B-side of the showroom to the rear after knocking a lock off a wooden gate at the B-C corner to gain access (see Diagram 3).

The fire fighters located the area where the employee was banging on the exterior wall. The fire fighters used a Haligan bar and axes to cut through the metal siding and opened a hole large enough for the employee to crawl through. The mutual aid department’s dispatch was notified at approximately 1931 hours that the employee had been rescued. The fire fighters assisted the employee to the front parking lot to receive medical attention. Note: The Assistant Chief of the municipal fire department radioed for an ambulance after the employee was extricated. Dispatch reported an ambulance was already in route. The fire fighters returned to the front entrance and observed heavy black smoke filling the showroom and pushing out the door, but no visible fire. They observed city fire fighters yelling about fire fighters missing inside the structure. They reported hearing orders for the front showroom windows to be knocked out to improve visibility inside the showroom. The E-2 acting captain and R-1 engineer knocked out the windows to the right of the doorway while the city BC-5 knocked out the windows to the left of the doorway. The fire fighters noted that air rushed inside the showroom after the windows were knocked out. The E-2 acting captain cut his hand (requiring time off) while knocking out the windows. The E-6 and E-15 fire fighters (from the city department) exited the building at approximately 1935 hours while the windows were being knocked out. Some of the city fire fighters were completely out of air. At approximately 1936 hours, the Fire Chief instructed the mutual aid fire fighters to go inside and search for the missing city fire fighters. Two city fire fighters (an off-duty battalion chief and the E-6 engineer) also entered the showroom. The R-1 engineer and the E-2 fire fighter teamed up and followed the hoselines inside the front door a short distance. They encountered two fire fighters who were in distress. One was down on his hands and knees screaming for help and also attempting to drag the other fire fighter. The R-1 engineer attempted to assist the fire fighters while the E-2 fire fighter guided them back to the hose line. The showroom erupted in flames and the heat knocked the fire fighters to the floor, causing them to become separated. Both rescue teams were forced to evacuate. The E-2 fire fighter found the door first and assisted the R-1 engineer outside at approximately 1938 hours. They both reported hearing PASS devices going off inside the structure. The R-1 engineer received second degree burns to his face, hands, and arm. The R-1 engineer reported that other fire fighters were just inside the door so another rescue attempt was made. An off-duty captain from the mutual aid department, along with city fire fighters, attempted to advance a 2 ½” hose line back inside the door, but their progress was quickly halted by the intense heat and fire and they were forced to retreat. At 1938 hours, the city Fire Chief radioed for everyone to stay outside and to abandon the building. One last attempt to enter the front entrance (by the off-duty battalion chief and the E-6 engineer) was stopped at the doorway by the intense fire and heat.



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At approximately 1935 hours, the mutual aid BC requested that Engine 7 (E-7) be dispatched and come to the rear (C-side) of the warehouse with E-1. At approximately 1943 hours, the mutual aid BC requested Engine 4 (E-4) come to the scene. The BC directed E-4 to go the rear of the warehouse and set the deck gun. At approximately 1948 hours, the BC requested Truck 1 (T-1) to come to the scene. The mutual aid BC radioed E-4 to hold up at the highway to let T-1 come down the back street first. T-1 arrived on scene at approximately 1950 hours and was set up at the rear of the warehouse to direct a master stream of water down onto the roof of the warehouse. At approximately 1952 hours, E-4 radioed the BC that the city fire department wanted E-4 to set up water supply to the city fire department’s Ladder 4 (L-4) in the parking lot at the front of the main showroom. At approximately 2000 hours, the E-4 acting captain announced E-4 was pumping water to the city’s L-4. Water Supply Water supply was a critical factor in the sequence of events leading up to the nine fatalities. Engine 10 should have been the second due engine and established the water supply to Engine 11. However, E-10 arrived first at 1911 hours and was directed to back down the alley to the loading dock on the D-side of the structure since that was where visible fire was located. Engine 11 positioned in front of the main showroom and the E-11 acting captain went inside the showroom while the E-11 fire fighter looked for a hydrant so E-11 could supply water to E-10. Engine 11 re-positioned closer to the main entrance when L-5 arrived in front of the showroom. Pre-plan information indicated the closest hydrant was located on the street behind the warehouse but this information was not utilized. Engine 12 was dispatched at 1912 hours and directed to lay a single 2 ½” supply line to Engine 10. Engine 16 was already enroute as the third-due engine. Engine 16 arrived on scene at 1915 hours and Engine 12 arrived on scene at 1917 hours. Engine 12 stretched approximately 750 feet of 2 ½” supply line and had water supply established to E-10 at approximately 1920 hours. Engine 16 stretched approximately 1,850 feet of supply line and had water supply established to E-11 at approximately 1926 hours. Both E-10 and E-11 put 1 ½” pre-connected hand lines into operation using tank water while waiting for supply lines to be established. The E-11 engineer reported experiencing problems with water pressure after water supply was established. The E-12 and E-16 engineers both radioed that vehicle traffic running over the supply lines were causing problems. Pressure had to be boosted by both E-12 and E-16 well above the 200 psi working limit of the supply hoses being used in order to accommodate for the friction losses and low water volume. Adequate water supply for the size of the structure and fuel loads inside was never established and hose lines capable of attacking the fire with adequate fire streams were not deployed. Ladder 5 was not put into master stream operation until after the fire had escalated. Additional supply lines for Engine 11, Ladder 5 and Ladder 4 were laid after the fire had escalated.

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E19 / E3 laid a second 2 ½” supply line to L-5 at approximately 1944 hours. BC-5 directed the acting captain on E-11 to drive E-15 west to the next hydrant to lay another supply line back to E-11. Then BC-5 told him to take E-19 instead. Engine 3 arrived on scene just as E-19 was positioning to the hydrant. A small mutual aid department (mutual aid # 2) supplied L-5 with tank water at approximately 1940 hours until a supply line was established at approximately 1944 hours. A second supply line from E-12 to L-5 was also put into service after 2000 hours. Ladder 4 was put into operation at approximately 2001 hours with a 2 ½” supply line laid by E-9. The first responding mutual aid department (mutual aid # 1) stretched a 4” supply line to L-4 at approximately 2005 hours so that both fire nozzles could be put into operation. The mutual aid departments utilized 4” supply lines. After the larger diameter supply lines were put into service, the water pressure issues with L-4 and L-5 improved. ADDITIONAL PHOTOS Additional photos pertaining to the incident are available in Appendix V. CAUSE OF DEATH According to the county coroner’s report, the cause of death for all nine victims was carbon monoxide toxicity, smoke inhalation and thermal injury due to fire. Diagram 4 shows the approximate location where each of the nine victims was located inside the structure per the city. RECOMMENDATIONS Recommendation # 1: Fire departments should develop, implement and enforce written standard operating procedures (SOPs) for an occupational safety and health program in accordance with NFPA 1500. Discussion: The risk for fatal injury among fire fighters is high compared to other occupations.11 There is an increasing body of scientific literature demonstrating that organizational practices that demonstrate top level management commitment to safety, establish and foster compliance with safety policies and practices, and involve workers in identifying safety hazards and promoting solutions are effective in reducing worker injuries.12-17 Many of these concepts are embodied in NFPA 1500, Standard for a Fire Department Occupational Safety and Health Program.18 Implementation of a strong fire department occupational safety and health program following written procedures and policies such as those outlined by NFPA 1500 can foster and improve the overall safety climate of a fire department, as well as improve specific safety and health areas, such as respiratory protection, risk management, training and competency in fireground operations, tactics, and equipment and apparatus use.



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During this investigation, NIOSH investigators reviewed some written departmental SOPs. While these documents contained some individual SOPs, they mainly contained administrative guidelines and did not contain detailed fireground operational procedures that would enhance fire fighter safety and health, such as a risk management plan, a fire department occupational safety and health policy, and other components of a fire department occupational safety and health program as outlined in NFPA 1500.18 It is important to understand the difference between a policy and a procedure. A department policy is a guide to decision-making that originates with or is approved by top management in a fire department. Policies define the boundaries within which the administration expects department personnel to act in specified situations. A procedure is a written communication closely related to a policy. A procedure describes in writing the steps to be followed in carrying out organizational policies. SOPs are standard methods or rules in which an organization or a fire department operates to carry out a routine function. Usually these procedures are written in a policies and procedures handbook and all fire fighters should be well versed as to their content.19 Operational procedures that are standardized, clearly written, and mandated to each department member establish accountability and increase command and control effectiveness.19 The benefits of having clear, concise, and practiced SOPs are numerous. For example, they can become a training outline and a tool to guide fire department members. Above all, a well applied SOP improves departmental safety. 20 Recommendation #2: Fire departments should develop, implement and enforce a written Incident Management System to be followed at all emergency incident operations. Discussion: National Fire Protection Association (NFPA) 1500 Standard on Fire Department Occupational Safety and Health Program, 2007 Edition,18 and NFPA 1561 Standard on Emergency Services Incident Management System, 2008 Edition,21 both state that an Incident Management System (IMS) should be utilized at all emergency incidents (including but not limited to training exercises). The U.S. Department of Labor, Occupational Safety and Health Administration has issued a guidance document intended to be used by agencies to prepare emergency response plans. The intent of the National Response Team (NRT) guidance is to provide a mechanism for consolidating multiple agencies’ plans into one functional emergency response plan or integrated contingency plan (ICP). 22 NFPA 1561, Chapter 3.3.29 defines the Incident Management System (also known as the Incident Command System (or ICS) as “A system that defines the roles and responsibilities to be assumed by responders and the standard operating procedures to be used in the management and direction of emergency incidents and other functions.21 Chapter 4.1 states “The incident management system shall provide structure and coordination to the management of emergency incident operations to provide for the safety and health of emergency services organization (ESO) responders and other persons involved in those activities.” Chapter 4.2 states “The incident management system shall integrate risk management into the regular functions of incident command.” Each fire department or emergency services organization (ESO) should adopt an incident management system to manage all emergency incidents. The IMS should be defined and in writing and include standard operating



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procedure (SOPs) covering the implementation of the IMS. The IMS should include written plans that address the requirements of different types of incidents that can be anticipated in each fire department’s or ESO’s jurisdiction. The IMS should address both routine and unusual incidents of differing types, sizes and complexities. The IMS covers more than just fireground operations. The IMS must cover incident command, accountability, risk management, communications, rapid intervention crews (RIC), roles and responsibilities of the Incident Safety Officer (ISO), and inter-operability with multiple agencies (police, emergency medical services, state and federal government, etc.) and surrounding jurisdictions (mutual aid responders). NIOSH investigators identified several examples in this incident in which recognized guidelines for IMS were not followed. Specific examples include multiple chief officers serving in command roles in an uncoordinated manner, lack of an established accountability system to track fire fighters on scene, a RIC was not established, an ISO was not assigned, and the fire department and police department did not work effectively together to control traffic and protect hoselines delivering water to the scene. Recommendation # 3: Fire departments should develop, implement and enforce written SOPs that identify incident management training standards and requirements for members expected to serve in command roles. Discussion: NFPA 1561, Chapter 4.8.3 states “Responders who are expected to perform as incident commanders or to be assigned to supervisory levels within the command structure shall be trained in and familiar with the incident management system and the particular levels at which they are expected to perform.” 21 NFPA 1001,61021,23 150018 and 152124 are just a few examples of recognized standards addressing fire fighter and officer qualifications. One of the fire officer’s primary responsibilities is safety both on the fireground and during normal operations. A partial list of officer qualifications (knowledge, skills, and abilities) necessary to accomplish the primary responsibility of fireground safety identified in these standards include: fire behavior; building construction; conducting pre-incident planning; inspection and incident report development; applicable codes, ordinances, and standards; identification of fire and life safety hazards; supervising emergency operations; and, deploying assigned resources in accordance with the local emergency plan. Training records for the chief officers who initially responded to this incident were provided to NIOSH by the city’s Safety Management Division. These records consisted mainly of NIMS certifications with little additional records to document specific training related to fire fighter and fire officer qualifications.

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Recommendation #4: Fire departments should ensure that the Incident Commander is clearly identified as the only individual with overall authority and responsibility for management of all activities at an incident. Discussion: NFPA 1561, Chapter 5 identifies the responsibilities and overall duties of the Incident Commander (IC).21 Chapter A.3.3.28 states “The IC has overall authority and responsibility for conducting incident operations and for managing all incident operations at the incident site.” There should be one, clearly identifiable Incident Commander for the duration of the incident, from the arrival of the first fire department unit until the incident is terminated. The Incident Commander must clearly be in charge of all fireground operations to ensure successful completion. If there is no established or single Incident Commander, fireground operations and incident conditions can break down. Some of the key responsibilities of the Incident Commander, as detailed in NFPA 1561, Chapter 5.3, which are relevant to this incident include:

• Overall authority for the management of the incident (Chapter 5.3.1) • Ensuring adequate safety measures are in place (Chapter 5.3.2) • Establishing a stationary command post (Chapter 5.3.7.1) • Continually conducting a thorough evaluation of the situation (Chapter 5.3.8) • Maintaining an awareness of the location and function of all companies or units at the scene

(Chapter 5.3.10) • Overall responder accountability for each incident (Chapter 5.3.11) • Initiating an accountability / inventory worksheet at the beginning of operations and

maintaining that system throughout operations (Chapter 5.3.12) • Evaluating the risk to responders with respect to the purpose and potential results of their

actions in each situation (Chapter 5.3.17) • Utilizing risk management principles (Chapter 5.3.19)

o Activities presenting significant risk to the safety of responders should be limited to situations having the potential to save endangered lives.

o Activities employed to protect property should be recognized as inherent risks to the safety of the responders and actions should be taken to reduce or avoid these risks.

o No risk to the safety of responders should be acceptable where there is no possibility to save lives or property.

• Developing the command organization for the incident (Chapter 5.3.20) • Assigning intermediate levels of supervision and organizing resources following SOPs based

on the scale and complexity of operations (Chapter 5.10.1.2) • All supervisory personnel assigned to operations functions shall support an overall strategic

plan, as directed by the Incident Commander, and shall work toward the accomplishment of tactical objectives (Chapter 5.10.1.3)

Chief Officers at the scene of an incident who are not officially a part of the command structure should refrain from giving tactical directions. One of the clear tenets of the Incident Command



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System is “unity of command.” By directing units outside of a role in the IMS, chief officers, by virtue of their rank, can create uncoordinated efforts outside the IMS which may not benefit the operational strategy and can actually have negative impacts upon the operational strategy. The resources that are taken from the operational structure to achieve the goals of the chief officers operating outside the IMS are lost to the tactical level operations or management elements that count on these resources to achieve their tactical objectives. During this incident, formal incident command was never formally announced or transferred as ranking officers arrived on scene. Fire attack operations at the loading dock (D-side) and the main showroom (A-side) were directed by different chief officers and were not coordinated. Recommendation #5: Fire departments should ensure that the Incident Commander conducts an initial size-up and risk assessment of the incident scene before beginning interior fire fighting operations. Discussion: Among the most important duties of the first officer on the scene is conducting an initial size-up of the incident. This information lays the foundation for the entire operation. It determines the number of fire fighters and the amount of apparatus and equipment needed to control the blaze, assists in determining the most effective point of fire extinguishment attack, the most effective method of venting heat and smoke, and whether the attack should be offensive or defensive. A proper size-up begins from the moment the alarm is received and it continues until the fire is under control. The size-up should also include assessments of risk versus gain during incident operations. 19, 25-29 Retired Chief Alan Brunacini recommends that the arriving IC drive partially or completely around the structure whenever possible to get a complete view of the structure. While this may delay the IC’s arrival by a few seconds, this drive-by may provide significant details not visible from the command post.27 The size-up should include an evaluation of factors such as the fire size and location, length of time the fire has been burning, conditions on arrival, occupancy, fuel load and presence of combustible or hazardous materials, exposures, time of day, and weather conditions. Information on the structure itself including size, construction type, age, condition (evidence of deterioration, weathering, etc), evidence of renovations, lightweight construction, loads on roof and walls (air conditioning units, ventilation ductwork, utility entrances, etc.), and available pre-plan information are all key information which can effect whether an offensive or defensive strategy is employed. The size-up and risk assessment should continue throughout the incident. Fires in commercial structures are typically more dangerous than residential building fires. Retired Assistant Chief Vince Dunn states that defensive operations should be used more often at special occupancy and commercial buildings. Chief Dunn cites statistics that 4 fire fighters die for every 100,000 residential fires compared to 9 fire fighter deaths for every 100,000 commercial structure fires.30 Interior size-up is just as important as exterior size-up. Since the IC is staged at the command post (outside), the interior conditions should be communicated to the IC as soon as possible. Interior conditions could change the IC’s strategy or tactics. For example, if heavy smoke is emitting from the exterior roof system, but fire fighters cannot find any fire in the interior, it is a good possibility

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that the fire is above them in the roof system. Other warning signs that should be relayed to the IC include dense black smoke, turbulent smoke, smoke puffing around doorframes, discolored glass, and a reverse flow of smoke back inside the building. It is important for the IC to immediately obtain this type of information to help make the proper decisions. Departments should ensure that the first officer or fire fighter inside the structure evaluates interior conditions and reports them immediately to the IC. In this incident, arriving officers concentrated on the A and D-sides of the structure. A complete 360 degree size-up was never conducted. Pre-plan information did not identify the potential hazards associated with the lightweight metal roof trusses, and the excessive fuel loads associated with the contents. Only one hydrant location was noted on the pre-plan form but it was not used. Smoke emitting from the connection between the original structure and the right-side addition, the deteriorating conditions in the main showroom, a rapid decrease in visibility coupled with a rapid rise in temperature, heavy smoke stains on windows, no visible fire in the showroom with a build-up of smoke and heat, and delays in establishing water supply, were all indicators that could have prompted consideration of switching from offensive to defensive strategies. Recommendation #6: Fire departments should train fire fighters to communicate interior conditions to the Incident Commander as soon as possible and to provide regular updates. Discussion: Proper size-up and risk versus gain analysis requires that the Incident Commander have a number of key pieces of information and keep informed of the constantly changing conditions on the fireground. New decisions must be made and old ones revised based upon increased data and improved information. Decisions can be no better than the information on which they are based. The Incident Commander must use an evaluation system that considers and accounts for changing fireground conditions in order to stay ahead of the fire. If this is not done, the attack plan will be out of sequence with the phase of the fire and the IC will be constantly surprised by changing conditions.27, 29, 31 Interior size-up is just as important as exterior size-up. Since the IC is staged at the command post (outside), the interior conditions should be communicated by interior crews as soon as possible to the IC. Interior conditions could change the IC’s strategy or tactics. Interior crews can aid the IC in this process by providing reports of the interior conditions as soon as they enter the fire building and by providing regular updates. According to Chief Dunn, one such example would be whenever a suspended ceiling is discovered in a commercial structure, this information should be immediately communicated to the IC.31 Based on a review of the training curriculum and available fire department SOPs, fire fighters and officers at this department were not trained to communicate interior conditions to the outside. During the initial attack, the interior conditions in the front show room (lack of fire) did not match the exterior conditions on the D-side (loading dock area fully involved and also the amount of smoke overhead). During NIOSH interviews, fire fighters and officers who had operated inside the structure reported signs of deteriorating conditions to the NIOSH investigators. However, no interior condition reports were broadcast over the radio (to the chief officers or other fire fighters) during this incident. Verbal exchanges between the attack crews and chief officers took place but this information did not

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impact the tactics being used. Information concerning the interior conditions could have been used to consider changing from a fast attack mode to a more cautious defensive operation. Recommendation #7: Fire departments should ensure that the Incident Commander establishes a stationary command post, maintains the role of director of fireground operations, and does not become involved in fire-fighting efforts. Discussion: According to NFPA 1561, §5.3.1, “The incident commander shall have overall authority for management of the incident.” 21 In addition to conducting an initial size-up, the Incident Commander must establish and maintain a command post outside of the structure to assign companies and delegate functions, and continually evaluate the risk versus gain of continued fire fighting efforts. In establishing a command post, the Incident Commander shall ensure the following (NFPA 1561, §5.3.7.2):

(1) The command post is located in or tied to a vehicle to establish presence and visibility. (2) The command post includes radio capability to monitor and communicate with assigned tactical, command, and designated emergency traffic channels for that incident. (3) The location of the command post is communicated to the communications center. (4) The incident commander, or his or her designee, is present at the command post. (5) The command post should be located in the incident cold zone.

The use of a tactical worksheet can assist the IC in keeping track of various task assignments on the fireground. It can be used along with pre-plan information and other relevant data to integrate information management, fire evaluation and decision making. The tactical worksheet should record unit status, benchmark times, and include a diagram of the fireground, occupancy information, activities checklist(s), and other relevant information. This can also aid the Incident Commander in continually conducting a situation evaluation and maintaining accountability. 27 To effectively coordinate and direct fire fighting operations on the scene, it is essential that the IC does not become involved in fire fighting efforts. A delay in establishing an effective command post may result in confusion of assignments and lack of personnel and apparatus coordination which may contribute to rapid fire progression. The involvement of the initial IC in fire fighting also hampers the collection and communication of essential information as command is transferred to later arriving officers. In this incident, a stationary command post was never established and separate and uncoordinated activities were taking place in multiple locations. This contributed to a failure to size-up the overall incident scene, to properly evaluate risk versus gain, and to maintain accountability on the fireground. Recommendation #8: Fire departments should ensure the early implementation of division and group command into the Incident Command System. Discussion: The early establishment of divisions and groups allows the command structure of an incident to grow more effectively than simply deploying resources and assigning division or group supervisors after units are in place. Delegating division / group command to other officers makes the management of a large incident more feasible by relieving the Incident Commander of these responsibilities which allows the IC to focus on the bigger picture while still maintaining the ability

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to react to progress reports and other information provided by the division / group commanders. The Model Procedures Guide for Structural Firefighting describes the application of the National Fire Service Incident Management System (NIMS) to structure fire incidents. These procedures recommend the establishment of division and group command.32 In this incident, a strategy of coordinated division and group command was not employed. Recommendation #9: Fire departments should ensure that the Incident Commander continuously evaluates the risk versus gain when determining whether the fire suppression operation will be offensive or defensive. Discussion: The initial size-up conducted by the first arriving officer allows the officer to make an assessment of the conditions and to assist in planning the suppression strategy. The following general factors are important considerations during a size-up: occupancy type involved, potential for civilians in the structure, smoke and fire conditions, type of construction, age of structure, exposures, and time considerations such as the time of the incident, length of time fire was burning before arrival, and time fire was burning after arrival.33,34 The Incident Commander must perform a risk analysis to determine what hazards are present, what the risks to personnel are, how the risks can be eliminated or reduced, and the benefits to be gained from interior or offensive operations.35 The size-up must include continued assessment of risk versus gain during incident operations. According to NFPA 1500 §A-8.3.3, “The acceptable level of risk is directly related to the potential to save lives or property. Where there is no potential to save lives, the risk to the fire department members must be evaluated in proportion to the ability to save property of value. When there is no ability to save lives or property, there is no justification to expose fire department members to any avoidable risk, and defensive fire suppression operations are the appropriate strategy.”18,36 Retired New York City Fire Chief Vincent Dunn states “When no other person’s life is in danger, the life of the firefighter has a higher priority than fire containment.”25 The first-responding officer, as well as the IC, needs to make a judgment as to what is at risk – people or property. This will help determine the risk profile for the incident. Many fire fighters stand by the notion that all incidents are “people” events until proven otherwise. Some fire fighters are willing to concede that a fire environment has become too hostile to sustain life and therefore, the only thing left to save is property. Historically, the fire service has a poor history of changing risk-taking based upon the people/property issue.37

In this incident, the store manager was present to inform the chief officers on the status of employees and patrons who had been inside the business. The fire department utilized offensive strategies focused on fire suppression. Truck company operations (search and rescue, ventilation, etc.) were not utilized until the fire department received word that an employee was trapped at the rear of the structure. As conditions inside deteriorated, offensive strategies were continued even as problems with establishing water supply mounted and the civilian was rescued.



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Recommendation #10: Fire departments should ensure that the Incident Commander maintains close accountability for all personnel operating on the fireground Discussion: Personnel accountability on a fireground means identifying and tracking all personnel working at the incident. A fire department should develop its own system and standardize it for all incidents. Accountability on the fireground can be maintained by several methods: a system using individual tags assigned to each fire fighter, a riding list provided by the company officer, a SCBA tag system, or incident command board.18,19,21 Modern radio systems also incorporate a means of tracking the identity of fire fighters at an incident scene. As the incident escalates, additional staffing and resources will be needed, adding to the burden of tracking personnel accountability. An incident command board should be established at this point with an assigned accountability officer or aide. The Incident Commander should also utilize the Incident Management System (IMS). Additionally, fire fighters should not work beyond the sight or sound of their supervising officer unless equipped with a portable radio. In this incident, the only accountability system used was the daily work roster. Several off-duty fire fighters and mutual aid companies responded without being dispatched. Not all fire fighters entering the structure had their designated hand held radio. Fire fighters were known to be trapped inside the structure, but the number and their identities were not determined until their bodies were recovered. Recommendation #11: Fire departments should ensure that a separate Incident Safety Officer, independent from the Incident Commander, is appointed at each structure fire. Discussion: According to NFPA 1561 Standard on Emergency Services Incident Management System, 2008 Edition, paragraph 5.3, “The Incident Commander shall have overall authority for management of the incident (5.3.1) and the Incident Commander shall ensure that adequate safety measures are in place (5.3.2).” This shall include overall responsibility for the safety and health of all personnel and for other persons operating within the incident management system. While the Incident Commander (IC) is in overall command at the scene, certain functions must be delegated to ensure adequate scene management is accomplished.21 According to NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, 2007 Edition, “as incidents escalate in size and complexity, the Incident Commander shall divide the incident into tactical-level management units and assign an incident safety officer (ISO) to assess the incident scene for hazards or potential hazards (8.1.6).”18 These standards indicate that the IC is in overall command at the scene, but acknowledge that oversight of all operations is difficult. On-scene fire fighter health and safety is best preserved by delegating the function of safety and health oversight to the ISO. Additionally, the IC relies upon fire fighters and the ISO to relay feedback on fireground conditions in order to make timely, informed decisions regarding risk versus gain and offensive versus defensive operations. The safety of all personnel on the fireground is directly impacted by clear, concise, and timely communications among mutual aid fire departments, sector command, the ISO, and IC.



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Chapter 6 of NFPA 1521, Standard for Fire Department Safety Officer, defines the role of the ISO at an incident scene and identifies duties such as: recon of the fireground and reporting pertinent information back to the Incident Commander; ensuring the department’s accountability system is in place and operational; monitoring radio transmissions and identifying barriers to effective communications; and ensuring established safety zones, collapse zones, hot zones, and other designated hazard areas are communicated to all members on scene.24 Larger fire departments may assign one or more full-time staff officers as safety officers who respond to working fires. In smaller departments, every officer should be prepared to function as the ISO when assigned by the IC. The presence of a safety officer does not diminish the responsibility of individual fire fighters and fire officers for safety. The ISO adds a higher level of attention and expertise to help the fire fighters and fire officers. The ISO must have particular expertise in analyzing safety hazards and must know the particular uses and limitations of protective equipment.26 A designated safety officer could have assisted at this incident with continual size-up, accountability, and timely communications regarding safety on the fireground and the rapidly deteriorating conditions inside the structure. Note: Since the fatal incident, the fire department has hired a full time, permanent Safety Officer. Recommendation #12: Fire departments should ensure that crew integrity is maintained during fire suppression operations. Discussion: Fire fighters should always work and remain in teams whenever they are operating in a hazardous environment.19 Team continuity means team members knowing who is on their team and who is the team leader; team members staying within visual contact at all times (if visibility is low, teams must stay within touch or voice distance of each other); team members communicating needs and observations to the team leader, and team members rotating together to rehabilitation, staging as a team, and watching out for each other (practicing a strong buddy system). Following these basic rules helps prevent serious injury or even death by providing personnel with the added safety net of fellow team members. Teams that enter a hazardous environment together should leave together to ensure that team continuity is maintained.25 In this incident, there were numerous instances where fire fighters were working independently, entering and exiting the structure alone, operating hose lines, pulling walls and ceiling, and other related activities. Working alone increases the risk for themselves, and possibly to others during search and rescue efforts. Federal regulations [the OSHA 2-in-2-out rule, 29 CFR 1910.134 (g)(4)(i)] states “…at least two employees enter the immediately-dangerous-to-life-or-health (IDLH) atmosphere and remain in visual or voice contact with one another at all times.”8

Recommendation #13: Fire departments should ensure that a rapid intervention crew (RIC) / rapid intervention team (RIT) is established and available to immediately respond to emergency rescue incidents. Discussion: A rapid intervention crew (RIC) or team (RIT) should be designated and available to respond during all fireground operations. 18,19, 21 The rescue crew should report to the Incident



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Commander (IC) and be available within the incident’s staging area. The rescue crew should be comprised of fresh, well-rested fire fighters, and be positioned and ready to respond when a fire fighter(s) is down or in trouble.18 NFPA 1500, Chapter 8.8, Rapid Intervention for Rescue of Members, provides detailed guidelines for the deployment of rescue teams at emergency incidents. Chapter 8.8.1 states “The fire department shall provide personnel for the rescue of members operating at emergency incidents.” During the initial stages of an incident, the rescue crew members may be engaged in support operations outside the structure. Once the incident expands in size or complexity and the IC requests additional resources, the rescue crew must be dedicated to stand-by in case rescue operations are needed.18 The rapid intervention crew or team should have all tools necessary to complete the job, e.g., search and rescue ropes, Haligan bar and flat-head axe combo, first-aid kit, resuscitation equipment, extra SCBA cylinders and/or transfill hoses, etc. RIC or RIT teams should have specialized rescue training to prepare them for rescue operations. RIC or RIT teams can intervene quickly to rescue a fire fighter who becomes disoriented, lost in smoke filled environments, trapped by fire, involved in a structural collapse, or has run out of breathing air. In this incident a dedicated rescue crew was never employed and no crews were held outside in standby or rescue mode. Once it was realized that fire fighters were trapped inside the structure, fire fighters from the first-responding mutual aid department as well as off-duty city fire fighters who came to the scene were pressed into service to attempt search and rescue operations at the front entrance. Recommendation #14: Fire departments should ensure that adequate numbers of staff are available to immediately respond to emergency incidents. Discussion: NFPA 1710 Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments (2004 Edition) contains recommended guidelines for minimum staffing of career fire departments.38 NFPA 1710 § 5.2.2 (Staffing) states the following: “On-duty fire suppression personnel shall be comprised of the numbers necessary for fire-fighting performance relative to the expected fire-fighting conditions. These numbers shall be determined through task analyses that take the following factors into consideration:

1. Life hazard to the populace protected 2. Provisions of safe and effective fire-fighting performance conditions for the fire fighters 3. Potential property loss 4. Nature, configuration, hazards, and internal protection of the properties involved 5. Types of fireground tactics and evolutions employed as standard procedure, type of apparatus

used, and results expected to be obtained at the fire scene.”

The NFPA standard states that both engine and truck companies shall be staffed with a minimum of four on-duty personnel. The standard also states that in jurisdictions with tactical hazards, high hazard occupancies, high incident frequencies, geographical restrictions, or other pertinent factors identified by the authority having jurisdiction, these companies shall be staffed with a minimum of five or six on-duty members.



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NFPA 1710 also states that the fire department’s fire suppression resources shall be deployed to provide for the arrival of an engine company within a 4-minute response time and/or the initial full alarm assignment within an 8-minute response time to 90 percent of the incidents as established in Chapter 4. The fire department shall have the capability to deploy an initial full alarm assignment within an 8-minute response time to 90 percent of the incidents as established in Chapter 4. The initial full alarm assignment shall provide for the following (Chapter 5.2.4.2):

1. Establishment of incident command outside of the hazard area for the overall coordination and direction of the initial full alarm assignment. A minimum of one individual shall be dedicated to this task.

2. Establishment of an uninterrupted water supply of a minimum 1520 L/min (400 gpm) for 30 minutes. Supply line(s) shall be maintained by an operator who shall ensure uninterrupted water flow application.

3. Establishment of an effective water flow application rate of 1140 L/min (300 gpm) from two hand lines, each of which shall have a minimum of 380 L/min (100 gpm). Each attack and backup line shall be operated by a minimum of two individuals to effectively and safely maintain the line.

4. Provision of one support person for each attack and backup line deployed to provide hydrant hookup and to assist in line lays, utility control, and forcible entry.

5. A minimum of one victim search and rescue team shall be part of the initial full alarm assignment. Each search and rescue team shall consist of a minimum of two individuals.

6. A minimum of one ventilation team shall be part of the initial full alarm assignment. Each ventilation team shall consist of a minimum of two individuals.

7. If an aerial device is used in operations, one person shall function as an aerial operator who shall maintain primary control of the aerial device at all times.

8. Establishment of an Incident Rapid Intervention Crew (IRIC) that shall consist of a minimum of two properly equipped and trained individuals.

The municipal fire department involved in this incident routinely operated with three fire fighters per apparatus depending on the staffing available during each shift. During this incident, many of the routine and necessary fireground operations were not initiated—e.g., establishment of Incident Command outside the hazard area overseeing all operations, search and rescue, a staged rapid intervention crew (RIC), hydrant connection and water supply, and coordinated ventilation. All resources on scene were engaged in attacking the interior fire. Due to the limited staffing, several fire fighters were operating alone inside the burning structure instead of pairing up with other fire fighters. Recommendation #15: Fire departments should ensure that ventilation to release heat and smoke is closely coordinated with interior fire suppression operations. Discussion: Ventilation is the systematic removal and replacement of heated air, smoke, and gases from inside a structure with cooler air. The cooler air facilitates entry by fire fighters and improves life safety for rescue and other fire fighting operations. Ventilation improves visibility and reduces



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the chance of flashover or backdraft.19 The ventilation opening may produce a chimney effect causing air movement from within a structure toward the opening. This air movement helps facilitate the venting of smoke, hot gases and products of combustion, but may also cause the fire to grow in intensity and may endanger fire fighters who are between the fire and the ventilation opening. For this reason, ventilation should be closely coordinated with hose line placement and offensive fire suppression tactics. Close coordination means the hose line is in place and ready to operate so that when ventilation occurs, the hose line can overcome the increase in combustion likely to occur. If a ventilation opening is made directly above a fire, fire spread may be reduced, allowing fire fighters the opportunity to extinguish the fire. If the opening is made elsewhere, the chimney effect may actually contribute to the spread of the fire.19,39 Proper ventilation during a structure fire will reduce the tendency for rising heat, smoke, and fire gases, trapped by the roof or ceiling, to accumulate, bank down, and spread laterally to other areas within the structure. Proper ventilation reduces the threat of flashover by removing heat before combustibles in a room or enclosed area reach their ignition temperatures. Proper ventilation reduces the risk of a backdraft by reducing the potential for superheated fire gases and smoke to accumulate in an enclosed area. The Incident Commander must consider many variables when deciding upon the plan of attack at a structure fire. Ventilation is just one of the many variables that must be considered. Before initiating the fire attack, the IC should ask the following questions:19

• Is there a need for ventilation at this time? The need must be based upon the heat, smoke, and gas conditions within the structure, the structural conditions, and the life hazard

• Where is ventilation needed? This involves knowing the construction features of the building, the contents, exposures, wind direction and strength, extent of the fire, location of the fire, location of top or vertical openings and location of cross or horizontal openings

• What type of ventilation should be used? Horizontal (either natural or mechanical) or vertical (natural or mechanical)?

• Do fire and structural conditions allow for safe roof operations? Knowledge of the building is paramount.

In this incident, the fire department did not attempt to coordinate ventilation with the offensive interior attack. Chief officers interviewed by NIOSH stated they would not ventilate the type of structure involved in this fire. Crews were directed to attack the fire with hose lines at the loading dock (D-side) and inside the showroom at the right rear addition. Every fire fighter interviewed by NIOSH who was inside the showroom area reported rapidly deteriorating conditions as thick gray and black smoke banked down to floor level reducing visibility to near zero with rapidly intensifying heat. Different ventilation techniques such as cutting holes in the roof or high on the D-side wall may



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have helped reduce the accumulation of smoke and hot gases inside the showroom. The use of a positive pressure fan at the front entrance along with adequate openings to vent the introduced air, may have helped reduce the amount of accumulating smoke in the front showroom and improved visibility, possibly allowing the disoriented fire fighters inside to find the front entrance. All ventilation techniques have both a positive and negative aspect. Venting can be a very effective life safety procedure. When venting for life safety purposes, the principle is to pull the fire, heat, smoke and toxic gases away from victims, stairs, and other egress routes. A vent opening made between the fire fighter or victims and their path of egress could be fatal if the fire is pulled to their location or cuts off there path of egress.39 Note: The NIST Fire Dynamic Simulator, a computational fire model, will examine the possible impact of different ventilation strategies and their effect on this incident. The NIST fire model will be available in the future at http://www.bfrl.nist.gov/. Recommendation #16: Fire departments should conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics. Discussion: National Fire Protection Association (NFPA) 1620 Recommended Practice for Pre-Incident Planning, 2003 Edition, § 4.4.1 states “the pre-incident plan should be the foundation for decision making during an emergency situation and provides important data that will assist the Incident Commander in developing appropriate strategies and tactics for managing the incident.” This standard also states that “the primary purpose of a pre-incident plan is to help responding personnel effectively manage emergencies with available resources. Pre-incident planning involves evaluating the protection systems, building construction, contents, and operating procedures that can impact emergency operations.” 40 A pre-incident plan identifies deviations from normal operations and can be complex and formal, or simply a notation about a particular problem such as the presence of flammable liquids, explosive hazards, modifications to structural building components, or structural damage from a previous fire.29, 30, 40 In addition, NFPA 1620 outlines the steps involved in developing, maintaining, and using a pre-incident plan by breaking the incident down into pre-, during- and post-incident phases. In the pre-incident phase, for example, it covers factors such as physical elements and site considerations, occupant considerations, protection systems and water supplies, hydrant locations, and special hazard considerations. Building characteristics including type of construction, materials used, occupancy, fuel load, roof and floor design, and unusual or distinguishing characteristics should be recorded, shared with other departments who provide mutual aid, and if possible, entered into the dispatcher’s computer so that the information is readily available if an incident is reported at the noted address. Since many fire departments have tens and hundreds of thousands of structures within their jurisdiction, making it impossible to pre-plan them all, priority should be given to those having elevated or unusual fire hazards and life safety considerations. The fire department had conducted several pre-plan inspections of the structure involved in this incident. A building pre-plan form obtained from the fire department dated April 26, 2006 noted that

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Recommendation #16: Fire departments should conduct pre-incident planning inspections of buildings within their jurisdictions to facilitate development of safe fireground strategies and tactics. Discussion: National Fire Protection Association (NFPA) 1620 Recommended Practice for Pre- Incident Planning, 2003 Edition, § 4.4.1 states “the pre-incident plan should be the foundation for decision making during an emergency situation and provides important data that will assist the Incident Commander in developing appropriate strategies and tactics for managing the incident.” This standard also states that “the primary purpose of a pre-incident plan is to help responding personnel effectively manage emergencies with available resources. Pre-incident planning involves evaluating the protection systems, building construction, contents, and operating procedures that can impact emergency operations.” 40 A pre-incident plan identifies deviations from normal operations and can be complex and formal, or simply a notation about a particular problem such as the presence of flammable liquids, explosive hazards, modifications to structural building components, or structural damage from a previous fire.29, 30, 40 In addition, NFPA 1620 outlines the steps involved in developing, maintaining, and using a preincident plan by breaking the incident down into pre-, during- and post-incident phases. In the preincident phase, for example, it covers factors such as physical elements and site considerations, occupant considerations, protection systems and water supplies, hydrant locations, and special hazard considerations. Building characteristics including type of construction, materials used, occupancy, fuel load, roof and floor design, and unusual or distinguishing characteristics should be recorded, shared with other departments who provide mutual aid, and if possible, entered into the dispatcher’s computer so that the information is readily available if an incident is reported at the noted address. Since many fire departments have tens and hundreds of thousands of structures within their jurisdiction, making it impossible to pre-plan them all, priority should be given to those having elevated or unusual fire hazards and life safety considerations. The fire department had conducted several pre-plan inspections of the structure involved in this incident. A building pre-plan form obtained from the fire department dated April 26, 2006 noted that



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store contents were “household furniture and office equipment” and that the rear warehouse contained racks approximately 30 feet high (see Appendix III). A more thorough building inspection and pre-incident plan for this single-story commercial building could have potentially identified the flat roof supported by lightweight metal bar joists (metal roof trusses), the immense fuel load considerations (i.e. large quantity of furniture and associated highly flammable furnishings in the showroom as well as stored in various locations throughout the facility), the presence of a drop ceiling and hydrant locations. Evaluating the size and construction features of the structure allows the fire department the opportunity to determine a response protocol for the specific identified hazards and to develop fireground strategies and tactics (hose line placement, water flow calculations, ventilation strategies, etc.) before an incident occurs. The hydrant location closest to the structure was noted on the April 2006 form (on the street to the rear of the warehouse), but was not used until the first mutual aid department set up operations at the rear of the warehouse. The construction features, occupancy (furniture retail), and fuel load present suggested large volumes of water would be necessary to fight a major fire at the site, which should have prompted the need to identify additional nearby hydrants. A more complete pre-planning process could have noted this information which may have aided the Incident Commander in developing a safer and more effective defensive strategy. Individual fire companies should be involved in pre-plan inspections outside their first-alarm territories so that they can become familiar with hazardous structures they may respond to on second and subsequent alarm assignments. Recommendation #17: Fire departments should consider establishing and enforcing standardized resource deployment approaches and utilize dispatch entities to move resources to fill service gaps. Discussion: On-scene commanders need to focus on the events occurring at the incident scene. Pre-planned resource deployment can be delegated to the dispatch system. Computer-aided dispatch can make this process automatic. Without a standardized deployment approach, on-scene commanders spend time making decisions that could have already been made. The movement of resources around the jurisdiction to fill coverage gaps should be delegated to others who do not have to focus their attention on the safety of the responders in the hazard zone, such as the dispatch center. According to retired Chief Alan Brunacini, “The IC must be highly familiar with dispatch / communications procedures and stay actively connected to the details of how that system works throughout operations. … The com center knows what resources are available, where they are, and directly controls the status keeping and dispatch system that can move and manage them. The IC must always use the IMS to get the right resources (closest to the incident / appropriate type) in the right place, doing the right things. … Having com work in concert with the IC many times makes a huge difference in the overall command and control.”41 For example, the dispatch center can advise the incident commander of time intervals since the initial dispatch (i.e. 10 minute or 15 minute intervals). Another example would be for dispatch to monitor fireground traffic or signs of problems, such as a Mayday call. The Incident Command System (ICS) Module Procedures Guide provides guidelines for managing major incidents and providing support to the IC by the establishment of a Planning Section to handle duties such as maintaining resource status and evaluating future resource requirements.42

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contained racks approximately 30 feet high (see Appendix III). A more thorough building inspection and pre-incident plan for this single-story commercial building could have potentially identified the flat roof supported by lightweight metal bar joists (metal roof trusses), the immense fuel load considerations (i.e. large quantity of furniture and associated highly flammable furnishings in the showroom as well as stored in various locations throughout the facility), the presence of a drop ceiling and hydrant locations. Evaluating the size and construction features of the structure allows the fire department the opportunity to determine a response protocol for the specific identified hazards and to develop fireground strategies and tactics (hose line placement, water flow calculations, ventilation strategies, etc.) before an incident occurs. The hydrant location closest to the structure was noted on the April 2006 form (on the street to the rear of the warehouse), but was not used until the first mutual aid department set up operations at the rear of the warehouse. The construction features, occupancy (furniture retail), and fuel load present suggested large volumes of water would be necessary to fight a major fire at the site, which should have prompted the need to identify additional nearby hydrants. A more complete pre-planning process could have noted this information which may have aided the Incident Commander in developing a safer and more effective defensive strategy. Individual fire companies should be involved in pre-plan inspections outside their firstalarm territories so that they can become familiar with hazardous structures they may respond to on second and subsequent alarm assignments.

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store contents were “household furniture and office equipment” and that the rear warehouse

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In this incident, the fire department’s procedure was for chief officers to call for additional resources as they deemed necessary. Delegating the tactical deployment and relocation of resources to dispatch or chief officers backfilling at other locations within the jurisdiction will allow Incident Commanders to focus on the fireground events. Using a standardized resource deployment approach, any Mayday should trigger the dispatcher to initiate additional measures in response to the emergency, such as notifying the Fire Chief and chief officers of the Mayday transmission and sending additional resources to the incident scene. Recommendation #18: Fire departments should develop and coordinate pre-incident planning protocols with mutual aid departments. Discussion: NFPA 1620 provides guidance to assist departments in establishing pre-incident plans. Pre-incident planning that includes agreements formed by a coalition of all involved parties including mutual aid fire departments, emergency medical services companies, and police, will present a coordinated response to emergency situations, and may save valuable time by a more rapid implementation of pre-determined protocols.40 Examples of such pre-incident planning for this incident include better coordination with the police department concerning traffic control and better utilization of the resources available from mutual aid departments, such as large diameter supply hoses. Recommendation #19: Fire departments should ensure that any offensive attack is conducted using adequate fire streams based on characteristics of the structure and fuel load present. Discussion: The objective of the offensive fire attack is to apply enough water directly to the burning fuel to achieve extinguishment.39 Determining the number and size of hose lines to deploy at a fire can be estimated by first estimating the size of the structure and applying various flowrate calculations such as what is taught at the U.S. National Fire Academy (area divided by 3) or by estimating the size of the fire. Retired Chief Alan Brunacini in his book Fire Command states “Big Fire = Big Water, Little Fire = Little Water.”27 In addition to the location and extent of the fire, factors affecting selection and placement of hose lines include the building’s occupancy, construction, and size. In addition, fire load and material involved, mobility requirements, and number of persons available to handle the hose lines are important factors. Regardless of the choice of attack method or the type of fire stream used, successful fire suppression depends upon discharging a sufficient quantity of water to remove the heat being generated, and ensuring that it reaches the fire rather than being turned into steam or being carried away by convective currents. A back-up line, at least as large as the initial attack line, should be in place and charged to protect the initial attack crew before interior fire fighting efforts begin.30 Some experts recommend that a 2 ½-inch attack hose line routinely be used with commercial and industrial structures if a sizable body of fire is present. The rational is that, compared to a residence, the fire load in commercial structures is usually heavier, will burn longer, and in need of harder hitting streams. In this incident, the loading dock area contained approximately 2,300 square feet of floor space, the right showroom addition contained approximately 7,000 square feet, and the main showroom contained approximately 17,000 square feet of floor space. Applying the National Fire Academy rule (area divided by 3), a minimum

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Recommendation #18: Fire departments should develop and coordinate pre-incident planning protocols with mutual aid departments. Discussion: NFPA 1620 provides guidance to assist departments in establishing pre-incident plans. Pre-incident planning that includes agreements formed by a coalition of all involved parties including mutual aid fire departments, emergency medical services companies, and police, will present a coordinated response to emergency situations, and may save valuable time by a more rapid implementation of pre-determined protocols.40 Examples of such pre-incident planning for this incident include better coordination with the police department concerning traffic control and better utilization of the resources available from mutual aid departments, such as large diameter supply hoses.

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of 800 gallons per minute (gpm) of water would have been required at the loading dock. Crews operating at both the loading dock and the right showroom addition initially employed 1 ½” preconnected hand lines capable of flowing 90 gpm. 1-inch booster lines were also deployed. As the fire progressed, 2 ½” hand lines capable of flowing 350 gpm were put into operation, but their use was hindered by inadequate water supply so that the actual flow rates likely never approached these capacities during the incipient fire stage due to the small diameter of the supply lines. Table 1 provides examples of hose sizes and the corresponding flow rates. Table 1: Example Hose Sizes and Corresponding Flow Rates.e

Generic 2 ½” supply hose Discharge Pressure = 175 psi Intake Pressure = 20 psi Distance = 750 feet

Hose Size Flow Available 2 ½ inch 321 gallons per minute (2) 2 ½ inch 643 gallons per minute 4 inch 1, 017 gallons per minute 5 inch 1, 607 gallons per minute

Recommendation #20: Fire departments should ensure that an adequate water supply is established and maintained. Discussion: Establishing adequate water supply on the fireground is an integral part of fire suppression. A supply hose is used to move large volumes of water between a pressurized water source and a pump that is supplying attack hose lines. It is also used to maintain a water system as a continuous conduit or by connecting water supply sources. Usually, the pressure in supply hose lines are lower than those used for the attack fire hose. According to Fire Hose Practices by IFSTA, the use of a 2 ½ inch hose was once considered the minimum diameter for a supply line, but is no longer recognized as an adequate supply hose. A 3 ½” supply line is now considered the minimum. In most instances, fire departments and industrial establishments have gone to a larger diameter supply line: 3 ½, 4, 4 ½, 5, 6, 8, 10 or 12 inches. In most cases, a short length of 5” or 6” diameter hose is used. With the ever-increasing demand for greater fire flow (water supply) over long distances, large diameter hoses (LDH) are used as above-ground water mains to allow for greater flow of water available for fire suppression, and to decrease friction loss due to a smaller diameter hose.44 The fire department involved in this incident routinely deployed 2 ½” hose as the main water supply line. In this incident, 23 50-foot sections of 2 ½” supply line were laid to a hydrant capable of supplying 1,256 gpm at 56 psi. Engine 16, stationed at the hydrant, pumped through the 23 sections e Partial Table 13.15 courtesy of IFSTA Pumping Apparatus Driver/Operator Handbook (1999).43

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of supply hose to supply Engine 11 located near the front entrance. Difficulties with the Engine 11 pump delayed the establishment of a constant water supply to the initial attack line (500 feet of 1 ½” hose line), causing the Engine 11 engineer to switch between tank water and the supply line. Crews also attempted to deploy a 1” booster line and a 2 ½” attack line (200 feet) from Engine 11. The deployment of a 1 ½” attack line over 250 feet increased the friction loss and lowered the water flow below safe and acceptable levels (150 gpm minimum). As the fire progressed and the need for additional water increased, chief officers radioed to the E-16 engineer to increase the water pressure. The officers ordered the E-16 engineer to go to 300 psi which was well over the maximum limit of 200 psi working pressure for the hose. It is likely that every time the 1" or the 2 ½" line nozzles were opened, the 1 ½" line pressure would drop. The 1 ½" line was the only one that was in position to effectively attack the fire at the rear of the showroom. To offset the reduced water flow (perceived as lack of water pressure at the nozzle), the engine operator was instructed to increase the pressure to pump more water, but this action would only increase the friction losses in the small diameter hose. A similar scenario developed on the D-side of the structure where Engine 12 was stationed at a hydrant pumping water through a single 2 ½” supply hose over 600 feet to Engine 10 which was pumping to multiple attack hoses. Additional supply hoses, increasing the volume of water available to both Engine 10 and Engine 11, were not added until after the fire fighters were determined to be missing. As the fire intensified and the need for additional water flow increased, the use of large diameter hoses for supply lines would have increased the water available at the pumps (E-10 and E-11). Recommendation #21: Fire departments should consider using exit locators such as high intensity floodlights, flashing strobe lights, hose markings, or safety ropes to guide lost or disoriented fire fighters to the exit. Discussion: The use of high-intensity floodlights, flashing strobe lights, or other high visibility beacons can be set up at the entry portals of burning structures as an aid to assist fire fighters in situations requiring emergency escape.39 If staffing permits, a fire fighter can be stationed at the doorway to assist with flaking hose through the entrance and to assist exiting fire fighters. Hose lines can be marked with raised chevrons pointing in the direction of the pump (to the outside). Another option for locating exits is the deployment of safety rope lines as crews enter a structure. The end of the safety rope is secured outside the doorway and the rope is laid out as the crew advances inside. During this incident, several fire fighters inside the structure became disoriented as the conditions deteriorated. Most of the fire fighters working inside the structure ran out of air. During the NIOSH interviews, fire fighters stated they had to search for a hoseline to follow outside. Other fire fighters reported hearing the sound of Engine 11 running in the parking lot and then moving toward the sound. Safety ropes were not deployed by the initial crews who entered the structure. Recommendation #22: Fire departments should ensure that Mayday transmissions are received and prioritized by the Incident Commander. Discussion: The Incident Commander must monitor and prioritize every message, but only respond to those that are critical during a period of heavy communications on the fireground. A radio



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transmission reporting a trapped fire fighter is the highest priority transmission that Command can receive. Mayday transmissions must always be acknowledged and immediate action must be taken.45,46 As soon as fire fighters become lost or disoriented, trapped or unsuccessful at finding their way out of the interior of a structural fire, they must initiate emergency radio transmissions. A Mayday call should receive the highest communications priority from dispatch, the IC, and all other units on-scene. In this incident, there were multiple radio transmissions of fire fighters asking for assistance in finding the exit. There was no reaction to these radio transmissions for several minutes, possibly due to the large volume of radio traffic and/or the chief officers being distracted by engaging in fireground activities. The sooner the IC is notified and a RIT is activated, the greater the chance of the fire fighter(s) being rescued. Recommendation # 23: Fire departments should train fire fighters on actions to take if they become trapped or disoriented inside a burning structure. Discussion: Fire fighters must act promptly when they become lost, disoriented, injured, low on air, or trapped.45-50 First, they must transmit a distress signal while they still have the capability and sufficient air, noting their location if possible. The next step is to manually activate their PASS device. To conserve air while waiting to be rescued, fire fighters should try to stay calm, be focused on their situation and avoid unnecessary physical activity. They should survey their surroundings to get their bearings and determine potential escape routes such as windows, doors, hallways, changes in flooring surfaces, etc.; and stay in radio contact with the IC and other rescuers. Additionally, fire fighters can attract attention by maximizing the sound of their PASS device (e.g. by pointing it in an open direction); pointing their flashlight toward the ceiling or moving it around; and using a tool to make tapping noises on the floor or wall. A crew member who initiates a Mayday call for another person should quickly try to communicate with the missing member via radio and, if unsuccessful, initiate another Mayday providing relevant information on the missing fire fighter’s last known location. In this incident, fire fighters radioed that they had lost contact with the hose, needed assistance getting out, and at least one fire fighter radioed “Mayday” then activated the emergency button on his radio. None of these radio transmissions gave any information regarding the fire fighters’ locations – i.e. “rear of the main showroom,” “near the loading dock,” etc. At least one fire fighter entered the structure without a radio. Recommendation #24: Fire departments should ensure that all fire fighters and line officers receive fundamental and annual refresher training according to NFPA 1001 and NFPA 1021. Discussion: Initial and continual training provides an opportunity to ensure that all fire fighters and line officers are proficient in their knowledge and skills in recognizing and mitigating hazards. Training on structural fire fighting should include, but not be limited to, departmental standard operating procedures, fire fighter safety, building construction, and fireground tactics. NFPA 1500, Chapter 5, requires that the fire department provide an annual skills check to verify minimum professional qualifications of its members.18 NFPA 1001 Standard for Fire Fighter Professional



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Qualifications was established to facilitate the development of nationally applicable performance standards for uniformed fire service personnel.6 NFPA 1021 Standard for Fire Officer Professional Qualifications was developed in the same way to determine that an individual possesses the skills and knowledge to perform as a fire officer.23 The intent of both of these standards is to develop clear and concise job performance requirements (JPRs) that can be used to determine that an individual, when measured to the standard, possesses the skills and knowledge to perform as a fire fighter or a fire officer, and that these JPRs can be used by any fire department in the country. Training is an ongoing process, whether held daily, weekly or monthly, it allows members to maintain proficiency at their present levels, meet certification requirements, learn new procedures, and keep up with emerging technology. This fire department required fire fighters to receive basic fire fighter training certification before being considered for employment. Once recruits were hired they were put through a ten day hands-on training and then assigned to their station. This ten day training included equipment use, SCBA use, ladder drills, hydrant hookup, hose lays, hose pulls, rescue drills, and live-burn exercises. The training provided for basic hose line operations was minimal. Hands-on training should also include topics such as hazard recognition, ventilation tactics, ICS/NIMS, scene size-up, and basic hose line operations. The basic training certification required by the fire department at the time of this incident did not meet NFPA Fire Fighter I requirements. Recommendation #25: Fire departments should implement joint training on response protocols with mutual aid departments. Discussion: Mutual aid companies should train together and not wait until an incident occurs to attempt to integrate the participating departments into a functional team. Differences in equipment and procedures need to be identified and resolved before an emergency occurs when lives may be at stake. Procedures and protocols that are jointly developed, and have the support of the majority of participating departments, will greatly enhance overall safety and efficiency on the fireground. Once methods and procedures are agreed upon, training protocols must be developed and joint-training sessions conducted to relay appropriate information to all affected department members. Fire departments should develop and establish good working relationships with surrounding departments so that reciprocal assistance and mutual aid is readily available when emergency situations escalate beyond response capabilities. During this incident, there was little coordination and communication between the municipal and the mutual aid departments, although fire fighters from the mutual aid department played key roles in rescuing the trapped employee, attempting to search the main showroom for missing fire fighters, and establishing water supply. Coordination of fireground efforts could have been enhanced if protocol planning, communication procedures (such as radio frequency/channel selection), and prior training had taken place among mutual aid departments.



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Recommendation #26: Fire departments should ensure apparatus operators are properly trained and familiar with their apparatus Discussion: Modern fire apparatus are complex equipment. Fire fighters require considerable knowledge, skills and abilities in order to properly and safely operate fire apparatus. NFPA 1002 Standard for Fire Apparatus Driver/Operator Professional Qualifications, Chapter 5 lists the requisite knowledge and skills necessary to safely operate fire apparatus equipped with fire pumps.51

Prior to this incident, the fire department provided driver / operator training that consisted mainly of on-the-job training. Individual fire fighters could request to be trained as a driver / operator and this request would be approved through the fire department chain-of-command. Fire fighters then received hands-on training during normal work hours. During this incident, an operator who was not experienced with one of the engines encountered trouble getting the pump to go into gear for pump operations. A detailed inspection report provided by the city (see Appendix II) demonstrates that specialized training and experience was needed to properly engage the pump. Recommendation #27: Fire departments should protect stretched hose lines from vehicular traffic and work with law enforcement or other appropriate agencies to provide traffic control. Discussion: In urban settings, fire hose is commonly used on the fireground to transfer water from the distribution system (usually from a hydrant) to the fire apparatus supplying water to the attack lines. Fire hose is often stretched across roadways and through parking lots. Fire hose may be damaged in a variety of ways while being used on the fireground. Fire departments should avoid laying or pulling hose over rough terrain, sharp edges or objects. A damaged hose may impede fire suppression activities or put fire fighters in an unsafe position by reducing the water needed for fire suppression while attacking the fire. Fire departments should provide protection for deployed hose lines that may potentially be run over by vehicular traffic or be damaged by vibration. This can be done by the use of chafing blocks, hose ramps, or hose bridges.19 Many commercial versions are available or these items can be custom made. Fire departments should also position someone at these protective devices so vehicular traffic can be properly guided across or re-routed, and to make sure the hose does not move around. Fire departments should work with the local police and law enforcement agencies to ensure adequate traffic control, warning barricades, and traffic re-direction takes place. During this incident, fire apparatus engineers radioed dispatch multiple times requesting public safety assistance for traffic control because civilian vehicle traffic was running over the 2 ½” supply lines, disrupting the water supply. During the incipient stage of the fire, traffic was not being redirected and protective devices were not in use (see Photo 11). Recommendation #28: Fire departments should ensure that fire fighters wear a full array of turnout clothing and personal protective equipment appropriate for the assigned task while participating in fire suppression and overhaul activities. Discussion: NFPA 1500 Standard on Fire Department Occupational Safety and Health Program, Chapter 7 contains the general recommendations for fire fighter protective clothing and protective equipment.18 Chapter 7.1.1 specifies that “the fire department shall provide each member with



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protective clothing and protective equipment that is designed to provide protection from the hazards to which the member is likely to be exposed and is suitable for the tasks that the member is expected to perform.” Chapter 7.1.2 states “protective clothing and protective equipment shall be used whenever the member is exposed or potentially exposed to the hazards for which it is provided.” Chapter 7.1.3 states “structural fire-fighting protective clothing shall be cleaned at least every 6 months as specified in NFPA 1851 Standard on Selection, Care, and Maintenance of Structural Fire Fighting Protective Ensembles.” 52 Chapter 7.2.1 states “members who engage in or are exposed to the hazards of structural fire fighting shall be provided with and shall use a protective ensemble that shall meet the applicable requirements of NFPA 1971 Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting.” 53 Chapter 7.9.7 states “when engaged in any operation where they could encounter atmospheres that are immediately-dangerous-to-life-or-health (IDLH) or potentially IDLH, or where the atmosphere is unknown, the fire department shall provide and require all members to use SCBA that has been certified as being compliant with NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus for Fire and Emergency Services.” 54 Additionally, the OSHA Respirator Standard requires that all employees engaged in interior structural fire fighting use SCBAs.8 During this incident, there were multiple instances where fire fighters were observed working in close proximity to the burning structure with incomplete personal protective ensembles including incomplete turnouts (i.e. no turnout pants, turnout coats unfastened, suspenders improperly worn, no gloves, no hoods), entering the burning structure without an SCBA, and off-duty fire fighters actively working in street clothing with no personal protection at all. The evaluation report of the PPE worn by the nine victims identified instances where the PPE was not properly worn such as turnout coat collars not fully extended upward and helmet ear flaps not deployed (see Appendix IV).

It is important to note that the 2007 revision to NFPA 1982 Standard on Personal Alert Safety Systems (PASS) includes new heat and flame resistance requirements resulting from documented reports where PASS devices were not heard during fatal fireground incidents.55 Laboratory testing conducted by NIST determined that exposure to high temperature environments caused the loudness of the tested PASS alarm signal to be reduced. This reduction in loudness can cause the alarm signal to become indistinguishable from background noise at an emergency scene. Initial laboratory testing by NIST highlighted that this sound reduction may begin to occur at temperatures as low as 300°F. Thus the use of PASS devices meeting NFPA 1982, 2007 Edition requirements is highly recommended. Recommendation #29: Fire departments should ensure that fire fighters are trained in air management techniques to ensure they receive the maximum benefit from their self-contained breathing apparatus (SCBA). Discussion: SCBA air cylinders contain a finite volume of air, regardless of the size. Air consumption will vary with each individual’s physical condition, the level of training, the task performed, and the environment. Depending on the individual’s air consumption and the amount of time required to exit an immediately-dangerous-to-life-and-health (IDLH) environment, the low air



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alarm may not provide adequate time to exit. Working in large structures (high rise buildings, warehouses, and supermarkets) requires that fire fighters be cognizant of the distance traveled and the time required to reach the point of suppression activity from the point of entry. When conditions deteriorate and the visibility becomes limited, fire fighters may find that it takes additional time to exit when compared to the time it took to enter the structure.46, 56 NFPA 1404 Standard for Fire Service Respiratory Protection Training Paragraph 5.1.4.2 requires fire departments to train fire fighters on air management techniques so that the individual fire fighter will develop the ability to manage his or her air consumption while wearing an SCBA. NFPA 1404 specifies that the individual air management program should include the following directives:

(1) Exit from an IDLH atmosphere should be before consumption of reserve air supply begins. (2) Low air alarm is notification that the individual is consuming the reserve air supply. (3) Activation of the reserve air alarm is an immediate action item for the individual and the

team.57

Fire departments and fire fighters should regularly conduct training exercises in which fire fighters perform various exercises and work tasks at different work rates until their SCBA cylinder air is exhausted so that fire fighters become familiar with the time they can expect to work before the low air alarm sounds, and how long they have to exit once the low air alarm sounds. In order to comply with NFPA 1404, fire departments and fire fighters should follow the Rule of Air Management which states “Know how much air you have in your SCBA and manage that air so that you leave the hazardous environment before your low-air alarm activiates.”57, 58 By being aware of these time parameters, fire fighters can make educated decisions on the time they can safely spend in IDLH atmospheres. In this incident, the majority of fire fighters who entered the main showroom ran out of air. Some of the fire fighters were able to exit. The nine victims are all believed to have run out of air. Recommendation #30: Fire departments should develop, implement and enforce written SOPs to ensure that SCBA cylinders are fully charged and ready for use. Discussion: During this incident, many of the fire fighters who entered the main showroom became disoriented due to the rapidly deteriorating conditions and ran low or completely exhausted their air supply. The examination of the remains of the SCBA used by the 9 victims suggested that all 9 SCBA were out of air. The SCBA used by this fire department include cylinders that are rated for a 30-minute duration when fully charged to 2216 psi. During the NIOSH interview process, several fire fighters stated that the fire department’s procedures were to refill cylinders when the pressure dropped to 1500 psi which is well below the required 90% level (1500 psi is 68% of full cylinder pressure). Although NIOSH did not examine all department SCBAs or a scientific sample of SCBAs, examination of a small convenience sample of in-service SCBAs did identify some below 2000 psi. Cylinders designed to be fully charged at 2,216 psi should be refilled whenever the pressure falls to 1,994 psi. Due to gauge accuracy and the type of scale used on the face of the cylinder pressure gauge, any cylinder at or below 2000 psi should be topped off to ensure fire fighters are entering IDLH conditions with a full cylinder. The OSHA Respirator Standard, 29 CFR 1910.134(h)(3)(iii)



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states “Air and oxygen cylinders shall be maintained in a fully charged state and shall be recharged when the pressure falls to 90% of the manufacturer's recommended pressure level.”8 NFPA 1852 and good SCBA practice dictate that SCBA air cylinders be refilled whenever the cylinder pressure falls to 90% of the manufacturer’s recommended pressure level.9, 59 A 30-minute cylinder typically holds 1,200 liters of air when fully charged. A cylinder charged to 1,500 psi would hold approximately 812 liters of air. A fire fighter working at a moderate work rate (40 liter per minute air consumption rate) would exhaust a cylinder holding 1500 psi in approximately 20 minutes (812 liters divided by 40 liters per minute). Fire fighters working at a higher work rate or breathing under duress (such as in an emergency situation) would exhaust a cylinder much quicker. During extreme exertion, the actual service time can be reduced by 50 percent or more. 9 A number of fire fighters inside the showroom were running low on air within 20-25 minutes. Recommendation #31: Fire departments should use thermal imaging cameras (TICs) during the initial size-up and search phases of a fire. Discussion: Thermal imaging cameras (TIC) can be a useful tool for initial size up and for locating the seat of a fire. Infrared thermal cameras can assist fire fighters in quickly getting crucial information about the location of the source (seat) of the fire from the exterior of the structure which can help plan an effective and rapid response. Knowing the location of the most dangerous and hottest part of the fire may help fire fighters determine a safer approach and avoid exposure to structural damage in a building that might have otherwise been undetectable. Ceilings and floors that have become dangerously weakened by fire damage and are threatening to collapse may be spotted with a thermal imaging camera. A fire fighter about to enter a room filled with flames and smoke can use a TIC to assist in judging whether or not it will be safe from falling beams, walls, or other dangers. The use of a thermal imaging camera may provide additional information the Incident Commander can use during the initial size-up. Thermal imaging cameras (TICs) should be used in a timely manner, and fire fighters should be properly trained in their use and be aware of their limitations.60 The use of a TIC during initial size-up and entry into the structure might have confirmed the presence of hot smoke and gases in the concealed space above the suspended ceiling, which would have been an indicator that more defensive tactics should be considered. TICs were available on the fireground but never put into service. Recommendation #32: Fire departments should develop, implement and enforce written SOPs and provide fire fighters with training on the hazards of truss construction Discussion: Fire departments should develop, implement and enforce SOPs or SOGs concerning safe fireground tactics when operating in structures containing truss construction and then train fire fighters to recognize the hazards of lightweight truss construction and the appropriate actions to take.61,62 Fire departments should use pre-incident planning and building inspections to identify structures within their jurisdiction that contain truss construction. Pre-plan information should be entered into the dispatcher's computer so that when a fire is reported at pre-planned locations, the

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Fire departments should use pre-incident planning and building inspections to identify structures within their jurisdiction that contain truss construction. Pre-plan information should be entered into the dispatcher's computer so that when a fire is reported at pre-planned locations, the

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Recommendation #32: Fire departments should develop, implement and enforce written SOPs and provide fire fighters with training on the hazards of truss construction



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dispatcher can notify by radio all first responders with critical information.61,62 Fire departments should ensure that the Incident Commander conducts an initial size-up and risk assessment of the incident scene before beginning interior fire-fighting operations. Hidden voids within truss construction provide large areas for smoke and hot gases to accumulate unseen. These hidden voids provide the potential for rapid fire spread, which may go unnoticed by fire fighters working below. The Rapid Intervention Team should be immediately notified when truss construction is identified. Fire departments should use defensive strategies whenever trusses have been exposed to fire or structural integrity cannot be verified. Unless life-saving operations are under way, fire fighters should immediately be evacuated and an exterior attack should be used.61,62 Fire fighters performing fire-fighting operations under or above trusses should be evacuated as soon as it is determined that the trusses are exposed to fire (not according to a time limit). A collapse zone should be established when operating outside a burning building, since truss roof collapses can push out on the walls, causing a secondary collapse of the exterior walls. The collapse zone should be equal to the height of the building plus allowance for scattering debris, usually at least 1½ times the height of the building.39, 61, 63 Defensive overhauling procedures should be used after fire extinguishment in a building containing truss construction. Outside master streams should be used to soak the smoldering truss building and prevent rekindling.39, 61, 63 Recommendation #33: Fire departments should establish a system to facilitate the reporting of unsafe conditions or code violations to the appropriate authorities. Discussion: In 1987 the responsibility for fire code inspections was transferred from the fire department to the city. In order to facilitate open communication, fire department personnel and building code officials should be cross-trained on each-others’ duties and responsibilities. Fire fighters should have a basic understanding of what a code violation is and building code inspectors should have a basic understanding of fire fighter safety issues. The fire department conducted a number of pre-plan inspections at the structure involved in this incident. However, unsafe conditions and code violations were not noted on the pre-plan inspection form presented to NIOSH. The pre-plan form did note the presence of the warehouse with storage shelves approximately 30 feet high, but did not note the lightweight metal roof trusses and the excessive fuel loads associated with the contents. Such information could be used to facilitate safer conditions for employees, the public and fire fighters and emergency responders called to the scene. The accumulation of trash outside the loading dock, large quantities of flammable liquids, solvents, and thinners in the loading dock area and storage of furniture and flammable materials in non-permitted areas were determined to be code violations after the incident. The identification and reporting of these conditions to the responsible authorities prior to the incident could potentially have resulted in corrective actions. Recommendation #34: Fire departments should ensure that fire fighters and emergency responders are provided with effective incident rehabilitation Discussion: Effective emergency incident rehabilitation is an important element of fire fighter health and safety. Quoting Gregory Cade, former U.S. Fire Administrator, “Emergency responder rehabilitation is designed to ensure that the physical and mental well-being of members operating at

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dispatcher can notify by radio all first responders with critical information

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the scene of an emergency do not deteriorate to the point where it effects their safety. It can prevent serious and life-threatening conditions such as heat stroke and heart attacks from occurring. Fireground rehab is the term often used for the care given to fire fighters and other responders while performing their duties at an emergency scene. Fireground rehab includes monitoring vital signs, rehydration, nourishment, and rest for responders between assignments.”64, 65 During this incident, the municipal fire department did not practice fireground rehab. While fireground rehab was not a direct contributing factor in the deaths of the nine fire fighters, fireground rehab is an important part of a fire department occupational safety and health program. Recommendation #35: Fire departments should provide fire fighters with station / work uniforms (e.g., pants and shirts) that are compliant with NFPA 1975 and ensure the use and proper care of these garments. Discussion: Fire fighters involved in structural fire fighting and other emergency activities should be provided, at a minimum, station / work uniforms that are certified and compliant with NFPA 1975 in order to avoid the potential for burn injuries that are more severe as the result of using thermally unstable or rapidly deteriorating materials (e.g., fabrics that contain a significant portion of polyester or other synthetic fabrics that easily melt at low temperatures). Ideally, the prescribed station / work uniforms should also be flame resistant certified to the optional requirements specified in NFPA 1975.7 The use of NFPA 1975-compliant station / work uniforms is specified in NFPA 1500 (paragraphs 7.1.5 and 7.1.6), which also recommends that departments provide for the adequate cleaning of station / work uniforms provided to their members (7.1.7).18 According to Appendix A.5.3.10 of NFPA 1500, clothing that is made from 100 percent natural fibers or blends that are principally natural fibers should be selected over other fabrics that have poor thermal stability or ignite easily. Appendix A.5.3.10 further states “The very fact that persons are fire fighters indicates that all clothing that they wear should be flame resistant (as children's sleepwear is required to be) to give a degree of safety if unanticipated happenings occur that expose the clothing to flame, flash, sparks, or hot substances. This would include clothing worn under their structural fire-fighting protective ensemble.” While compliance with NFPA standards is voluntary, in many instances NFPA standards represent fire service “best practices” available for ensuring fire fighter safety and health, especially where state and federal laws are silent on health and safety issues. In this incident, the fire fighters were not supplied with nor were they wearing station/work uniforms that were compliant with NFPA 1975. Although the use of polyester work clothing was not a direct contributing factor to the nine fatalities that occurred in this incident, the wearing of polyester-based uniforms can contribute to significant potential for severe burn injury.



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Recommendation #36: Federal and state occupational safety and health administrations should consider developing additional regulations to improve the safety of fire fighters, including adopting National Fire Protection Association (NFPA) consensus standards. Discussion: Fire fighters have a high rate of injury death compared to other occupations,11 yet federal and state regulations addressing the risks of fire fighting are sparse. In September 2007, the federal Occupational Safety and Health Administration (OSHA) requested information from the public to evaluate what action, if any, the US Department of Labor should take to further address emergency response and preparedness, including the safety of fire fighters during common responses such as structural fires, as well as rare and unexpected events, such as natural disasters and terrorist attacks.66 In this request for information, OSHA noted that elements of emergency responder health and safety are currently regulated by a number of standards, many of which were promulgated decades ago, and none designed as a comprehensive emergency response standard. Consequently, existing standards do not address the full range of hazards or concerns currently facing emergency responders, including fire fighters. NIOSH provided comments in response to this request.67 NIOSH expressed support for this information gathering process, and provided data, information, and recommendations from NIOSH fire fighter fatality investigations and research. NIOSH suggested that OSHA consider regulating all types of emergency incidents, both common and rare events, and that OSHA consider the full continuum of emergency response activities, from pre-planning for emergency response activities through recovery and post-incident treatment. NIOSH provided information from fire fighter fatality investigations, including large numbers of investigations in which NIOSH recommended that fire departments: comply with NFPA standards for personal protective clothing and equipment,52,53 require the use of Personal Alert Safety Systems,55 require minimum standards for safety and health training, require the use of an Incident Management System to manage emergency events,21 require a designated Safety Officer at emergency events, require the use of thermal imaging cameras at structure fires, require that fire departments have written SOPS and a written safety and health program, and require that RIT teams be established at emergency events before fire fighters enter IDLH environments. NIOSH referenced several NFPA standards in these comments. Compliance with existing federal and state occupational safety and health regulations may not be adequately protecting fire fighters, and is inconsistent with industry “best practices” developed through the NFPA consensus process. In addition to OSHA considering additional regulations to protect fire fighters, state occupational safety and health agencies that cover public employees should similarly consider enhancing the protection of fire fighters through their state regulations. Recommendation #37: Manufacturers, equipment designers, and researchers should continue to develop and refine durable, easy-to-use radio systems to enhance verbal and radio communication in conjunction with properly worn SCBA. Discussion: The use of Personal Protective Equipment (PPE) and an SCBA make it difficult to communicate, with or without a radio.68,69 Faced with the difficult task of communicating while



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wearing a SCBA, fire fighters sometimes momentarily remove their face pieces to transmit a message directly or over a portable radio. Considering the toxic and oxygen-deficient hazards posed by a fire and the resulting products of combustion, removing the SCBA face piece, even briefly, is a dangerous practice that should be prohibited. Even small exposures to carbon monoxide and other toxic agents present during a fire can affect judgment and decision making abilities. To facilitate communication, equipment manufacturers have designed face piece-integrated microphones, intercom systems, throat mikes and bone mikes worn in the ear or on the forehead.69,70 Recent testing of portable radios in simulated fire fighting environments by the National Institute for Standards and Technology (NIST) has identified that radios are vulnerable to exposures to elevated temperatures. Some degradation of radio performance was measured at elevated temperatures ranging from 100OC to 260OC, with the radios returning to normal function after cooling down. Additional research is needed in this area.71 During this incident fire fighters experienced intermittent radio communication problems and interruptions. Audio transcripts of the fireground channel recorded multiple instances where fire fighters inside the structure (including some of the victims) transmitted over the radio, but the transmissions were not heard or could not be understood. Effective radio communication is an important part of safe fireground operations. Recommendation #38: Manufacturers, equipment designers and researchers should conduct research into refining existing and developing new technology to track the movement of fire fighters inside structures.

Discussion: Fire fighter fatalities often are the result of fire fighters becoming lost or disoriented on the fireground. The use of systems for locating lost or disoriented fire fighters could be instrumental in reducing the number of fire fighter deaths on the fireground. The National Institute for Standards and Technology (NIST) has been evaluating the feasibility of real-time fire fighter tracking and locator systems.68,72 Research into refining existing systems and developing new technologies for tracking the movement of fire fighters on the fireground should continue. Recommendation #39: Code setting organizations and municipalities should require the use of sprinkler systems in commercial structures, especially ones having high fuel loads and other unique life-safety hazards, and establish retroactive requirements for the installation of fire sprinkler systems when additions to commercial buildings increase the fire and life safety hazards. Discussion: This recommendation focuses on fire prevention and minimizing the impact of a fire if one does start. The NFPA Fire Protection Handbook states “throughout history there have been building regulations for preventing fire and restricting its spread. Over the years these regulations have evolved into the codes and standards developed by committees concerned with fire protection. The requirements contained in building codes are generally based upon the known properties of materials, the hazards presented by various occupancies, and the lessons learned from previous experiences, such as fire and natural disasters.”73 Although municipalities have adopted specific



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codes and standards for the design and construction of buildings, structures erected prior to the enactment of these building laws may not be compliant. Such new and improved codes can improve the safety of existing structures.73 Sprinkler systems are one example of a safety feature that can be retrofitted into older structures. Sprinkler systems can reduce fire fighter fatalities since such systems can contain and may even extinguish fires prior to the arrival of the fire department. In this incident, this structure incorporated mixed-used construction types and was non-sprinklered. The original structure was built in the 1960s (17,500 square feet), with additions added in 1994 (6,970 square feet) and 1995 (7,020 square feet). The structure was annexed into the city in 1990. City ordinances required commercial structures over 15,000 square feet to have a sprinkler system. The original structure was grandfathered, and the subsequent additions were treated as separate buildings so the facility was never sprinklered. The additions were treated as separate structures with the end result being that each addition did not meet the threshold at which a sprinkler system would be required. Recommendation #40: Code setting organizations and municipalities should require the use of automatic ventilation systems in commercial structures, especially ones having high fuel loads and other unique life-safety hazards. Discussion: The use of automatic ventilation systems in roofs and enclosed void spaces that would open in the event of a fire and allow smoke, hot fire gases and heat to escape could aid fire fighters by helping control fire spread. Smoke venting through these openings would also give Incident Commanders and fire fighters very useful information related to the fire’s size, location and stage of growth. Many European standards such as the UK legislation requirements of BS7346 part 1 (European National (EN) 12101) & BS 5588 part 5 require automatic roof ventilation systems that automatically open to ensure rapid dispersal of smoke, heat and toxic gases.74

Recommendation #41: Municipalities and local authorities having jurisdiction should coordinate the collection of building information and the sharing of information between building authorities and fire departments. Discussion: Municipalities and local authorities having jurisdiction should develop a questionnaire or checklist to ensure that pre-plan inspections collect the appropriate information. The questionnaire or checklist could focus on building characteristics including the type of construction, materials used, occupancy, fuel load, roof and floor design, and unusual or distinguishing characteristics. Once obtained, this information should be recorded, shared with all departments who provide mutual aid, and if possible, entered into the dispatcher’s computer so that the information is readily available if an incident is reported at the noted address. Municipalities and local authorities having jurisdiction should also include experienced fire personnel throughout any zoning or building code developmental process concerning life safety to the public and fire department members. Typically, pre-incident planning focuses on commercial buildings and the specific hazards they have due to their size, construction, and contents.

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Recommendation #42: Municipalities and local authorities having jurisdiction should consider establishing one central dispatch center to coordinate and communicate activities involving units from multiple jurisdictions. Discussion: An effective radio communication system is a key factor in fire department operations. The communication system, or central dispatch center, is used for receiving notification of emergencies, alerting personnel and fire apparatus, coordinating the activities of the units engaged in emergency incidents, and providing non-emergency communications for the coordinating fire departments. The dispatch system must be able to identify the type and number of units due to respond to the type of incident in advance based on risk criteria and unit capabilities. The central dispatch center should also monitor fireground activity and inform command of time intervals or of possible missed transmissions such as Maydays. A central dispatch center equipped with regional mutual aid channels could serve multiple jurisdictions.38,70 This type of system would provide operational advantages in the communication system, reflect a more functional mutual aid system, and reduce overall costs of operating centers in individual jurisdictions. Having a pre-determined response for apparatus arranged by district, address or by type of incident, makes the job of the Incident Commander and the dispatcher much easier. The pre-determined assignment lists the apparatus slated to respond to the incident and should take into account apparatus that are out of service by filling in for such units with similar units. In this incident, the municipal fire department maintained its own dispatch center in cooperation with the city policy department. The neighboring departments either had their own dispatch centers or were serviced by the county dispatch system. The municipal fire department relied upon the chief officers to request companies as the need was identified, instead of having predetermined response assignments. Recommendation #43: Municipalities and local authorities having jurisdiction should ensure that fire departments responding to mutual aid incidents are equipped with mobile and portable communications equipment that are capable of handling the volume of radio traffic and allow communications among all responding companies within their jurisdiction. Discussion: Units responding to or engaged at incidents should have the necessary radio frequencies/channels to be in contact with other units providing mutual aid. These units should also have the capability to monitor the fireground activities while en-route. 38 During this incident, some mutual aid departments could not communicate with the IC or the municipal dispatch center on either their portable or mobile radios. REFERENCES 1. Routely JG, Chiaramonte M, Crawford B, Piringer P, Roche K, Sendelbach T [2007]. City of

Charleston Post Incident Assessment and Review Team: Phase 1 Report. October 16, 2007. 2. Routely JG, Chiaramonte M, Crawford B, Piringer P, Roche K, Sendelbach T [2008]. City of

Charleston Post Incident Assessment and Review Team: Phase II Report. May 15, 2008.



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Fire Protection Publications, International Fire Service Training Association. 20. Dodson D [2007]. Fire Department Incident Safety Officer. 2nd Edition. New York:

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28. Dunn V [1998]. Risk management and lightweight truss construction. New York: WNYF, Official training publication of the New York City Fire Department, 1st issue.

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night club arson fire – Texas. Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2004–14, p. 6.

34. International Fire Service Training Association (IFSTA)[2002]. Fireground support

operations. 4th Edition. Stillwater, OK: Fire Protection Publications.

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handbook. 1st ed. Quincy, MA: National Fire Protection Association (chapter 3). 37. Dodson, D [2005]. The art of first-due. Fire Engineering. March 2005, pp. 135-141. 38. NFPA [2004]. NFPA 1710 Standard for the Organization and Deployment of Fire

Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments. 2004 Edition. Quincy, MA: National Fire Protection Association.

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Protection Association. 40. NFPA [2003]. NFPA 1620: Recommended practice for pre-incident planning. Quincy, MA:

National Fire Protection Association.



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41. Brunacini A, Brunacini N [2004]. Command Safety: The IC’s role in protecting firefighters.

Peoria, AZ: Across the Street Productions, Inc. 42. National Incident Management System Consortium [2007]. Incident Command System (ICS)

Model Procedures Guide for Incidents Involving Structure Fire Fighting, High-Rise, Multi-Casualty, Highway, and Managing Large-Scale Incidents Using NIMS-ICS. First Edition. Oklahoma State University. Fire Protection Publications.

43. IFSTA [1999]. Pumping Apparatus Driver/Operator Handbook. 1st ed. Fire Protection Publications. International Fire Service Training Association.

44. IFSTA [2004]. Fire Hose Practices. 8th ed. Stillwater, OK: Fire Protection Publications,

Oklahoma State University. International Fire Service Training Association. 45. Carter W, Childress D, Coleman R, et al. [2000]. Firefighter’s Handbook: Essentials of

firefighting and emergency response. Albany, NY: Delmar Thompson Learning. 46. Hoffman, JJ [2002]. MAYDAY-MAYDAY-MAYDAY. Fire Department Safety Officers

Association Health and Safety for Fire and Emergency Service Personnel 13(4):8. 47. Angulo RA, Clark BA, Auch S [2004]. You called Mayday! Now what? Fire Engineering,

Sept 2004, Vol. 157, No. 9, pp. 93-95. 48. DiBernardo JP [2003]. A missing firefighter: Give the Mayday. Firehouse, Nov 2003, pp. 68-

70. 49. Sendelbach TE [2004]. Managing the fireground Mayday: The critical link to firefighter

survival. http://cms.firehouse.com/content/article/article.jsp?sectionId=10&id=10287. Date accessed: October 29, 2008.

50. Miles J, Tobin J [2004]. Training notebook: Mayday and urgent messages. Fire Engineering,

April 2004, Vol. 157, No. 4, pp. 22. 51. NFPA [2008]. NFPA 1002 Standard for Fire Apparatus Driver/Operator Professional

Qualifications. 2009 ed. Quincy, MA: National Fire Protection Association. 52. NFPA [2008]. NFPA 1851 Standard on Selection, Care, and Maintenance of Structural Fire

Fighting Protective Ensembles. Quincy, MA: National Fire Protection Association. 53. NFPA [2007]. NFPA 1971 Standard on Protective Ensembles for Structural Fire Fighting and

Proximity Fire Fighting, 2007 Edition. Quincy, MA: National Fire Protection Association.



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54. NFPA [2007]. NFPA 1981 Standard on Open-Circuit Self-Contained Breathing Apparatus for Fire and Emergency Services, 2007 Edition . Quincy, MA: National Fire Protection Association.

55. NFPA [2007]. NFPA 1982 Standard on Personal Alert Safety Systems (PASS), 2007 Edition.

Quincy, MA: National Fire Protection Association. 56. NIOSH [2001]. Supermarket Fire Claims the Life of One Career Fire Fighter and Critically

Injures Another Career Fire Fighter – Arizona. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Fatality Assessment and Control Evaluation (FACE) Report F2001-13.

57. NFPA [2006]. NFPA 1404 Standard for Fire Service Respiratory Protection Training.

Quincy, MA: National Fire Protection Association. 58. Bernocco S, Gagliano M, Phippips C, and Jose P. [2008]. Is your department complying with

the NFPA 1404 air management policy? Fire Engineering. Vol 161, No 2. February. Pp 103-108.

59. Peterson JA and Merinar TR [1997]. Respirator Maintenance Program Recommendations for

the Fire Service. Journal of the International Society for Respiratory Protection. Vol 15, Issues III & IV. Fall/Winter 1997.

60. Corbin DE [2000]. Seeing is believing. Dallas, TX: Occupational Safety and Health, Aug

69(8): 60-67. 61. NIOSH [2005]. NIOSH alert: preventing injuries and deaths of fire fighters due to truss

system failures. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2005-132.

62. Dunn V [2001]. The deadly lightweight truss. Firehouse. Jan:16-20. 63. Brannigan FL [1999]. Building construction for the fire service. 3rd ed. Quincy, MA: National

Fire Protection Association, pp. 517-563. 64. USFA [2008]. Emergency Incident Rehabilitation Manual for Firefighters and Other

Emergency Responders. U.S. Department of Homeland Security, U.S. Fire Administration. February 2008.

65. USFA [2008]. Press Release: USFA Releases New Emergency Incident Rehabilitation

Manual for Firefighters and Other Emergency Responders



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http://www.usfa.dhs.gov/media/press/2008releases/031208.shtm. Date accessed: October 29, 2008.

66. 72 Fed Reg 51735 [2007]. Emergency Response and Preparedness. Occupational Safety and

Health Administration, Request for Information. Federal Register: September 11, 2007. Volume 72, Number 175. Page 51735-51743.

67. NIOSH [2007]. Comments of the National Institute for Occupational Safety and Health on the

Occupational Safety and Health Administration Request for Information: Emergency Response and Preparedness, Docket No. H-010. November 26, 2007. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, Ohio.

68. NIST [2007]. Advanced fire service technologies program. Proceedings of the 2007 NIST

Annual Fire Conference. National Institute of Standards and Technology, Building and Fire Research Laboratory. Gaithersburg, MD.

69. USFA/FEMA [1999]. Improving firefighter communications. USFA-TR-099. Emmitsburg.

MD: United States Fire Administration. 70. TriData Corporation [2003]. Current status, knowledge gaps, and research needs pertaining to

fire fighter radio communication systems. Report prepared for NIOSH. Arlington, VA: TriData Corporation.

71. Davis WD, Donnelly MK, and Selepak MJ [2006]. Testing of portable radios in a fire

fighting environment. NIST Technical Note 1477. National Institute of Standards and Technology. Gaithersburg, MD. Building and Fire Research Laboratory.

72. NIST [2008]. Wireless Sensor Research at NIST. National Institute of Standards and

Technology, Building and Fire Research Laboratory. Gaithersburg, MD http://www.bfrl.nist.gov/WirelessSensor/. Date accessed October 29, 2008.

73. NFPA [1997]. Fire Protection Handbook, 18th ed. Quincy, MA: National Fire Protection

Association. 1-42. 74. BSRIA [2008]. New European standard for smoke extraction fans. Press Release.

http://www.bsria.co.uk/services/testing/standard-testing/fans Building Services Research and Information Association of Great Britain. Date accessed: October 29 2008.

INVESTIGATOR INFORMATION This investigation was conducted by Timothy Merinar, Safety Engineer, Matt Bowyer, General Engineer, Jay Tarley, Safety and Occupational Health Specialist, and J. Scott Jackson, Occupational



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Nurse Practitioner, with the NIOSH Fire Fighter Fatality Investigation and Prevention Program. Stacy Wertman, Safety and Occupational Health Specialist, NIOSH, Division of Safety Research, provided technical support. This report was authored by Timothy Merinar. Jeffrey O. Stull, President, International Personnel Protection, Inc., conducted a forensic evaluation of the personal protective equipment (PPE), protective clothing and station uniforms worn by the victims. Expert technical reviews were provided by Chief Alan Brunacini (retired), Phoenix Fire Department; I. David Daniels, Fire Chief / Emergency Services Administrator, Renton Washington; Assistant Chief Vincent Dunn (retired), Fire Department of New York; Battalion Chief John Salka, Fire Department of New York and President of Fire Command Training; Gordon Routley, fire service consultant and FRT Project Leader; Kevin Roche, Phoenix Fire Department and FRT member; Nelson Bryner, National Institute of Standards and Technology (NIST), and Ken Farmer, U.S. Fire Administration (USFA). Special thanks to Nelson Bryner, Paul Fuss, and Glenn Forney of NIST for their assistance during this investigation and to Lee Baughman, South Carolina OSHA, for his assistance at the site. The investigators would also like to thank the fire department, the International Association of Fire Fighters local union, local mutual aid departments, the county coroner, the city Director, Safety Management Division, and the city police department for their assistance during this investigation. Finally, a very special “thank you” to all the fire fighters who provided valuable information during this investigation.



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Photo 1. Time approximately 1924 hours. Fire is visible over showroom roof. Smoke is dark gray in color and becoming turbulent. The flames may not have been visible from front parking lot or close to

the building on the D-side. (Photo courtesy of Dan Folk.)



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Photo 2. Time approximately 1930 hours. Note how smoke has changed to dark black color indicating it

is rich with products of incomplete combustion. Note Ladder 5 and Engine 11 in front of structure as well as fire department vehicle in lower left corner. The top of Engine 10 is just visible over the fence at

the lower right. (Photo courtesy of Associated Press, Alexander Fox photographer.)



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Photo 3. Time approximately 1934 hours. Note lack of any fire personnel in front of structure. At this point, the E-11, L-5, E-16, E-15, E-19, and E-6 crews are inside the showroom. Also note how the color

of smoke column appears different from previous photo which may be due to the angle of the photograph and position of the sun. (Photo courtesy of Police Department, Bill Murton, photographer.)



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Photo 4. Last surviving members of the initial attack crews exit showroom at approximately 1935 hours.

(Photo courtesy of Police Department, Bill Murton, photographer.)



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Photo 5. Time approximately 1935 hours. Mutual aid fire fighter breaking showroom front window. Photo taken just prior to mutual aid department making rescue attempt in front showroom. Note the heavy tar

stains on the windows indicating the smoke inside the showroom is rich with flammable products of incomplete combustion. (Photo courtesy of Police Department, Bill Murton, photographer.)



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Photo 6. Time approximately 1936 hours. Note turbulent dark gray smoke rolling out of the showroom as the front windows are being knocked out. Mutual aid crew is assembling for search and rescue attempt.

(Photo courtesy of Associated Press, Alexander Fox, photographer.)



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Photo 7. Time approximately 1938 hours. Photo shows conditions at front of showroom just before the

interior search and rescue attempts were halted due to the interior conditions. (Photo courtesy of the Charleston Post and Courier.)



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Photo 8. Time approximately 1938 hours. Photo taken less than a minute after rescue crews are forced out

of the showroom by the interior conditions. Note fire rolling out the showroom windows. (Photo courtesy of the Charleston Post and Courier.)



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Photo 9. Storage racks in warehouse post fire. Storage racks were filled with various furniture and mattress items. Note the extent to which the storage racks filled the warehouse which gives an

indication of the volume of merchandise and the fuel load inside the 15,600 square foot warehouse. The warehouse measured approximately 130 ft. by 120 ft. and was 29 ft from floor to roof. (Photo – NIOSH.)



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Photo 10. Time approximately 1942 hours. Engine 10 and Engine 12 crews battle fire in warehouse from outside. (Photo courtesy of police department, Bill Murton, photographer.)



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Photo 11. Time approximately 1925 hours. Note traffic on major highway in front of incident site driving over 2 ½ inch supply line. The hose line runs from Engine 12 (to left of photo) to Engine 10 (to right of photo. Photo shows mutual aid crew members arriving on scene. (Photo courtesy of Dan Folk.)



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Diagram 1. Floor plan of furniture store and warehouse



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Diagram 2. Location of Engine 10 and Engine 11, supply lines and hose lines pulled at different

times during the incident. Note accumulation of trash at loading dock on the day photo was taken, 3 months prior to the incident. Note the absence of ventilation ductworks or other roof

penetrations over the showroom, thus no path for smoke and hot gases to escape. From aerial photo taken in March 2007

(copyright Pictometry International – used with permission of Pictometry)



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Diagram 3: Note location where mutual aid crew cut through exterior wall to extricate male employee trapped inside the warehouse. From aerial photo taken in 2007.

(copyright Pictometry International – used with permission of Pictometry).



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Diagram 4. Approximate Location of 9 Victims



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Appendix I

Recruit Class Schedule



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Appendix II

Engine 11 Inspection Report Dated

December 16, 2008.

The fire department reported that no change had been made to Engine 11 since the day of the fire.



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Appendix III

Pre-plan Inspection Form

Pre-plan inspection form for the incident location. Note that names, addresses, phone numbers and other identifiers have been removed. Page 1 of 2.



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Pre-plan inspection form, page 2 of 2.



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Appendix IV

PPE Evaluation Report

For a copy of the complete PPE Evaluation Report, contact NIOSH Fire Fighter Fatality Investigation and Prevention Program

304-285-5916



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Appendix V

Additional Photos

Photo A-1. Time is approximately 1923 hours. Fire is visible over showroom roof. Smoke is dark gray in color and becoming turbulent. The flames may not have been visible from front parking lot or close

to the building on the D-side. (Photo courtesy of Dan Folk.)



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Photo A-2. Time is approximately 1936 hours. Loading dock area approximately 20 minutes after first

crews arrived on scene. Note heat damage to metal siding on loading dock and warehouse. (Photo courtesy of Police Department, Bill Murton, photographer.)



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Photo A-3. Time approximately 1939 hours. Fire fighters near front entrance to showroom. Note lack

of water pressure on the red booster line and the 2 ½” hand line. Also note lack of gloves and hood. (Photo courtesy of the Charleston Post and Courier.)



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Photo A-4: Time approximately 1951 hours. Front façade beginning to collapse. (Photo courtesy of the Charleston Post and Courier.)

.

FIREFIGHTER FATALITY INVESTIGATIVE REPORT

Sofa Super Store 1807 Savannah Highway Charleston, South Carolina June 18, 2007 City of Charleston Post Incident Assessment and Review Team Phase II Report

.

This report was prepared by the City of Charleston Post Incident Assessment and Review Team and represents a consensus view of the team. J. Gordon Routley, Project Leader Michael D. Chiaramonte Brian A. Crawford Peter A. Piringer Kevin M. Roche Timothy E. Sendelbach May 15, 2008

SOFA SUPER STORE FIREFIGHTER FATALITY INVESTIGATION REPORT

Page 1

Table of Contents Introduction .........................................................................................................6 Dedication ..........................................................................................................8

Bradford Rodney "Brad" Baity – Engineer 19 ...........................................8 Theodore Michael Benke – Captain 16 ......................................................9 Melvin Edward Champaign – Firefighter 16.............................................10 James "Earl" Allen Drayton – Firefighter 19............................................11 Michael Jonathon Alan French – Engineer 5...........................................12 William H. "Billy" Hutchinson, III – Captain 19 ........................................13 Mark Wesley Kelsey – Captain 5 ..............................................................14 Louis Mark Mulkey – Captain 15...............................................................15 Brandon Kenyon Thompson – Firefighter 5 ............................................16

Acknowledgements ..........................................................................................19 Sofa Super Store...............................................................................................25 Building Information .........................................................................................25

Building Description..................................................................................26 Building Permits ........................................................................................29 Fill-in Additions..........................................................................................31 Lack of Effective Fire Separations ...........................................................33 Exits ............................................................................................................34 Building Contents ......................................................................................36 Inspection History .....................................................................................37 Summary of Fire Code and Building Code Compliance Issues.............38 Significant Building Construction Details ...............................................39 Void Spaces above Ceilings .....................................................................39 Holding Room ............................................................................................40 Façade and Parapet ...................................................................................41 Roof Coverings ..........................................................................................42 Limited Access and Ventilation Openings ..............................................43 Site Arrangement .......................................................................................43 Public Water Supply and Hydrants ..........................................................44

Charleston Fire Department.............................................................................46

The Charleston Fire Department ..............................................................47 Mutual Aid ..................................................................................................49 Units by order of arrival: ...........................................................................51


Page 2

Incident Chronology .........................................................................................52 Fire Discovery ............................................................................................53 Initial Response .........................................................................................54

PHASE ONE OPERATIONS - 19:11 TO 19:18 ........................................................55

Offensive Strategy .....................................................................................55 Engine 10....................................................................................................56 Engine 11....................................................................................................56 Ladder 5......................................................................................................56 Engine 16....................................................................................................61 Engine 12....................................................................................................61 Fire Chief ....................................................................................................61 Engine 15....................................................................................................62

PHASE TWO OPERATIONS - 19:19 TO 19:25 .......................................................62

Engine 15....................................................................................................64 Engine 19....................................................................................................64 Engine 6......................................................................................................64 Operations inside the Showrooms...........................................................65 Fire Extension into Warehouse ................................................................66

PHASE THREE OPERATIONS - 19:26 TO 19:37.....................................................68

Trapped Employee Reported ....................................................................68 Firefighters in Distress..............................................................................70 Reaction to Firefighters in Distress .........................................................74 Rescue Attempt .........................................................................................76

PHASE FOUR OPERATIONS – AFTER 19:38 ........................................................77

Defensive Strategy ....................................................................................77 Missing Firefighters...................................................................................79 Recovery Operations.................................................................................80 Locations of Deceased Firefighters .........................................................81


Page 3

ANALYSIS..........................................................................................................83 Fire Analysis ..................................................................................................84

Fire Origin...................................................................................................84 Fire Extension ............................................................................................85 Conditions inside the Main Showroom....................................................86 Conditions inside the West Showroom ...................................................88 Interior Hose Lines ....................................................................................91 Path of Fire through the Showrooms.......................................................91 Fire Extension to Warehouse ...................................................................93

Analysis of Fire Department Operations ........................................................94

Incident Management....................................................................................95

Incident Commander .................................................................................95 Strategy ......................................................................................................97 Risk Management ......................................................................................99 Fire Fighting Tactics................................................................................102 Situational Awareness ............................................................................104 Pre-fire Plan..............................................................................................106 Communications......................................................................................111 Tactical Communications .......................................................................113 Mayday Communications........................................................................113

FIREFIGHTER SAFETY ...............................................................................117

Safety Officer ...........................................................................................117 Respiratory Protection ............................................................................117 Air Management Program .......................................................................120 Rapid Intervention Team .........................................................................121 Accountability and Crew Integrity ..........................................................122

TACTICAL OPERATIONS............................................................................124

Water Supply............................................................................................124 Lack of Coordination ...............................................................................125 Supply Lines ............................................................................................126 Delay in Charging Lines ..........................................................................128 Lack of Truck Work .................................................................................129 Inadequate Company Staffing and Initial Response ............................130 Traffic Control ..........................................................................................130 Protective Clothing and Equipment .......................................................130


Page 4

CONCLUSIONS, LESSONS, AND RECOMMENDATIONS ............................132 KEY FACTORS IDENTIFIED IN THE ANALYSIS ........................................133

Building and Property .............................................................................133 Fire Department Operations ...................................................................134

Lessons and Recommendations ...............................................................136

Incident Management ..............................................................................137 Risk Management ....................................................................................138 Strategy and Tactics................................................................................138 Firefighter Safety .....................................................................................139 Self-Contained Breathing Apparatus .....................................................140 Radio Communications...........................................................................140 Training ....................................................................................................141 Fire Department Resources ....................................................................141 Advancing Technology ...........................................................................142 Pre-fire Planning ......................................................................................143 Code Enforcement and Risk Mitigation .................................................143 Coordination and Liaison........................................................................144

Team Biographies...........................................................................................145

Appendix A: Firefighter Listing…………..………………………………..... A-1 Appendix B: Radio Transcript Log……..…………………………………... B-1 Appendix C: Unit Summaries………………………………………………... C-1 Appendix D: Detailed Timeline………………………………………………. D-1 Appendix E: Communications Summary……..…………………………… E-1 Appendix F: Hydraulic Calculations……………..…………………………. F-1 Appendix G: Building and Code Enforcement Information…………..... G-1


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Page 6

Introduction This analysis of the Sofa Super Store incident was produced by the City of Charleston Post Incident Assessment and Enhancement Review Team. The Review Team has conducted a comprehensive analysis of the incident and examined a wide range of factors that could have contributed to the tragic loss of nine members of the Charleston Fire Department. The ultimate objective of this analysis is to identify the lessons that may be learned from this incident, with the goal of reducing the risk of future occurrences of a similar nature. This report and the resulting lessons and recommendations are specifically directed to the City of Charleston and to the Charleston Fire Department and its members. The incident analysis is equally intended to provide important information for the families and survivors of the nine deceased firefighters. The report is also intended to provide valuable information to a much larger audience of firefighters, public officials and other interested parties to help them understand the factors that contributed to the tragedy that occurred in Charleston and the lessons that should be taken from it. The analysis is directed toward developing the most thorough understanding that is possible of the events that occurred on June 18, 2007 and the factors that contributed to those events. The Review Team assembled and analyzed a mass of information from numerous sources, including interviews, written statements and notes, hundreds of photographs, video images, audio recordings, files, records, reference sources and personal observations. During this process information was obtained from and shared with several other agencies that are involved in examining the incident from different perspectives and for different purposes, including the National Institute for Occupational Safety and Health (NIOSH), the National Institute of Standards and Technology (NIST), the Charleston County Coroner, the Charleston Police and Fire Departments, and the Bureau of Alcohol, Tobacco and Firearms (ATF). It will never be possible to determine every factor relating to this incident with absolute certainty. The deceased firefighters were the only witnesses who could have described or explained some of the events that occurred inside the Sofa Super Store. In some cases witnesses had difficulty remembering specific points or provided information that appeared to be inconsistent with information obtained from other sources. There was no indication that anyone attempted to provide inaccurate or incomplete information; the investigators accepted the information that was provided as the best recollections and interpretations of each witness, considering the stressful circumstances and emotional impact of the incident. The investigators carefully and conscientiously attempted to interpret all of the information that could be assembled to produce a factual expert analysis of the


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incident and avoided drawing conclusions from information that could not be validated with a reasonable degree of confidence. Where appropriate, the uncertainty of specific information is noted in the report. The development of a consistent timeline for the incident was one of the challenges that had to be addressed by the investigators. Several different information sources included time references, including the computer-aided dispatch records, audio recordings of radio traffic, the radio system controller (System Watch), and the digital time stamp that is imbedded in the file with most digital photo and video images. The time recorded by each system or device depended on the setting of an internal clock and significant discrepancies were noted among the different sources when the data was compared. The times obtained from all of these different sources had to be synchronized by determining the “correct time” and applying an adjustment factor to each source. The encoded camera time for images taken by Charleston Police Department Photographer Bill Murton was established as the “correct time”. Events photographed by Mr. Murton were then compared with events photographed by other photographers and a correction factor was established for each camera or recording device. The dispatch recording clock was determined to be two minutes and two seconds slow and the Systemwatch clock was two minutes and two seconds fast. All time references in this report have been adjusted to the same time base, which is believed to be accurate within 10 seconds. The final compilation of corrected times uses a 24-hour clock and reports times as HH:MM:SS or as HH:MM where the seconds were not available. This report is the second phase of a three-phase project undertaken by the Review Team. The first phase, which was conducted before the incident analysis began, produced approximately 200 recommendations for changes and improvements in the Charleston Fire Department. Many of those recommendations have been partially or fully implemented since the Phase I report was issued and many of the lessons that are incorporated in this report lead to the same or very similar recommendations.


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Dedication – This report is dedicated to the nine Charleston firefighters that lost their lives on June 18, 2007, to their families and friends, to the surviving members of the Charleston Fire Department, and to the Charleston community. May the lessons learned from a truthful and complete analysis of this incident prevent future tragedies.

Bradford Rodney "Brad" Baity – Engineer 19

Engineer Bradford “Brad” Baity’s home town is Mocksville, NC. How he'll be remembered: As a soft-spoken man with a dry sense of humor who was quick to help others, friends and strangers alike. Brad Baity was an engineer at Station 16, a soft-spoken and smart man who sometimes impressed his buddies with his computer skills. Baity, 37, had been with the department for nine years, driving Engine 19 for Captain William "Billy" Hutchison. "He was always seeking knowledge, trying to learn new things," said Derek Noffsinger, one of his colleagues at the station. Sometimes, Baity could be found pecking on his laptop computer, doing virtual tours of faraway countries. "He would talk about how he had just visited the historic sites in Greece and Rome," Noffsinger said. Baity wasn't one to bend your ear. Amid the bustle and bravado of a typical fire station, he spoke in a soft voice. He was an aggressive firefighter. "It didn't make a difference to Brad Baity. Whatever the task was, he did it. "Like many firefighters, Baity had a second job. For the last three years, he had worked as a stagehand at the Gaillard Municipal Auditorium, the North Charleston Coliseum and other venues around the area, said Mike Coffey, a member of IATSE Local 333, a union that represents stagehands and technicians. "Brad was new, but he was always watching and learning," said Coffey, a retired Charleston firefighter himself with more than three decades of service. Sometimes, he and Baity and another firefighter/stagehand, James "Earl" Drayton, would get together and talk shop. "You get firemen together anywhere, and you're going to start telling stories," Coffey said. "That's the way firemen are." Drayton also died in Monday's fire. Baity lived in a quiet neighborhood off the bustle of S.C. Highway 61, where he leaves behind his wife, Heather, a daughter, Mariah, and a son, Noah.


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Theodore Michael Benke – Captain 16

Captain Mike Benke, age 49, was a 29 year veteran of the fire service. How he'll be remembered: Benke was a big fan of the Pittsburgh Steelers. He also liked to take his son fishing, he was a soccer coach, and his nickname around the firehouse was "Cappy." Captain Mike Benke was known to his fellow firefighters at Station 16 as a family man and NASCAR fan. He enjoyed laughing but was serious about his job, Captain Gary Taylor said. "You're kind of numb about these kinds of things. You're at a loss for words. It's devastating," Taylor said. Benke, 49, is survived by his wife, Kim, his daughter, Holly Gildea, 30, daughter, Taylor, 14, his son, Hunter, 10, and grandchildren, Kayla Cofield and Chris Cofield, Jr., Captain Taylor said. They live in Springfield subdivision. Benke always took his son fishing, Taylor said. Taylor, who also lives in Springfield, said he saw the Benkes often around the neighborhood. Benke was a soccer coach, and his kids were active in sports. "He's a good fellow. Mike's good people. Good family man," Taylor said. He said Benke, a Charleston native, was a happy person who was always laughing and cutting up. He never saw Benke angry about anything. "He would do anything for anybody," Taylor said. Like many firefighters, Benke, a 29-year-veteran of the department, worked part time. He did inventory for Sears, Taylor said. Engineer Derek Noffsinger recalled Benke as an ambitious, organized person who was a role model for him. Benke had a map book of city streets that included family and career photos. He rode with the book on calls. The inside of his locker was covered with family photos, Noffsinger said. "He was a good guy, a great guy. All of them were," Noffsinger said. Benke had relatives who were Charleston firefighters a generation ago. He was recognized as a person who knew his job, never complained and was soft-spoken. He was a leader who gave off a quiet confidence. Sullivan's Island Town Manager Andy Benke, a first cousin to Benke, recalled him as a dedicated family man. "He was a devoted husband and father and took his responsibility to his family very seriously," Benke said.


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Melvin Edward Champaign – Firefighter 16

Firefighter Melvin Champaign was 46 years old. He was an Army veteran, aspiring pastor, and Tae Kwan Do black belt. Melvin Champaign joined the Charleston Fire Department two years ago. Before that, a varied career had taken the 46-year-old to the West Coast and back. He leaves behind a teenage daughter and two younger boys in Washington State. Family from his native James Island spoke of him with glowing admiration. "He was a man in a million," said his older sister, Gardenia Champaign-Moore. "You had to meet him to believe what this man is made out of." Champaign worked out of Station 16 on Ashley Hall Plantation Road, as did five of the other nine firefighters who died. Colleagues recognized his fashion sense when he showed up for the first week of fire class wearing a leather hat with a feather in it. They also noted a penchant for jokingly quoting Bible verse to get through a situation. He wanted to become a pastor. And he once heard saying, "I just want to help people." Relatives Mary and Mikell Fludd raised him on James Island. He went to Fort Johnson High School, where he wrestled and played baseball. Afterward, he joined the Army and resettled in Tacoma, Washington, near Fort Lewis. He served in the infantry but hurt his back several years ago in an accident involving a military truck. He later worked as a welder. As a firefighter, he was among the crews who responded to a fatal December 22, 2005, blaze at the Indigo Creek Apartments that killed two young siblings and uprooted six families. Assistant Engineer Sean Rivers, 30, also remembered lighter times at the fire station, full of card games and pranks. Champaign continuously worked with youth. His nephew, Tony Moore, remembered him almost like an older bother. "No matter what the circumstances were, he always had a smile," he said. "We thank him for making us all feel better."


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James "Earl" Allen Drayton – Firefighter 19

Firefighter James "Earl" Allen Drayton, 56, was the oldest of the nine firefighters who died at the Sofa Super Store. A 32-year veteran of the Charleston Fire Department, he was known by generations of city firefighters. They called him "old school" around Station 19 in West Ashley. He is survived by his wife Kimberly, five children, three stepchildren, and several grandchildren. Kimberly Drayton said she last saw her husband the day of the fire as he left for work from their Sangaree home near Summerville. The couple had planned to leave for a cruise to Puerto Rico that weekend. "He was all packed," she said. "He was so excited." Drayton exuded a quiet confidence. His rhythmic walk and talk earned him the nickname "Cool Earl," said his older brother, Herbert Drayton. "I never really heard him raise his voice." One of eight children, he was born on Charleston's West Side and his family moved to Amherst Street on the city's East Side when he was a child. After graduating from C.A. Brown High School, he enlisted in the Marine Corps and served eight years on active duty. He had a reputation for dressing to the nines and meticulously washing his black Chrysler. He was selected several times to drive Mayor Joe Riley in the city's Christmas Parade. He was on his third retirement with the department, his wife said. "They kept asking him back. He was going to give it two more years." Drayton also worked as a stagehand. He painted scenes and built sets for countless local performances. He also wore the battle scars of a seasoned firefighter. He was knocked unconscious by an electrical shock while battling a blaze in 1999. His family says he was once trapped in another fire.


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Michael Jonathon Alan French – Engineer 5

Assistant Engineer Michael French was 27 years old. He was an Assistant Engineer with 1.5 years service with the Charleston Fire Department. Michael "Frenchie" French was among the youngest firefighters who lost their lives at the Sofa Super Store, but whatever he lacked in experience, he more than made up for in enthusiasm for the job. French, 27, of Eadyville began volunteering with the Pine Ridge Rural Fire Department outside Summerville and developed a reputation as someone who always could be relied upon to show up when the department's alarm tones sounded. He previously worked for the Saint Andrews Fire Department, but he wanted to jump to the city. Charleston firefighter Tim Black got to know French well in January 2006, when the two trained together for a city job. Black said his friend talked a lot about his 5-year-old daughter. As for his other interests, Black said, "He always liked to go out boating and just hanging with the guys." In his short time with the city, French rose to the position of assistant engineer — a relatively quick move. Engineer Derek Noffsinger of Station 16 said French was a quiet sort who only opened up after you got to know him. "He was ready to go places in the fire department," Noffsinger said of French. "He took his job seriously." Black said French was the kind of person willing to fill in on a shift at the last minute. Jonathan Ryan, a Pine Ridge volunteer and Mount Pleasant firefighter, said French had two passions: "He loved the fire department and he loved his daughter," he said, adding that French recently moved in with his cousin to spend more time with her. Black said that upon getting the job with the Charleston Fire Department he and French worked together to help get through the physical agility and stress test — the most challenging part of that training. "He was a real go-getter," Black said. "He wouldn't let you quit. He wouldn't let you slow down. He wouldn't let you give up."


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William H. "Billy" Hutchinson, III – Captain 19

Captain Billy Hutchinson was 48 years old. He was a Captain with 30 years service. To friends, Fire Captain William "Billy" Hutchinson was a good-natured man and a sports enthusiast who at age 48 still loved to play golf and shoot hoops. But to fellow firefighters, he was the go-to guy for haircuts. At $2 a pop, it was a skill carried over from his second job at Williams Barber Shop in Goose Creek. He was known as an all-around, super-nice guy, and a super firefighter. Hutchinson worked out of fire stations in downtown and West Ashley, most recently at Station 19 on Ashley Hall Plantation Road. "He never had a harsh word to say about anybody, and you couldn't argue with the guy because he'd agree with you. He was a (practical) joker, like most firefighters tend to be," noted a co-worker. "His nickname was 'Lightning,' because he didn't move fast unless there was a fire. We gave him that nickname when he first came on the job here," a friend said. Hutchinson played football and baseball for Middleton High School in the mid-1970s, and basketball for the church league and fire department teams. "We were good," insists Hutchinson's brother, Randy Hutchinson, a former firefighter himself, who played on sports teams with Billy. Randy last saw his brother a few weekends before the fire, when they went jet-skiing. He said Billy was married to Phyllis Hutchinson and had three children, including twin daughters.


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Mark Wesley Kelsey – Captain 5

Engineer Mark Kelsey was 40 years old. He was an Engineer with 12.5 years service. Mark Kelsey had a loud voice described as the hardest thing in the Ashley River Fire Department station. He was a gruff retired Navy veteran who told it like it is. He'd come into the station, set his walkie-talkie into the community room charger and ask who hadn't made his pot of coffee. And the coffee better be made with one large scoop, no more. "He was a very aggressive person, kept you straight," said Ashley River Captain Wayne Sammons. It was a gruff front of a kind man who took rookies under his wing and drilled them until they had it down. He left the firefighters at Ashley River with their voices choking as they talked about him. Kelsey, 40, was an engineer and a 12 1/2-year veteran with the city of Charleston Fire Department. He was serving as an acting captain as the trucks drove to the Sofa Super Store blaze just down Savannah Highway from their Station 10. He was a captain working part time with the Ashley River Fire District, joining 15 1/2 years ago when the Charleston Naval Base closed. Born in Indiana, he had come to Charleston with the Navy and never left. He had a teenage son. His passion was his custom motorcycle. He rode the chopper rain or shine. Short and stocky, he kept his blond hair cut short and didn't like to dress up in suit and tie for the station Christmas party. He lived to fight fires. "If there was a fire, he was there. He always wanted to be the first one in," Sammons said. Kelsey refused an office in the Ashley River station, pointed to the housekeeping supply closet where he kept inventory and said that was his office. "He said an office closes him up, and he didn't want to be closed up," Sammons said. Shortly after the fire, an Ashley River firefighter took Kelsey's son to the Savannah Highway station. The son wanted to see where his dad worked. And at the Ashley River station, Fire Marshal Joe Friend stood in the community room staring at the coffee pot. "I was waiting for that 'pot of coffee.' I was waiting for him to come in," Friend said. "I can't tell you how I'm going to miss him."


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Louis Mark Mulkey – Captain 15

When Captain Louis Mulkey wasn't on duty at Coming Street Station 15, he often was coaching athletes at Summerville High School. Mulkey, 34, lived and breathed Green Wave sports, and firefighters openly joked that the 1991 Summerville graduate should quit fighting fires and succeed football coach John McKissick. Mulkey was a coach for the school's junior varsity football and basketball teams. McKissick said Mulkey would do anything for students. He always checked athletes' report cards and often accompanied students on recruiting trips. "We lost a good guy, a good friend, a good citizen and a good all-around guy," McKissick said. After the fire, Summerville athletes and fellow firefighters surrounded the home of Mulkey's parents, Ann and Mike Mulkey. Captain Jake Jenkins of Station 15 said Mulkey was known for his competitiveness. He wanted to win, but he always looked out for his team. "He was the bravest of the bravest," Jenkins said. Mulkey's mother phoned her son just before he was called to the Sofa Super Store fire. As news came out about the fire, she saw him on television. "Well, he's fine," she said to herself. And that's what she told people who called asking about her son, until an emergency-services chaplain called her to Station 11 in West Ashley. Mulkey had 11 1/2 years of fire fighting experience and once saved a police officer who had collapsed in the line of duty. Mulkey leaves behind his mother and father; his wife, Lauren, of West Ashley, and a brother, Wayne, of Florida. "We never dreamed he would be a firefighter. One day he just took the job. He loves it," Ann Mulkey said, holding a tissue to her eyes. "That was his love."


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Brandon Kenyon Thompson – Firefighter 5

Fire Fighter Brandon Thompson was born in Mobile, Alabama. He was a four year veteran of the Charleston Fire Department, but had about 11 years of fire service experience. How he'll be remembered: Brandon Thompson was always looking for a grant to buy a thermal imaging camera for the Pine Ridge Rural Fire Department in Berkeley County, where he volunteered for 11 years and was a captain. Memorials made to the Pine Ridge department in his name will be used for that purpose. Brandon Thompson, 27, had been a volunteer at the Pine Ridge Rural Fire Department since he was a teenager but had recently told the guys they probably wouldn't see him around the station as much because he was preparing for a fall wedding. Thompson and Rachel Sheridan were to be married October 7th on Folly Beach. They'd already sent out "save the date" cards. Thompson's chief at Pine Ridge, Ben Waring, was to be the best man. Thompson had been a Charleston firefighter for four years. He had started his career in the fire service at the age of 14. "He had an older brother that was in it and he just kinda tagged along. That's what he decided to do with his career," Waring said. Thompson was too young to fight fires, but he could go along with the Pine Ridge crews to watch and learn, roll hoses and fetch tools. Thompson worked for the Summerville Fire Department before he joined Charleston. He broke his leg while off-duty last year, and he was given a job working in the mechanic shop and testing hydrants. Thompson, also a captain with Pine Ridge, usually stopped by the Myers Road station in Summerville two or three times a week, Waring said. The two spoke by phone just before the fire, mostly about how Thompson needed some time off for his wedding preparations. Thompson was already on his shift at Station 10 off Savannah Highway, known to firefighters as the Five and Dime because it's the home of Ladder 5 and Engine 10. Full-time Mount Pleasant firefighter and Pine Ridge volunteer Jonathan Ryan said Thompson was an aggressive firefighter who would have seen the Sofa Super Store fire as "just another day on the job. He had the skin of an alligator. He wasn't scared of anything."


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Acknowledgements The City of Charleston Fire Service Enhancement and Review Team wishes to thank the executive team that oversaw the development of this report:

Mayor Joseph P. Riley, Jr. Fire Chief Russell B. Thomas, Jr. Police Chief Gregory G. Mullen

The City of Charleston Fire Service Enhancement and Review Team wishes to thank the membership of the following organizations:

Charleston Fire Department Charleston Police Department Charleston Department of Public Service, Building Inspections Division Charleston City Employees

James Island Public Service District Mount Pleasant Fire Department North Charleston Fire Department Saint Andrews Fire Department Saint Johns Fire District

Charleston County Coroner’s Office Charleston County Emergency Medical Services

Bureau of Alcohol, Tobacco, and Firearms National Institute of Standards and Technology National Institute for Occupational Safety and Health South Carolina Law Enforcement Division

The radio, print, photo, and television media of Charleston, including WCBD, WCIV, WCSC, and the Charleston Post and Courier.

In addition, a number of individuals provided important input into the research and development process for this document. They are too numerous to be listed here. Every single person that we contacted in association with this review went out of their way to show us every courtesy and provide us with the information that we needed.


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Executive Summary On the evening of June 18, 2007, units from the Charleston Fire Department responded to a fire at the Sofa Super Store, a large retail furniture outlet in the West Ashley district of the city. Within less than 40 minutes, the fire claimed the lives of nine firefighters and changed the lives of countless others. The Sofa Super Store fire is a monumental tragedy that will be remembered and discussed for many years. The City of Charleston Post Fire Incident Analysis and Review Team was appointed by Mayor Joseph P. Riley, Jr. to conduct a detailed analysis of the incident to identify the key factors that directly and indirectly contributed to the loss of nine firefighters. The ultimate goal of this project was to identify the lessons that should be taken from this devastating experience so that every possible effort may be made to prevent future occurrences of a similar nature. There is no intent in this report to establish blame or assign responsibility for the situation that occurred in Charleston on that fateful evening. The analysis is intended to provide a factual report of what happened, why it happened, and the important lessons that can make a difference in the future. The loss of nine lives speaks for itself as to the importance of learning and applying those lessons in the Charleston Fire Department and every fire department and in the City of Charleston and every community. This report examines a wide range of issues related to the Sofa Super Store fire. Some of the key issues include:

The Sofa Super Store was a large property that incorporated a very significant potential for a major fire to occur.

The fire risk factors associated with the Sofa Super Store exceeded the

limits prescribed by the applicable building and fire codes. An automatic sprinkler system should have been installed to reduce the level of fire risk or the buildings should have been divided into manageable fire compartments by a system of fire walls.

♦ If a sprinkler system had been installed, the fire probably would likely have been controlled within the loading dock area.

♦ If effective fire walls had been provided, the fire probably would not have spread beyond the loading dock.

The fire originated in discarded furniture and materials that had been

placed outside the loading dock. The suspected cause of the fire was careless disposal of smoking materials.


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The loading dock had been enclosed by a structure that did not meet building code requirements. The loading dock enclosure failed to stop the exterior fire from spreading to the interior and subsequently contributed to the spread of the fire into the adjoining areas.

The highly flammable characteristics of the materials that were stored in

the loading dock and throughout the premises provided an ample supply of fuel and caused the fire to spread rapidly. The burning contents released copious quantities of heat and toxic smoke.

Significant quantities of flammable and combustible liquids that were

stored in the loading dock likely contributed to the severity and rapid spread of the fire.

The fire had extended to the loading dock when firefighters arrived.

Charleston Fire Department members attempted to fight the fire by initiating an offensive interior attack into the loading dock.

The offensive attack was launched from two directions. One attack line

entered the loading dock from the exterior, while a second line was stretched through the showrooms and into the loading dock.

The offensive attack failed to control the fire. The fire extended into

adjoining areas on three sides of the loading dock.

At least 16 firefighters, who were operating deep inside the showrooms, became enveloped in heavy smoke.

An employee who was trapped in a room at the rear of the building called

9-1-1 to request assistance and was rescued by firefighters.

Conditions inside the showrooms became critical as the fire began to involve this part of the building. Several firefighters became disoriented and were running short of air. Radio messages requesting assistance were not heard.

Seven firefighters managed to find their way out of the showrooms. The

nine deceased firefighters were unable to find their way out as the fire spread rapidly from the rear of the building to the front.

The size and layout of the building, inadequate exits, and the highly

flammable nature of the contents likely contributed to the inability of the lost firefighters to escape from the building.


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Rescue efforts were attempted when the situation inside the showrooms was recognized. In spite of valiant efforts, it was too late to save the missing firefighters before the store became fully involved in flames.

The analysis of operations conducted by the Charleston Fire Department includes the following observations and findings:

Fire fighting operations at the Sofa Super Store did not comply with

Federal occupational safety and health regulations, recommended safety standards, or accepted fire service practices.

The Charleston Fire Department failed to provide adequate direction,

supervision, and coordination over the operations that were conducted.

The documented duties and responsibilities of an Incident Commander were not performed and risk management guidelines were not adequately applied to the situation.

The culture of the Charleston Fire Department promoted aggressive

offensive tactics that exposed firefighters to excessive and avoidable risks and failed to apply basic firefighter safety practices.

Insufficient training, inadequate staffing, obsolete equipment and outdated

tactics all contributed to an ineffective effort to control the fire with offensive tactics during the early stages of the incident.

The Charleston Fire Department continued to apply offensive tactics after

the situation had evolved to a point where risk management guidelines called for defensive strategy.

Factors that should have caused firefighters to be removed from interior

tactical (offensive) positions were not recognized.

There was a lack of accountability for the location and function of firefighters who were operating inside the building.

The Charleston Fire Department did not have appropriate Mayday

procedures to be followed by firefighters in distress, for dispatchers, or for command officers on the scene.

All of the listed factors and many others are analyzed and discussed in detail within the body of this report. This document presents the dedicated and conscientious efforts of the review team to honor the nine fallen firefighters by making every possible effort to learn from their sacrifice.


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Sofa Super Store Building Information


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Building Description The Sofa Super Store on West Savannah Highway was the flagship outlet of a chain that operated three retail furniture stores in the metropolitan Charleston area. The business occupied a complex of interconnected structures that had been constructed in several phases. The showroom building, facing Savannah Highway, was actually an assembly of three separate structures. The front wall was a façade, with a parapet extending above the roof line, creating the appearance of one large building when viewed from Savannah Highway. The front wall, including the parapet, was approximately 23 feet tall, while the roof behind the parapet varied from 12 to 14 feet above grade. The main showroom was originally constructed as a grocery store, probably during the 1950s or 60s. The original building was approximately 125 feet in width and 130 feet deep, with a rectangular extension in the southwest corner (right-rear facing the building from Savannah Highway). The front wall was brick construction with large storefront windows, while the side and rear walls were constructed of concrete block. The original structure had a flat metal deck roof, supported by lightweight steel bar joists (trusses), spanning from east to west across the store. The side walls supported the ends of the bar joists, while two rows of steel beams and columns provided intermediate support. A suspended ceiling was installed below the roof trusses.


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Savannah Highway

Pebble Road

Original Building

125' X 130'

EXITEXIT

Figure 1: The original grocery store building was constructed in the 1950s or 1960s and annexed into the City of Charleston in 1990.

After the property was converted to a furniture store, two pre-engineered metal buildings were added-on to the original structure to expand the showroom area. Each showroom addition was approximately 60 feet in width and 120 feet deep. The first showroom addition was constructed on the west side of the original


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building in 1994 and the second was added on the east side in 1995. (The add-on structures are referred to as the east and west showrooms in this report, while the original structure is identified as the main showroom.) Six large openings in the concrete block side walls, three on each side of the original building, provided connections between the showroom areas; their combined floor area was in excess of 31,000 square feet. An additional pre-engineered metal structure was erected at the rear of the property in 1996 to serve as a warehouse. This structure was approximately 120 feet wide by 130 feet deep and 29 feet tall. Furniture was stored on steel racks, 20 feet in height, inside the warehouse. An enclosed sheet metal corridor, approximately 20 feet in length, connected the warehouse to the rear of the original building.

Photo 1: Aerial view of the north side of the Sofa Super Store. (Photo courtesy of Pictometry, International)


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Building Permits City of Charleston records indicate that the original structure was the only building on the site when the property was annexed into the city in 1990. Building permits were issued for the construction of the three pre-engineered structures in 1993, 1995 and 1996. The building permit files indicate that the original building and the three additions were considered as four separate structures for building code purposes. The concrete block side walls of the original structure were designated as fire walls and roll-down fire doors were installed in the six large (8’ X 8’) openings that connected the showrooms. A seventh roll-down fire door was installed at the point where the corridor leading to the warehouse was connected to the rear wall of the original building. All of the fire doors had fusible link release mechanisms. The division of the property into four separate structures allowed the additions to be constructed without automatic sprinklers. The floor area of each individual building was below the threshold that would have required automatic sprinklers to be installed. Two building code variances were obtained when the warehouse was constructed. The variances allowed the property owner to omit fire resistance requirements for the north and west walls of the warehouse. The variances were based on physical separation distances from adjacent structures and distances from property lines, as well as an interpretation of the “fire district” definition in the Building Code.


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Savannah Highway

Pebble Road

Original Building

125' X 130'

West Showroom

Addition (1994)

60' X 120'

East Showroom

Addition (1995)

60' X 120'

Warehouse

(1996)

120' X 130'

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

EXIT

EXIT

EXIT

EXIT

EXIT

EXIT

EXIT

EXIT

Figure 2: Site plan indicating 4 permitted structures as of 1996. Roll-down fire doors and exits are indicated.


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Fill-in Additions The spaces between the warehouse and the showroom buildings were filled-in gradually by the addition of four smaller structures between 1996 and 2005. The sequence of construction was interpreted from a series of aerial photographs that were taken during that period. The City of Charleston files do not contain any records of building permits or permit applications for the four additional structures. Interior alterations were also conducted at the rear of the original building, presumably without permits, to construct office spaces. The non-permitted structures included a wooden loading dock that was constructed in the space between the warehouse and the western addition to the showroom. The loading dock was subsequently enclosed by erecting a wood frame structure that was covered with sheet metal. The loading dock enclosure was constructed in two stages - the roof of the older section, adjacent to the warehouse, was 9 feet above the deck, while the newer section, adjacent to the west showroom, was 12 feet tall. Two large sliding doors were provided in the west wall of the loading dock facing the open yard. A wooden ramp allowed furniture to be rolled-up to one of the doors, while the other door was at truck bed height. When completed, the enclosed loading dock covered approximately 2,200 square feet and occupied most of the former open space that was bordered by the warehouse, the connecting corridor, the southwest quadrant of the original building and the south wall of the west showroom addition. The covered loading dock was used as a temporary storage area for furniture. This area was sometimes referred-to as the staging area, because it was used to assemble furniture orders that were scheduled for delivery on the following day. Part of the loading dock was also used for long-term storage, including an enclosed area at the southeast corner, adjacent to the warehouse and the connecting corridor. Two workshop rooms that were used for furniture repairs and refinishing were added on the east of the connecting corridor, between the warehouse and the rear of the original structure. The only access to the two workshop rooms was through the warehouse. These additions were also wood frame structures enclosed by sheet metal. A small courtyard, approximately 15 feet wide and 5 feet deep, was located between the east wall of the loading dock and the west wall of the passageway leading to the warehouse. Several air conditioning units were located in this space that was accessed by a doorway at the east end of the loading dock.


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Loading

Docks

9 ft. height

12 ft. height

WorkshopsRamp

Savannah Highway

Pebble Road

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

FIREDOOR

EXIT

EXIT

EXIT

EXIT

EXIT

Main

Showroom

West

Showroom

East

Showroom

Warehouse

Offices

Figure 3: The space between the warehouse and the showrooms was filled-in with the construction of the loading docks and workshops. Interior partitions were constructed to create offices and other spaces at the rear of the main showroom.


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Lack of Effective Fire Separations The four additions that were constructed in the spaces between the showrooms and the warehouse interconnected three of the four larger structures and compromised the required fire separations between them. Their construction invalidated the building code provisions that allowed the four permitted structures to be constructed without automatic sprinkler systems. The loading dock was directly connected to the west showroom, the warehouse, and the connecting corridor. The walls between these spaces were sheet metal assemblies that provided no fire resistance. A pair of swinging metal doors provided a direct connection from the west showroom into the loading dock. The concrete block wall that separated the loading dock from the rear portion of the original building was compromised by a large open doorway. This opening, which appears to have been a loading dock for the grocery store, was equipped with an electrically operated garage door (non-fire rated). This door was open when the fire occurred. A smaller personnel door also passed through this wall and two window openings had been covered-over in the process of additions and renovations.

Photo 2: Post-fire view of the loading dock. Note the double doors (A) connecting the loading dock to the west showroom at the upper left and the open garage door (B) in the concrete block wall between loading dock and the holding room. (Photo courtesy Bill Murton, Charleston Police Department)


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If building permits had been obtained for the construction of the loading dock and the workshops, the previous classification of the property as four separate buildings would have been invalidated. All of the property encompassing the original structure, the west showroom addition, the warehouse, the connecting corridor, the loading dock and the workshops would have been reclassified as a single structure, because the fire resistive separations and open spaces had been compromised. The building code would have required the installation of an automatic sprinkler system to protect this entire area. The alternative to installing sprinklers would have been to construct a system of rated fire walls to maintain the required separations, so that none of the individual spaces would have exceeded the maximum floor area permitted without sprinklers. Also, wood frame construction would not have been approved as an addition to the existing non-combustible construction buildings. The additions would have been required to meet the same construction standards as the permitted buildings. On June 18, 2007, there were no effective fire walls or physical separations to stop a fire that originated in the loading dock area from spreading into the three adjoining areas. The fire could spread directly into the rear of the original building through an open doorway. The fire could also spread to the warehouse and to the west showroom through sheet metal walls that offered no fire resistance. Exits The original grocery store appeared to have been constructed with a main entrance and exit at the front of the building and two additional exits at the rear. The building permit files indicate that two additional exits were provided from each of the three permitted additions to the Sofa Super Store. Examination of the premises after the fire determined that three of the required exits had been compromised by the non-permitted additions and modifications and that all of the exits, with the exception of the main entrance/exit doors, were obstructed and/or locked at the time the fire occurred. The two sets of double doors that were located at the center of the building, facing the parking lot and Savannah Highway, served as the main entrance and exit from the showrooms. There were no exits at the rear of the main showroom building. The rear (south) wall of the original building gave the appearance that several openings had been filled-in during the process of constructing offices and reconfiguring the ancillary spaces outside the main structure. At least one filled-in doorway at the rear of this building appeared to have been an exit at some time in the past.


Page 35

Another door that appeared to have been an exit from the grocery store was blocked by a vending machine. This door connected the holding room to the loading dock. The loading dock also obstructed the egress path from this exit. There were no entrances to the east and west showrooms from the exterior of the building. Both showroom additions were accessed from the main showroom via the six large openings in the side walls. The exits that were provided when the showroom additions were constructed included two sets of double doors in the east wall of the east showroom; a single exit door in the west wall of the west showroom; and a set of double doors in the south wall (rear) of the west showroom. The addition of the loading dock obstructed the double doorway exit at the rear of the west showroom. These doors were marked as an exit; however the egress path through the loading dock did not meet the code requirements for an exit. The addition of the loading dock blocked the egress path from the double doors. Another exit should have been added to the rear of the west showroom to compensate for the loss of the double doors as an exit. There were no approved exits from the loading dock. The two large sliding doors in the west wall of the loading dock did not meet the code requirements to be classified as exits. Exit doors were provided at the north and south ends of the warehouse. The only exits from the workshop rooms were the openings into the warehouse. Occupants of these rooms would have had to travel through the warehouse to reach the north or south exits. Photographs that were taken after the fire indicate that all of the exit doors from the showroom buildings and the warehouse were secured by padlocks and hasps or by slider mechanismsF

1F. One of the exits from the warehouse was also

physically obstructed by a large shipping container. The main entrance and exit doors at the front of the showroom building were unlocked.

1 South Carolina OSHA issued citations to the business in reference to the locked exits.


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FIRE

DOOR

FIRE

DOORFIRE

DOOR

WAREHOUSE

MAIN SHOWROOM WEST SHOWROOMEAST SHOWROOM

Exit

Blocked by

AlterationsExits Blocked by

Loading Dock

Figure 4: Construction of the loading dock obstructed the egress path from two showroom exits. The construction of offices and modifications to ancillary spaces at the rear of the main showroom obstructed an additional exit.

Building Contents The fire load in most areas of the Sofa Super Store was very high, due to the nature of the business and the contents that were on display and in storage. The contents were predominantly home furniture and furnishings, which typically incorporate large quantities of foam plastics and other synthetic materials. These materials burn quickly, produce large quantities of smoke and have high thermal energy release rates. Many of the products on display were easily ignited and supported rapid fire spread. The showrooms were crowded, with narrow aisles among the displays of furniture and household accessories. Firefighters reported that it was very difficult to advance hose lines through the store and even more difficult to navigate when the showrooms filled with smoke. Several firefighters reported that they were falling over furniture and becoming entangled as they tried to find their way back to the main entrance The showroom areas of the Sofa Super Store property were classified as a mercantile occupancy, while the warehouse was classified as a storage occupancy. These occupancy classifications were appropriate for the sale and distribution of furniture. The occupancy classifications did not permit the storage of flammable liquids or hazardous materials, spray finishing operations, or other hazardous activities. A large quantity of aerosol containers of spray paints and finishes were found in the workshop area after the fire. The presence of these


Page 37

containers suggests that spray finishing operations were conducted in the workshops. In addition to the containers that were found in the workshops, remnants of numerous one gallon metal containers were found in the debris. These containers are believed to have contained a variety of flammable and combustible liquids, including naphtha and lacquer thinner. At least 28 such containers were found in the rubble near the southeast corner of the loading dock. Additional flammable liquids containers were found in the warehouse and in a storage room behind the office area. The presence of these products greatly increased the level of fire risk within the Sofa Super Store property. No permits had been issued by the City of Charleston for spray finishing or for the storage or use of flammable liquids, combustible liquids, or hazardous materials2

F. These activities would likely not have been permitted in a building that did not comply with the building and fire codes. Inspection History The Sofa Super Store had not been inspected by the City of Charleston for code enforcement purposes since 1998. A fire inspection that was conducted in 1998 identified several fire code violations which the owner was notified to correct3F. The violations that were noted included obstructed paths to exits and exit signs in need of repair. The inspection report did not identify any non-permitted additions to the buildings and did not refer to spray finishing operations or improper use and/or storage of flammable liquids. It could not be determined if the additions had been constructed or if the non-permitted activities were occurring at the time of the inspection. The annual fire inspection program for commercial occupancies was discontinued after the 1998 inspection was conducted. The City of Charleston Code was amended in 2001F

4F to remove a mandatory requirement for annual fire

inspections in mercantile occupancies. The Fire Department had conducted pre-fire planning and familiarization visits during the intervening years. These visits did not involve code enforcement activities.

2 The Fire Code would permit the storage of small quantities of these materials for incidental use

without permits. The quantities of aerosols and flammable liquids that were determined to be present exceeded the allowances for incidental storage and use of these products. 3 The 1998 inspection was conducted by a fire inspector under the authority of the City of

Charleston Fire Official. The Fire Official is assigned to the City of Charleston Building Department. A copy of the inspection report is provided in Appendix G of this report. 4 Regular occupancy inspections appear to have been discontinued in 1999; the related code

amendment was adopted in 2001.


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Summary of Fire Code and Building Code Compliance Issues The fire at the Sofa Super Store could have been prevented, and should have been quickly controlled, if the property had been constructed and maintained in compliance with the building and fire codes:

The fire could have been prevented if the discarded combustible materials had not been improperly stored in close proximity to the building and/or if the employees had not been permitted to smoke in proximity to this fuel supply.

The loading dock enclosure was constructed without permits and did not

meet building code requirements. If the loading dock had not been enclosed by exterior walls and a roof, the fire probably could have been controlled before the flames spread beyond the area of origin. The loading dock enclosure caused the fire to spread to all of the contents within the loading dock and then to adjacent areas.

If building permits had been obtained for the construction of the loading

dock and workshop additions, the owner would have been required to install an automatic sprinkler system or additional fire walls.

If an automatic sprinkler system had been installed and properly

maintained, the fire would have been quickly controlled and would have caused relatively minor damage.

If a system of fire walls had been constructed and properly maintained

(as an alternative to a sprinkler system), the fire would not have spread beyond the loading dock.

The presence of improperly stored flammable and combustible liquids

within the loading dock, in quantities greater than the Fire Code would permit for incidental use, probably accelerated the fire and enabled it to spread more quickly to the adjoining areas.

The inadequate number of exits, locked exits, and obstructed paths to

exits significantly reduced the potential for firefighters who were inside the showroom buildings to find a path to safety.


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Significant Building Construction Details In addition to the previously noted code compliance issues, several factors contributed to the severity and rapid spread of the fire that occurred in the Sofa Super Store. While these factors were not in violation of any codes or regulations, they played a significant role in relation to the manner in which fire spread from the loading dock to the showrooms and claimed the lives of nine firefighters. Void Spaces above Ceilings The primary path of fire extension from the loading dock into the main and west showrooms was probably via the void spaces above the ceilings. Suspended ceilings were installed above the retail spaces in all three showroom areas, creating three large interstitial void spaces. The concrete block walls of the original building divided these void spaces into three separate sections. Each void space was equal in area to the occupied area below the ceiling. The smoke and hot fire gases that were produced by the fire in the loading dock entered and accumulated within the void spaces. The hot fire gases produced a rich mixture of pre-heated fuel within the void spaces that could easily ignite if a supply of fresh air was introduced. The ceiling above the main showroom was approximately 9 feet above the floor level. The void space above the ceiling in this area was approximately 5 feet in height and enclosed the lightweight steel bar joists that supported the metal roof deck. The ceilings in the east and west showroom areas were approximately 8’-6” above the floor. The roof lines above both of these areas sloped toward the outer edges, creating void spaces above the ceilings that varied from approximately 2’-6” in height at the outer walls to 5 feet at the concrete block walls of the original building. When the void spaces were filled, the smoke would have continued to bank down into the showrooms where the firefighters were working. The smoke would have quickly obscured their visibility and the temperature would have gradually increased as the hot gases stratified at the ceiling level and descended toward the floor. This would produce the same type of fuel-rich atmosphere within the showrooms as above the ceilings, setting the stage for the contents of the store to become involved in a rapidly spreading fire.


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Figure 5: Cross section through the concrete block wall, separating the middle showroom from the west showroom. The interstitial void spaces above the ceilings in both areas are indicated. Holding Room The area in the southwest corner of the main showroom structure was known as the “holding room”. This room, used for temporary storage, was enclosed by the concrete block walls of the original building on two sides and by interior partitions on two sides. Combustible materials, including futon cushions, were stored in the holding room. Two large openings in the concrete block walls provided direct connections from the holding room to the loading dock and to the corridor leading to the warehouse. The opening leading to the corridor was protected by an eight and one half foot wide roll-down fire door with a fusible link release mechanism. An eight-foot wide non-fire rated garage door was installed in the opening between the holding room and the loading dock. This door was operated by an electric motor and was open at the time the fire occurred. The open doorway provided a direct path for the fire in the loading dock to extend into the holding room.


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The large opening between the holding room and the loading dock could not be seen from the showroom. A standard (3’0” X 7’0”) personnel door, which was normally closed, provided access from the rear portion of the middle showroom into the holding room. Fire extension from the loading dock into the holding room could not be observed as long as this door was closed and the interior partition walls retained their integrity. There was no ceiling above the holding room – the steel bar joists that supported the roof were exposed. The heat, smoke and fire gases that were produced by the fire in the loading dock flowed into the holding room and had direct access to the interstitial void space above the main showroom.

HO

LD

ING

RO

OM

Open

Garage

Door

Double

Doors

WORKSHOPS

LOAD

ING

DO

CKS

FIRE

DOOR

FIRE

DOORFIRE

DOOR

WAREHOUSE

MAIN SHOWROOM WEST SHOWROOMEAST SHOWROOM

Figure 6: The holding room was located within the walls of the original building. An open garage door provided a direct path for the fire to spread from the loading dock into the holding room. Façade and Parapet The façade that was constructed across the front of the Sofa Super Store gave it the appearance of one large structure when viewed from the street. The parapet above the front wall made the showroom buildings appear to be approximately 23 feet tall, while the roofs behind the parapet were 12 to 14 feet in height. This feature prevented ladder access to the roof from the front of the building. The parapet also created a visual obstruction; the roof lines could not be observed from the ground in front of the building.


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There were no physical or visual obstructions on the sides or at the rear of the showroom building. The roof lines could be viewed from the sides and the rear and the different construction types and ages of the structures were evident from these vantage points. The roofs were easily accessible from ground ladders. Roof Coverings The roof coverings over all the different sections of the Sofa Super Store incorporated corrugated metal decking or sheet metal roof panels. A metal roof deck tends to retain heat and fire gases within the building until the structure collapses, unless vertical ventilation openings5

F are available to release them. In the absence of vertical ventilation, the hot gases will tend to mushroom (spread horizontally) over a large area. A series of aerial photographs that were taken over several years indicate that the flat roof above the grocery store was originally constructed with a built-up covering of tar and gravel on top of the steel deck. The photographs indicate that a layer of sprayed-on foam insulation was applied to this roof between 1998 and 2001. The additional insulation would have increased the tendency to retain heat and fire gases within the building. It could not be determined if the built-up tar and gravel layers were removed before the sprayed-on coating was applied or if the new material was applied on top of the old roofing. Most of the roof coating and membrane materials, including the foam insulation, were consumed by the fire, leaving only the corrugated metal decking. Analysis of the debris indicated that the roofing incorporated a 4-inch thick layer of polyurethane foam, a roof membrane, protective coatings and ballast (small rocks). If the tar and gravel layers remained in place, or a substantial residue of tar, the additional risk of a combustible roof deck fire would have been present. This type of fire can occur when the heat of a fire under a metal deck roof causes tar above the deck to melt. The melted tar can drip into the void space through the joints in the metal decking: the flammable vapors released by the tar are then ignited in the void space. The roofs above the west and east showroom additions were corrugated sheet metal, attached directly to the metal stringers or metal supports with screws. Approximately 3 inches of fiberglass insulation was installed underneath the metal roof, within the interstitial void spaces.

5 Firefighters routinely use power saws to cut vertical ventilation openings in roofs.


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Limited Access and Ventilation Openings There were very few openings in the exterior walls of the Sofa Super Store, other than the large windows across the front of the showrooms. The limited openings restricted the number of points where firefighters could enter the buildings to attack a fire and also limited the potential for horizontal ventilation. The metal roof deck over the main showroom and the sheet metal roof coverings over the newer areas presented significant barriers to vertical ventilation. The firefighters had very few options to release the smoke and heat that entered the showroom areas. Power saws with metal cutting blades would have been required to provide vertical ventilation openings to release the smoke and heat. A limited number of translucent plastic panels were installed in the roof above the loading dock and the warehouse. These panels tend to melt or burn away when exposed to a fire; however they did not provide sufficient openings to create effective vertical ventilation. The limited number of openings in the exterior walls was also a very significant factor in relation to exit paths that were available to the firefighters who were operating inside the showrooms. There were very few exits and all of the exit doors, other than the main entrance, were either locked or secured by mechanical devices. Site Arrangement Access for fire apparatus to the Sofa Super Store was limited to the front parking lot, facing Savannah Highway, and the driveways along the east and west sides of the showroom buildings. The driveway on the east side was obstructed by parked delivery trucks at the time of the fire. A gate was installed across the west driveway, which provided access to the loading dock and a delivery door at the northwest corner of the warehouse. The gate was unlocked and opened by a store employee before the first fire apparatus arrived. A narrow footpath provided the only access to the rear of the east and main showroom buildings. This area was obstructed by fences and several trees. A small building on an adjacent property created an exposure directly behind the original grocery store building. The warehouse extended back to Pebble Road on the south side of the property. The south wall of the warehouse was accessible from the street, while fences obstructed access to the east and west sides. The property on the east side of the warehouse was residential and provided very limited access for fire apparatus. Most of the property on the west side was vacant except for a small building adjacent to the front section of the warehouse.


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Public Water Supply and Hydrants The closest hydrants to the Sofa Super Store property were in the residential area on Pebble Road; however, there was no access from this side of the property to the showroom buildings or the loading dock area. There were no hydrants in the section of Savannah Highway directly in front of the showroom buildings. Hydrants were located to the east and west on Savannah Highway and on side streets north of Savannah Highway. The closest hydrant to the front entrance was approximately 500 feet northwest at the intersection of Blitchridge Road and First Drive. The closest hydrant to the east was on the north side of Savannah Highway, approximately 1500 feet from of the main entrance. A hydrant that was previously located on the east side of Wappoo Road, north of Savannah Highway, had been removed before the fire occurred6

F. The east-west water main in Savannah Highway was 8 inches in diameter. The east-west main diverted one block north to First Street, between Blitchridge Road and Wappoo Road. The water mains in Wappoo Road were 8 inches to the south of Savannah Highway and 10 inches to the north. Flow test records indicated that most of the hydrants in the area could deliver 1200 to 1400 gallons per minute at 20 psi residual pressure when tested individually. There were no test records to indicate the total flow that would have been available from a combination of hydrants flowing simultaneously.

6 The hydrant had been removed because it was in a location where it was frequently struck and

damaged by trucks entering the adjacent property.


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Figure 7: Fire hydrants and water mains in proximity to the fire scene.


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Charleston Fire Department


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The Charleston Fire Department The City of Charleston occupies an area of almost 110 square miles with a total estimated population of 121,247. The city includes the original peninsula area, bounded by the Ashley and Cooper Rivers, as well as parts of Johns Island, West Ashley, James Island, and Daniel Island. In 2007, the Charleston Fire Department included 19 fire companies, operating out of 14 fire stations. The Department employed 246 sworn members and 14 civilians with an operating budget of 14.9 million dollars. The fire suppression crews worked on a 24 hours-on/48 hours-off work schedule, staffing 16 engine companies and three ladder companies. A minimum of four members were assigned to each company on each shift, although most companies operated with 3 crew members on duty most of the time. If staffing was short on a particular shift, ladder companies could be operated with a minimum of two on-duty members. On occasion, a ladder company would be removed from service due to staffing shortages. An Assistant Fire Chief was assigned to command each shift. The Assistant Chief responded to alarms in a first-due district in the peninsula area of the city and to working incidents city-wide. The city was divided into four battalions with a Battalion Chief on duty in each district at all times. The standard response to a reported structure fire was two engine companies, one ladder company, and a battalion chief. A third engine company would automatically respond to the scene of any working fire and a third engine company was also dispatched to alarms for high rise buildings. Depending upon the area of the city where an incident occurred, the initial dispatch to a structure fire or a report of a working fire would initiate the relocation of additional companies to cover the area vacated by the responding units. At the time of the Sofa Super Store fire, the Charleston Fire Department did not use greater alarms to bring additional resources to the scene of an incident. The chief officer in command of the incident would specifically request additional companies through the dispatcher.


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215

6

8

9

18

20

12

1619

1110

13

717

3

4

5

1

2 Engine Company

Ladder Company1

Sofa Super

Store

Figure 8 – Charleston Fire Department fire stations and company locations. At the time of the fire, Engines 16 and 19 were housed at Fire Station 16.


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Figure 9 – Fire stations and company locations in the West Ashley and Peninsula areas, including Saint Andrews Fire Stations 1 and 2.

Mutual Aid At the time of the Sofa Super Store fire, the Charleston Fire Department did not routinely utilize mutual aid resources for response to emergencies. The Charleston Fire Department would occasionally request mutual aid units from surrounding agencies, particularly during periods of exceptional activity or when a mutual aid unit was closer to an emergency incident than any available Charleston company. Similarly, Charleston Fire Department units were occasionally, but not systematically, requested to provide mutual aid to the surrounding cities and districts. The Charleston units were generally called to assist the local jurisdiction at a major incident or to respond to calls when the local companies were unavailable. In areas such as West Ashley, where Charleston and Saint Andrews fire stations are located close to one another and the jurisdictional boundaries are particularly complicated, there was limited coordination between the two departments. In many cases, both departments would be called to respond to the same incident, or one department might arrive and determine that the incident was actually in the other’s jurisdiction. In other cases, units from one fire department would literally drive past the other department’s fire station during a response.


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The Sofa Super Store was located within the Charleston city limits; however most of the adjacent properties were within the Saint Andrews response district. Several of the Saint Andrews units that responded to the Sofa Super Store fire were deployed to protect exposures that were within their own jurisdiction, while other Saint Andrews companies were involved in operations on the main fire building. The Charleston and Saint Andrews firefighters generally worked cooperatively when they responded together; however their apparatus, equipment, staffing and standard operating procedures were not compatible. In most cases the companies from each agency would operate under their own command structures with “loose coordination” between the two departments. The operational effectiveness of mutual aid operations tended to depend on the particular individuals who were on duty and responded to the scene. Most of the fire departments that serve areas adjacent to the City of Charleston, including Saint Andrews, operate their own individual dispatch centers. Their radios are on a separate 800 MHz trunking system, however the technology is compatible with the City of Charleston system and most agencies have the frequencies and talk groups of the neighboring departments programmed into their portable and mobile radios. The Saint Andrews dispatchers routinely monitor the Charleston radio system due to the proximity of their districts. Following the Sofa Super Store fire, the Charleston Fire Department and the other fire departments in the area have participated in several initiatives to develop a more effective mutual aid system. Several of the surrounding fire departments are planning to consolidate their communications centers along with Charleston County EMS.


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Units by order of arrival: Battalion 4 (Dispatched: 19:09 - On Scene: 19:10) Car 2 (Dispatched: 19:10 - On Scene: 19:11) Engine 10 (Dispatched: 19:09 - On Scene: 19:11) Engine 11 (Dispatched: 19:09 - On Scene: 19:11) Ladder 5 (Dispatched: 19:09 - On Scene: 19:12)

Engine 16 (Dispatched: 19:10 - On Scene: 19:15) Car 1 (On Scene: 19: 16) Engine 12 (Dispatched: 19:12 - On Scene: 19:17) Engine 15 (Dispatched: 19:13 – On Scene 19:17) Engine 19 (Dispatched: 19:15 - On Scene 19:20) Engine 6 (Dispatched: 19:16 – On Scene 19:21) Battalion 5 (On scene: 19:24) Saint Andrews Car 3 (On scene: 19:24) Saint Andrews Engine 2 (On scene: 19:25) Saint Andrews Rescue 1 (On scene: 19:25) Engine 3 (Dispatched: 19:31 – On Scene 19:40)

A listing of firefighters assigned to each apparatus and fire department vehicle is included as Appendix A.


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Incident Chronology


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Fire Discovery The fire at the Sofa Super Store originated at approximately 19:00 hours (7:00 p.m.) on Monday, June 18, 2007. The store was open for business at the time, although no customers were present. There were five employees working in the showroom area and one in the workshop at the rear when the fire was discovered.

The weather recorded at the Charleston International Airport at 19:00 on June 18, 2007 was clear, 79 oF (26 oC), with 82 % relative humidity. The winds were 9 to 11 mph from 190 to 200 degrees (south-southwest), and the barometric pressure was 30.0 – 30.05 in. hg.

The fire was first reported by a passer-by who observed smoke and flames at the rear of the Sofa Super Store, near the loading dock. The passer-by called 9-1-1 on his cell phone to summon the fire department and went into the store to alert the employees that their building was on fire. After being alerted by the passer-by, a store employee obtained a fire extinguisher, walked back through the showroom to the holding room and entered the loading dock through the open garage door. Inside the loading dock enclosure he encountered moderate smoke and observed flames entering from the exterior around the frame of the door at the top of the ramp. He discharged the dry chemical extinguisher, attempting to keep the flames from spreading to the interior of the loading dock. After expending the contents of one extinguisher, he returned to the showroom to obtain a second extinguisher. When the employee returned with the second extinguisher, he was unable to re-enter the loading dock due to the heavy smoke condition that had developed in the loading dock and the holding room. He estimated that smoke had completely filled this area in less than one minute. He discharged the second extinguisher from the holding room into the loading dock through the garage door opening. While he was operating the second fire extinguisher, the employee heard one of the fire doors rolling down into position. The employee could not see which door had closed through the heavy smoke; however, the only fire door that he could have heard operating in this area was located at the end of the corridor leading to the warehouse. The fusible link release mechanism for this door was inside the holding room. This suggests that the fire had extended into the loading dock and sufficient heat had passed through the opening, from the loading dock into the holding room, to cause the fusible link to release the automatic closing mechanism. The fire door probably closed at approximately the same time the first firefighters were arriving at the Sofa Super Store.


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Initial Response The first call reporting the fire was made to Charleston 9-1-1 and transferred to a fire dispatcher at 19:07:58F

7F. The caller reported a “huge fire at the back…” of the

Sofa Super Store. At 19:09:02 hours, Engines 11 and 10, Ladder 5, and Battalion Chief 4 were dispatched for a possible structure fire behind the Sofa Super Store at 1807 Savannah Highway. When the alarm was transmitted, Battalion Chief 4 responded immediately from Fire Station 11, which is located one mile east of the fire scene on Savannah Highway. Battalion Chief 4 observed a column of smoke and reported “heavy smoke coming from that direction” as he pulled out of the fire station and turned toward the fire. When this message was transmitted, Engine 16 self-dispatched as the third-due engine company, according to the Charleston Fire Department response policy, and Engine 15 began to relocate from downtown to cover the West Ashley district. The on-duty Assistant Chief (Car 2) was at Fire Station 11 for dinner and responded when he heard the “smoke showing” report. Battalion Chief 4 was the first unit on the scene at 19:10:46 hours, less than 2 minutes after the initial dispatch. He pulled into the driveway on the west side of the fire building where he observed a fire immediately in front of the loading dock, with flames reaching above the roofline. The initial report from Battalion 4 indicated trash and debris burning outside the building; a few seconds later he added that the fire might have extended into the building. Battalion Chief 4 then backed his car out of the driveway to make room for an engine company to come in and attack the fire. Engine 11 was slightly delayed leaving quarters because the apparatus was being washed on the rear ramp and some equipment had to be placed back into compartments. The column of smoke was visible as Engine 11 responded westbound on Savannah Highway and heard Battalion Chief 4 report a trash and debris fire at the rear of the building. Engine 11 turned south on Wappoo Road and then west on Pebble Road to approach the warehouse from the rear. Upon reaching the south side of the warehouse, Captain 11 realized that the fire was between the warehouse and the main building and could not be accessed from Pebble Road. Engine 11 continued on to Stinson Drive and returned to Savannah Highway, approaching the fire scene from the west.

7 The all of the times cited in this report have been adjusted to correspond with a common time

base as described in the introduction.


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The Assistant Chief continued west on Savannah Highway to the front parking lot of the Sofa Super Store, where he met Battalion Chief 4 near the northwest corner of the building. The two chief officers had a brief exchange at that location; the Assistant Chief indicated that he would go inside the store to check for fire extension into the building, while Battalion Chief 4 should go to the west side of the building and direct operations in that area.

PHASE ONE OPERATIONS - 19:11 TO 19:18 Offensive Strategy Engine 10 was the first fire company to arrive at the front of the building8

.. At 19:11:45, the Assistant Chief directed Engine 10 to back down the driveway on the west side of the Sofa Super Store. Battalion Chief 4 walked back along the west side of the building. As soon as he reached the loading dock area, he advised the Assistant Chief that the fire had extended into the building. Flames were visible inside the loading dock through a large ventilation fan opening in the west wall. At 19:12:04, the Assistant Chief contacted Engine 16 with instructions to come inside with him when they arrived on the scene. At 19:12:49 he called for Engine 12 to be dispatched to the fire. When Engine 11 reached the front of the building, Captain 11 noted that Engine 10 had taken the first-arriving engine position and that Engine 11 would be responsible for laying the supply line. He directed his crew to lay a supply line to Engine 10. Captain 11 went to the front door and entered the showroom to check for fire extension into the building. Inside the showroom he met the Assistant Chief and two store employees. The employees led them back through the main showroom and to the right, through an opening into the west showroom. They arrived at the double doors that provided access from the west showroom to the loading dock. They did not observe any indications of smoke or fire in the main showroom and only encountered a small amount of smoke at the ceiling level when they reached the double doors. The Assistant Chief opened one of the double doors and they immediately observed smoke and flames involving furniture on the loading dock to the right of the doorway. The draft pulled the door out of his hand as air from the showroom was drawn toward the fire. Captain 11, who was wearing protective clothing, was able to pull the door closed with a gloved hand.

8 Engine 10 arrived faster than usual, because they were returning from training when the alarm was transmitted. Engine 10 was less than one minute behind Engine 11 approaching the fire scene. When Engine 11 turned on Wappoo Road, Engine 10 continued west to the front of the fire building.


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At 19:13:17 Captain 11 transmitted the message, “I need an inch-and-a-half inside this building.” This message was not specifically directed to anyone. At 19:13:46, The Assistant Chief ordered Engine 15 to respond to the fire with instructions to bring a 1-1/2 inch line inside the building to the right side. (Engine 15 was en route to fill-in at Station 11 at that time.) Engine 10 When Engine 10 was in position on the west side of the building, Captain 10 pulled a booster line (1-inch diameter, rubber hose on a reel) and began to attack the exterior fire, while Firefighter 10 and Engineer 10 deployed a 1-1/2 inch preconnected line. After knocking down most of the exterior fire, Captain 10 and Firefighter 10 advanced the 1-1/2 inch line up the ramp and into the loading dock through the sliding door. They were able to advance approximately 20 feet into the loading dock while directing their stream onto the burning furniture. Engine 11 While Captain 11 went inside the Sofa Super Store with the Assistant Chief, Engineer 11 prepared to lay a supply line to Engine 10. Firefighter 11, following the Charleston Fire Department standard operating procedure, took the soft sleeve (the hose used to connect a pumper to a hydrant) and a hydrant wrench and set out on foot, eastbound on Savannah Highway toward a hydrant. Anticipating a first due arrival, he had already donned his full protective clothing and SCBA backpack - he removed his SCBA and left it on the street in front of the Sofa Super Store. Firefighter 11 was at the intersection of Savannah Highway and Wappoo Road when he observed Engine 11 repositioning at the front of the building. Assuming that the plan had changed, he returned to the fire scene, where he obtained another SCBA from the apparatus and prepared to enter the fire building. Ladder 5 Ladder 5 arrived at 19:12:25 and positioned the tower ladder at the front of the Sofa Super Store near the main entrance. When Captain 11 transmitted the request for a line inside the building, Captain 5 directed Engineer 11 to position his apparatus near the front doors, with the rear toward the building. The crew of Ladder 5 then began advancing a 250 foot preconnected 1-1/2 inch attack line from Engine 11 into the building.


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Presumably, Captain 5 had heard the Assistant Chief call for Engine 12 to respond to the fire, followed by Battalion Chief 4’s instruction to Engine 12 to lay a supply line to Engine 10. This instruction was transmitted immediately after Engine 12 was dispatched to the fire and a few seconds before Captain 11 called for a line inside the building. This would have caused Captain 5 to believe that Engine 11 was uncommitted. In addition, Engine 11 was on the street in front of the building at that time, while Engine 10 had backed down the driveway on the west side and could not be seen from the front of the building. Captain 11 encountered the crew of Ladder 5 advancing hose into the main showroom and directed them toward the double doors. He asked Captain 5 why Engine 11 was at that location instead of laying a supply line for Engine 10. Captain 5 replied that another company was providing the supply line for Engine 10. As the hose line was extended, they realized that the 250 foot preconnected line was not long enough to reach the double doors. Captain 11 went outside and disconnected the hose from the outlet at the rear of Engine 11. He then removed the nozzle from the other preconnected line and joined the two lines together, extending the attack line to 500 feetF

9F. He helped feed the additional hose through

the front doors and into the showroom, assisted by Firefighter 11.

At 19:14:10 the Assistant Chief advised Battalion Chief 4 that the fire on the loading dock was advancing toward the retail area. He reported “I’ve got fire inside the rear of the building and it’s walking its way right on into the showroom.” The Assistant Chief believed that the wall between the loading dock and the west showroom was brick construction and that the firefighters would be able to stop the progress of the fire at the double doors.

The Assistant Chief called for the attack line from Engine 11 to be charged at 19:15:05. Ladder 5 called for the line to be charged at 19:15:56. By this time, Captain 11 and Firefighter 11 were with the crew of Ladder 5 at the double doors, waiting for the line to be charged. There was only a moderate amount of smoke and no sensation of heat in that part of the building at that time. Captain 11 sent Firefighter 11 back to the apparatus to determine why the line had not been charged.

9 The direct rectilinear distance from the main entrance to the double doors was approximately 188 feet - measured straight back from the front entrance, followed by a right turn to reach the west showroom and a left turn to reach the double doors. The showroom aisles were narrow and did not provide a direct path from the entry point to the loading dock. While 250 feet of hose would not reach the doors, extending the line to 500 feet provided approximately 200 feet of excess hose that had to be distributed along the length of the line. Each additional length of hose creates additional friction loss (reduction in pressure) as water flows through the hose.


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Photo 3: The earliest photo of the front of the Sofa Super Store, taken at approximately 19:16. (Photo courtesy of Lindsay Ackermann)


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After waiting a few moments for the line to be charged, Captain 11 returned to the main entrance, where he found that Engineer 11 was unable to engage the pump on Engine 11. Engine 11’s apparatus had an idiosyncrasy that required the pump panel throttle control to be fully retracted when the apparatus was placed in pump gear. If the throttle was advanced, even minimally, the pump would go in gear but the pump panel throttle would not operate. Being familiar with the vehicle, Captain 11 was able to perform the required procedure and successfully engage the pump and charge the 1-1/2 inch attack line. He then went back inside the building, where he observed that Captain 5 was operating the 1-1/2 inch line inside the loading dock and Engineer 5 was positioned at the double doorway. The members from Ladder 5 were using their self-contained breathing apparatus at that time.


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Figure 10: Initial attack hose lines in operation. (Approximate time 19:16)

1: 1” booster line from Engine 10 attacking exterior fire. 2: 1-1/2” preconnect from Engine 10 advanced into the loading dock 3: 1-1/2” preconnect from Engine 11 advanced by Ladder 5 crew through the showrooms to the double doors and into the loading dock. The fire has extended across the loading dock and into the holding room.


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Engine 16 At 19:15:15, the Assistant Chief directed Engine 16 to come to the front of the building and to bring a 2-1/2 inch hose line through the front door. Captain 16 and Firefighter 16 went to the rear of Engine 11 and began to remove 2-1/2 inch hose, while Engineer 16 parked the apparatus on Savannah Highway and donned his protective clothing and SCBA. Upon reaching Engine 11, Engineer 16 encountered Engineer 11 who told him that he needed a supply line. Engineer 16 checked with Captain 16 and then returned to his apparatus, removed his SCBA and turnout coat, and pulled enough hose from the 2-1/2 inch bed to hand the end of the supply line to Engineer 11. At 19:17:36, the Assistant Chief transmitted, “Alright, 16, go to the hydrant.” Captain 16 and Firefighter 16 advanced the 2-1/2 inch attack line through the showrooms to the double doors. When they reached the area in front of the double doors, they encountered Captain 11 and the crew from Ladder 5. Engine 12 Engine 12 was dispatched to the fire at 19:12:53. Immediately after the dispatch message was transmitted, Battalion Chief 4 instructed Engine 12 to lay a supply line to Engine 10F

10F. Battalion Chief 4 repeated the instruction to Engine 12 as

they were arriving on the fire scene at 19:17. Engineer 10 had pulled a 2-1/2 inch hose line from Engine 10 out to Savannah Highway to wait for the arrival of Engine 12. Engineer 12 connected the 2-1/2 inch line from his apparatus to the line from Engine 10, while Captain 12 and Firefighter 12A walked back toward the loading dock. Firefighter 12B started out on foot toward the hydrant that was located at the intersection of Blitchridge Road and 1st Drive. When the engine arrived at the hydrant, Firefighter 12B completed the hook-up procedure. At 19:20:31 Engineer 12 advised Engine 10 that he was charging the supply line. Fire Chief The Fire Chief arrived on the fire scene at 19:16:32 and met Engineer 12 shortly thereafter as he was connecting the 2-1/2 inch hoses from Engine 12 and Engine 10 together. The Fire Chief pointed the way to the hydrant and secured the hose as Engine 12 laid the supply line to the hydrant.

10 This instruction was acknowledged by Captain 12 as he prepared to respond.


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The Fire Chief then met briefly with the Assistant Chief in the parking lot near the northwest corner of the fire building. The Fire Chief indicated that he would direct operations at the rear of the building, where the fire appeared to be most severe, while the Assistant Chief should continue to direct operations at the front of the building. Engine 15 When Engine 15 arrived on the scene at 19:17, the 1-1/2 inch line that had been taken into the building by Ladder 5 was already charged with water. The 2-1/2 inch line that had been stretched by Engine 16 was still dry. PHASE TWO OPERATIONS - 19:19 TO 19:25 Captain 10 and Firefighter 10 operated their 1-1/2 inch line inside the loading dock for 3 to 4 minutes before the fire intensified, forcing them to crouch down and then begin to back out. At that moment the fire burned through their hose line, causing it to rupture near the doorway where they had entered. The rupture sent a heavy spray of water upward that provided a safe path for Captain 10 and Firefighter 10 to exit. When they reached the exterior, Firefighter 10 realized that the lens of his SCBA face piece was deformed from the heat exposure. Captain 10 noted that while they were inside, there were indications that another line was operating on the fire from the opposite side of the loading dock. Captain 12 and Firefighter 12A reached the loading dock just after Captain 10 and Firefighter 10 had exited from the loading dock. They clamped the ruptured line, pulled the nozzle outside, and replaced the damaged section of hose. Captain 12, Captain 10, and other firefighters then attempted to advance the 1-1/2 inch line back into the loading dock. The Fire Chief, who had just arrived in that area, instructed them to back out and hold their position at the doorway – not to take the line back inside the loading dock. At 19:19:36, Captain 16 called for the 2-1/2 inch attack line that had been taken into the showroom to be charged. The Assistant Chief advised Engineer 11 not to charge the 2-1/2 inch line until the supply line from Engine 16 was chargedF

11F.

Captain 16 was not advised of the delay in charging the line. Captain 11 was with Captain 16 near the double doors and began using air from his SCBA while waiting for the 2-1/2 inch hose line to be charged. During this period Captain 16 made a statement to the effect that, “if this fire gets behind us, we’re in big trouble.”

11

Engine 11 was already operating a 1-1/2 inch line using water from the 750 gallon on board tank. The additional flow from the 2-1/2 inch line would have consumed the remaining water supply in approximately 2 minutes.


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After waiting additional time for the line to be charged, Captain 11 went back out to Engine 11 to find out if there was a problem. Smoke was banking down in the main showroom and he noted that the temperature was increasing. Captain 11 had to follow the hose line to find his way out. He heard the voices of two crewmembers from Engine 19 who were on their way into the showroom as he was leaving.

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Figure 11: Additional hose lines stretched. (Approximate time 19:20)

4: 2-1/2” attack line (uncharged) from Engine 11 advanced by Engine 16. 5: 2-1/2” supply line for Engine 10 – Engine 12 pumping at hydrant. 6: 2-1/2” supply line for Engine 11 – Engine 16 en route to hydrant. The fire is still concentrated in the loading dock and the holding room, although heat and smoke are spreading into the adjacent areas, including the void spaces above the showroom ceilings.


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Engine 15 After their arrival on the scene at 19:17:30, Captain 15, Firefighter 15A and Firefighter 15B went directly to the front entrance and followed the two hose lines into the building at approximately 19:19. They encountered smoke approximately halfway back into the showroom and stopped to don their SCBA face pieces. After advancing farther into the store, Captain 15 directed Firefighter 15B to go back outside to get a hose line and bring it insideF

12F. When he returned with a

booster line from Engine 11, Firefighter 15B was unable to find his Captain or Firefighter 15A in the smoke-filled interior. Engineer 15 entered the showroom after the other members of Engine 15 but was unable to locate them in the smoke. (Approximate time 19:20) Engine 19 Engine 19 reported on the scene at 19:20:08. The apparatus was parked in the middle turning lane of Savannah Highway and all three crew members entered the showroom through the front doors. The Assistant Chief met Captain 19 in the front part of the showroom and directed him toward the area where Engine 16 and Ladder 5 were already operating. Engineer 19 and Firefighter 19 followed Captain 19. The Assistant Chief recalled that there was enough smoke in the showroom at that time to obscure visibility, but conditions did not require the use of his self-contained breathing apparatus. Engine 6 Engine 6 was directed to respond to the fire scene by the Fire Chief at 19:19:12, with instructions to “Park your truck in the middle of the street on Savannah Highway and come in the front door.” After reporting on the scene at 19:21:50, Captain 6 and Firefighter 6 followed the hose lines through the front door into the showroom. (Approximate time 19:23) Heavy smoke was banked down to the floor a few feet inside the showroom; they had to use self-contained breathing apparatus and feel their way along the hose lines to find their way to the back of the store.

At 19:23:09 the Fire Chief called the Assistant Chief and asked “Alright, Larry, how we looking inside the store?” The Assistant Chief replied “Chief, I’m trying to get back to it now.”

12 Captain 15 had previously instructed Firefighter 15B to stay close to him, because it was the firefighter’s first duty shift on the Charleston Fire Department.


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Engineer 6 donned his protective clothing and SCBA and entered the showroom approximately one minute behind Captain 6 and Firefighter 6. (Approximate time 19:24F

13F) He noted that the atmosphere was clear for a few feet inside the front

door, before he encountered a wall of dark smoke from floor to ceiling. He followed the hose lines leading toward the rear of the main showroom. Operations inside the Showrooms At this point in the operation, approximately 19:25, all of the firefighters who were inside the showrooms were operating in zero visibility conditions. Eight firefighters are presumed to have been in the vicinity of the double doors at the rear of the west showroom at this time: Captain 5, Engineer 5, Firefighter 5, Captain 16, Firefighter 16, Captain 19, Engineer 19 and Firefighter 19. Captain 15 and Firefighter 15A were in the rear of the main showroom, most likely in the area close to the holding room, searching for the fire. (They had turned to the right after reaching the rear of the main showroom.) The temperature was increasing as they penetrated deeper into the building, although no flames were visible. Captain 15 told Firefighter 15A that they had to stop the fire from advancing across the rear of the showroom. He directed Firefighter 15A to try to find a hose line while he continued to searchF

14F.

Firefighter 15B had obtained a booster line from Engine 11 and was looking for his Captain in the main showroom. He was alone inside the showroom for several minutes, while encountering increasing heat. At some point he observed a red glow overhead and began to flow water from the booster line toward the ceiling. He operated the booster line in this area for several minutes. Engineer 15 had entered through the front doors and was also looking for the other members of his company inside the smoke-filled showroom. His low air pressure alarm activated and he went outside to obtain a replacement air cylinder for his SCBA. Firefighter 11 had also re-entered the showroom and was looking for his Captain in the rear of the main showroom. He heard the voices of other firefighters, although he could not see them. Captain 6 and Firefighter 6 were in the rear of the main showroom, probably in the vicinity of the holding room. They were encountering increasing temperatures as they attempted to locate the fire.

13

The entry time for Engineer 6 may have been as late as 19:26 or 19:27. He recalled that a civilian had told him that someone was still inside the building as he was entering through the front doors. 14

Firefighter 15A recalled that they had heard radio traffic referring to a person trapped in the rear of the building. He believed that they were searching for the person and the fire simultaneously.


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Engineer 6 was unable to find the other members of his company inside the smoke-filled store. He followed the hose lines to the rear of the main showroom noting that the temperature was increasing as he moved deeper into the store. He was aware of the presence of other firefighters in the same general area, but could not identify them. Engineer 6 was carrying a pike pole and when he reached the back of the showroom, he began trying to open a wall and a section of the ceiling to see if he could find a concealed fire. He observed flames at the ceiling level and shouted for one of the other firefighters to bring a hose lineF

15F.

Fire Extension into Warehouse At approximately 19:25, Saint Andrews Fire Department Engine 2, Rescue 1 and Car 3 arrived at the fire scene with a total of 5 personnelF

16F. The Assistant Chief

from Saint Andrews met the Charleston Fire Chief on the west side of the fire building and offered to provide assistance. He reported that the offer was initially declined. The fire had extended into the large warehouse at the rear of the Sofa Super Store property by this time. The Saint Andrews Assistant Chief offered to deploy his units to attack the warehouse fire from the south side. This offer was accepted and the Saint Andrews Assistant Chief began directing his companies to set-up on Pebble Road. Eventually, Saint Andrews Engine 1, Engine 7, and Ladder 1 operated on Pebble Road. Firefighter 12B returned from the hydrant and began forcible entry into the warehouse with Firefighter 12A. Off-duty firefighters and a fire department mechanic who had arrived on the scene assisted with the forcible entry. Two additional 2-1/2 inch hand lines were deployed from Engine 10 to attack the fire in the warehouse. Both 2-1/2 inch lines were positioned in front of the large roll-up door on the north side of the warehouse and began flowing water before the door was opened. Observing the volume of fire inside the warehouse, Battalion Chief 4 and the Fire Chief both directed the companies to stay outside and operate the lines from the doorway. At 19:25:26, the Fire Chief called Engine 12 to increase the pressure in the supply line by 50 pounds in order to provide for the increased flow. Several additional requests for more pressure were transmitted during the following minutes.

15

Engineer 6 did not have his portable radio. It had been left behind at the apparatus, 16

The Saint Andrews firefighters had been eating dinner at a restaurant a few blocks west of the Sofa Super Store when they became aware of the incident. They responded to the scene to determine if the fire was in their jurisdiction or the City of Charleston.


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Engine 3, which had been attending an event in Summerville, was directed to cover at Fire Station 16/19 at 19:24.

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7: 2-1/2” attack line from Engine 10. 8: 2-1/2” attack line from Engine 10. 9: 1” booster line from Engine 11 – advanced into showroom by Engine 15.

The fire has spread to the warehouse and to the void spaces above the main and west showrooms.


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PHASE THREE OPERATIONS - 19:26 TO 19:37 Trapped Employee Reported At 19:26:35 one of the two Fire Dispatchers on duty picked-up a 9-1-1 call from an employee who stated that he was trapped in the rear of the Sofa Super Store. The trapped individual was calling on his cell phone and was in severe emotional and physical distress. He said that he was beating on the wall of the building with a hammer.

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Figure 13: The employee was trapped in a workshop room that was located between the warehouse and the main showroom. The rescue team came from the front of the showroom building, around the east end to the rear, and cut through the metal wall to rescue him.


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At the same time, the second Fire Dispatcher advised the Fire Chief that they were receiving a 9-1-1 call indicating that a person was trapped in the building. This information had been provided by a Charleston Police 9-1-1 operator who had spoken to the trapped individual before transferring the call to Fire Dispatch. The Assistant Chief was inside the showroom when he heard the radio transmission to the Fire Chief and returned to the front entrance. The store manager and the assistant manager had previously assured him that everyone was out of the building. They subsequently noticed that the employee’s car was still in the parking lot and told the Assistant Chief that he must still be inside at the back of the building. At 19:27:55, the Fire Chief called the Assistant Chief and advised him that they had the door open to the back building and a stacked tip nozzle flowing water inside. The Assistant Chief responded that the managers had confirmed that an employee must still be in the building. The Fire Chief told the Assistant Chief, “Just do what we can do.” The Assistant Chief then walked around the east end of the building to the rear, accompanied by the two managers. When they reached the southeast corner of the building they encountered a locked gate blocking their path. At 19:28:42 the Assistant Chief called on his portable radio for “any firefighter that’s in front, up by number 11” to come to the rear to assist him. Battalion Chief 5 had just arrived at the front entrance when he met the Assistant Chief who was headed toward the rear of the building. He was attempting to assist Engineer 11 with a water supply problem when he heard the Assistant Chief calling for manpower. Four Saint Andrews firefighters, who had been advised of the trapped employee by a police officer, were approaching the front of the building at that time. These firefighters had arrived aboard Saint Andrews Engine 2 and Rescue 1. Battalion Chief 5 and three Saint Andrews firefighters went around the east end of the building to assist with the rescue. Saint Andrews Captain 2 called his Chief and asked him to bring the thermal imaging camera to the front of the building17. He also instructed the fourth Saint Andrews firefighter to obtain a circular saw from their apparatus. The firefighters forced entry through the gate and worked their way around to the rear of the building to the workshop area, where one of the managers indicated that the employee should be located. Based on the sound of the hammer and the manager’s directions, they began to cut a hole in the metal exterior wall of the workshop.

17

The Saint Andrews Assistant Chief attempted to deliver the thermal imaging camera to the Charleston Fire Chief who was unaware that it had been requested and said that it was not needed at that time.


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Almost immediately, the trapped individual stuck a hand out through the opening. The opening was quickly enlarged to allow the firefighters to pull the man to safety. At 19:31:19 Battalion Chief 5 reported “Car 5 to Dispatcher – we got the man.” Engine 3 was ordered to respond to the fire scene by the Fire Chief at 19:31:11. After acknowledging the order, the Fire Chief directed them to supply water to Ladder 5 when they arrived on the scene.

Photo 4: Saint Andrews firefighters escort the rescued civilian to the front of the building at approximately 19:33. (Photo courtesy WCIV)

Firefighters in Distress The recorded radio traffic included 16 distress messages that were transmitted by firefighters inside of the Sofa Super Store. Distress messages were recorded from Firefighter 16, Firefighter 5, and Engineer 5. The recordings included additional distress messages in which the firefighter speaking could not be identified. None of these messages were heard by a command officer on the scene. The first fragment of a distress message was recorded at 19:27:44 when an unknown firefighter is heard saying “… lost inside or … trapped inside”. The first clearly discernable distress message, “… which way out?” was transmitted by Firefighter 16 at 19:29:00. Firefighter 5 called for help at 19:30:22. Engineer 5 activated the emergency button on his portable radio at 19:34:40 and later identified himself on the radio. A complete transcript of all radio and telephone recordings is contained in Appendix B of this report.


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Engineer 6 was somewhere in the rear of the main showroom, enveloped in smoke, when a panic-stricken firefighter ran into him. Within seconds, other firefighters ran into Engineer 6 and one of them crawled between his legs. He was unable to identify the firefighters in the complete darkness; however, he had no doubt that they were disoriented and they were either running out of air or had already run out of air. Engineer 6 was only in contact with the firefighters for a few seconds. A moment later Engineer 6 encountered Firefighter 15A, who was also disoriented and running short of air. Firefighter 15A had located a charged 1-1/2 inch hose line on the floor and followed it to the nozzle. The line was entangled in furniture and he was unable to move it. At this point the heat conditions were becoming severe. Firefighter 15A lost contact with the hose line and realized that he was alone and lost in the smoke. He could not find Captain 15 in the area where they had been together a few moments earlier. When he met-up with Engineer 6, his low air pressure alarm was vibrating. Engineer 6 told Firefighter 15A that he was in contact with a hose line and they could use it to find their way out. They followed the line back until they could hear the sound of Engine 11, which was outside the main entrance. From that point they followed the sound until they were outside the building. They exited at approximately 19:33 hours. Engineer 6 then went back inside, following the hose lines toward the rear of the store. By this time, Captain 6 had located the 1-1/2 inch line and followed it to the nozzle. The atmosphere was very hot and flames were visible overhead. Captain 6 opened the nozzle and began flowing water, while Firefighter 6 attempted to pull more hose. Captain 6 believes that he was at the double doors and flowing water into the loading dock. Captain 6 operated the line for a few minutes and then shut down the nozzle to assess conditions. When he reopened the nozzle, water flowed momentarily and then stopped. He waited for the flow to be restored until flames began swirling overhead and the heat became too intense to remain in that area. At that point, Captain 6 abandoned the 1-1/2 inch nozzle and tried to find his way out. He was disoriented and his air supply was exhausted when he encountered Engineer 6. Engineer 6 led his Captain and Firefighter 6 back to the main entrance, exiting at approximately 19:35 hours.


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Photo 5: The crew of Engine 6 and Engineer 15 emerge from the structure. Battalion Chief 5 is breaking a window in the background. This photo was taken at 19:35:14. (Photo courtesy Bill Murton, Charleston Police Department)

Engineer 15, Firefighter 15B and Firefighter 11 also made their way out of the showroom at approximately the same time. Each of them had remained inside the showroom until their low air pressure alarms began vibrating and then followed the hose lines back to the main entrance. Firefighter 15A had obtained a replacement air cylinder for his SCBA and briefly reentered the showroom. He exited a second time as conditions inside the showroom became untenable.


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Figure 14: Conditions in the rear of the showrooms changed quickly, causing the firefighters to abandon their hose lines and attempt to find their way out of the building. The fire was extending from north to south inside the warehouse at the same time. (Approximate time 19:28 – 19:29)


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Reaction to Firefighters in Distress The first person outside the building to become aware that firefighters were in trouble inside was an off-duty Battalion Chief (Car 303), who was enroute to the scene in his personal vehicle. He heard traffic on his portable radio that indicated a firefighter was lost and unable to find his way out of the building. The radio traffic was not heard by anyone at the fire scene. Car 303 attempted to contact the Fire Chief at 19:30:27 to advise him of the situation, but was unable to establish contact on the busy radio channel. He continued to the fire scene as quickly as possible, parked his vehicle, and located the Fire Chief on the west side of the fire building, near the loading dock. The face-to-face exchange with Battalion Chief 303 was the Fire Chief’s first indication that firefighters were in distress. A series of radio messages between the Fire Chief and the Assistant Chief began at 19:33:08. At that time, the Assistant Chief was just returning to the front of the building after participating in the rescue of the trapped employee at the rear. The Fire Chief told him that someone had called a “Mayday” and asked if everyone was out at the front of the building. The Assistant Chief responded that firefighters were still inside the building at the front. A few seconds later he reported that Firefighter 15A had come out of the building, but that he had not called a “Mayday”. The Assistant Chief noted that conditions inside the showroom had deteriorated radically since he had left to go around to the rear of the building. The interior was now filled with smoke down to the floor and smoke was issuing from the front doors. The Fire Chief reached the front entrance at approximately 19:35. The Assistant Chief directed Battalion Chief 5 and two Saint Andrews firefighters to begin breaking the windows, hoping to provide visibility for the firefighters who were still insideF

18F. Captain 6, Engineer 6, Firefighter 6, and Engineer 15 all exited through

the main doors at 19:35, just as the first windows were being broken. Photographs indicate that there was severe heat stratification inside the store at the time the windows were broken. The images indicate that the temperature at the upper level was very hot, down to within 6 feet from the floor. The sequence of photographs indicates that outside air was initially drawn into the showroom when the windows were broken. Within approximately one minute the flow reversed and heavy smoke began to issue from the windows.

18

Neither the Fire Chief nor the Assistant Chief could recall directing anyone to break the windows. Several witnesses reported that the order was first given by the Fire Chief and then repeated by the Assistant Chief.


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Photo 6: Firefighters break out windows to the right of the store entrance. Note air being drawn into the broken windows to the left of the firefighters. The heat stratification inside the showroom is evident. This photograph was taken at 19:35:31. (Photo courtesy of Bill Murton, Charleston Police Department)


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Photo 7: Smoke begins to flow from the broken windows on both sides of the store entrance. This photograph was taken at 19:36:05. (Photo courtesy of Stewart English)

Rescue Attempt The Fire Chief directed two Saint Andrews firefighters (Firefighters SA1 and SA2) to try to enter the store to locate the missing firefighters. Battalion Chief 303, who had just arrived at the front entrance, and Engineer 6, who had obtained a fresh SCBA cylinder, also attempted to enter and conduct a search for the missing crews. The two search teams entered and penetrated a short distance into the store before the rapidly increasing heat forced them to retreat. Firefighters SA1 and SA2 reported that they were briefly in contact with at least one of the missing firefighters inside the showroom, but they were unable to hold onto him. Both rescue teams observed flames overhead and a flame front moving rapidly from the right rear quadrant of the main showroom toward the front. They described the furniture displays igniting progressively. The heat damaged their protective clothing and all of them suffered first and second degree burns as they crawled out. Flames began issuing from the front windows to the right of the main entrance within seconds after they escaped.


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The first flames came through the large windows to the west of the main entrance at approximately 19:37:37. The main showroom became fully involved in flames approximately one minute later as the fire spread across the front of the building from east to west. Within two minutes flames were issuing from all of the large windows across the front of the main showroom while the contents of the west showroom were igniting. At 19:38:09, the Fire Chief broadcast “Everyone abandon the building.” Captain 11 sounded the air horn on Engine 11 as a signal to abandon the building at approximately the same time. Firefighters SA1 and SA2 noted that the air horn was blowing as they were crawling back toward the front door. They were the last firefighters to escape from the building. Battalion Chief 303 and Engineer 6 made one last attempt to enter through the front of the building with a hose line. They were only able to advance a few feet before they were forced to back out.

PHASE FOUR OPERATIONS – AFTER 19:38 Defensive Strategy When the fire came through the front of the store, Engine 16 was pumping a single 2-1/2 inch supply line to Engine 11 at the front door. Engine 12 was pumping a single 2-1/2 inch supply line to Engine 10 in the alley on the west side of the fire building. Ladder 5 was setting up in the field to the west of the store, waiting for Engine 3 to provide a water supply. Engine 6, Engine 15, Engine 19, and Saint Andrews Engine 2 and Rescue 1 were all parked on Savannah Highway. Engine 3 arrived on the scene at 19:30:19. Initially, all the hose lines at the front of the structure led into the building and could not be used by firefighters on the exterior. The lines that had been stretched into the showroom remained charged until they were reported to be free flowing inside the building some time later. An additional 2-1/2 inch attack line was assembled and attached to a discharge on Engine 11. A booster line that had been spraying the ground below Engine 11 was moved to the door. The 2-1/2 inch line was charged, but the limited water supply available to Engine 11 rendered it ineffective. A second 2-1/2 inch handline began to operate at the front of the building at approximately 19:46.


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Photo 8: Firefighters flow a 2-1/2 inch handline at the front of the store. (Photo courtesy Charleston Post and Courier) Ladder 5 began to flow water onto the warehouse and the west showroom at approximately 19:46. Initially, Ladder 5 was supplied by a single 2-1/2 inch line. A second supply line was charged at approximately 19:52. Firefighters used Engine 19’s apparatus to lay an additional supply line. A partial collapse of the building façade occurred at approximately 19:50. Firefighters had been operating in the collapse zone moments earlier; however, no injuries occurred. A second partial façade collapse occurred at approximately 19:56. The roof of the west showroom began sagging into the store in stages beginning at approximately 19:52. The roof over the main showroom collapsed at approximately 19:56. Firefighters on the west side of the structure flowed several handlines into the warehouse and the loading dock area. At approximately 20:00, firefighters began opening holes in the west wall and flowed water into the west showroom.


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Firefighters on the east side of the structure forced entry to two sets of doors on the east wall. An entry was attempted when they heard the sound of a PASS device inside the building; however, they were forced to back out due to fire conditions. Firefighters also cut access panels into the south wall of the east showroom to search for the missing firefighters and attack the fire inside. Charleston Ladder 4 arrived on the scene at approximately 19:56. The ladder was backed into the parking lot near Engine 11 and the aerial tower was elevated. Ladder 4 began flowing water onto the main showroom and east showroom at approximately 20:03. The water supply for Ladder 4 was established by Saint Andrews Engine 4 using 4-inch supply line. Car 3, Ladder 1, Engine 1, and Engine 7 of the Saint Andrews Fire Department set up on Pebble Road to protect residential exposures from the fire that was consuming the warehouse. Handlines and a ladder pipe (elevated high-volume water stream) were used in these efforts. The ladder pipe went into service at approximately 20:03. The main and west showrooms burned extensively. The contents and interior finishes of these showrooms were almost completely consumed. Fire spread into the east showroom was limited because the three fire doors leading to that part of the building closed automatically. The full closure of one door was blocked by a piece of furniture. All of the contents of the east showroom were damaged to some extent, although the structure remained standing after the fire was brought under control. A number of units from surrounding fire departments, rescue squads, and Charleston County EMS responded to the scene or provided coverage from Charleston Fire Department stations. Most of the off-duty Charleston firefighters reported to the scene to offer their assistance. Missing Firefighters There was an immediate realization that one or more firefighters were missing inside the Sofa Super Store, although several individuals stated that they assumed, or at least hoped, that the missing individuals had found other exits and managed to escape. There was no command board or accountability system in place to identify the crews that had gone inside or who had come out. Firefighter 15A reported that he had lost track of his Captain somewhere inside the store and that Firefighter 15B could be with him. Several radio transmissions were made calling for Captain 15 or anyone from Engine 15; there was no response. Firefighter 15B was later located working on the exterior of the building on the west side, near Engine 10.


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A list of missing members was assembled by identifying apparatus on the scene and attempting to find the crew members assigned to each apparatus. Engine 11 was parked at the front of the building and Engineer 11 could not account for Captain 11 or Firefighter 11. They were subsequently located performing other tasks on the incident scene. The Ladder 5 crew members were not initially identified as missing, because their apparatus was in operation on the west side of the building and it was assumed that they were in the aerial platform of the ladder flowing water on the fire. It was later discovered that Ladder 5 had been repositioned and was being operated by off-duty personnel. All three members assigned to that company were missing. Captain 16 and Firefighter 16 were subsequently added to the missing list, along with Captain 19 and Firefighter 19. Engineer 19 was added to the list when it was determined that he was not with his apparatus. Recovery Operations When the main body of fire had been suppressed, the Fire Chief and senior officers conferred on how best to search for the remains of the missing firefighters. A team was assembled to begin searching the main showroom area at approximately 20:40 hours. They began their efforts walking on top of the collapsed roof. Void spaces were found in some areas that allowed firefighters to drop down under the deck to perform a search. At 21:08 firefighters discovered the remains of a firefighter. The firefighters believed that they had located Captain 15, the only firefighter known to be missing at that time. When the coroner arrived and the firefighter’s identification was located, the firefighter was identified as Engineer 19. At the time Engineer 19 was identified by the coroner, his name was not on the list of missing firefighters. The remains of Firefighter 19 were found in the same area a short time later. Hydraulic rescue tools and power saws were needed to remove the metal roof that had collapsed over the main showroom. After the roof decking and other wreckage had been removed from the area of the bodies, the County Coroner and a photographer came inside to document the scene. The remains were then packaged in body bags and carried out to the Coroner’s vehicle in rescue baskets. Additional search teams were organized to continue searching for the missing members. The recovery process continued through the night.


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Locations of Deceased Firefighters

The remains of all nine deceased firefighters were found in the main and west showroom buildings. The locations of the bodies suggest that all of the deceased firefighters were searching for ways out of the building when they either ran out of air or became incapacitated by the rapidly growing fire. The circumstances suggest they were lost in the heavy smoke and became disoriented.

Eight of the firefighters were last seen in the vicinity of the double doors that connected the west showroom to the loading dock, or headed in that direction. The ninth deceased firefighter (Captain 15) was last seen in the same general area, but the last surviving firefighter to see him alive, Firefighter 15A, believes that they were on the opposite side of the wall that separated the main and west showrooms. All of the deceased firefighters appeared to have been trying to move away from that area of the building. All of the deceased firefighters died from combination of smoke inhalation and/or thermal burns. These types of injuries are consistent with being lost or disoriented in a hazardous atmosphere or overwhelmed by rapidly developing fire conditions. Analysis of their air supplies indicates that they were all running out or had run out of air.

The evidence indicates that the structural collapse of the roof occurred after the firefighters were incapacitated or deceased. The roof of the main showroom did not collapse until almost 20 minutes after the interior became fully involved in fire. The roof collapse did not cause their deaths.


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Victim Locations 1 Engineer 19

2 Firefighter 19

3 Firefighter 16

4 Engineer 5

5 Captain 16

6 Captain 19

7 Captain 5

8 Captain 15

9 Firefighter 5

2-½ inch

Nozzle

1-½ inch

Nozzle

1 2

3

4

5

6

7

8

9

Savannah Highway Figure 15: Locations of the deceased firefighters as recorded by the Charleston County Coroner.


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ANALYSIS


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Fire Analysis Fire Origin The fire is believed to have originated outside the loading dock, adjacent to the wooden rampF

19F. Packing materials and discarded furniture were frequently piled

in this area, awaiting pick-up by a disposal service. The source of ignition is believed to have been discarded smoking materials: the area adjacent to the ramp was used by Sofa Super Store employees as a smoking area. A fire at this location could quickly spread to the loading dock via the crawl space under the wooden deck or through gaps between the sheet metal wall panels and the front of the deck. The fire could also enter the loading dock through a large ventilation fan opening or through gaps around the sliding doors. The information provided by the store employee who used a fire extinguisher inside the loading dock indicates that flames were initially observed around the door at the top of the ramp. The fire had extended into the loading dock by the time the first firefighters arrived and heat and smoke were already flowing into the holding room. The loading dock was approximately 2,200 square feet in area and contained a substantial quantity of furniture and other fuels, including containers of flammable liquidsF

20F. The dock was constructed of wood and the structure built to enclose it

was wood frame covered by sheet metal. The fire had immediate access to all of this fuel. The Assistant Chief and Captain 11 did not observe any indications of smoke or fire in the main showroom when they first entered. They could not see into the holding room as they passed through the main showroom and entered the west showroom. After entering the west showroom they observed a small quantity of smoke at the ceiling level, just inside the double doors. When the double doors were unlatched, the intensity of the fire was sufficient to suck the doors open and draw air from the showroom into the loading dock. They observed a free-burning fire involving the furniture on the loading dock. The main body of fire was to the right of the opening and flames were advancing toward the doorway.

19

The official investigation of the fire cause and origin had not been completed when this report was prepared. The information relating to fire cause and origin in this report is tentative and unofficial. 20

NIST fire protection engineers estimated the magnitude of the fire in the loading dock at between 50 and 125 MegaWatts.


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Fire Extension Analysis of the fire spread indicates that the fire extended from the loading dock into three separate areas of the Sofa Super Store complex:

1. Into the holding room and then into the interstitial void space above the main showroom:

2. Through the sheet metal wall into the interstitial void space above the west

showroom: 3. Through the sheet metal wall into the warehouse.

The fire probably was extending through the open doorway from the loading dock into the holding room when the double doors from the west showroom to the loading dock were opened, or soon after. Highly combustible cushions were stored on racks in the holding room and probably became involved in the fire very quickly. The fire in the holding room could not be observed from the showrooms. The burning furniture produced large quantities of thick smoke and hot fire gases. The visible smoke was rich in soot and particulates that obscured visibility, while the gases produced by the fire included large quantities of carbon monoxide, which is highly toxic. The gaseous mixture probably contained additional highly toxic products of combustion, including cyanides, along with a rich mixture of unburned or partially burned hydrocarbons that were released from the burning materials. The gaseous mixture was probably hot enough to burn, but lacked sufficient oxygen to ignite within the confines of the structure. The smoke and hot gases had direct access to the interstitial void space above the main showroom ceiling. The absence of a ceiling in the holding room provided an unobstructed path for the smoke and hot fire gases into this void and spread horizontally above the ceiling. The heat produced by the fire would have caused the sheet metal panels in the walls adjacent to the loading dock to deform, creating a series of gaps at the seams. The smoke and heated products of combustion would have penetrated through these gaps into the west showroom as well as the warehouse. Inside the west showroom a layer of gypsum wallboard had been installed on steel studs attached to the inner surface of the wall. The interior wall extended from the floor to a short distance above the suspended ceiling and would have caused any smoke and heat that penetrated through the sheet metal to be directed upward into the void space above the west showroom.


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The hot fire gases were probably flowing into and accumulating within the void spaces above the ceilings in both showroom areas by the time the first hose lines were being advanced into the building. The heated fire gases had access to the void spaces on both sides of the wall that divided the main and west showrooms, which caused the wall to be ineffective in limiting the spread of the fire. The rich mixture of hot flammable gases could accumulate and spread horizontally above the suspended ceilings, over the heads of the firefighters who had entered the showrooms. When the void spaces were filled, the smoke would have begun to bank down into the showrooms, obscuring their visibility. The presence of smoke and hot gases above the ceiling void spaces could have been detected from below by opening ceilings or, possibly, by scanning overhead with a thermal imaging camera. The only thermal imaging camera that was on the scene at that time was assigned to Ladder 5 and was not taken into the building. A second thermal imaging camera arrived on the scene with the Saint Andrews units. This is the camera that was offered to the Fire Chief and later used at the rear of the warehouse by Saint Andrews firefighters. The void space above the main showroom also enclosed the lightweight steel bar joists that supported the roof. This type of roof structure can collapse quickly and suddenly if the unprotected steel is exposed to the heat of a fire. The metal roofs retained the heat and fire gases inside the structures, causing them to spread horizontally over a large area. Vertical ventilation would have been the only feasible tactic to release the hot gases from the void spaces above the showrooms. Total containment of the fire would have required rapid vertical ventilation on three sides; north, south and east of the loading dock. The fire was probably extending into the warehouse at the same time that it was extending into void spaces above the showrooms. The only separation between the loading dock and the warehouse was a single thickness of sheet metal, with furniture in direct contact or in close proximity on both sides. The fire probably ignited contents inside the warehouse by conduction and/or radiation from the heated metal wall. Conditions inside the Main Showroom The atmosphere inside the showrooms was clear during the early stages of the incident. Several witnesses reported that the atmosphere inside the main showroom was still clear when the 2-1/2 inch back-up line was advanced and positioned near the double doors. Captain 16 first called for this line to be charged at 19:19:36 hours; however, it could not be charged until the supply line from Engine 16 to Engine 11 was charged.


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Captain 11 noted that the 1-1/2 inch line was operating inside the loading dock, through the double doors, when Captain 16 and Firefighter 16 arrived with the 2-1/2 inch line. Captain 5 was operating the nozzle, backed-up by Engineer 5. The members from Ladder 5 were using their self-contained breathing apparatus at that time. Captain 11 began using air from his SCBA while he was with Captain 16 in the rear of the west showroom, waiting for the 2-1/2 inch line to be charged. He encountered heavier smoke and heat in the main showroom on his way outside to determine why there was a delay in charging the line. This was at approximately 19:22 hours. Engine 15 reported on the scene at 19:17:30 hours and probably entered the showroom at approximately 19:19. The crew of Engine 15 encountered smoke and stopped to don their SCBA facepieces after entering the showroom. Captain 15 was recorded transmitting on his portable radio, through an SCBA, at 19:21:21 hours. Firefighter 15B reported that the smoke was so thick that he could not locate the other members of his crew after going outside to obtain a hose line. The Assistant Chief had donned an SCBA backpack after his first trip into the showroom. He recalled entering the showroom on multiple occasions, but did not recall using air from his SCBAF

21F. He met the crew of Engine 19 as they were

entering and directed them to the area where the interior lines had been deployed. He recalled that the crew members from Engine 19 were not using their SCBAs at that time. Engine 19 reported on the scene at 19:20:08 and the crew members probably entered the main showroom at 19:21 or 19:22 hours. The crew of Engine 6 reported heavy smoke and zero visibility in the showroom when they entered at approximately 19:23 hours. They noted that there was a clear area just inside the front doors, but the smoke was banked down to the floor beyond that point. All of the observations are consistent with smoke entering or banking down into the main showroom at approximately 19:22 hours. This suggests that the interstitial space above the ceiling had filled with smoke by that time and the smoke began to bank down into the showroom. A rapid change in smoke conditions could have been caused by circumstances that allowed more air to reach the fire, such as a partial collapse of the loading dock roof.

21

The radio recordings captured three transmissions from Car 2 at 19:23 and 19:24 hours in which it sounds like he is using an SCBA. He did not recall using air from his SCBA.


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The surviving firefighters also reported that the atmosphere became hotter with the passage of time and as they penetrated deeper into the showroom. The temperature above the ceiling was increasing as the fire progressed. The firefighters were probably encountering a combination of radiant heat from above and a convective flow of the hot gases in the upper part of the showroom. Firefighter 15B reported that he began to operate the booster line while he was somewhere in the main showroom. He stated that he was enveloped in smoke and could feel the increasing temperature. He began to flow water when he saw a red glow in the direction of the ceiling. It was not possible to determine if he actually observed flames at the ceiling level or through a ceiling vent. The glow might have been produced by the overhead lights or some other source that was obscured by the smoke. Conditions inside the West Showroom The sequence of events suggest that conditions in the rear part of the west showroom changed, either gradually or suddenly, and that all of the firefighters who were operating in that area abandoned their hose lines and began searching for ways out of the building. It is impossible to determine the exact sequence of events that occurred, although the critical time was close to 19:27. The radio transmissions from firefighters in distress began at 19:27 and continued until approximately 19:35. Engineer 6 encountered the three lost firefighters in the rear section of the middle showroom at approximately 19:30. The showrooms had filled with smoke approximately 5 minutes before the situation became critical. During that period, the firefighters were operating in near-zero visibility conditions and encountering increasing temperatures. A sudden change of conditions could have been caused by the collapse of a section of the ceiling in the rear portion of the main showroom; this event would have suddenly released a large quantity of superheated fire gases from the interstitial void space down into the showroom, subjecting firefighters to intense heat and causing the contents of the showroom to become involved in the fire. The ceiling failure could have been precipitated by the ignition of gases in the void spaces or by mechanical failure of the ceiling support system. It is also possible that a rapid acceleration of the fire, caused by the ignition of fire gases and flammable vapors in the loading dock or a change in the air flow to the fire, could have pushed the fire through the double doors and overwhelmed the rear part of the west showroom. The rapid fire growth would have forced the firefighters to abandon their positions.


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Engineer 10, who was operating his apparatus on the west side of the building, reported that he observed the eruption of a fireball from the southeast quadrant of the loading dock, near the point where the connecting corridor met the warehouse. This eruption was followed by a puff of dark smoke pushing out from the void space above the west showroom. Numerous one gallon containers of flammable liquids were stored in the area where the fireball was observed. Engineer 10 was the only firefighter who reported this observation and he could not pinpoint the time when it occurred. A series of photographs taken on the west side of the building begins at approximately 19:23 hoursF

22F. These photographs show heavy smoke and flames

at the roof level, above the west showroom, extending toward the front of the building. Subsequent photos and videos show smoke issuing from below the roof along the west side of the building. The photos establish that the fire had extended into the void space above the west showroom at that time; however, there is no evidence to make a determination if there was fire in this space earlier than 19:23.

Photo 9: Fire visible from the roof of the retail area. This photo was taken at 19:23:16. (Photo courtesy of Dan Folk)

22

The referenced photos are the earliest series showing the west side of the building that were obtained during the investigation. Several photographers provided images that were taken during the following minutes.


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Photo 10: Fire visible from the roof of the retail area. This photo was taken at 19:23:46. (Photo courtesy of Dan Folk

Photo 11: Fire Visible from the roof of the retail area. This photo was taken at 19:24:07. (Photo courtesy of Dan Folk)


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Interior Hose Lines After the fire, both of the hose lines that had been stretched to the rear of the showrooms from Engine 11 (one 1-1/2 inch and one 2-1/2 inch) were found on the floor of the west showroom near the double doors. The position of the 2-1/2 inch line suggests that water never flowed from the nozzle23

F. Three different individuals were reported to have operated a 1-1/2 inch hose line in the vicinity of the rear part of the west showroom, although there was only one 1-1/2 inch line inside the showroom buildings during that time period. This leads to the conclusion that they each had the same line at a different time. The crew of Ladder 5 initially operated this line inside the loading dock. Firefighter 15A found the nozzle on the floor at around 19:28 or 19:29 and attempted to pull it free. The firefighters who had been operating the line had obviously abandoned it and left the area before Firefighter 15A arrived. He subsequently abandoned the nozzle due to the increasing temperature and his inability to untangle the hose. Captain 6 found the 1-1/2 inch nozzle on the floor shortly after Firefighter 15A had abandoned it. Captain 6 flowed water for two or three minutes before the line lost pressure and finally abandoned it at approximately 19:33 hours. The location where Captain 6 abandoned the 1-1/2 inch nozzle was in the immediate area where the deceased firefighters had been operating and within a few feet of the 2-1/2 inch nozzle. Path of Fire through the Showrooms Witness observations, photographs, videos, and examination of the fire debris all indicate that the fire advanced very rapidly through the main showroom, from the rear to the front, shortly after the windows at the front of the building were broken. The rate of fire growth was limited by the air supply (ventilation controlled) as long as the windows were in place. When the windows were broken, the fresh air supply allowed the fire to grow and progressively ignite the contents of the showroom. The fire then advanced across the front of the building into the west showroom. There is ample evidence that breaking the windows provided air to the fire and accelerated the ignition of the showroom contents. The windows were broken at approximately 19:35 and the interior of the main showroom became fully involved within three to four minutes.

23 At 19:26:17, Engineer 16 radioed Engineer 11 to advise that he was charging the supply line.

At 19:29:02 Engineer 11 transmitted a message indicating that ”water’s coming right now,” which suggests that he was charging the 2-1/2 inch line at that time. The first radio transmissions indicating that firefighters were in distress inside the building were recorded at approximately 19:28.


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Breaking the windows probably accelerated the flashover sequence that occurred in the main showroom; however there were very few options available at that time. Firefighters were lost and either out of air or running out of air inside the building. The interior was filled with heavy smoke and heat that had banked down from the ceiling to approximately six feet above the floor. If the windows had not been broken, the atmosphere probably would have become ripe for a backdraft to occur within a short time. The most appropriate manner to release the hot smoke and fire gases from the interior of the building under these circumstances would have been vertical ventilation, but opening the roof was not a feasible option at that point in time. There were not enough fire fighting resources, firefighters or equipment, on the scene at this point to mount an effective roof operation and time was a critical factor. The roof structure was likely compromised at this point and a roof operation would have been extremely risky, if the resources had been available. Breaking the windows was the only option that could have possibly released enough smoke to allow any of the firefighters to find their way out of the building – there was no better option available once the incident had progressed to these conditions. From the exterior, the fire appeared to advance through the main showroom from the rear to the front and then quickly spread across to the west showroom. The fire damage in the mid-section of the west showroom was less severe than the front and rear areas. This could be an indication that the fire initially entered the rear part of the west showroom from the loading dock and a second wave entered from the main showroom at the front of the building. There was heavy fire inside the west and main showrooms, on opposite sides of the dividing wall, at approximately the same time. All three fire doors in the wall between the main and west showrooms failed to close, although the fusible links operated and caused the mechanisms to release. If the fire doors had closed, the firefighters who were in the west showroom would have been trapped in this part of the building. The only exit from the west showroom was locked and the fire doors would have come down on the hose lines, potentially interrupting the flow of water. Two of the three fire doors that separated the east showroom from the main showroom did close. The third fire door released and closed partially, but was prevented from fully closing by a coat rack that was in its path. The fire spread to the east showroom; however, the damage in this area was considerably less severe than the other showroom areas.


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Fire Extension to Warehouse The fire extension into the warehouse created a second major fire that was at least equal in magnitude to the fire in the showroom buildings. The fire spread through the sheet metal wall that separated the loading dock from the warehouse and ignited furniture that was stored adjacent to the wall. After entering the warehouse the fire spread to the racks of furniture that filled the interior of the building. The fire in the warehouse was first observed at approximately 19:20 hours and captured the attention of firefighters who were working in the vicinity of the loading dock. The large fire in the warehouse distracted the Fire Chief and other firefighters from observing the indications of fire extension into the void space above the west showroom. Two additional 2-1/2 inch lines (from Engine 10) were established to attempt an attack on the warehouse fire. By the time entry could be made into the warehouse, the situation was too dangerous for firefighters to conduct interior operations. The Saint Andrews companies that were assigned to the south side of the warehouse quickly reached the same conclusion. A thermal imaging camera that was taken inside the warehouse from the entrance near Pebble Road showed the fire was advancing quickly from north to south and was beyond the ability of firefighters to control. A defensive strategy was implemented to protect the residential exposures.


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Analysis of Fire Department Operations


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Incident Management The analysis of operations conducted at the scene of the Sofa Super Store fire begins with an examination of the organization that was established and the procedures that were implemented to direct and coordinate the efforts of firefighters. Incident Commander The Incident Commander is the individual with overall responsibility for directing operations. The identity of the Incident Commander may change as the operation is conducted; however, there is always one (and only one) individual in overall command of the incident at any point in time. The essential responsibilities of an Incident Commander are listed in NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, and include:

(1) Arrive on-scene before assuming command

(2) Assume and confirm command of an incident and take an effective command position

(3) Perform situation evaluation that includes risk assessment

(4) Initiate, maintain, and control incident communications

(5) Develop an overall strategy and an Incident Action Plan (IAP) and assign companies and members consistent with the standard operating procedures

(6) Initiate an accountability and inventory worksheet

(7) Develop an effective incident organization by managing resources, maintaining an effective span of control, and maintaining direct supervision over the entire incident, and designate supervisors in charge of specific areas or functions

(8) Review, evaluate, and revise the incident action plan as required

(9) Continue, transfer, and terminate command


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The Incident Commander is expected to evaluate and continually reevaluate the situation and to determine the appropriate strategy based on risk management considerations. The Incident Commander is also expected to assign resources and direct a coordinated fire suppression operation.

The first arriving unit at the Sofa Super Store fire was Battalion Chief 4. He performed a rapid visual size-up of the situation on the west side of the building and directed the positioning of the first arriving engine company. He did not formally assume command and did not perform the listed functions of an Incident Commander. When the Assistant Chief arrived, less than 60 seconds behind him, Battalion 4 took a position on the west side of the fire building.

According to Charleston Fire Department practice, the Assistant Chief

became the Incident Commander upon arrival, by virtue of his rank. He did not formally assume command of the incident or establish a fixed command post. He spoke briefly to Battalion 4 near the northwest corner of the fire building and then went inside the building to perform personal reconnaissance.

The Assistant Chief supervised tactical operations at the front of the

building and inside the showrooms. He reported that he entered the showroom on two or three occasions to observe the situation. He abandoned his post at the front of the building to become personally involved in the rescue of a civilian at the rear.

According to Charleston Fire Department practice, the Fire Chief became

the Incident Commander by virtue of his rank from the time of his arrival. He did not formally assume command or establish a fixed command post. He met briefly with the Assistant Chief at the northwest corner of the building, before taking personal responsibility for operations on the west side of the building. No chief took overall command of the entire incident scene. The Fire Chief operated at the tactical level, directly supervising task level work.

The Fire Chief became directly involved in supervising tactical operations

in the vicinity of the loading dock and the warehouse during the critical phase of the incident. This should not be the role of the Incident Commander. He was not in a position to view or to manage the overall incident.

The Fire Chief and the Assistant Chief were operating independently,

supervising operations in different areas. There was no effective coordination between them.


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There was no systematic size-up of the situation (360o view) and no one was in a position to view the overall incident scene.

There was no overall strategy for attacking the fire. Operations were

conducted independently from two different sides of the incident.

There was no accountability system in place to keep track of the position, function, and status of companies and members operating in different areas.

The communications process was not controlled. The Fire Chief, the

Assistant Chief, and Battalion Chief 4 were all issuing orders and providing direction independently, using a single overloaded radio channel. Critical messages, including distress message from firefighters inside of the structure, were not heard.

Strategy The Incident Commander is responsible for determining the strategy that will be used to conduct fire fighting operations and for the formulation of a plan to implement that strategy through tactical assignments. The strategy – either offensive or defensive – defines the overall plan that will be used to attack the fire. At the Sofa Super Store incident, the absence of an effective overall Incident Commander and an appropriate command structure resulted in the establishment of two separate operational commands. Both teams were attempting to attack the fire simultaneously, with no coordination between them. The two groups attempted to conduct simultaneous offensive attacks into the loading dock from diagonally opposite directions. Both offensive attacks were unsuccessful and the firefighters were forced to retreat. The firefighters who were attacking from the west side were close to an exit and were able to escape when the increasing volume of fire forced them to retreat. The fire that burned through their hose line created a heavy protective spray that allowed them to make a safe escape from an extremely dangerous situation. The firefighters who were attempting to attack the fire from the front of the building were approximately 200 feet inside a complex building when the situation became untenable, forcing them to abandon their attack. Nine firefighters lost their lives because they were too deep inside a highly combustible smoke-filled building and could not find their way back to the entrance or locate alternative exits before they ran out of air or were overwhelmed by the fire.


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The offensive strategy was appropriate during the first stage of the operation, based on the conditions that were observed. The Assistant Chief believed that the fire could be contained within the loading dock. If the offensive strategy had been successful, the incident would have had a positive outcome – the fire in the loading dock would have been suppressed and any fire extension into the adjacent areas would have been stopped before it could spread. The initial evaluation of fire conditions was based on incomplete and partially erroneous information. The Assistant Chief believed that the walls between the loading dock and the showrooms were brick construction and that the fire could be stopped at the double doorway. He was unaware of the unprotected opening from the loading dock into the holding room, as well as the direct exposure of the warehouse to the loading dock. At a critical point, the fire fighting strategy should have changed from offensive to defensive and the firefighters operating inside the showrooms should have been withdrawn. The decision to withdraw the interior companies should have been based on several factors:

The fire in the loading dock was not controlled; Companies were operating deep inside a building with only one identified

exit;

The interior of the building was difficult to navigate and contained a very high fire load;

The interior of the building had filled with smoke, reducing visibility to zero;

No ventilation actions had been initiated to relieve the smoke condition;

The companies that were working inside the showroom had only one

operating hose line with a very limited water flow capability;

The engine company that was supplying that line did not have a continuous water supply;

A larger hose line had been stretched and positioned to back-up the first

line; however the line could not be charged since a water supply had not been established to Engine 11 and only tank water was available at this point;

There was visual evidence (that was not observed by any fire officer or

firefighter) that the fire had extended into the void space directly above the area where the firefighters were operating;


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There was no Rapid Intervention Team in place and no back-up resources were available at the fire scene. Resources were committed to tactical operations as quickly as they arrived.

The decision to switch from offensive to defensive strategy should have been made early enough to allow the firefighters who were operating inside the showrooms to withdraw safely. This critical decision was not made, because there was no effective Incident Commander coordinating the operation, continually revaluating the situation, and providing overall direction. The Fire Chief made a tactical-level decision to switch to a defensive strategy on the west side of the fire, when he directed the firefighters from Engine 10 to hold their position at the doorway and not attempt to reenter the loading dock with their hose line. The firefighters who were operating inside the showrooms probably could have escaped safely if the same decision had been made at a strategic level (for the entire incident), and implemented through an appropriate incident command structure. Risk Management Risk management is the fundamental factor that must be considered in determining the appropriate strategy for each situation. The determination of the appropriate strategy provides the basis for planning, organizing and conducting the overall operation. The cornerstone considerations for risk management are incorporated into the Ten Rules of Engagement for Structural Firefighting, published by the International Association of Fire Chiefs.

RISK ASSESSMENT

IT IS THE RESPONSIBILITY OF THE INCIDENT COMMANDER TO EVALUATE THE LEVEL OF RISK IN

EVERY SITUATION. THIS RISK EVALUATION SHALL INCLUDE AN ASSESSMENT OF THE

PRESENCE, SURVIVABILITY AND POTENTIAL TO RESCUE OCCUPANTS. WHEN THERE IS NO

POTENTIAL TO SAVE LIVES, FIREFIGHTERS SHALL NOT BE COMMITTED TO OPERATIONS THAT

PRESENT AN ELEVATED LEVEL OF RISK. AN INCIDENT COMMAND SYSTEM SHALL BE ESTABLISHED, BEGINNING WITH THE ARRIVAL OF

THE FIRST FIRE DEPARTMENT MEMBER AT THE SCENE OF EVERY INCIDENT. THE INCIDENT

COMMANDER MUST CONDUCT AN INITIAL RISK ANALYSIS TO CONSIDER THE RISK TO

FIREFIGHTERS IN ORDER TO DETERMINE THE STRATEGY AND TACTICS THAT WILL BE

EMPLOYED.


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THE RESPONSIBILITY FOR RISK ASSESSMENT IS A CONTINUOUS PROCESS FOR THE ENTIRE

DURATION OF EVERY INCIDENT. THE INCIDENT COMMANDER SHALL CONTINUALLY

REEVALUATE CONDITIONS TO DETERMINE IF THE LEVEL OF RISK HAS CHANGED AND A CHANGE

IN STRATEGY OR TACTICS IS NECESSARY. THE INCIDENT COMMANDER SHALL ASSIGN ONE OR

MORE SAFETY OFFICERS TO MONITOR AND EVALUATE CONDITIONS TO SUPPORT THIS RISK

ANALYSIS. AT A MINIMUM THE RISK ANALYSIS FOR A STRUCTURE FIRE SHALL CONSIDER:

BUILDING CHARACTERISTICS o CONSTRUCTION TYPE AND SIZE o STRUCTURAL CONDITION o OCCUPANCY AND CONTENTS

FIRE FACTORS

o LOCATION AND EXTENT OF THE FIRE o ESTIMATED TIME OF INVOLVEMENT o WHAT ARE THE SMOKE CONDITIONS TELLING US?

RISK TO BUILDING OCCUPANTS

o KNOWN OR PROBABLE OCCUPANTS o OCCUPANT SURVIVAL ASSESSMENT

FIRE FIGHTING CAPABILITIES

o AVAILABLE RESOURCES OPERATIONAL CAPABILITIES AND LIMITATIONS

TEN RULES OF ENGAGEMENT FOR STRUCTURAL FIRE FIGHTING

ACCEPTABILITY OF RISK: 1. No building or property is worth the life of a fire fighter 2. All interior fire fighting involves an inherent risk 3. Some risk is acceptable, in a measured and controlled manner. 4. No level of risk is acceptable where there is no potential to save lives or property 5. Fire fighters shall not be committed to interior offensive fire fighting operations in

abandoned or derelict buildings.

RISK ASSESSMENT: 1. All feasible measures shall be taken to limit or avoid risks through risk

assessment by a qualified officer. 2. It is the responsibility of the Incident Commander to evaluate the level of risk in

every situation. 3. Risk assessment is a continuous process for the duration of every incident 4. If conditions change and risk increases, change strategy and tactics. 5. No building or property is worth the life of a fire fighter.


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RISK ASSESSMENT RULES OF ENGAGEMENT FIRE FIGHTER

INJURY/LIFE SAFETY RISK

HIGH PROBABILITY OF

SUCCESS

MARGINAL PROBABILITY OF

SUCCESS

LOW PROBABILITY OF

SUCCESS

Low Initiate Offensive operations. Continue to monitor risk factors.

Initiate Offensive operations. Continue to monitor risk factors.

Initiate Offensive operations. Continue to monitor risk factors.

Medium

Initiate Offensive operations. Continue to monitor risk factors. Employ all available risk control options.

Initiate Offensive operations. Continue to monitor risk factors. Be prepared to go defensive if risk increases.

Do not initiate offensive operations. Reduce risk to fire fighters and actively pursue risk control options.

High

Initiate Offensive operations only with confirmation of realistic potential to save endangered lives.

Do not initiate offensive operations that will put fire fighters at risk for injury or fatality.

Initiate Defensive operations only.

The risk management guidelines are intended to assist the Incident Commander in identifying the appropriate strategy for a particular situation.

Offensive strategy involves committing firefighters to conduct an interior fire attack. The objective of an offensive attack is to control and extinguish the fire within the area that is already burning, while preventing extension to any of the exposures.

Defensive strategy is directed toward confining a fire within a defined area,

while keeping firefighters outside and in safe operating positions. The IAFC Acceptable Risk Guidelines would support the initiation of an offensive attack during the initial stage of the Sofa Super Store incident, if the Incident Commander believed the fire could be contained to the loading dock without exposing firefighters to excessive risk. (This situation would be classified as Medium Risk and Marginal Probability of Success.) The fire that was burning in the loading dock presented a significant tactical challenge. The fire involved a relatively large space (approximately 2,200 square feet) that was filled with highly combustible contents. A successful offensive attack would have to deliver sufficient fire flow (water) to overcome the volume of fire within this space. The situation was greatly compounded by the circumstances. Access to the fire area was difficult and the building configuration created immediate exposures on three sides. In addition to delivering a powerful attack to suppress the fire within the loading dock, the Incident Commander would have to ensure the fire did not extend into any of the exposures.


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The Incident Commander was responsible for determining whether the available fire fighting resources had the ability to control and/or contain the fire and whether this action could be accomplished safely. The risk assessment should have changed as additional information was obtained and fire conditions were re-evaluated. If the Incident Commander lacked the capability to conduct a safe and effective offensive fire attack in the time that was available, the strategy should have changed to defensive. As soon as the fire extended into the void spaces above the showrooms, the situation exceeded the capability of the Charleston Fire Department to control the fire with an offensive strategy. Multiple large hose lines would have been required to stop the spread of hot fire gases within the void spaces. The hose lines would have to be operated by crews operating inside the showrooms and opening ceilings to attack the fire. This attack would have to be coordinated with vertical ventilation, opening holes in the roof to release the trapped smoke and fire gases. The Charleston Fire Department did not have the resources, training, or leadership that would have been required to conduct an operation of this size and complexity in the limited time that was available. A risk management analysis at that point would have determined that attempting to conduct an interior offensive fire attack under these circumstances placed firefighters in conditions of unacceptable risk. (The risk analysis would classify this situation as High Risk and Low Probability of Success.) The revised risk analysis would dictate a switch to defensive strategy and the withdrawal of all firefighters from interior positions. Fire Fighting Tactics The offensive attack into the loading dock area was unsuccessful for three primary reasons:

1. The attack was attempted with hose lines that were inadequate for the size of the space and the volume of fire;

2. The offensive attack was not supported by vertical ventilation;

3. The fire extended into the exposures on three sides of the loading dock.

Two 1-1/2 inch preconnected hose lines were advanced into the loading dock, one by Ladder 5 from the showroom and one by Engine 10 from the exterior. Each attack line was configured to flow 60 gallons per minute, even though the nozzles had higher available settings. The combined flow of 120 gallons per minute was insufficient to control a fire in an area of more than 2,200 square feet that was loaded with highly combustible furniture.


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The additional 2-1/2 inch hose line that was advanced through the showroom by Engine 16 would have increased the total flow to approximately 376 gallons per minute. This line was never operated due to the water supply deficiency. If this line had been charged, the resulting flow rate probably would have been insufficient to control the volume of fire in the loading dock. The most commonly used fire flow formula used in the United States is the one developed by the National Fire Academy. Using this formula (square feet divided by 3 equals necessary fire flow) at least 733 gallons per minute would have been required to suppress the fire within the loading dock. The two 1-1/2 inch attack lines were advanced into the loading dock from opposing directions by Ladder 5 through the double doors and by Engine 10 from the exterior. The line operated by Ladder 5 may have contributed to the deteriorating conditions that caused the Engine 10 crew to begin backing out however, this is unlikely. When the limited flows are compared with the volume of fire in the loading dock, the opposing hose lines probably had very little influence on each other24

F. Neither line was positioned to prevent the fire from extending into the holding room, which was the most vulnerable direction for fire extension. The fire was probably extending into the holding room before the interior attack was initiated. No horizontal or vertical ventilation measures were initiated to support the offensive attack. Vertical ventilation was needed to release the hot fire gases that were trapped inside the building and spreading throughout the void spaces. The ladder company, which would normally be expected to provide ventilation, was operating one of the hose lines. No ceilings were opened in the showrooms to check for fire extension into the void spaces. The thermal imaging camera from Ladder 5 was not brought into the building. The thermal imaging camera would have allowed firefighters to scan the ceilings for indications of fire in the void spaces and also might have helped them find their way out of the smoke-filled building. When the fire extended into the warehouse at the rear of the property, two additional 2-1/2 inch hand lines were deployed to initiate an additional offensive attack into the much larger space. The two additional lines overwhelmed the water supply that was available to Engine 10, resulting in reduced flows to all of the lines that were operating on the west side of the fire. The flow from the two lines had no impact on the volume of fire inside the large warehouse.

24 Captain 10 reported that he sensed the presence of a second line inside the loading dock, but was driven out by the increasing intensity of the fire and the rupture of the hose line.


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Situational Awareness The Incident Commander has the ultimate responsibility for making the determination when strategy should be changed and firefighters should be withdrawn from interior positions. This requires the Incident Commander to maintain situational awareness at all times. At a large scale incident, where it is impossible to monitor the overall situation from one vantage point, the Incident Commander has to establish an appropriate command structure and rely on subordinate officers to provide progress and condition reports from different perspectives. At the Sofa Super Store incident, the Fire Chief and the Assistant Chief were operating independently. Neither command officer was aware that the situation inside the showrooms had changed and the risk factors had become critical. The factors that should have caused them to switch to a defensive strategy were not recognized and the critical information was not communicated. The Assistant Chief neither conducted an overall size-up when he arrived on the scene nor assumed an effective command position that would have allowed him to observe the overall situation and manage resource. He went inside the building to personally evaluate conditions and became personally involved in tactical operations. His attention was focused on one side of the fire. When the Fire Chief became the Incident Commander, the Assistant Chief became responsible for supervising operations at the front of the building and inside the showrooms. At that point he should have been closely monitoring conditions inside the building - either directly or by continually communicating with company officers who were inside the showroom. He also should have been managing and keeping track of the companies that were operating inside the building. He should have known where the interior companies were operating and what they were doing. When the interior began filling with smoke and the temperature began increasing significantly, he should have directed those companies to withdraw and immediately advised the Incident Commander, recommending a change in strategy. When the trapped civilian was reported, the Assistant Chief left his position at the front of the building and went around to the rear to personally supervise the rescue operation. He only became aware of the changing conditions inside the showrooms when he returned to the front door after the civilian had been rescued. The situation inside the building had changed radically during his absence. The Fire Chief became the Incident Commander within the first 8 minutes of the incident. He had a brief view of the front of the building when he arrived and conferred with the Assistant Chief before assigning himself to direct tactical operations on the west side of the fire.


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The Fire Chief should have established a command post in a location that allowed him to view the overall situation and direct operations at a strategic level25

F. An exterior Command Post position would have allowed him to assemble information from officers assigned to supervise tactical operations in different areas and provide direction to them. The Fire Chief’s position on the west side of the building, directly in front of the loading dock, afforded a very limited view of the fire scene and he became preoccupied with supervising tactical operations within that limited area. The Fire Chief’s attention was initially focused on attacking the fire in the loading dock. The subsequent extension of the fire into the warehouse captured his attention for several minutes while he directed companies to set-up for an offensive attack into that buildingF

26F. He then became distracted by water supply

issues involving Engine 10 and Engine 12, and later with providing a water supply for Ladder 5. (Ladder 5 was being set-up on the west side of the building.) The Fire Chief did not become aware of the critical situation occurring inside the showrooms until off-duty Battalion Chief 303 arrived on the scene and told him what he had heard on the radio. He did not have overall situational awareness and had assumed that the Assistant Chief was conducting a successful operation to keep the fire from extending into the showrooms. Miscommunication between the Fire Chief and the Assistant Chief contributed to the lack of situational awareness. At 19:23:09 the Fire Chief asked. “Alright, Larry, how we looking inside the store?” and the Assistant Chief replied, “I’m trying to get back to it now.” This message was interpreted as “We’re getting to it now,” which caused the Fire Chief to believe that the risk of fire extension into the showrooms had been alleviated.

25

The usual location for a fixed command post would be “Side A” – directly in front of the building. Because the fire was on the west side at the rear of the building and the parapet blocked the view from Side A, a more appropriate location for a fixed command post would have been northwest of the building. If the Command Post had been established directly in front of the building, an officer could have been assigned to observe operations from the northwest position and keep the Incident Commander updated. 26

Once the fire entered the warehouse, that building and its contents were essentially lost. Several firefighters, who could have performed more critical tasks, were assigned to force entry and to prepare hose streams to attempt an interior (offensive) attack into the warehouse. From the outset, a defensive strategy was appropriate for the warehouse.


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Pre-fire Plan The Charleston Fire Department routinely conducts pre-fire planning visits at properties that were considered to be high fire risks. Pre-fire planning serves two major purposes:

Pre-fire planning visits make firefighters aware of the general arrangement and specific details of properties where they may have to fight a fire or conduct other emergency operations.

Pre-fire plans (information gathered during pre-fire planning visits) can

provide valuable information that will assist a command officer in managing an incident at a specific property. This information is particularly valuable when the property is large and complex or when an incident could involve unusual risks or hazards to firefighters.

In addition to the familiarization and planning aspects of pre-fire planning, the process of visiting properties and gathering information often identifies fire hazards, unusual risks and situations that require special attention. The appropriate action can vary from providing information or recommendations to the business or property owner to referring a situation for follow-up by code enforcement personnel. The most recent pre-fire planning visit to the Sofa Super Store property had been conducted on April 26, 2006 by crews from Fire Station 11. An information form was filled-out and a sketch of the building layout was placed in the file. (A copy of the pre-fire plan is provided on the following pages.). The sketch provided a very rough floor plan of the showroom buildings, but did not include any details of the warehouse, loading dock or other spaces that were located behind the three showroom buildings. The critical details of the connections between the loading dock and the showrooms were not documented. Knowledge of the building construction and arrangement would have allowed the Incident Commander to recognize the risk of fire extension in multiple directions and to identify key points to attempt to stop the fire. This information could have been provided by a more detailed pre-fire plan. A complete pre-fire plan would have allowed the command officers to recognize the risk of fire extension from the loading dock into the west and main showroom buildings, as well as the warehouse. The presence of a lightweight steel truss roof over the main showroom also should have been noted.


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The command officers at the scene of the fire did not have access to the limited pre-fire plan information that had been obtained or to any other information about the building:

They were not aware of the complex building configuration; They did not know the specific locations where a fire could easily extend

from the loading dock into the adjacent areas; They did not know which walls were fire walls.

A detailed pre-fire plan would have provided information on the building construction and arrangement, contents, access points, exposures, hydrant locations, available flows, and other factors that could have been extremely valuable in managing the incident.


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Figure 16: Pre-fire plan information sheet, completed April 26, 2006.


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Figure 17: Pre-fire plan sketch.


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The Charleston Fire Department members assigned to the incident had varying degrees of familiarity with the Sofa Super Store. Most of the firefighters who were assigned to companies in the West Ashley area were generally familiar with the Sofa Super Store and recognized the potential for a major fire at that location. In addition to conducting pre-fire planning visits, several of the firefighters had shopped in the store; others had picked-up discarded furniture from the area where the fire originated for use in training exercises. The Assistant Chief shopped for furniture in the store during the week before the fire and was familiar with the showroom layout. In an interview conducted during the investigation he stated that he would not have committed firefighters to fight a fire in the showrooms, based on their size, arrangement, and fuel load. He also stated that he did not observe indications of fire or heavy smoke inside the showrooms until after the civilian rescue was accomplished. None of the firefighters interviewed during the investigation were familiar with the complex arrangement of the buildings at the rear of the property or the construction details.


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Communications Communications problems and deficiencies played a very significant role in the Sofa Super Store fire. Both operational and technological communications problems were encountered. The single radio channel used during the fire was severely overloaded and the communications process was not controlled at the command level. The recorded radio traffic includes numerous messages that were either missed or misunderstood due to the volume of traffic and the lack of control over the communication process. The most critical messages that were not successfully communicated were the transmissions from firefighters who were in distress inside the building. All three command officers on the scene during the early stages of the incident issued instructions over the radio to companies that were enroute or as they arrived. The instructions to companies were very brief, such as “Come to the front door and get me a 2½ and bring the 2½ in here” or “I want you to come on and park your truck in the middle of the street on Savannah Highway and come in the front door.” In most cases the response to an assignment was either “copy” or “10-4” and several instructions were not acknowledged. Some of the assignments changed before the company arrived on the scene. Company officers interviewed after the incident indicated they had a general notion of what the chiefs wanted them to do, or at least where to go, with the overall understanding that the plan was to go inside the building and attack the fire. In most cases the companies determined the specific action to be taken based on their on their own perceptions of the situation. The Charleston Fire Department operates on an 800 MHz analog trunked radio system that is shared with the Charleston Police Department. The radio system provides several optional talk groups for Fire Department use; however all of the radio traffic relating to the Sofa Super Store incident was conducted on “Fire 1” which is also used as the primary dispatch channelF

27F. The single talk group was

severely overloaded with the heavy radio traffic that was generated by the incident. Additional information about the Charleston Fire Department communications system is provided in Appendix E. The Department’s operational policy at the time of the incident left the decision to the Incident Commander to determine if and when tactical communications for an incident should be switched to a different talk group. The Incident Commander could have directed the dispatcher to move the incident to an alternative talk group.

27 NFPA 1561 requires ”one radio channel for dispatch and a separate tactical channel to be

used initially at the incident” [6.1.1]


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The Incident Commander also had the option of activating a local repeater system that allowed portable radios at an incident scene to communicate in simplex mode, while relaying their communications to the trunked system through a vehicle mounted repeater. Mobile repeaters were mounted in the Assistant Chief’s vehicle and in the Battalion Chiefs’ vehicles. The mobile repeater had been found particularly valuable when companies were operating inside large buildings and had difficulty maintaining contact with the trunked system. The trunked system operates from a single radio tower that is located in Mount Pleasant, approximately 8 miles from the fire scene, and it was not unusual for the signal from low-power portable radios to have difficulty reaching the tower. The portable radios also had “private call” capability which allowed two units to communicate directly through the trunked system. Private call messages were not recorded and could not be monitored by anyone else. All radio traffic on fire department talk groups is recorded at the Communications Center. The recordings indicate that there was heavy traffic on “Fire 1” throughout most of the incident. The radio traffic during the critical period jumped back and forth from one subject to another, with numerous interruptions and incomplete exchanges28

F. The recorded radio traffic during this period included requests for additional companies to respond, dispatch instructions, companies relocating to cover different areas, instructions for companies arriving on the scene, requests for hose lines to be charged, and requests for additional pressure in supply lines. Many messages and fragments of messages that were not heard at the time were captured by the recording system and deciphered through repeated playbacks during the investigation29

F. All of the transmissions from firefighters inside the building indicating that they were in distress are included among the messages that were not heard or understood at the time of the incident. A detailed transcription of incident radio traffic is contained in Appendix B.

28 NFPA 1500 identifies the responsibility of the Incident Commander to “Initiate, maintain, and

control incident communications” [8.1.8 (4)] 29

Several individuals who were monitoring the incident on fire station radios and scanners reported hearing transmissions that were not recorded. A technological analysis of the radio and recording systems indicates that this is unlikely to occur while the trunked radio system is in operation. See Appendix E.


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Tactical Communications Most of the recorded radio traffic involved the dispatchers, command officers, units en route to the incident, and apparatus operators. There was very little radio communication involving the members who were conducting interior fire fighting operations, other than the fragmented distress messages. No progress or condition reports were transmitted by company officers during the period of offensive interior operations. The command officers who were on the scene did not transmit any specific instructions to the companies inside the building or request any progress reports from them.

Discussions with Charleston Fire Department members indicate that company officers and firefighters were not in the habit of using their portable radios for tactical communications while conducting interior operations. The portable radios were normally carried in an external pouch attached to the firefighter’s turnout coat; most radios were not provided with extension microphones and speakers. Several members indicated that they usually could not hear their radios when they were working inside buildings and tended not to use them. Mayday Communications A portable radio was provided for each on-duty member and several off-duty members also had “take-home” portables. One of the primary reasons for providing portable radios for all firefighters was to provide a means to call for assistance if a member was in distress. The portable radios were equipped with emergency buttons that transmitted a digital identifier signal to the Communications Center. The Charleston Fire Department had also adopted a standard operating procedure establishing the use of the term “MAYDAY” for a firefighter in need of assistance. Eight of the nine deceased members had their assigned portable radios with them. (The radio assigned to Captain 5 remained in the apparatus.) The first message indicating that a firefighter was in distress was recorded at 19:27 hours. Fragmented communications from lost and disoriented firefighters continued for approximately 7 minutes, until 19:34. The recording system captured at least 16 such messages or fragments of messages. The radio messages indicating that firefighters were in distress were not heard by anyone at the incident scene, although some of those messages were heard by other companies in fire stations and by individuals monitoring the incident on scanners. The term “Mayday” was recorded only one time.


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Several factors contributed to the failure to hear or understand the messages from firefighters in distress:

Heavy radio traffic pertaining to several different subjects, including the rescue of the Sofa Super Store employee from the rear of the building that occurred during the same time period;

Ambient noise at the fire scene;

Absence of a fixed Command Post;

Utilization of low power portable radios on a trunked radio system with za

single reception tower. No one at the incident scene was specifically assigned to monitor the tactical radio channel to listen for indications of problems, including mayday messages. This duty should be routinely assigned within the command structure when firefighters are conducting interior fire fighting operations. The critical radio traffic coincides with the period when the rescue of the store employee was occurring at the rear of the building. During this period, while firefighters were attempting to call for assistance, the following radio traffic was recorded:

Car 1 called for more pressure in the supply line from Engine 12 to Engine 10;

Car 1 called for Engine 3 to respond to the fire scene and lay a line to Ladder 5; (Ladder 5 was being set-up by off-duty firefighters on the west side of the building.)

Car 2 called for manpower to assist with the civilian rescue operation Car 5 reported that the trapped employee had been rescued Car 2 called for EMS to respond for the rescued employee Engineer 11 advised that he was charging the 2-1/2 inch line Engineer 16 called for traffic control on Savannah Highway because cars

were still running over the supply line.

The two dispatchers who were on-duty in the Communications Center were also exceptionally busy during this period. They heard fragments of messages, but did not initially recognize that firefighters were calling for assistance. In addition to monitoring the radio traffic, they were occupied with requesting an ambulance from Charleston County EMS and answering a rapid succession of telephone calls. A Battalion Chief monitoring the incident at his station called at 19:31:40 and told a dispatcher that he had heard radio traffic indicating that a firefighter had lost connection with the hose line and was lost.


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The only individual who understood and reacted to the urgent radio messages was an off-duty Battalion Chief (Car 303) who was en route to the scene in his privately owned vehicle and heard the radio traffic on his portable radio. He attempted to contact the Fire Chief by radio at 19:30:27 to relay the information, but was unable to reach him. He drove to the scene as quickly as possible and relayed the information in person to the Fire Chief at approximately19:33. His face-to-face report to the Fire Chief was the first recognition at the fire scene that firefighters were in trouble inside the building. Analysis of the recorded radio traffic indicates that the deceased members did not attempt to call for assistance until they were in critical distress. All of the recorded messages indicate that the firefighters are lost, disoriented, and either running out of air or already out of air. The firefighters were already in imminent danger, deep inside the building, when they began to call for assistance. All of the “firefighter in distress” messages came from the radios assigned to the deceased members. The recording system did not capture any distress messages from the surviving members who were operating inside the building. Seven surviving members were inside the smoke-filled showroom and had lost contact with their company officers or other crew members30

.. At least two of the surviving firefighters were either out of air or very close to running out of air. None of them used their radios to report they were in distress or request assistance. These observations are similar to the behavior of firefighters in several other incidents where fire departments had not adopted very specific “Mayday” procedures and conducted extensive training in their application. Experience suggests that firefighters tend to wait until they are in dire distress before requesting assistance. Realistic training based on specific criteria and procedures tends to make firefighters more comfortable initiating a “Mayday” while there is still time for a Rapid Intervention Team to take action. The Charleston Fire Department Standard Operating Procedures included the use of the term “Mayday” to indicate that a firefighter is in distress. The SOP indicated that a firefighter should call “Mayday” and describe the situation as well as possible so that the Incident Commander could determine the best action. The procedure did not describe specific situations when a Mayday should be called and did not specify additional actions that should be taken by the member calling a Mayday, by the Incident Commander, by Communications Center personnel, or by a Rapid Intervention Team.

30

Captain 6, Engineer 6, Firefighter 6, Firefighter 11, Engineer 15, Firefighter 15A and Firefighter 15B.


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The single use of the term “Mayday” was recorded at 19:32:15. The “Mayday” was not heard by the Incident Commander or by anyone else at the fire scene. The Communications Center immediately notified the Incident Commander when a firefighter’s emergency button was activated at 19:34:40.


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FIREFIGHTER SAFETY Safety Officer There was no designated Safety Officer at the scene of the Sofa Super Store fire. The role of an Incident Safety Officer had not been integrated into the Charleston Fire Department’s standard operating procedures and no members had been trained to perform this role. A properly trained Safety Officer would likely have recognized that the situation had evolved to a point where the firefighters inside the building should have been withdrawn and the incident strategy should have switched to defensive. Respiratory Protection Autopsy reports indicate that all of the firefighters who died in the Sofa Super Store had inhaled smoke and superheated gases. Their deaths were caused by a combination of smoke inhalation and thermal burns. All of the firefighters were wearing self-contained breathing apparatus and had either run out of air, or encountered overwhelming fire conditions that compromised the integrity of their breathing apparatus.

At the time of the Sofa Super Store incident, the Charleston Fire Department used low pressure (2216 psi) self-contained breathing apparatus rated for a nominal 30 minutes of use. One SCBA was provided for each riding position, with additional units carried on ladder companies and reserve apparatus. Each apparatus carried one spare air cylinder for each assigned SCBA. All of the SCBA units were of similar design and were manufactured by the same supplier, although at least four different models of different vintage were in use.

The typical experience of firefighters using 30-minute rated SCBA units, while performing structural fire fighting operations, suggests that a full cylinder will provide approximately 14 to 16 minutes of operational timeF

31F. The low pressure

alarm is required to activate at between 20 and 25% of the full cylinder pressure, which generally provides 3 to 4 minutes of warning time before a cylinder is exhausted.

The operational policy of the Charleston Fire Department at the time of the incident was to refill air cylinders that were at or below 1500 psi. Under this policy an SCBA that was carried on apparatus was considered “ready for use” with

31

The rated duration of an SCBA is based on an average flow of 40 l/min. Firefighters engaged in high exertion activities are estimated to consume air at an average rate of 80 l/min and a maximum rate of 100 l/min. A 30-minute rated cylinder contains approximately 1200 liters of usable air. This volume of air would be consumed in 15 minutes at a flow rate of 80 l/min.


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anywhere between 1500 and 2216 psi in the cylinderF

32F. This policy conflicts with

specific requirements of NFPA Standard 1500 and the OSHA Respiratory protection standardF

33F.

The refill policy had the impact of potentially reducing the service time of an SCBA by approximately one-third; a cylinder that was charged to 1500 psi could be expected to provide only 10 minutes of operating time and the low pressure alarm would begin to activate after only 6 to 7 minutes of use.

The following table indicates the estimated times that the air supply for each firefighter working inside the building would have been exhausted, based on a minimum duration of 10 minutesF

34F and a maximum duration of 16 minutes:

ESTIMATED START TIME

EARLIEST (+10 MINUTES)

LATEST (+16 MINUTES)

EXIT TIME

Ladder 5

Captain 19:16 19:26 19:32

Engineer 19:16 19:26 19:32

Firefighter 19:16 19:26 19:32

Engine 16

Captain 19:19 19:29 19:35

Firefighter 19:19 19:29 19:35

Engine 15

Captain 19:20 19:30 19:36

Firefighter A 19:20 19:30 19:36 19:33

Firefighter B 19:20 19:30 19:36 19:35

Engineer 19:22 19:32 19:38 19:35*

Engine 19

Captain 19:22 19:32 19:38

Engineer 19:22 19:32 19:38

Firefighter 19:22 19:32 19:38

Engine 6

Captain 19:23 19:33 19:39 19:35

Firefighter 19:23 19:33 19:39 19:35

Engineer 19:24 19:34 19:40 19:35

* Changed cylinder

32

An informal survey of Charleston Fire Department apparatus in fire stations found many SCBAs with cylinders in the 1700 to 1800 psi range and some that were below 1600 psi. 33 NFPA Standard 1500 7.14.3 In-service SCBA cylinders shall be stored fully charged. OSHA Respiratory Protection Standard 29 CFR H1910.134(h)(3)(iii) …Air and oxygen cylinders shall be maintained in a fully charged state and shall be recharged when the pressure falls to 90% of the manufacturer's recommended pressure level…. 34 10 minutes duration assumes an air utilization rate of 80L/min with a starting cylinder pressure of 1500 psi.


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The first firefighters observed using breathing apparatus were Captain 10 and Firefighter 10 who entered the loading dock from the west side at approximately 19:14 hours. They exited before their air supplies were exhausted.

The first firefighters who entered through the showrooms to begin using SCBA were the three crew members from Ladder 5. They advanced the1-1/2 inch handline from Engine 11 into the loading dock through the double doors at approximately 19:16 hours. The low pressure alarms for the three crew members from Ladder 5 probably activated somewhere between 19:22 and 19:29 hours and their air supplies probably would have been exhausted between 19:26 and 19:32 hours.

Captain 16 and Firefighter 16 are believed to have donned their SCBA facepieces at approximately 19:19 hours, based on reports of increasing smoke conditions inside the store.

Captain 15, Firefighter 15A and Firefighter 15B are believed to have donned their SCBA facepieces at approximately 19:20 hours, based on their entry time. Engineer 15 was probably 2 minutes behind the other members of his crew entering the building. Firefighter 15A had exhausted his air supply when he exited at 19:33. He had been using his SCBA for approximately 13 minutes.

Captain 19, Engineer 19 and Firefighter 19 are believed to have donned their SCBA facepieces at approximately 19:22 hours, based on their entry time.

Captain 6 and Firefighter 6 are believed to have donned their SCBA facepieces at approximately 19:23 hours, based on their entry time. Engineer 6 entered approximately one minute behind the other members of his crew. Engineer 6 had approximately 600 psi remaining in his SCBA when he left the building at 19:35 hours, after using air for approximately 11 minutes. Captain 6 had run out of air when he exited at 19:35, approximately 12 minutes after he entered the showroom.

The analysis of air supplies and work duration is consistent with the finding that all of the deceased firefighters inhaled lethal or potentially lethal concentrations of carbon monoxide and other fire gases. This is also consistent with the reports provided by survivors who encountered members who were lost and disoriented and appeared to be out of air. The evidence indicates that all of the deceased firefighters ran out of air while they were inside the Sofa Super Store and were unable to find their way outside.


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The key factors that must be recognized are:

1) the extreme danger of becoming disoriented in a smoke-filled building; and

2) the time it can take to exit from a work area deep inside a smoke-filled building.

The area where the crews were operating was approximately 200 feet inside the showroom from the front entrance. The entire showroom was filled with smoke and the path back to the front entrance was a series of narrow aisles among the furniture displays. The only guide available to the firefighters was to follow the hose lines back toward the entrance; they had to feel their way along the hose lines which included loops and turns and had become entangled with the furniture.

If the firefighters waited until the low pressure alarms on their SCBA activated, they would have had only 3 to 4 minutes to find an exit from the depths of the Sofa Super Store before their air supplies were exhausted. A firefighter who was disoriented or had lost contact with the hose line would have been unlikely to find a way out of the building within the limited available time.

Air Management Program

The concept of air management has been widely discussed recently, based on the investigation of firefighter fatalities that involved running out of air in an IDLHF

35F atmosphere. One of the causal factors in several of these fatalities was

excessive reliance on the low pressure alarm to warn the firefighter when it is time to leave the IDLH atmosphere.

The accepted SCBA use policy in the Charleston Fire Department (and in many other fire departments) at the time of the Sofa Super Store incident was to work until the low pressure alarm sounded and then exit the building to obtain a replacement cylinder. The air management concept requires a fire department to train members to continually monitor and manage their air supplies so that they will be able to leave the IDLH atmosphere UbeforeU the low pressure alarm is activated. This policy is now incorporated within NFPA 1404 – Standard for Fire Service Respiratory Protection Training.

35 IDLH refers to an atmosphere that is Immediately Dangerous to Life and Health. By definition, interior fire fighting operations are considered to be conducted under IDLH conditions by definition.


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Reference: NFPA 1404 - Standard for Fire Service Respiratory Protection Training - 2006 edition

5.1.4 The AHJ shall establish and enforce written standard operating procedures for training in the use of respiratory protection equipment that shall include the following:

HU(2)*UH Individual air management program A.5.1.4(2) This program will develop the ability of an individual to manage his or her air consumption as part of a team during a work period. This can require team members to rotate positions of heavy work to light work so air consumption is equalized among team members. The individual air management program should include the following directives:

(1) Exit from an IDLH atmosphere should be Ubefore U consumption of reserve air supply begins.

(2) Low air alarm is notification that the individual is consuming the reserve air supply.

(3) Activation of the reserve air alarm is an immediate action item for the individual and the team.

The NFPA standard for self-contained breathing apparatus (NFPA 1981, Standard for Open-Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services) has been revised to require a heads-up display that provides a continual indication of the remaining air supply and begins to warn the user when the air supply reaches 50% of the rated capacity of the SCBA. One of the firefighters who operated inside the smoke-filled showroom was working his first shift as a Charleston firefighter. He reported that he could not locate his Captain or any other members of his company after he was sent outside to obtain a hose line. He remained inside the showroom and operated the hose line in the direction of a red glow (which he believed was the fire) until he became concerned about his air supply. He followed his hose line and escaped from the building shortly before the situation became critical. This individual reported that he was unfamiliar with the model of self-contained breathing apparatus assigned to him that day and did not understand the meaning of the “heads-up display” inside his face piece. Rapid Intervention Team The Charleston Fire Department did not have an established policy to apply the “2-in/2-out” rule for the initial phase of interior fire fighting operations nor to assign Rapid Intervention Teams during fire incidentsF

36F. The OSHA Respiratory

Protection Standard (29CFR1910.134) and NFPA 1500 Section 8.5 both require the assignment of at least one Rapid Intervention Team (or crew) whenever firefighters are operating in an IDLH environment.

36

Specific requirements for assigning Rapid Intervention Teams are documented in OSHA 1910.134 (g) (3) and (4), and in NFPA 1500, sections 8.5 and 8.8.


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At the Sofa Super Store incident, companies were operating in IDLH conditions deep inside a building with only one identified entrance/exit. There was no Rapid Intervention Team standing by outside the IDLH area. A “standby” company was routinely dispatched to working fires in Charleston; however this company was generally given the next tactical assignment, as opposed to standing by to rescue firefighters in distress. In many cases, a succession of companies were called to standby at an incident and each company was quickly assigned to perform a task. At the Sofa Super Store fire, six additional engine companies were requested in rapid succession and each of those companies (Engines 16, 12, 19, 15, 6 and 3) was given an assignment prior to arrival. In addition, three companies from the Saint Andrews Fire Department arrived and quickly initiated operations. During this period there was never a standby company at the scene. The primary duty of a Rapid Intervention Team is to be prepared to assist firefighters who are in distress inside a building or within an IDLH atmosphere. At least one RIT should have been available outside the Sofa Super Store to respond immediately when the first report of firefighters in trouble was transmitted; additional resources should have been mobilized as soon as the RIT was activated. When the size and configuration of the Sofa Super Store are considered, as well as the fact that companies were entering the building from two remote locations, a minimum of two RIT company assignments would have been appropriate. One RIT should have been assigned to the front of the building; the second should have been assigned to the west side. It is important to recognize the limitations of a Rapid Intervention Team. Rapid intervention procedures are generally directed toward providing the ability to locate and rescue a single firefighter. It is highly unlikely that a single RIT could have entered the showroom, located, and then rescued the number of firefighters who were in distress deep inside the smoke-filled building37

F. Accountability and Crew Integrity At the time of the Sofa Super Store incident, the Charleston Fire Department had not adopted a personnel accountability system to keep track of individual firefighters, companies, or crews that were operating on the scene of an incident. The Department did not make use of status boards, tactical worksheets, accountability tracking devices or personnel accountability reports (PAR). Command officers relied on memory to keep track of company locations and assignments.

37 Kreis, Steve. Rapid Intervention Isn’t Rapid, Fire Engineering, December 2003, pp. 56-66.


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The Charleston Fire Department did not utilize multiple alarm assignments, grouped resources, or staging. Companies that responded after the initial alarm were requested and dispatched individually and were given assignments enroute or as they arrived. There was no fixed Command Post at the Sofa Super Store incident and no tracking of resources as they were assigned. The six additional engine companies that were dispatched during the first 20 minutes of the incident all went directly to work without reporting to a command officer. The accountability problem was compounded by an absence of crew integrity policies and procedures. The Department did not enforce a policy that required members to work in teams of 2 or more, or to maintain company integrity while working in IDLH environments. The OSHA Respiratory Protection Standard and NFPA 1500 both explicitly require firefighters operating in IDLH conditions to work in teams of 2 or more and to maintain contact among team members. Each entry team is required to maintain communications with someone outside the IDLH area. Charleston Fire Department members routinely entered and operated in IDLH atmospheres alone. In many cases the company officer operated a hose line while the other crew members operated semi-independently. Company officers frequently lost track of their assigned crew members. Firefighters who lost track of their assigned company officers took direction from any other officer who was present or became involved in whatever task caught their attention. Members who had expended their air supplies went outside individually, obtained replacement SCBA cylinders, and returned to conduct interior operations. Interviews with members of the Charleston Fire Department suggest this was the routine mode of operation. Several of the surviving members reported that they lost contact with their officers and other company members inside the smoke-filled building. The firefighters did not consider these situations unusual; they all continued to operate under these conditions until their low air pressure alarms activated. None of them attempted to use their portable radios to report that they were lost or in distress.

The routine and institutionalized practice of off-duty firefighters showing up at working fires, and spontaneously volunteering to assist, further complicated the accountability problem. It was not uncommon for several off-duty members to show up at a fire scene and become involved in tactical operations. Several members had been issued portable radios and carried protective clothing in their personal vehicles to facilitate off-duty response. A written policy requiring off-duty members to report-in to the officer in command of an incident was often overlooked.


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The magnitude of the Sofa Super Store incident prompted a large number of off-duty members to respond and provide assistance, even before it became known that firefighters were missing. Some of the firefighters arrived with their protective clothing: others borrowed protective clothing from members who were operating apparatus or working outside the fire perimeter, and still others went to work wearing street clothes.

Several off-duty members of both the Charleston and Saint Andrews Fire Departments can be seen in photographs and videos that were taken while the operation was still in the offensive phase, although none of them were involved in interior fire fighting operations. Off-duty members relocated and set-up Ladder 5 for elevated master stream operations on the west side of the building while the assigned crew members were operating inside the building.

The situation became chaotic after the firefighters were reported to be missing. Dozens of firefighters from Charleston and neighboring fire departments responded and became involved in the operation. Command officers from mutual aid departments responded to the scene to offer assistance or assigned units to cover Charleston fire stations. Members of volunteer departments, some of whom were off-duty Charleston firefighters, arrived with additional apparatus.

TACTICAL OPERATIONS

Water Supply Water supply issues played a very significant role at the Sofa Super Store fire and contributed to the loss of the nine firefighters. The established practice in the Charleston Fire Department called for the first arriving engine company at a structure fire to position close to the fire scene and begin the attack using water from the on-board tank. The second arriving engine company would prepare to lay a supply line from the attack engine to a hydrant. In many cases the second engine would back into position near the first engine and stand-by to lay a supply line, if needed. In most cases a fire attack was initiated using 1-inch booster lines, with 1-1/2 inch preconnected lines as an option. The second engine was required to lay a supply line and hook-up to a hydrant if the first engine used most of its tank water or if a 1-1/2 inch line was operated. The Charleston Fire Department did not use large diameter hose for supply lines; the standard hose load on engine companies provided only a single bed of 2-1/2 inch hose that could be used as a supply line. This arrangement severely limited the volume of water that was available for fire attack.


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The standard attack lines were configured to deliver very limited flows. The nozzles on the 1-1/2 inch preconnected lines were set to deliver 60 gallons per minute. The nozzle operator had the option of resetting the nozzle to a higher flow, if necessary, and advising the pump operator to increase the pressure to provide the higher flow rate38

F. Larger (2-1/2 inch) attack lines were rarely used inside structures. Engine companies were not equipped with pre-piped master stream devices. Lack of Coordination The standard operating procedure was not followed during the early stage of the Sofa Super Store incident. Both of the first alarm engines initiated interior fire attack operations using water from their tanks, with no additional engines on the scene to lay supply lines for them. This situation occurred due to an unusual set of circumstances and a lack of coordination at the command level.

• The confusion began when Engine 11 initially went to the rear of the property. This caused Engine 10 to arrive first at the front of the property and become the attack engine - the Assistant Chief directed Engine 10 to back down the driveway to attack the fireF

39F.

• When they arrived at the front of the building, Captain 11 told his engineer and firefighter that they would be laying a supply line to Engine 10. Captain 11 then went inside the store, while Firefighter 11 started out on foot toward a hydrant.

• The plan was disrupted when Captain 11 called for a 1-1/2 inch line to be brought into the showroom. This message was transmitted just after Ladder 5 arrived at the front of the building. Captain 5 could see Engine 11 at the front of the building, while Engine 10 was in the driveway and out of sight. Captain 5 had also heard the Assistant Chief call for Engine 12 to respond, followed by Battalion Chief 4 directing Engine 12 to lay a line to Engine 10.

• Captain 5 redirected Engineer 11 to position his apparatus near the front door. The crew of Ladder 5 then advanced the preconnected line from Engine 11 into the showroom.

38 There were no requests to increase the flows in the two lines that were operated inside the loading dock at the Sofa Super Store. 39 Engineer 10 stated that he expected to find Engine 11 at the end of the driveway and was surprised when he realized that Engine 10 had become the attack engine.


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Conducting an offensive fire attack with two engines supplying the attack lines with tank water and no supply lines connected to hydrants is a very high risk situation under any circumstances. The risk was even greater when the particular circumstances of the Sofa Super Store are considered – a very large building with a heavy fuel load requiring firefighters to operate deep inside the structure.

• Engine 10 briefly supplied a one-inch booster line, before the 1-1/2 inch attack line was charged. From that point, the smaller line was used intermittently as other firefighters arrived in the area. With a combined flow of 100 gpm, the 750 gallon tank could supply the two lines for 7 minutes and 30 seconds. The first line began flowing water at approximately 19:14 and the supply line from Engine 12 was charged at 19:20. If the 1-1/2 inch line had not ruptured, the tank would have been close to empty before the supply line was charged.

• Engine 11 was operating two lines from the onboard tank. The 1-1/2 inch line began flowing 60 gallons per minute at approximately 19:17 hours. The flow increased to 100 gallons per minute when the booster line began operating at approximately 19:25. At this flow rate, the 750 gallon tank would have been exhausted at approximately 19:27. The supply line from Engine 16 to Engine 11 was charged at 19:26.

Supply Lines The single 2-1/2 inch supply lines that were established for Engines 10 and 11 were incapable of providing the flows that those engines were attempting to deliver to attack lines. This resulted in compromised and/or interrupted flows in all of the attack lines that were operating during the most critical stage of the incident. Engine 10 was initially pumping a booster line and one 1-1/2 inch line, with a combined flow of 100 gallons per minute. When the fire spread to the warehouse, two 2-1/2 inch lines with 1” smooth bore nozzles were deployed. A total flow of 612 gallons per minute would have been required to operate all four lines, based on Charleston Fire Department standard operating procedures. Engine 12 supplied water to Engine 10 through a single 2-1/2” line, 850 feet in length. The pressure in the supply line was increased on multiple occasions in response to requests from senior officers. Calculations indicate that maximum practical flow through this line would have been approximately 325 gallons per minute40

F.

40

See calculations in appendix


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Engine 11 was pumping a 1-1/2 inch line and a booster line with a combined flow of 100 gallons per minute. The 2-1/2 inch line, which was not charged until the supply line was charged, increased the demand to 356 gallons per minute. Engine 16 supplied water to Engine 11 through a supply line that was comprised of 1750 feet of 2-1/2 inch hose and 100 feet of 3-inch hose. Calculations indicate the maximum practical flow through this line would have been approximately 240 gallons per minute41

F. The supply line from Engine 16 to Engine 11 was pumped at more than 250 psi at the supply end; however, photographs that were taken shortly after it was charged show that the hose was limp and there were multiple kinks near the delivery endF

42F.

Photo 12: The scene at the front of the store at 19:31:23. Note the lack of pressure evidenced by the kinks in the supply line feeding Engine 11. (Photo courtesy Charleston Post and Courier)

41

See calculations in appendix 42

The photographs indicate that five lengths of 2-1/2 inch hose were flaked out on the ground next to Engine 11, adding 250 feet of unneeded hose and six kinks to the to the supply line. The extra hose significantly increased the friction loss in the supply line and restricted the volume of water that could be delivered to Engine 11. It was not determined who pulled the additional hose from the bed of Engine 16. It was presumably a well-intentioned effort of someone who anticipated that the line was going to be advanced into the Sofa Super Store.


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Senior officers attempted to compensate for the inadequate supply lines by repeatedly calling for “more pressure” from the pumpers that were connected to hydrants. The preoccupation with water supply problems distracted the command officers from effectively managing the overall incident. The friction loss calculations demonstrate that the 2-1/2 inch supply lines were incapable of delivering the desired flows and the problem could only be solved by stretching additional supply lines – preferably using large diameter hose. During later stages of the incident several master streams were set-up and the resulting demand exceeded the volume available from the water mains and hydrants in the West Ashley area. The hydrants were capable of supplying all of the attack lines that were deployed during the first 30 minutes, if appropriate supply lines had been established. Delay in Charging Lines Delays were encountered in charging both of the hose lines that were taken through the showrooms to attack the fire in the loading dock. The delays and subsequent flow interruptions placed crews in extremely dangerous situations inside the building.

The 1-1/2 inch attack line that was taken into the fire building by the crew of Ladder 5 was in position for at least two minutes before it was charged. This delay occurred because Engineer 11 was unfamiliar with an idiosyncrasy of the apparatus and was unable to engage the pump.

The 2-1/2 inch line that was stretched by Engine 16 was in position inside

the building for approximately 10 minutes before it was charged. The delay in charging the attack line was caused by the delay in charging the supply line from Engine 16 to Engine 11F

43F.

The attack line was found in the area in front of the double doors, where

Captain 16 and Firefighter 16 had been waiting for the line to be charged. The position of the hose and the nozzle found after the fire suggest that the 2-1/2 inch line had not been operated. The line was probably abandoned before it was charged.

Several other problems and interruptions in water flow were reported. The problems began during the early stages of the incident and increased as the incident grew in magnitude and complexity. The water problems became even more severe when the showrooms and the warehouse became involved and the demand for additional hose lines increased in proportion to the magnitude of the fire.

43

Engineer 16 performed commendably in his single-handed effort to provide a supply line for Engine 11.


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Most of the water problems were related to inadequate supply lines and inexperienced pump operators. The single 2-1/2 inch supply lines that were used by the Charleston Fire Department could not deliver the flows that were required to conduct an effective fire attack, even if fire hydrants had been closer to the scene. The engineers who were operating Engines 10 and 11 both stated that their supply lines were pulsating and attributed this condition to cars driving over the lines. Witnesses suggested that both pumps were cavitating due to inadequate flows in their supply linesF

44F.

When the 2-1/2 inch line was charged, Engineer 11 momentarily throttled-

down the engine in order to switch the pump over from pressure to volume mode (series to parallel). He had been instructed to change over when the flow exceeded 50% of the pump’s capacity and he believed that he had reached that pointF

45F.

Captain 6 reported that the flow in the 1-1/2 inch line was interrupted after

he had been operating the nozzle for 2 or 3 minutes. The flow interruption may have coincided with the changeover from pressure to volume or it could have resulted from inadequate water supply to Engine 11.

Lack of Truck Work The standard tactical functions that are commonly classified as “truck work” were not performed at the Sofa Super Store incident. These functions include raising portable and aerial apparatus ladders, performing vertical and horizontal ventilation, forcible entry, opening walls and ceilings, and performing search and rescue operations. The single ladder company that was assigned on the first alarm at this incident advanced a hose line and functioned as an engine company. The lack of truck work appears to have been a common situation in the Charleston Fire Department. The Department operated ladder company apparatus, but the crews assigned to those vehicles generally did not perform ladder company functions (“truck work”). Several members noted that vertical ventilation was rarely, if ever, performed at structure fires.

44

Engines 10 and 11 were both operated by recently promoted Assistant Engineers who had very little experience pumping at fires. They were called upon to operate unfamiliar apparatus under extremely stressful conditions. 45

Engine 11 is a 1500 gpm pumper. The maximum flow, with the 2-1/2 inch line charged, would have been approximately 350 gpm. The supply line from Engine 16 to Engine 11 was incapable of delivering more than 250 gpm


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Inadequate Company Staffing and Initial Response The minimum recommended staffing level for engine and ladder companies in career fire departments is four crew members per vehicle46

F. The operational policy of the Charleston Fire Department at the time of the Sofa Super Store incident was to assign four crew members to each company on each shift; however, companies routinely operated with only three members on duty. All three companies that were initially dispatched to the Sofa Super Store were operating with three crew members and only two of the first nine companies were staffed with four members. The inadequate company level staffing meant that each individual unit was operating with limited capabilities and could not be expected to perform as an efficient and effective company at a working structure fire. The inadequate company staffing compromised the effectiveness of the overall operation. In addition to inadequate company staffing, the standard response to a reported structure fire did not provide sufficient resources to conduct a safe and effective offensive fire attack in a large commercial building. The initial dispatch provided only 10 firefighters, including one command officer. Although additional companies were quickly requested and dispatched, the response was fragmented and the offensive attack was clearly disorganized. Traffic Control Savannah Highway and Wappoo Road are heavily traveled streets under normal circumstances. The large column of smoke generated by the fire drew spectators on foot and by car. Cars drove over the uncharged and charged supply lines laid by Engine 12 and Engine 16. Engineer 12 called dispatch to request Police Department assistance with civilians driving over his supply line to Engine 10 at 19:20:55 and Engineer 16 called dispatch with a similar complaint at 19:31:28 and 19:43:49. Although law enforcement officers arrived on the scene fairly quickly, it took some time to gain control of traffic in the area. Protective Clothing and Equipment All of the personal protective clothing and equipment that was worn by the deceased firefighters was damaged by the fire. The items that could be recovered were preserved for detailed examination during the investigation. All of the deceased firefighters were wearing structural fire fighting coats and trousers, with either rubber or leather fire fighting boots, as well as gloves and helmets.

46

The recommended minimum company staffing levels are described in NFPA 1710.


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Many of the firefighters were found to be wearing protective hoods. All of the items that could be closely examined were determined to comply with the appropriate NFPA standards. At least one firefighter wore a protective clothing ensemble that had not been provided by the Charleston Fire Department, although the protective clothing was NFPA compliant. All of the firefighters utilized Scott Airpak 50 Self-Contained Breathing Apparatus (SCBA). Each SCBA was equipped with a composite air cylinder that was designed, when full, to contain 45 cubic feet of air at 2,216 psi. All nine firefighters were found with their SCBA backframe and air cylinder in place or nearby. All components of each SCBA sustained severe thermal damage. Different versions of the Airpak 50 were in use by the deceased firefighters. All SCBA units were equipped with the Vibra-alert low air alarm and some were recent versions that also included heads up displays and low air alarm bells. Some of the SCBA facepieces were found with the regulator in place while others were too severely damaged to make a determination. The Personal Alert Safety System (PASS) device used by the Charleston Fire Department at the time of the fire was a Grace Industries Superpass. The device was worn on the SCBA waist belt. The PASS was activated by the removal of a “key” that detached from the device as it was removed from the apparatus-mounted SCBA bracket. The “key” was tethered to the bracket by a small piece of rope so the removal of the “key” and activation of the PASS were automatic. With the exception of Captain 5, each firefighter was equipped with a portable radio. At least two firefighters had clip microphones and one firefighter utilized a radio pouch and strap. The firefighters were found to be wearing station uniform shirts and trousers that were made of 100 percent polyester. These uniforms did not comply with the NFPA standard for such items. In several cases the uniform items had melted due to direct or indirect thermal exposure. The melting of the uniform items was likely not a factor in the deaths of the firefighters.


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CONCLUSIONS, LESSONS, AND RECOMMENDATIONS


Page 133

KEY FACTORS IDENTIFIED IN THE ANALYSIS The analysis of the Sofa Super Store Incident is divided into two primary sections;

1. Factors relating to the building and the property where the fire occurred

2. Factors relating to the operations that were conducted by the Charleston Fire Department

The key factors within each area are summarized in the following statements. These summaries represent the most significant factors Uin the collective opinion of the Review Team membersU and are intended to focus attention on the points that should have had the greatest impact on preventing future fire fighter fatalities. Building and Property The Sofa Super Store was a high risk occupancy that presented several specific risks to the health and safety of firefighters. The fire risk factors that were found in this occupancy also presented risks to the employees, customers, neighbors, and the surrounding community. The level of fire risk exceeded the limits prescribed by established regulations and would have - or should have - been mitigated if the applicable codes and standards had been followed, applied, and enforced. The fire could have been prevented. If the property had been constructed and maintained in accordance with state and local codes the fire would have been quickly controlled: no lives would have been lost and the fire would have been of little consequence.

The fire would not have occurred if the combustible materials had not been stored in proximity to a smoking area or of smoking had been prohibited in that area.

The fire would have been quickly controlled with minor damage if a

sprinkler system had been installed.

A sprinkler system would have been required if the building owner had obtained permits for the loading dock and other “fill-in” construction projectsF

47F.

47

The Building Code would have required the installation of a sprinkler system unless the property could be divided into compartments by a system of fire walls. If the fire walls had been constructed the fire would likely not have extended beyond the loading dock.


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The fire would not have spread to the showroom areas or the warehouse if the loading dock enclosure had not been constructed.

The fire would have been less severe if flammable liquids had not been

improperly stored in the loading dock.

The firefighters might have been able to find their way out of the building if the required exits had been properly maintained.

The code violations would have been discovered if the City of Charleston

had conducted regular fire inspections and if firefighters had been trained to identify code violations during pre-fire planning visits and report them to the Inspections Department.

Fire Department Operations The fire suppression operations that were conducted by the Charleston Fire Department at the Sofa Super Store did not comply with federal occupational health and safety regulations, with NFPA consensus standards, or with modern fire service expectations. These deviations from standard operational and safety practices exposed firefighters to excessive risks and failed to remove the nine deceased firefighters from a critically dangerous situation. The predominant factor identified in the analysis of Fire Department operations is the failure to manage the incident according to accepted practices. There was no structured incident command system in place and the essential duties of an Incident Commander were not performed. The operation was conducted in an unstructured and uncoordinated manner, without overall direction and with inadequate supervision. The Charleston Fire Department was inadequately staffed, inadequately trained, insufficiently equipped, and organizationally unprepared to conduct an operation of this complexity in a large commercial occupancy. The Department attempted to compensate for the limited resources and organizational inadequacies by engaging in dangerously aggressive and uncoordinated fire fighting operations. This placed the firefighters deep inside a large building without the systems that should have been in place to ensure their safety and to provide for the removal of all firefighters when the situation became critical. The Charleston Fire Department took pride in conducting aggressive interior fire attack using small hose lines with very limited water flows. The organizational culture emphasized fast attack and independent action. The Department operated with a “default offensive strategy” based on a general expectation that firefighters could go inside and conduct an aggressive offensive attack that would control Ualmost U any fire they were likely to encounter.


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This highly aggressive interior attack approach is appropriate for many situations and was effective in controlling a large percentage of the fires the Charleston Fire Department had encountered over the years, particularly in residential occupancies. The offensive attack orientation was not balanced by alternative strategies that would have been more appropriate for a major fire in a large and complicated commercial occupancy. The Sofa Super Store fire required a very different combination of strategy and tactics. The volume of fire could not be controlled by the limited flow from small hose lines. Firefighters were operating deep inside the building without the capability to control the fire and without the support systems that should have been in place to protect them. The strategy and tactics attempted by Department members were inappropriate for the situation and exposed the firefighters to extreme and unnecessary risks. Several additional contributing factors were identified in the analysis of operations. Each of these factors played a part in the tragedy that occurred and all of them are interrelated. The report attempts to place these contributory factors and interrelationships in an appropriate context. It is almost inevitable that the detailed investigation of a complex incident will reveal a number of errors and performance problems. Fire fighting is not an exact science and it is unrealistic to expect that every firefighter will perform flawlessly in every situation. Fire fighting is inherently dangerous and firefighters are human beings who can make mistakes. The final analysis of this incident does not suggest that any of the firefighters who lost their lives, or any of the surviving members of the Charleston Fire Department, failed to perform their duties as they had been trained or as expected by their organization. The analysis indicates that the Charleston Fire Department failed to adequately prepare its members for the situation they encountered at the Sofa Super Store Fire.


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Lessons and Recommendations

LESSONS One of the primary objectives of the detailed investigation of the Sofa Super Store incident is to identify the lessons that should be taken from this very sad experience and applied to prevent future tragedies. While it is impossible to change events that have already occurred, it is essential to learn from those experiences in order to prevent the same circumstances and outcomes from repeating themselves in Charleston or in any other community Every investigation of this type produces valuable information. The circumstances of firefighter fatalities are often complicated and invariably involve a sequence of interrelated events that produce an unplanned, unintended, and undesirable outcome. Fire fighting involves inherent dangers and hazardous situations that must be anticipated, recognized, evaluated, and properly managed to produce positive outcomes. The mission of a fire department is to protect lives and property from those hazards and firefighters must be prepared to perform their duties in the face of those inherent risks. The health and safety of firefighters are directly related to the ability of the fire department to skillfully and effectively perform every aspect of that mission. The following section of the report presents a compilation of lessons and recommendations that should be taken from the Sofa Super Store incident and implemented by the Charleston Fire Department. Unfortunately, as in many other cases, the lessons do not provide new insight or information and the recommendations are not revolutionary. The situation that occurred in Charleston on June 18, 2007 was predictable and the outcome was preventable. All of the lessons and recommendations listed below are restatements of lessons that have been identified in previous investigations involving other fire departments and recommendations that have been widely adopted as standard practices within the fire service. The loss of nine firefighters is a sad and very significant occurrence within the fire service – on the local level in Charleston and for the fire service as a whole. The gravity of this experience should inspire renewed emphasis on learning the lessons and fully implementing the recommendations contained in this report, so that some degree of a positive outcome may result from this tragic event.


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Incident Management The Sofa Super Store incident clearly demonstrates the critical importance of a comprehensive Incident Management System (IMS) to provide command, control, and coordination of emergency operations. The IMS should be fully incorporated into the basic operational processes of the Charleston Fire Department and routinely applied to every emergency incident and training exercise to provide the appropriate structure for conducting operations. The application of IMS is absolutely essential in situations that involve complex problems and exceptionally hazardous circumstances, as occurred at the Sofa Super Store incident. Since the Sofa Super Store incident, the Charleston Fire Department has provided its members at all levels with basic incident management training. The training that has been provided is a first step in the process of fully implementing and integrating IMS into the Department’s standard operating procedures. The key concepts of Incident Management that must be fully integrated into the operations of the Charleston Fire Department include:

• A clearly identified Incident Commander, performing a standard set of functions within a well-defined system.

• Establishment of a fixed Command Post in a location that allows the Incident Commander to view the overall incident scene.

• Delegation of authority and responsibility to subordinate officers with pre-defined roles within a standard structure.

• Determination of an overall strategy for the incident, based on an appropriate size-up.

• The application of accepted risk management principles at the start of the incident and continually thereafter, at all levels.

• Translation of the strategy into an incident action plan and specific tactical assignments.

• Management and allocation of resources to accomplish the tactical assignments

• Continual reevaluation of the situation, based on observation, reconnaissance, information gathering, effective communications and situational awareness.


Page 138

• Assignment of one or more designated safety officers, functioning within the command structure.

• Maintenance of control over the incident communications process.

• Continual systematic accountability for the location, function, and status of all firefighters and all other persons operating within hazardous areas at the incident scene.

• Standard procedures to ensure that a single IMS structure is implemented at incidents involving resources from multiple jurisdictions, including Unified Command where appropriate.

Risk Management The fundamental concepts of operational risk management must be understood at every level within the Charleston Fire Department and applied to every situation. The level of acceptable risk must be weighed against and justified by the realistic benefits that can be obtained. Strategy and Tactics The determination of the appropriate strategy – either offensive or defensive – is the key factor that controls firefighter safety. The determination of appropriate strategy must be based on an appropriate size-up of the situation, a realistic evaluation of the resources and capabilities that are available to conduct operations and the application of risk management principles. Offensive strategy can only be effective when the fire department has the capability to conduct an interior attack that delivers a sufficient quantity of extinguishing agent by firefighters to suppress the fire. Attempting an offensive attack without the resources that are required to suppress the fire places firefighters in needless jeopardy. If an offensive attack cannot be accomplished safely and effectively with the resources at hand, it should not be attempted. The Incident Commander is directly responsible for making that determination. An incident action plan for a fire fighting operation is implemented through the coordinated application of fire fighting tactics. A successful offensive strategy requires effective action at the tactical level and coordination among actions. If the Incident Commander lacks the resources to execute the plan or the tactics are not adequately executed and coordinated, the operation cannot be accomplished safely or effectively.


Page 139

The effectiveness of an offensive attack must be closely monitored and evaluated to ensure that it is meeting the Incident Commander’s expectations. If the attack is not effective and/or conditions change in a manner that shifts the risk management balance, the Incident Commander must reevaluate the strategy, adjust the tactics and, if necessary, change the incident action plan. Firefighter Safety Fire fighting operations in Charleston should be conducted in a manner that routinely incorporates all of the standard components of safe practices, including:

• The designation of Safety Officer(s) at all working incidents.

• Company Integrity – Firefighters and company officers should be trained to operate as tactical units. All company members should operate under the direct supervision of a company officer within a structured Incident Management System. The company officer must be continually aware of the location, status, and function of every member assigned to that company.

• Firefighters should be trained in and systematically apply the principles of Crew Resource Management.

• Firefighters operating in IDLH conditions must work in teams of 2 or more, remaining in direct contact with each other at all times. The members of each team (or full company) enter, work and leave the IDLH area together.

• Charleston must implement and utilize an Accountability System to track the entry and exit of members from the IDLH area. Personnel Accountability Reports (PAR) must be routinely employed to verify the status of operating companies or teams as they work in an IDLH area.

• Rapid Intervention Crew(s)/Team(s) must be assigned at all appropriate emergency incidents. These teams must be trained, equipped, and prepared to provide assistance to firefighters in distress.

• All Charleston Fire Department members must be trained in Mayday, self-rescue, and rapid intervention procedures.

• All Charleston Fire Department members must be trained to recognize hazardous conditions and situations, such as lightweight construction and unusual fire loads, and react appropriately.

• All off-duty members who respond to incidents and become involved in operations must be integrated into the IMS and accountability systems and utilize the appropriate protective clothing and equipment.


Page 140

Self-Contained Breathing Apparatus

• The City of Charleston has made a significant investment in new Self-Contained Breathing Apparatus. These units need to be properly maintained and inspected by certified personnel. Each firefighter must check and test his/her assigned SCBA at the beginning of each shift and after each use. In order to provide firefighters with the highest margin of safety, SCBA cylinders must be maintained fully charged.

• The Charleston Fire Department must adopt and implement a comprehensive respiratory protection program that complies with OSHA regulations and NFPA standards.

• All Charleston Fire Department members must be trained in and routinely employ the principles of Air Management.

Radio Communications

• The Charleston Fire Department needs to continue and expand the use of tactical channels on emergency incidents. The Charleston radio system appears to have the capacity, functionality, and reliability to support effective tactical communications. The system should be assessed to ensure that it is configured to provide all members operating in IDLH areas with the ability to maintain communications with the Command Post or a designated individual outside the IDLH area.

• The available system components, including mobile repeaters, need to be used on a regular basis to ensure that effective tactical communications are established and maintained at all incidents.

• Charleston should designate an individual at the Command Post, outside the IDLH area or at the dispatch center to continually monitor the tactical radio channel used by members operating inside an IDLH area.

• All Charleston firefighters should be trained to use the “order model” to ensure that messages are clearly stated and understood.

• Charleston firefighters must be trained to continually monitor the tactical radio channel for instructions and advisories, especially when they are operating in an IDLH area.

• Charleston Fire Department dispatchers should be fully trained to function within the IMS, including application of the order model and monitoring tactical communications.


Page 141

• All Charleston Fire Department company officers should be trained to provide progress, accountability (PAR), and situational awareness reports to the incident commander.

• When units from multiple agencies are involved in an incident, the communications system(s) must provide sufficient interoperability to ensure that operations are fully coordinated within an appropriate IMS structure.

• Charleston should continue discussions with other area fire departments related to improvements in dispatch and communications systems, including potential consolidation of dispatch centers and radio systems.

Training All Charleston Fire Department members must be properly trained and qualified to perform their assigned duties, including temporary assignments. Members who are authorized to work temporarily in higher level assignments must be trained and evaluated in performing those duties. All members must be periodically reevaluated to ensure that they are capable of performing their assigned duties safely and effectively.

• The Charleston Fire Department must establish realistic training and educational requirements for all positions and ranks and a promotional process that ensures that all members demonstrate the necessary knowledge, skills, and abilities to perform their assigned duties and responsibilities.

• All Charleston Fire Department companies should be trained and periodically evaluated in performing a range of standard company functions within a system of standard operating procedures.

• Charleston Fire Department company and command officers should be trained at an appropriate level in fire fighting strategy and tactics, including the application of operational risk management principles.

• Simulation exercises should be conducted to provide experience in managing unusual, complex, and challenging situations.

Fire Department Resources

• The Charleston Fire Department must ensure that all companies are adequately staffed to perform a menu of standard company operations efficiently and effectively. Engine and ladder companies should be staffed by a minimum of four members on duty at all times. (The Department is committed to reaching this objective during 2009.)


Page 142

• The Charleston Fire Department should ensure that sufficient resources are dispatched to reported structure fires to conduct operations on scale that is appropriate for the magnitude and complexity of the risk.

• The Charleston Fire Department should deploy additional resources to working incidents in a structured manner. The transition to a new computer aided dispatch system provides the opportunity to standardize response levels to incidents.

• The Incident Commander should ensure that sufficient resources are available on the incident scene to conduct operations safely and effectively, with additional resources on standby for contingencies and to rotate or relieve companies that require rehabilitation.

• The Charleston Fire Department should ensure that individual companies are staffed, trained, and equipped to perform a specific set of functions. Their collective capabilities must include all of the functions that are essential to conduct effective fire fighting operations. The Charleston Fire Department needs to place an emphasis on truck company operations, including ventilation, forcible entry, and search and rescue tasks.

• The Charleston Fire Department and surrounding fire departments should work as mutual aid partners to develop a regional system that includes common standard operating procedures and compatible equipment, as well as seamless command, coordination, and communications components. A system that provides for the automatic dispatch of the closest available units with appropriate capabilities is highly desirable.

Advancing Technology The Charleston Fire Department should continually research, adopt and employ technological advances that improve the safety and effectiveness of fire fighting operations. The Department should continue to involve firefighters from every level of the organization in this ongoing effort. These systems include a number of technologies such as:

• Thermal imaging cameras

• Improved communications systems

• Firefighter accountability and tracking systems

• Pre-fire planning and information management systems

• Positive pressure ventilation equipment and techniques


Page 143

Pre-fire Planning

• The Charleston Fire Department should adopt a more systematic pre-fire planning process to gather and document information and develop familiarity with individual properties, based on risk factors.

• The pre-fire planning system should capture pertinent information in a manner that makes it readily available to command officers during actual incidents – particularly in relation to unusual hazards and special risks.

• The pre-fire planning process should identify properties and situations that require special techniques or capabilities or where the risk exceeds the operational capabilities of the Charleston Fire Department.

• The pre-fire planning process should include a direct connection to code enforcement and risk mitigation programs to address hazardous situations that are encountered.

Code Enforcement and Risk Mitigation

• It is a governmental responsibility to ensure that adopted fire and safety codes are adequately enforced through systematic inspections. The City of Charleston has committed additional resources to code enforcement in the wake of the Sofa Super Store incident. The City should continue to provide sufficient resources to identify and cause correction of hazardous situations.

• Mitigation programs to reduce or eliminate excessive risk levels should be encouraged and supported. Measures that mandate or provide incentives to encourage the installation of automatic sprinklers or support alternative fire protection measures should be adopted as public policy. The City of Charleston should continue to encourage actions at the state level that will support these efforts.

• All Charleston firefighters should be trained and should have a specific responsibility to recognize fire hazards and code violations and to initiate appropriate corrective actions.


Page 144

Coordination and Liaison The Charleston Fire Department should have effective liaison relationships with agencies that have closely related responsibilities, including:

• Structured liaison with the Charleston Water System to ensure that hydrants are properly located and maintained and that adequate flows are available to protect the risks in each area of the city. (The City of Charleston should also work closely with the Water System to ensure that sprinkler system connections are provided at the least possible cost.)

• Coordination with the Charleston Police Department and other law enforcement agencies to ensure that traffic control and incident scene perimeters are promptly established and effectively managed.

• Coordination with emergency medical services and volunteer rescue squads in Charleston and Berkeley Counties.

• Coordination with the Charleston Department of Public Service, Building Inspections Division. To assure that fire safety concerns observed by firefighters are corrected, to assure that code compliance inspections of commercial occupancies are conducted on a regular basis, and to assure that buildings are constructed utilizing fire safe practices.


Page 145

Team Biographies Post Incident Assessment and Review Team J. Gordon Routley, Project Leader, is a 40-year veteran of the fire service. He served as the Fire Chief in Shreveport (LA) and was previously an Assistant to the Fire Chief in Phoenix (AZ). He is a Fire Protection Engineer, a Licensed Professional Engineer, and a Technical Advisor to the Fire Director, Montreal, Canada. He also served as a Safety Officer in Prince George’s County, Maryland, Fire and EMS Department. Routley is a member of the International Association of Fire Chiefs (IAFC), National Fire Protection Association (NFPA), Institution of Fire Engineers, and the Society of Fire Protection Engineers. He is a Member of the Board of Directors of the Safety, Health and Survival Section of the International Association of Fire Chiefs and liaison between the IAFC-SHS and the National Fallen Firefighters Foundation. He is a graduate of Harvard University’s Kennedy School of Government, holds a Master of Arts in Public Administration from Arizona State University, and a Bachelor of Science in Engineering from McGill University. Michael Chiaramonte is a 40-year veteran of the Lynbrook Volunteer Fire Department in New York. He is a past chief of the department and held the position of Chief Fire Inspector for many years until his retirement from the department. Chiaramonte taught high school English for 36 years and retired from Jericho Public Schools in 1999. He has a Master of Arts in Communications Education from Hofstra University and a Bachelor of Science in English and Public Speaking Education from the University of Houston. He is a certified New York State Building and Fire Inspector. Chiaramonte is an instructor at the National Fire Academy, instructing in fire prevention, communications and leadership. He is a past president of the Eastern Division of the International Association of Fire Chiefs (IAFC), a past chairman of the IAFC Volunteer and Combination Officers Section and past chairman of the IAFC Election Committee. Chiaramonte is a peer evaluator for the Center for Public Safety Excellence and a Chief Fire Officer Designee. He is a contributing editor to Fire Chief Magazine and an advisory board member for the National Fallen Firefighters Foundation.


Page 146

Brian A. Crawford is an assistant chief and 24-year veteran of the Shreveport (LA) Fire Department, currently serving as the Assistant to the Fire Chief. He is a National Fire Academy (NFA) resident instructor as well as a NFA Executive Fire Officer Program (EFO) graduate, an IAEM Certified Emergency Manager and IAEM Certification Commissioner, as well as holding the Chief Fire Officer (CFO) designation from the Commission on Professional Credentialing. Crawford is a member of the International Association of Fire Chiefs (IAFC), serving on their Human Relations Committee, the National Fire Protection Association (NFPA), and serves on the Editorial Advisory Board for Fire Chief Magazine. He is a graduate of Harvard University’s Kennedy School of Senior Executives in State and Local Government, holds a Master of Arts in Industrial Psychology from Louisiana Tech University, a Bachelor of Science in Organizational Management from Wiley College, and an Associate of Science in Paramedic from Bossier Parish Community College where he is currently an adjunct faculty member. Peter A. Piringer is currently the Public Information Officer (PIO) for Montgomery County Fire & Rescue Services (MD) a position he has held since 2001. Piringer has over 35-years of public safety experience including twenty-four years with Prince George’s County (MD) Fire Department where he served as the PIO for more than ten years and as the Assistant PIO with the Maryland State Police. Piringer attended St. Mary’s college of Maryland and the University of Maryland College Park and is a graduate of the Prince George’s Fire Department Senior Management Institute of Bowie University. Piringer is also the President of the College Park Volunteer Fire Department, Maryland. Kevin Roche is an Assistant Fire Marshal and 18-year veteran for the Phoenix (AZ) Fire Department. He is a graduate of the Fire Protection and Safety program at Oklahoma State University and earned a Master of Arts in Political Science from the University of Florida. Roche began his career with the Gainesville (FL) Fire-Rescue Department. Roche’s experience includes significant work in the areas of fire department facilities planning and fire department logistics. Roche was the author of the “Capital Resource Management” chapter in the text Managing Fire and Rescue Services, published by the International City Management Association. He is also an active writer and consultant on firefighter safety and fire service management issues.


Page 147

Timothy E. Sendelbach is a 23-year student and educator of the fire & emergency services currently serving as Editor-in-Chief for FireRescue Magazine and President of TES² Training & Education Services in Savannah (GA). Sendelbach is the Immediate Past President of the International Society of Fire Services Instructors (ISFSI) and has served as Chief of Training for Savannah (GA) Fire & Emergency Services, as Assistant Fire Chief in Missouri City (TX) and as a Firefighter/Paramedic in Kansas City (KS). Sendelbach has earned a Master of Arts in Leadership from Bellevue University, a Bachelor of Science in Fire Administration and Arson and an Associate of Science in Emergency Medical Care from Eastern Kentucky University. Sendelbach has also served as the editor of the International Society of Fire Service Instructors (ISFSI) publication The Instructor, and as a contributing author to numerous other publications including: The Volunteer Voice, firehouse.com Members Zone, National Fire & Rescue, The Atlantic Firefighter, and the Fire & Emergency Television Network (FETN) in which he is the writer/developer of the featured “SURVIVAL!” program.


Page A-1

Appendix A – Firefighter Listing Fire Chief - Car 1 – Fire Chief Russell Thomas Assistant Chief - Car 2 – Assistant Chief Larry Garvin Battalion 4 - Car 4 – Battalion Chief Buddy Aytes Battalion 5 - Car 5 – Battalion Chief Raymond Lloyd Car 303 – Battalion Chief Robert O’Donald Training Chief – Training Chief Ricky Shriver Saint Andrews Car 3 – Acting Assistant Chief Morris Sills Captain 5 – Acting Captain Mark Kelsey Captain 6 – Captain Mark Davis Captain 11 – Acting Captain William Johnson Captain 10 – Captain Chris Villareal Captain 12 – Acting Captain John Hackett Captain 15 – Captain Louis Mulkey Captain 16 – Captain Theodore “Mike” Benke Captain 19 – Captain William “Billy” Hutchinson Captain Saint Andrews Engine 2 – Acting Captain Marques Bush Engineer 5 – Assistant Engineer Michael French Engineer 6 – Engineer William Kilcoyne Engineer 10 – Assistant Engineer John Butler Engineer 11 – Assistant Engineer David Griffin Engineer 12 – Engineer Tom Horn Engineer 15 – Engineer Reggie Wescott Engineer 16 – Engineer Art Wittner Engineer 19 – Engineer Rodney “Brad” Baity Saint Andrews Rescue 1 Driver – SA1 - Driver Steven Beasley Firefighter 6 – Firefighter Thad Morgan Firefighter 10 – Firefighter Nathan Hawkins Firefighter 11 – Firefighter TJ Axton Firefighter 12A – Firefighter John Lemacks in the nozzle position Firefighter 12B – Firefighter Ed Henry in the suction position Firefighter 15A – Assistant Engineer Mike Walker in the suction position Firefighter 15B – Firefighter Scott Thomes in the nozzle position Firefighter 16 – Firefighter Melvin Champaign Firefighter 19 – Firefighter James “Earl” Drayton Ladder 5 Firefighter – Firefighter Brandon Thompson Saint Andrews Engine 2 Firefighter – SA2 - Firefighter Daniel Bilton Saint Andrews Rescue 1 Firefighter – Firefighter Jared Malone

Radio Transmission and Phone Call TranscriptSofa Super Store - Charleston, South CarolinaJune 18, 2007

System Watch Corrected Time Since Unit or Name Spoken Words CommentsCorrected Time if no Incident Location

Time System Watch Dispatch

Telephone

19:07:58 Dispatch Barrineau Charleston Fire. How can I help you?

19:08:01 Caller Yes, Sir. I'm at Sofa Super Store on Highway 17.

There is a huge fire on the back of the alley

[inaudible]

19:08:08 Dispatch Barrineau Sofa Super Store

19:08:09 Caller Highway 17 You need to go over to that side gate,

man. They ain’t gonna be able to get through

there.

19:08:14 Dispatch Barrineau Okay and that’s.. What's the address for me?

19:08:16 Caller What's the address, Sir? What's the address?

1807 Savannah Highway

19:08:22 Dispatch Barrineau What's burning in the back?

19:08:25 Caller What's that?

19:08:26 Dispatch Barrineau What's burning?

19:08:27 Caller Uh, It's in the back of the Sofa Super Store it looks

like a little shed or something.

19:08:32 Dispatch Barrineau OK got you. I'll have someone out there. 1807

Savannah Highway.

19:08:35 Caller Yes Sir.

19:08:36 Dispatch Barrineau Thank you.

Channel 1

19:09:02

0:00:00 Dispatch Barrineau Dispatcher to Engine 11, Engine 10, Ladder 5,

Battalion 4 go to unit for possible structure. [alarm

tones] Dispatcher to Engine 11, Engine 10, Ladder

5, Battalion 4 start enroute to 1807 Savannah

Highway, behind the Super Store, Super Sofa

Store, possible 76. 19:09 hours

19:09:13 0:00:11 Car 2 Garvin System Watch activation, no audio

19:09:33

0:00:31 Engine 10

Mobile Radio

Villereal System Watch activation, no audio

19:09:37

0:00:35 Engine 10

Captain

Villereal Engine 10 is 10-8 Super Sofa Store Siren in the

background

19:09:39

0:00:37 Engine 10

Mobile Radio


19:09:44 0:00:42 Dispatch Barrineau 10-4, 10, 19:09

19:09:44

0:00:42 Battalion 4

Mobile Radio

Aytes Battalion 4 10-8. We got heavy smoke coming

from that direction.

Siren in the

background

19:09:49 0:00:47 Dispatch Barrineau 10-4

19:09:51

0:00:49 Engine 11

Mobile Radio

Johnson 11

19:09:51

0:00:49 Ladder 5

Mobile Radio

Kelsey Ladder 5, 10-8

Channel 1

19:10:18

0:01:16 Engine 16

Mobile Radio

Benke System Watch activation, no audio

19:10:26

0:01:24 Engine 16

Mobile Radio

Wittner Engine 16, 10-8 going to standby Engineer Art Wittner

talking

19:10:30 0:01:28 Dispatch Barrineau 10-4 16

19:10:32

0:01:30 Engine 15

Mobile Radio

Mulkey Dispatcher 15, 10-8. Relocating to Station 11

19:10:43 0:01:41 Dispatch Barrineau 10-4, 15

19:10:46

0:01:44 Battalion 4

Mobile Radio

Aytes Battalion 4, 10-97. Bunch of trash and debris

burning along side the building.

19:10:54 0:01:52 Dispatch Barrineau 10-4, Chief.

Sofa Super Store Transcript Page B-1 May 9, 2008



19:10:56

0:01:54 Battalion 4

Mobile Radio

Aytes Battalion 4, dispatcher. It may have got in the

building it’s right up against the wall

Radio feedback.

19:11:00 0:01:58 Dispatch Barrineau 10-4. All units, y’all heard the Chief.

19:11:03

0:02:01 Engine 10

Mobile Radio

Villereal Engine 10 Read

19:11:07

0:02:05 Ladder 5

Mobile Radio

Kelsey Ladder 5 Read

19:11:09

0:02:07 Engine 16

Mobile Radio

Benke 16 Read

19:11:11 0:02:09 Dispatch Barrineau 10-4 all units, 19…

19:11:11

0:02:09 Car 2 Mobile

Radio

Garvin …11 you need to come behind the Sofa Super

Store.

Siren in background

19:11:13

0:02:11 Battalion 4

Mobile Radio

Aytes Number 11, come in the second entrance right

here. I'm right here at the entrance come in here.

Siren in background

19:11:23

0:02:21 Engine 11

Mobile Radio

Johnson 10-4 Chief. We come to the back of the building,

coming around.

Siren in background

Channel 1

19:11:35 0:02:33 Car 2 Garvin Engine 10 come to me.

19:11:40

0:02:38 Engine 10

Mobile Radio

Villereal We’re 10-97, Chief. Siren winding down in

the background

19:11:45

0:02:43 Car 2 Garvin Get your truck in here and back it in right here. Siren winding down in

the background

19:11:50

0:02:48 Engine 10

Mobile Radio

Villereal 10-4

Channel 1

19:12:04 0:03:02 Car 2 Garvin Car 2 to Engine 16

19:12:08

0:03:06 Engine 16

Mobile Radio

Benke Go ahead, Chief. Siren in the

background

19:12:10

0:03:08 Car 2 Garvin When you get 10-97, come inside the building with

me.

Siren in the

background

19:12:15

0:03:13 Engine 16

Mobile Radio

Benke 16 Read Siren in the

background

19:12:17 0:03:15 Car 2 Garvin Engine 11….

19:12:18

0:03:16 Engine 15

Mobile Radio

Mulkey …15 to Car 2

19:12:22

0:03:20 Ladder 5

Mobile Radio

Kelsey System Watch activation, no audio

19:12:25

0:03:23 Ladder 5

Mobile Radio

Kelsey Ladder 5 10-97 Last transmission

Ladder 5 Captain -

Captain Kelsey did

not bring his portable

radio with him when

he entered the

structure.

19:12:28 0:03:26 Dispatch Barrineau 10-4, Ladder 5, 19:12

19:12:31


Radio

Thomas Car 1 to 15 you just go ahead to 11


19:12:37

0:03:35 Engine 11

Captain

Johnson System Watch activation, no audio

19:12:37

0:03:35 Engine 15

Mobile Radio

Mulkey 15 Read

19:12:40

0:03:38 Ladder 5

Ladderman 1

Thompson System Watch activation, no audio

19:12:43

0:03:41 Battalion 4 Aytes Battalion 4 to Car 2. Chief, I know it’s inside that

part of the building right there.

19:12:49 0:03:47 Car 2 Garvin 10-4. Dispatcher send me Engine 12.

19:12:53

0:03:51 Dispatch Barrineau 10-4. Dispatcher to Engine 12 standby [alarm

tones] Dispatcher to Engine 12 start in route to

1807 Savannah Highway, 1807 Savannah

Highway, structure.




19:13:03

0:04:01 Engine 10

Captain


19:13:10

0:04:08 Battalion 4 Aytes Battalion 4 to Engine 12. You need to lay a supply

line down here to number 10 down this alleyway,

right along side the building.

Sound of pump

primer in the

background

19:13:17

0:04:15 Engine 11

Captain

Johnson I need an inch and a half inside this building

19:13:19

0:04:17 Private call from

Engine 3 Captain to

Car 2

19:13:24

0:04:22 Engine 12

Mobile Radio

Hackett 12 copies

19:13:27

0:04:25 Engine 15

Mobile Radio

Mulkey Dispatcher, 15’s west side

19:13:28


Engine 3 Captain to

Car 2

19:13:31 0:04:29 Dispatch Barrineau 10-4, 15, I copy

19:13:31 0:04:29 Car 2 Garvin 15 come on

19:13:35

0:04:33 Engine 12

Mobile Radio

Hackett 12’s, 10-8 Siren starting in the

background

19:13:39 0:04:37 Dispatch Barrineau 10-4 12

19:13:41

0:04:39 Engine 15

Mobile Radio

Mulkey Dispatcher, 15’s 10-8 to the 76 Siren in the

background

19:13:44

0:04:42 Dispatch Barrineau 10-4, we copy Phone ringing in the

background

19:13:46

0:04:44 Car 2 Garvin Car 2 to Engine 15, when you get here, bring me an

inch and half on the inside of this building, to the

rear on the left side, I mean the right side

19:13:46

0:04:44 Engine 6

Mobile Radio

Davis System Watch activation, no audio

19:13:54

0:04:52 Engine 15

Mobile Radio

Mulkey 10-4, copy, going to the rear of the right side Siren in the

background

19:13:59

0:04:57 Engine 6

Mobile Radio

Davis Engine 6 is 10-8 relocating west side


19:14:05

0:05:03 Battalion 4 Aytes Battalion 4 to Car 2. Chief, can you get in that back

building.

19:14:10

0:05:08 Car 2 Garvin Car 4, I’ve got fire inside the rear of the building and

it’s walking its way right on into the, into the

showroom.

19:14:17

0:05:15 Engine 15

Nozzle

Thomes System Watch activation, no audio

19:14:19 0:05:17 Battalion 4 Aytes System Watch activation, no audio

19:14:23 0:05:21 Car 2 Garvin Car 2 to dispatcher, send me Engine 6

19:14:27

0:05:25 Dispatch McIver 10-4, dispatcher to Engine 6, 1807 Savannah

Highway, 1-8-0-7 Savannah Highway, at the Sofa

Super Store, time out 19:14

19:14:37


Radio

Thomas [inaudible] Is engine 19 in the station? Siren in the

background

19:14:37

0:05:35 Engine 6

Mobile Radio


19:14:41

0:05:39 Engine 15

Nozzle


19:14:44 0:05:42 Dispatch McIver Affirmative

19:14:45


Radio

Thomas Alright, send 19, umm, and tell, umm, 6 to relocate

to 11.

Siren in the

background

19:14:54

0:05:52 Engine 13

Mobile Radio

Harrison 13’s 10-13 10-13 = back in

service

19:14:56 0:05:54 Dispatch McIver 10-4 13

19:14:56

0:05:54 Dispatch Barrineau Dispatcher to Engine 6 go to 11, relocate to 11, 6

19:15:01

0:05:59 Engine 6

Mobile Radio


19:15:01

0:05:59 Engine 16

Mobile Radio





19:15:01 0:05:59 Dispatch McIver Engine 19 you copy?

19:15:05

0:06:03 Car 2 Garvin Charge that line that’s coming [inaudible] that line

19:15:07

0:06:05 Engine 19

Captain

Hutchinson System Watch activation, no audio

19:15:10

0:06:08 Engine 16

Mobile Radio

Benke 16 to Car 2, Chief, do you want us at the rear of the

building making entry?

Siren in the

background

19:15:11

0:06:09 Engine 19

Captain


19:15:15

0:06:13 Car 2 Garvin Negative, come to the front door and get me a 2 ½

and bring the 2 ½ in here


19:15:19

0:06:17 Engine 16

Mobile Radio

Benke 16 copy, we’re 10-97.

19:15:24

0:06:22 Engine 19

Captain


19:15:25 0:06:23 Dispatcher Barrineau 10-4, 16

19:15:26

0:06:24 Engine 10

Captain


19:15:27

0:06:25 Engine 19

Captain


19:15:30

0:06:28 Battalion 5

Mobile Radio

Lloyd Battalion 5, [inaudible] Assume Battalion 5 is

beginning his

response to the

incident.

19:15:31


Radio

Thomas Car 1 to Dispatcher, how about call St. Andrews

and just ask them to help us West Ashley pick up

the calls if we get anything

Siren in the

background

19:15:32

0:06:30 Engine 10

Captain


19:15:38 0:06:36 Dispatch Barrineau 10-4 Chief, I copy.

19:15:42

0:06:40 Engine 10

Captain


19:15:45

0:06:43 Engine 15

Mobile Radio

Mulkey Engine 15 to Car 2. Siren in the

background

Channel 1

19:15:56

0:06:54 Ladder 5

Engineer

French Engine 11 charge your line. May be in SCBA

facepiece.

19:15:59

0:06:57 Engine 10

Captain


19:16:01

0:06:59 Engine 19

Mobile Radio

Hutchinson 19, 10-8 Dispatcher.

19:16:04 0:07:02 Dispatch McIver 10-4, 19, 19:16

19:16:09

0:07:07 Engine 6

Mobile Radio

Davis 6 is West side

19:16:11 0:07:09 Dispatch McIver 10-4, 6

19:16:16

0:07:14 Ladder 5

Ladderman 1


19:16:21

0:07:19 Engine 11

Captain


19:16:23

0:07:21 Engine 11

Captain


19:16:23

0:07:21 Ladder 5

Ladderman 1

Thompson Truck 5 to Engine 11, charge that inch and a half In SCBA facepiece.

19:16:28

0:07:26 Ladder 5

Ladderman 1


19:16:32


Radio

Thomas Car 1 10-97 Dispatcher

19:16:35 0:07:33 Dispatch Barrineau 10-4, Car 1, 19:16

Channel 1

19:16:39

0:07:37 Engine 11

Suction

Axson System Watch activation, no audio




19:16:51

0:07:49 Engine 11

Captain


19:16:56

0:07:54 Engine 10

Captain


19:16:56 0:07:54 Battalion 4 Aytes Battalion 4,

19:16:57

0:07:55 Car 2 Garvin [inaudible] to Engine 16 PASS in the

background.

19:16:58

0:07:56 Engine 10

Captain


19:17:01

0:07:59 Battalion 4 Aytes Battalion 4 to Captain Engine 12 Siren in the

background.

19:17:05

0:08:03 Engine 12

Mobile Radio

Hackett …12 Siren in the

background.

19:17:07

0:08:05 Battalion 4 Aytes Captain Johnny, I need you to come down and a lay

a supply line to number 10

Siren in the

background

19:17:11

0:08:09 Engine 12

Mobile Radio

Hackett Where do you want us? Siren in the

background

19:17:13

0:08:11 Engine 16

Mobile Radio


19:17:14

0:08:12 Car 2 Garvin [inaudible] ten, engine 12, lay a supply line to

engine 10

Siren in the

background


19:17:22

0:08:20 Engine 11

Captain


19:17:25

0:08:23 Car 1 Thomas 12 give #10 a supply line Siren in the

background

19:17:28

0:08:26 Engine 12

Mobile Radio

Hackett Copy

19:17:30

0:08:28 Engine 15

Mobile Radio

Mulkey 15’s coming, 97 Siren in the

background.

19:17:31

0:08:29 Engine 16

Captain


19:17:34

0:08:32 Dispatch McIver 10-4, 15, 19:17 Siren in the

background

19:17:36 0:08:34 Car 2 Garvin Alright, 16, go to the hydrant

19:17:39

0:08:37 Engine 12

Mobile Radio

Hackett Where’s 10, alright we got ‘em

19:17:47

0:08:45 Engine 19

Captain


19:17:49

0:08:47 Ladder 5

Ladderman 1


Channel 1

19:18:00

0:08:58 Engine 3 Waring Engine 3 to Car 2 Engine 3 was on a

detail out of their first-

due area.

Channel 1

19:18:03

0:09:01 Engine 9

Suction

Holt System Watch activation, no audio

19:18:04 0:09:02 Car 1 Thomas System Watch activation, no audio

19:18:17

0:09:15 Engine 16

Suction

Champaign System Watch activation, no audio

19:18:24

0:09:22 Engine 10

Captain


Channel 1

19:18:31

0:09:29 Engine 11

Engineer

Griffin System Watch activation, no audio

19:18:57

0:09:55 Engine 10

Captain





Channel 1

19:19:07

0:10:05 Car 1 Thomas Alright, Engine 6 what’s your 20? 20 is short for 10-20

and means location

19:19:10

0:10:08 Engine 6

Mobile Radio

Davis In front of station 10

19:19:10

0:10:08 Engine 12

Engineer

Horn System Watch activation, no audio

19:19:12

0:10:10 Car 1 Thomas I want you to come on and park your truck in the

middle of the street on Savannah Highway and

come in the front door.

19:19:14

0:10:12 Engine 10

Captain

Villareal System Watch activation, no audio

19:19:18

0:10:16 Engine 6

Mobile Radio

Davis 6 is 10-8


19:19:25

0:10:23 Private call from BC3

to the Engine 3

Captain

Channel 1

19:19:28

0:10:26 Engine 12

Engineer


19:19:33 0:10:31 Car 1 Thomas Car 1 dispatcher, give us the power company

19:19:36 0:10:34 Dispatch Barrineau 10-4, Chief

19:19:36

0:10:34 Engine 16

Captain

Benke Charge that 2 ½ In SCBA facepiece

19:19:40

0:10:38 Engine 11

Engineer

Griffin Engineer 11 to Captain 11

19:19:44

0:10:42 Engine 11

Captain


19:19:50

0:10:48 Engine 11

Captain


19:17:48


Engine 3 Captain to

BC3

19:19:54

0:10:52 Engine 11

Engineer

Griffin Engineer 11 to Captain 11

19:19:59

0:10:57 Engine 11

Captain


19:20:00

0:10:58 Car 2 Garvin What you need, David, he’s busy Not in facepiece, faint

siren in the

background

19:20:03

0:11:01 Engine 11

Engineer

Griffin Do you want the 2 ½ charged?

19:20:05


Engine 3 Captain to

BC3

19:20:05

0:11:03 Car 2 Garvin Not until you get that supply line charged. Faint siren in the

background.

19:20:05

0:11:03 Engine 11

Captain


19:20:07

0:11:05 Engine 16

Captain


19:20:07

0:11:05 Ladder 5

Ladderman 1


19:20:08

0:11:06 Engine 19

Mobile Radio

Hutchinson 19’s, 10-97 Siren in background,

last transmission from

Engine 19 Captain

19:20:08

0:11:06 Engine 11

Engineer


19:20:14

0:11:12 Engine 10

Captain





19:20:25

0:11:23 Engine 15

Engineer

Wescott System Watch activation, no audio

Telephone

19:19:58 0:10:56 Power

Company

[ringing} Good evening, this is Deborah.

19:19:59 0:10:57 Dispatch Barrineau Yeah, Deborah. This is Operator 4 with the

Charleston Fire Department. I need a truck

immediately to 1807 Savannah Highway. We got

about ten engines at a big fire and we need the

power cut and I need to get them there as soon as

you can get one rolling there.

19:20:16 0:11:14 Power

Company

Okay, this is number 4?

19:20:17 0:11:15 Dispatch Barrineau Yeah, Operator 4. 1807 Savannah Highway

between Wappoo Road and Stinson. They can't

miss it.

19:20:23 0:11:21 Power

Company

Wappoo and Stinson?

19:20:24 0:11:22 Dispatch Barrineau Yeah.

19:20:25 0:11:23 Power

Company

S-t-i-n-s-o-n?

19:20:26 0:11:24 Dispatch Barrineau Right, exactly.

19:20:28 0:11:26 Power

Company

And what is your call back number?

19:20:30 0:11:28 Dispatch Barrineau XXX-XXXX. Number removed by

Kevin Roche during

transcript preparation

19:20:33 0:11:31 Power

Company

Area code 843?

19:20:34 0:11:32 Dispatch Barrineau Yeah, please just get them in route, okay, hon?.

We got ten engines there and it is burning like

crazy. We need the power cut.

19:20:40 0:11:38 Power

Company

Alright, Sir.

19:20:41 0:11:39 Dispatch Barrineau Thank you, love. We appreciate it.

19:20:16 0:11:14 Power

Company

Okay, bye bye.

Channel 1

19:20:31

0:11:29 Engine 12

Engineer

Horn Water coming 10

19:20:38 0:11:36 Battalion 3 Ackerman System Watch activation, no audio

19:20:41 0:11:39 Battalion 3 Ackerman Captain 3 stand by for a page

19:20:46

0:11:44 Engine 19

Engineer

Baity System Watch activation, no audio


19:20:55

0:11:53 Private call to Engine

3 Captain from BC3

19:20:55

0:11:53 Engine 12

Engineer

Horn [inaudible].. to dispatch, we need PD we got people

running over the hose.

19:20:59 0:11:57 Dispatcher McIver That’s Affirmative. They’re enroute.

19:21:00 0:11:58 Dispatcher System Watch activation, no audio

Channel 1

19:21:04

0:12:02 Private call to BC3

from Engine 3

Captain


19:21:20

0:12:18 Engine 11

Captain





19:21:21

0:12:19 Engine 15

Captain

Mulkey Engine 15 to Car 2 In SCBA facepiece


19:21:26

0:12:24 Engine 16

Suction


19:21:26

0:12:24 Engine 11

Captain


19:21:26 0:12:24 Car 2 Garvin 16, what about that supply line?

19:21:27

0:12:25 Engine 11

Captain

Johnson System Watch activation, no audio [inaudible voices]

19:21:29

0:12:27 Engine 15

Captain

Mulkey System Watch activation, no audio [inaudible voices]

19:21:32

0:12:30 Engine 16

Suction

Champaign System Watch activation, no audio [inaudible voices]

19:21:34 0:12:32 Car 2 Garvin System Watch activation, no audio [inaudible voices]

19:21:38

0:12:36 Engine 16

Suction


19:21:39

0:12:37 Engine 10

Captain

Villareal System Watch activation, no audio [inaudible voices]

19:21:40

0:12:38 Engine 12

Suction

Henry System Watch activation, no audio [inaudible voices]

19:21:41

0:12:39 Engine 16

Mobile Radio

Wittner [inaudible] …a hydrant chief

Unknown [inaudible voices] Possibly in SCBA

facepieces.

19:21:50

0:12:48 Engine 6

Mobile Radio

Davis 6, 10-97 Siren in background.

19:21:52

0:12:50 Engine 9

Suction


19:21:53 0:12:51 Dispatcher Barrineau 10-4, 6, 19:22

19:21:57

0:12:55 Engine 10

Captain


19:21:58

0:12:56 Engine 15

Captain

Mulkey System Watch activation, no audio [inaudible voices]

19:21:59

0:12:57 Engine 12

Captain

Hackett System Watch activation, no audio [inaudible voices]

19:22:05

0:13:03 Engine 10

Captain


19:22:08

0:13:06 Engine 12

Suction


19:22:16

0:13:14 Engine 16

Suction


19:22:21

0:13:19 Engine 12

Nozzle

LeMacks System Watch activation, no audio [inaudible voices]

19:22:28

0:13:26 Engine 12

Suction





[inaudible] ...0HAH0700 on a black Jeep Cherokee

[inaudible] Mallery Street to Park Street

This transmission

appears to be a radio

transmission by a law

enforcement officer

from Saint Simons

Island, Georgia.

Charleston Police

Department

Communications has

reported receiving

audio from Georgia

due to a phenomenon

called "skip". Saint

Simons Island has a

Mallery Street that

intersects with a Park

Avenue.

Communications for

Saint Simons Island

has confirmed that

this is their traffic.

19:22:33

0:13:31 Engine 11

Engineer

Griffin Engine 11, Engineer 16

19:22:36

0:13:34 Engine 10

Captain


19:22:39

0:13:37 Engine 16

Mobile Radio

Wittner Go ahead

19:22:41

0:13:39 Engine 11

Engineer

Griffin I’m half way

19:22:44

0:13:42 Engine 16

Mobile Radio

Wittner 10-4, I’m trying to get you a supply line, I gotta find

a hydrant

19:22:48

0:13:46 Engine 11

Engineer

Griffin 10-4

Channel 1

19:23:09 0:14:07 Car 1 Thomas Alright, Larry, how we looking inside the store?

19:23:16 0:14:14 Car 2 Garvin Chief, I’m trying to get back to it now In SCBA facepiece

Channel 1

19:23:18

0:14:16 Engine 16

Captain


19:23:30

0:14:28 Car 2 Garvin Car 2 to Captain of Engine 11 In SCBA facepiece,

PASS device in

prealert in the

background

19:23:35

0:14:33 Engine 19

Engineer

Baity System Watch activation, no audio

19:23:44

0:14:42 Engine 12

Suction

Henry System Watch activation, no audio

19:23:49

0:14:47 Engine 10

Engineer

Butler Engine 12 you sending us some more water?

19:23:55

0:14:53 Engine 12

Engineer

Horn Affirmative

19:24:02

0:15:00 Engine 10

Captain

Villareal [PASS alarm]

19:24:09 0:15:07 Battalion 5 Lloyd Battalion 5 is 10-97


19:24:10

0:15:08 Engine 16

Captain


19:24:12 0:15:10 Dispatch McIver 10-4, Battalion 5, 19:24

19:24:14

0:15:12 Dispatch Barrineau Dispatcher to Engine 3 relocate to 16 and 19,

Engine 3 go to 16 and 19, per Car 3

19:24:22 0:15:20 Engine 3 Waring Engine 3 read




19:24:22

0:15:20 Car 2 Garvin [inaudible} ...we need that 2-1/2 …. Likely in SCBA

facepiece., C2 begins

to talk, if overridden

by Dispatch and then

completes his

message after

dispatch completes

its "10-4" message

19:24:25

0:15:23 Dispatch Barrineau 10-4 Dispatcher takes

priority over portable

Car 2

19:24:29 0:15:27 Car 1 Thomas [Inaudible] …to Engine 12

19:24:35 0:15:33 Car 1 Thomas Car 1 to Engineer 12

19:24:35

0:15:33 Engine 16

Mobile Radio

Wittner System Watch activation, no audio

19:24:37

0:15:35 Engine 12

Engineer

Horn Go ahead Chief

19:24:45 0:15:43 Car 1 Thomas Car 1 to the engineer in 12

19:24:48

0:15:46 Engine 12

Engineer

Horn Go ahead Chief

19:24:50

0:15:48 Car 1 Thomas Alright, give us 50 more pounds on that supply line,

50 more pounds on that supply line

19:24:57

0:15:55 Engine 12

Engineer

Horn 50 pounds, coming.

Telephone


19:24:01 0:14:59 Battalion 3 Ackerman Hey, Budro

19:24:02 0:15:00 Dispatch Barrineau Yeah

19:24:03 0:15:01 Battalion 3 Ackerman Who's at 16 and 19?

19:24:04 0:15:02 Dispatch Barrineau Uh, 16 and 19, Chief? Amm…

19:24:06 0:15:04 Battalion 3 Ackerman Station, yeah, station. Nobody, right?

19:24:07 0:15:05 Dispatch Barrineau Nobody, no.

19:24:08 0:15:06 Battalion 3 Ackerman Tell three to go ahead and relocate there.

19:24:10 0:15:08 Dispatch Barrineau Alright.

19:24:10 0:15:08 Battalion 3 Ackerman Alright

19:24:11 0:15:09 Dispatch Barrineau Thank you

Channel 1

19:25:13

0:16:11 Engine 10

Engineer

Butler 12, I’m down to a quarter.

19:25:15

0:16:13 Engine 16

Suction


19:25:18

0:16:16 St. Andrews

Engine 2

Bush St. Andrew’s Engine 2 and Rescue 1 to City of

Charleston

19:25:19

0:16:17 Ladder 5

Ladderman 1


19:25:26 0:16:24 Car 1 Thomas Car 1 to 12, did you give me my 50 pounds?

19:25:29

0:16:27 Engine 12

Engineer

Horn That’s affirmative

19:25:33

0:16:31 Ladder 5

Ladderman 1


19:25:34

0:16:32 Engine 10

Captain


19:25:37

0:16:35 Engine 16

Suction


19:25:38 0:16:36 Car 1 Thomas Car 1 to Engine 12

19:25:40

0:16:38 Engine 16

Suction


19:25:41

0:16:39 Engine 12

Engineer

Horn [inaudible] I’ve got 50 pounds to you

19:25:41

0:16:39 Engine 10

Captain





19:25:45

0:16:43 Car 1 Thomas Alright, give me 50 more pounds on the supply line

19:25:45

0:16:43 Engine 11

Captain


19:25:47

0:16:45 Engine 16

Suction


19:25:49

0:16:47 Engine 12

Engineer


19:25:51

0:16:49 Engine 12

Engineer

Horn … 50 pounds on the supply line

19:25:53 0:16:51 Car 1 Thomas 50 more on the supply line

19:25:59

0:16:57 Engine 12

Engineer

Horn Affirmative. 50 pounds

19:26:07

0:17:05 Engine 11

Engineer

Griffin Engine 11, Engineer 16 PASS in the

background.


19:26:17

0:17:15 Engine 16

Mobile Radio

Wittner Water coming

19:26:20

0:17:18 Engine 11

Engineer


Telephone

19:26:35 0:17:33 Dispatch Barrineau Charleston Fire.

19:26:36 0:17:34 Caller Yes


19:26:38 0:17:36 Caller Yeah, I'm trapped inside.

19:26:40 0:17:38 Dispatch Barrineau You're inside?

19:26:41 0:17:39 Caller I'm inside, can you help please?

19:26:43 0:17:41 Dispatch Barrineau You're inside, whereabouts?

19:26:45 0:17:43 Caller At the back.

19:26:46 0:17:44 Dispatch Barrineau Oh, at the back. At the back? He's in the back,

he's trapped in the back.

19:26:50 0:17:48 Caller [Inaudible] I'm choking

19:26:51 0:17:49 Dispatch Barrineau Okay, we'll get you there, buddy. We coming in

there for you right now, okay?

19:26:55 0:17:53 Caller Alright, please [inaudible]

19:26:56 0:17:54 Dispatch Barrineau Okay buddy, we’re there, we’re there, we’ll be

there, okay buddy

19:27:00 0:17:58 Caller Thank you. Excuse me, I've got a wife and kids.

19:27:02 0:18:00 Dispatch Barrineau I know. Partner, just hang in there. Just stay low

for me. You get low on the ground.

19:27:07 0:18:05 Caller [Inaudible] It's getting hot.

19:27:09 0:18:07 Dispatch Barrineau Once they, once they get in there, you holler as

loud as you can, okay?

19:27:13 0:18:11 Caller I'm beating on the walls with a hammer.

19:27:16 0:18:14 Dispatch Barrineau Okay, keep beating, just keep beating. But try to

stay as low and as calm as you can be. They'll get

in. They'll bust in and get in for you. They've got a

bunch of trucks there. Don't worry. We're gonna

get you out of there. [dial tone]

19:27:27 0:18:25 Dispatch Barrineau He just hung up. [dial tone}

19:27:47 0:18:45 Dispatch Barrineau Charleston Fire, how can I help you?

19:27:50 0:18:48 Caller Is there a fire on James Island?

19:27:51 0:18:49 Dispatch Barrineau No, there's one on Savannah Highway.

19:27:53 0:18:51 Caller Savannah Highway, is it City of Charleston?


19:27:56 0:18:54 Caller But where is it located?

19:27:58 0:18:56 Dispatch Barrineau Partner, listen we can't talk right now. Just call

back later.

Channel 1




19:26:35

0:17:33 Dispatch McIver Dispatcher to Car 1 Barrineau can be

heard in the

background initiating

call with trapped

worker

19:26:38 0:17:36 Car 1 Thomas Go ahead

19:26:40

0:17:38 Dispatch McIver 10-4, Be advised we’re getting a 911 call stating

that there is a person trapped in the building, at the

back of the building, at the back of the building.

19:26:41 0:17:39 Battalion 5 Lloyd System Watch activation, no audio

19:26:49

0:17:47 Ladder 5

Ladderman 1


19:26:51

0:17:49 Car 1 Thomas 10-4 PASS in background.

19:26:53

0:17:51 Ladder 5

Ladderman 1


19:26:59

0:17:57 Car 2 Garvin Car 2 to Car 1. Not likely in

facepiece.

19:27:01

0:17:59 Car 1 Thomas Go ahead, Chief PASS in background.

19:27:03

0:18:01 Engine 10

Captain



19:27:04

0:18:02 Outside Agency … to the City of Charleston, City PD’s got us…

19:27:05

0:18:03 Engine 11

Captain


19:27:06

0:18:04 Engine 16

Mobile Radio

Wittner water coming to you

19:27:12

0:18:10 Ladder 5

Ladderman 1


19:27:18

0:18:16 Engine 12

Suction


19:27:19

0:18:17 Engine 15

Nozzle


19:27:44

0:18:42 Ladder 5

Ladderman 1


Unknown [Inaudible – possibly “lost inside” or “trapped

inside”]

vibralert sound

Telephone

19:27:24 0:18:22 McIver [ringing] Fire Department

19:27:25 0:18:23 Hawkins Is that caller inside the building calling you?

19:27:28 0:18:26 McIver Yes.

19:27:29 0:18:27 Hawkins Then you need to tell him that.

19:27:30 0:18:28 McIver I did.

19:27:32 0:18:30 Hawkins No you didn't.

19:27:32 0:18:30 McIver I said we received a 911 call that he is in the

building.

19:27:35 0:18:33 Hawkins That ain't what it sounded like. It sounds like we

are getting a 911 call that somebody is trapped in

the building.

19:27:41 0:18:39 McIver No

19:27:42 0:18:40 Hawkins And the people calling you is in the building.




19:27:44 0:18:42 McIver Yeah. ‘cause I said he’s in the back of the store.. I..

well…. I don't know..wait a minute. [Inaudible in

background]

Chief Thomas can be

heard in the

background on

channel one talking

about the rear door

(192755) McIver and

Hawkins are likely

listening to channel

one during the pause

and hear a more

detailed description of

the trapped person’s

location on that

channel.

19:28:07 0:19:05 Hawkins There you go. That's good stuff

19:28:09 0:19:07 McIver Okay

19:28:10 0:19:08 Hawkins Alright, bye.

19:28:11 0:19:09 McIver Alright

Channel 1

19:27:51 0:18:49 Car 1 Thomas Car 1 to Car 2

19:27:53 0:18:51 Car 2 Garvin Go ahead Chief

19:27:55

0:18:53 Car 1 Thomas Alright, we got the door open to this back building

now. We’ve got a stacked tip inside. Ahh, tell me

what you got in there.

PASS in background.

Chief Thomas is

referring to the

warehouse as the

back building.

19:28:03

0:19:01 Car 2 Garvin They told me at first, Chief, that he left but now they

realize he’s in the building

19:28:08

0:19:06 Car 1 Thomas Just do what we can do. PASS in background.

19:28:10 0:19:08 Car 2 Garvin 10-4

Channel 1

19:28:19

0:19:17 Dispatch Barrineau Chief, he's going to be in the very back and is going

to be beating on the wall with a hammer. I just

talked to him on the phone and then we got cut off.

He's going to be in the rear of the building.

19:28:29 0:19:27 Car 2 Garvin 10-4

Channel 1

19:28:42

0:19:40 Car 2 Garvin Car 2 to any available fireman that’s in front up by

number 11

PASS in background,

not in SCBA

facepiece.

19:28:53

0:19:51 Car 2 Garvin Car 2 to Engineer number 11 PASS in background.


19:28:58

0:19:56 Engine 11

Engineer


19:29:00

0:19:58 Engine 16

Suction

Champaign Which way out? In SCBA facepiece.

19:29:02

0:20:00 Engine 11

Engineer

Griffin Water’s coming right now This is most likely

when the 2-1/2 line

through the front door

was charged.

19:29:03

0:20:01 Engine 16

Suction

Champaign [inaudible] …way out In SCBA facepiece.




19:29:07

0:20:05 Engine 16

Suction

Champaign System Watch activation, no audio There are a total of

nine radio activations

by Firefighter

Champaign, many

with no discernable

audio

19:29:11

0:20:09 Engine 16

Suction


19:29:15

0:20:13 Engine 16

Suction


19:29:24

0:20:22 Engine 16

Suction


19:29:30

0:20:28 Engine 16

Suction


Telephone

19:29:14 0:20:12 Dispatch Barrineau [Inaudible] Send someone over there right now. Charleston County

EMS shows this time

as 19:20:45 and

acknowledges that it

is not correct

19:29:19 0:20:17 EMS Dispatch EMS

19:29:20 0:20:18 Dispatch Barrineau Hey, Sweetie. This is Operator 4. How about do

me a favor and get a unit over to 1807 Savannah

Highway, the Super Store. We got about ten trucks

over there and there is supposed to be a man

trapped inside too, okay.

19:29:29 0:20:27 EMS Dispatch Oh, that's at that fire y’all working?

19:29:30 0:20:28 Dispatch Barrineau Yeah, please send a, please send one to be

standing by for us.

19:29:34 0:20:32 EMS Dispatch Alright, and what’s the name of the business?

19:29:35 0:20:33 Dispatch Barrineau Super Sofa, Super Sofa Store…

19:29:38 0:20:36 EMS Dispatch Okay, gotcha.

19:29:39 0:20:37 Dispatch Barrineau It’s at 1807 Savannah Highway, Sweetheart.

19:29:41 0:20:39 EMS Dispatch Gotcha, okay

19:29:41 0:20:39 Dispatch Barrineau Thanks, love.

19:29:42 0:20:40 EMS Dispatch Bye, bye.

19:29:42 0:20:40 Dispatch Barrineau Bye bye, Baby.

Channel 1

19:29:35

0:20:33 Engine 16

Suction

Champaign [inaudible] which way out

19:29:42

0:20:40 Engine 16

Suction

Champaign Everybody out. In SCBA facepiece,

maybe vibra-alert.

19:29:49

0:20:47 Engine 16

Suction

Champaign [inaudible]

Channel 1

19:29:59

0:20:57 Engine 11

Engineer

Griffin Engineer 11 to Car 2 PASS in the

background.

19:30:02

0:21:00 Car 2 Garvin I’ve got some help back here Likely in the rear of

the building?

19:30:03

0:21:01 Engine 10

Captain


19:30:06

0:21:04 Engine 11

Engineer

Griffin …2 ½ charge

Channel 1

19:30:15

0:21:13 Engine 16

Suction

Champaign We need some help out




19:30:20

0:21:18 Engine 16

Captain

Benke System Watch activation, no audio Last transmission

from Engine 16

Captain

19:30:22

0:21:20 Engine 16

Suction


19:30:22

0:21:20 Ladder 5

Ladderman 1

Thompson This is Thompson. We need some help. [inaudible] Vibra-alert in

background, another

voice in facepiece in

background. – Maybe

“Help!” at the end -

Identifed by voice, no

System Watch record

for Thompson, may

be on Mulkey

portable radio

19:30:22

0:21:20 Engine 15

Captain

Mulkey System Watch activation, no audio Last transmission

from Engine 15

Captain

19:30:27 0:21:25 Car 303 O'Donald 303 to Car 1

19:30:31

0:21:29 Engine 16

Suction

Champaign [inaudible] …firefighter. Needs some help out. Lost

connection with the hose.

In facepiece, vibra-

alert in background,

may be Champaign

19:30:41

0:21:39 Car 1 Thomas Car 1 to Dispatcher PASS in the

background

19:30:44 0:21:42 Dispatch McIver Go ahead

19:30:45

0:21:43 Car 1 Thomas What’s my closest unit to the 76? PASS in the

background

19:30:51

0:21:49 Unknown [inaudible] … I’m in the building… Likely in SCBA

facepiece.

19:30:51

0:21:49 Engine 16

Suction


19:30:52 0:21:50 Dispatch System Watch activation, no audio


19:30:58 0:21:56 Car 2 Garvin Car 1, we trying to get in to this guy now

19:31:03

0:22:01 Car 1 Thomas 10-4. Car 1 to Dispatcher, what’s my closest unit to

the 76?

19:31:08 0:22:06 Dispatcher McIver Engine 3 is relocating to Station 16


19:31:08

0:22:06 Engine 16

Suction

Champaign [inaudible] Possible in facepiece

19:31:11

0:22:09 Car 1 Thomas Alright, tell number 3, I want them to come to the 76

and I want them to lay the line to the aerial ladder, a

line to the snorkel

19:31:14

0:22:12 Engine 12

Suction


19:31:19 0:22:17 Battalion 5 Lloyd Car 5 to Dispatcher, we got the man

19:31:19

0:22:17 Engine 16

Suction

Champaign [inaudible, possible “what?”]




19:31:25

0:22:23 Engine 16

Suction


19:31:28

0:22:26 Engine 16

Mobile Radio

Wittner 16 Dispatch. Ahh, tell PD they need to stop traffic

going eastbound on a, or northbound on 17 from

Wappoo to Randall, [inaudible] on the supply line

19:31:29

0:22:27 Engine 16

Suction

Champaign Can you hear me dispatch? In facepiece

19:31:42

0:22:40 Car 2 Garvin Car 2 Dispatcher. Get me EMS to this 20, please PASS in background.

19:31:43

0:22:41 Ladder 5

Engineer

French System Watch activation, no audio

19:31:46 0:22:44 Dispatch McIver Affirmative, they are already in route




19:31:46

0:22:44 Car 1 Thomas … what I want you to do when you get here, is

come past Sofa Super Store and lay a line to

Ladder 5

PASS in background.

19:31:48

0:22:46 Engine 16

Suction


19:31:50

0:22:48 Ladder 5

Engineer


19:31:55

0:22:53 Engine 19

Suction

Drayton System Watch activation, no audio On Channel 2

19:31:56

0:22:54 Engine 3 Waring Engine 3 to Car 1, we’re coming down 526 right

now

Siren in background.

19:32:00

0:22:58 Car 1 Thomas 10-4. When you get here, umm, just past Super

Sofa Store, in the parking lot next door, James

Richardson’s gonna set it up.

PASS in the

background.

19:32:02

0:23:00 Engine 16

Suction


19:32:07

0:23:05 Ladder 5

Engineer


19:32:11 0:23:09 Engine 3 Waring 10-4, Chief

19:32:12

0:23:10 Engine 16

Suction

Champaign

System Watch activation, no audio

19:32:15

0:23:13 Ladder 5

Engineer

French [inaudible] Mayday

19:32:19

0:23:17 Car 303 O’Donald Car 1… Full message was –

Car 1 somebody’s

calling a mayday

19:32:20

0:23:18 Unknown [inaudible] for a message PASS device

sounding in the

background

19:32:20

0:23:18 Engine 16

Suction



19:32:28

0:23:26 Unknown I love you PASS in the

background

19:32:28

0:23:26 Ladder 5

Engineer


19:32:33

0:23:31 Car 303 O'Donald [Inaudible] Everybody stay off the radio. Possible backup

alarm in the

background, likely

Ladder 5 backing up

19:32:40

0:23:38 Engine 16

Suction

Champaign In Jesus Name, Amen PASS in the

background, likely not

in facepiece. Likely

Champaign

19:32:46 0:23:44 Car 2 Garvin Dispatcher, give me an ETA on EMS

19:32:49

0:23:47 Dispatch Barrineau EMS should be enroute. I’ve already called them,

Chief.

19:32:53

0:23:51 Car 2 Garvin 10-4. Tell them, call them back and tell them to

come in the parking lot and go by one of the Sofa

Super Store’s trucks, we’ve got a man that was in

that building.


19:33:01

0:23:59 Car 1 Thomas Chief Larry [inaudible] in the back, everybody’s out

of the back

PASS in the

background

19:33:05 0:24:03 Car 2 Garvin Yes sir, Chief, we got him out over here.

19:33:08

0:24:06 Car 1 Thomas Alright, everybody stay off the radio, Chief Larry PASS in the

background.

19:33:12 0:24:10 Car 2 Garvin Yes sir.

19:33:14

0:24:12 Car 1 Thomas Is everybody out where you are at? PASS in the

background.

19:33:17 0:24:15 Car 2 Garvin No sir, we’ve still got guys in there

19:33:20

0:24:18 Car 1 Thomas Chief O'Donald said that sombody’s calling for a

Mayday. Now, my people in the back are out.

What about your people in the front?

PASS in the

background.

19:33:26 0:24:24 Car 2 Garvin 10-4




19:33:30

0:24:28 Car 1 Thomas Make sure they’re out. Everybody stay off the

radio. Chief Larry, we need to make sure your

people are accounted for first, you need to make

sure of that.

PASS in the

background.


19:33:44

0:24:42 Car 2 Garvin 10-4, Chief. We just got one man out. PASS in background

19:33:44

0:24:42 Ladder 5

Engineer


19:33:47

0:24:45 Car 1 Thomas Larry, who is it? PASS in background.

19:33:52

0:24:50 Car 2 Garvin Mike Walker. PASS in the

background

19:33:53 0:24:51 Unknown [breathing] Dispatch [inaudible]

19:33:53

0:24:51 Engine 16

Suction


19:33:57 0:24:55 Car 1 Thomas Chief Larry [inaudible]

19:33:58

0:24:56 Battalion 4 Aytes System Watch activation, no audio Possible sound of

breathing.

19:34:01

0:24:59 Car 2 Garvin Car 2 to Car 1, Mike Walker said it was not him, it

was somebody else.

PASS in background

19:34:11

0:25:09 Car 1 Thomas We need to find out who it is, Chief Larry. PASS in the

background.

19:34:18

0:25:16 Ladder 5

Engineer

French Mikey French is.

19:34:21

0:25:19 Car 1 Thomas Who is it, whose calling the mayday? PASS in background.

19:34:27

0:25:25 Battalion 4 Aytes Battalion 4 to Car 1. Chief, do you have a pumper

coming to the aerial.

19:34:31

0:25:29 Car 1 Thomas Chief Buddy stay off the radio. We’re trying to find,

to see if we’ve got a fireman down.

PASS in the

background.

19:34:35


to Car 303

19:34:35

0:25:33 Ladder 5

Engineer

French [alarm sound] Emergency alarm

received at Dispatch

19:34:40 0:25:38 Car 1 Thomas [alarm sound] [inaudible]

19:34:40

0:25:38 Private call from Car

303 to BC3

19:34:40

0:25:38 Dispatch McIver Car 1. [alarm sound] Ladder 5’s engineer’s walkie’s

off.



19:34:45

0:25:43 Ladder 5

Engineer


19:34:47 0:25:45 Car 1 Thomas [inaudible] we need to vacate the building

19:34:57

0:25:55 Dispatch McIver Car 1, the Engineer on Ladder 5’s emergency

button has been activated


19:34:59

0:25:57 Engine 10

Captain


19:35:08 0:26:06 Battalion 4 Aytes Car 1 that’s ahh Mike French

19:35:12 0:26:10 Car 1 Thomas Where’s Michael French?

19:35:34 0:26:32 Car 2 Garvin We found William Johnson

19:35:34

0:26:32 The emergency

signal activation

initiated by Michael

French is cleared

from the dispatch

console.

19:35:38

0:26:36 Car 1 Thomas Car 1 to Dispatcher. Umm, Car 1 to, everybody

stay off the radio. Is everybody accounted for?

PASS in the

background.

19:35:47 0:26:45 Car 1 Thomas Car 1 to the Captain of 15.





Telephone


19:31:41 0:22:39 Battalion 6 Neilson Geno

19:31:41 0:22:39 Dispatch Barrineau Yes

19:31:42 0:22:40 Battalion 6 Neilson Hey, listen. It sounds like there is fireman saying

he's lost connection with the hose and he's lost.

19:31:47 0:22:45 Dispatch Barrineau They've got too many around there, doll baby. I

think they just got the guy that was caught in the

back.

McIver can be heard

in the background

saying that EMS is

already enroute - on

channel one -

19:31:59

19:31:54 0:22:52 Battalion 6 Neilson Okay, because it sounds like a guy says he's lost

connection with the hose.

19:31:56 0:22:54 Dispatch Barrineau Alright.

19:31:57 0:22:55 Battalion 6 Neilson Just listen if hear [inaudible].

19:31:58 0:22:56 Dispatch Barrineau Yeah. We will, we try to listen.

19:32:00 0:22:58 Battalion 6 Neilson I know.

19:32:01 0:22:59 Dispatch Barrineau Thank you.

19:32:01 0:22:59 Battalion 6 Neilson I hate to bother you.

19:32:02 0:23:00 Dispatch Barrineau That's okay darlin'. Appreciate it. I love you man.

Telephone

19:33:07 0:24:05 EMS Dispatch [ringing] Hey Charleston County

EMS shows this time

as 19:24:33 and


is not correct

19:33:08 0:24:06 Dispatch Barrineau Hey, doll baby.

19:33:09 0:24:07 EMS Dispatch Hey.

19:33:09 0:24:07 Dispatch

Barrineau

You all been 97 yet? We need you to go into the

back. They've got the guy that was trapped inside.

19:33:14 0:24:12 Okay

19:33:15 0:24:13 He's in the back of the Super Super, Super, I can't

even…

19:33:18 0:24:16 EMS Dispatch I know it

19:33:19 0:24:17 Dispatch Barrineau Damn, I can't pronounce that, Sofa Store.

19:33:21 0:24:19 EMS Dispatch Okay

19:33:22 0:24:20 Dispatch

Barrineau

He's in the back. So tell that unit to come around to

the back for me, darling.

19:33:25 0:24:23 EMS Dispatch Gotcha

19:33:25 0:24:23 Dispatch Barrineau Love you man.

19:33:26 0:24:24 EMS Dispatch Alright

19:33:26 0:24:24 Dispatch Barrineau Alright baby, bye bye

Telephone

19:33:45 0:24:43 Dispacth Barrineau Yeah

19:33:46 0:24:44 Engine 9

Captain

Hess

Get on the radio. Tell the man down to hit his

orange button so they know who it is. You know

what I mean?

19:33:52 0:24:50 Dispacth Barrineau Yeah, yeah.

19:33:54 0:24:52 Engine 9

Captain Hess

Do that

Telephone

19:34:52 0:25:50 Dispatch Barrineau [ringing] Yeah. We are trying to get. Charleston

Fire Department, what can I do for you?

19:34:57 0:25:55 Hawkins Hey.





19:34:59 0:25:57 Hawkins Who was that was talking when praying.

19:35:00 0:25:58 Dispatch Barrineau I don't know, man, talking. I don't know. We just

trying to find out who…

19:35:04 0:26:02 Hawkins [inaudible] on the list coming down, who it was

19:35:06 0:26:04 Dispatch Barrineau No, we didn't see it, it was too fast. We got the

Engineer, Ladder 5, the code was going off. Mike

French. Alright, let's go. It's too much going on

right now. Love you, Man.

19:35:16 0:26:14 Hawkins Alright, bye.

Channel 1

19:36:07

0:27:05 Car 1 Thomas Car 1 to the Captain of 15 or anybody on 15. PASS in the

background.

Channel 1

19:36:22 0:27:20 Car 1 Thomas Car 1 to anybody in Engine 15.

Channel 1

19:36:41 0:27:39 Car 1 Thomas Car 1 to the Captain on 15 or anybody at 15.

Channel 1

19:36:55

0:27:53 Car 1 Thomas Car 1 to anybody in 15 or 11. PASS in the

background.

19:37:02

0:28:00 Car 1 Thomas Car 1 to Dispatcher. Send me a fresh crew. PASS in the

background.

19:37:08 0:28:06 Dispatcher McIver Car 1, send you what?

19:37:10

0:28:08 Car 1 Thomas Send me my next closest pumper for manpower as

quick as you can.

19:37:18

0:28:16 Battalion 5 Lloyd Battalion 5, Dispatcher, send 13 across the bridge

19:37:22

0:28:20 Dispatch McIver 10-4. Dispatch to Engine 13, 1807 Savannah

Highway, 1807 Savannah Highway, time out 19:37


19:37:23

0:28:21 Engine 16

Suction

Champaign System Watch activation, no audio Last transmission

from Engine 16

Suction

19:37:29 0:28:27 Car 303 O'Donald System Watch activation, no audio


19:37:32

0:28:30 Engine 13

Mobile Radio

Harrison 13, 10-8

19:37:33 0:28:31 Car 11 Thomas Car 11 to Captain [inaudible]



19:37:34 0:28:32 Car 1 Thomas [inaudible]

19:37:34

0:28:32 Engine 9

Suction


19:37:39 0:28:37 Battalion 5 Lloyd Car 5 to Engine 7 move up to Engine 13

19:37:42

0:28:40 Engine 11

Captain


19:37:51

0:28:49 Car 11 Shriver Car 11 to Captain Louis Mulkey Air horns sounding in

background.

Channel 2

19:37:43

0:28:41 Engine 7

Captain

Harriss

10-4 Chief

First recorded

transmission on

channel 2

Channel 1




19:38:03

0:29:01 Car 1 Thomas Car 1 to anybody on 15. Air horns sounding in

background.

19:38:09

0:29:07 Car 1 Thomas Everybody abandon the building PASS in the

background

19:38:11

0:29:09 Engine 12

Suction


19:38:14

0:29:12 Engine 11

Engineer

Griffin Engine 11, Engine16, I need more pressure

19:38:23

0:29:21 Ladder 5

Engineer

French Michael French

presses the transmit

button on his portable

radio and reinitiates

the emergency

system. Since the

emergency mode was

not cleared from his

portable radio after it

was activated earlier,

the system reverts

back to emergency

mode.

19:38:26

0:29:24 Engine 12

Suction


19:38:28

0:29:26 Ladder 5

Engineer


19:38:32 0:29:30 Car 11 Shriver Car 11 to Captain Louis Mulkey

19:38:33

0:29:31 Ladder 5

Engineer


19:38:38

0:29:36 Engine 9

Captain

Hess System Watch activation, no audio

19:38:39

0:29:37 Ladder 5

Captain

Richardson System Watch activation, no audio The Ladder 5 Captain

portable radio was

used by James

Richardson as he

operated as a part of

the Ladder 5

apparatus.

19:38:41 0:29:39 Car 11 Shriver …anybody on Engine 15

19:38:42

0:29:40 Ladder 5

Engineer

French System Watch activation, no audio Last transmission

from Ladder 5

Engineer

19:38:54

0:29:52 Car 1 Thomas Car 1 to 15 PASS in the

background

19:38:59

0:29:57 Engine 12

Suction


19:39:11 0:30:09 Battalion 4 Aytes Battalion 4 to Car 1

19:39:15

0:30:13 Engine 7

Nozzle

Singletary System Watch activation, no audio

19:39:21

0:30:19 Car 2 Garvin [inaudible] …16 give me some more water Possibly “engine 6…”

19:39:24 0:30:22 Car 1 Thomas Car 1 to the Captain on 15 or anybody on 15

19:39:37

0:30:35 Engine 13

Mobile Radio

Harrison 13 to Car 1 Siren in the

background.


19:39:42

0:30:40 Engine 13

Mobile Radio

Harrison Do you need Air One? Air One is a support

vehicle that has a

large cascade system

for refilling SCBA

cylinders.


19:39:47

0:30:45 Car 11 Shriver Car 11 to Engine 16 PASS in the

background

19:39:50

0:30:48 Engine 16

Engineer

Wittner Go ahead




19:39:52

0:30:50 Car 11 Shriver We need more pressure on this supply line. PASS in the

background

19:39:56

0:30:54 Engine 16

Engineer

Wittner 10-4

19:39:59

0:30:57 Car 11 Shriver Take it to 200 pounds if you have to, we’re running

dry on this end, we’ve got 2 ½’s off

19:40:05

0:31:03 Engine 16

Engineer

Wittner 200 pounds it is, Chief

19:40:09

0:31:07 The second

emergency signal

activation initiated by

Michael French is

cleared from the

dispatch console.

19:40:11

0:31:09 Car 1 Thomas …we need to, everybody, Car 1 to Battalion 4.

Everybody stay out of the building.

Siren in the

background at the

end of the

transmission.

19:40:19

0:31:17 Engine 3

Mobile Radio

Waring Engine 3, 10-97 Siren in the

background.

19:40:21 0:31:19 Dispatch Barrineau 10-4, 3, 19:40

19:40:23

0:31:21 Battalion 4 Aytes Battalion 4 to Car 1. I’ve got Hollywood coming to

lay a line to the aerial, Chief, and put it up.

Hollywood = St. Pauls

Fire District

19:40:29 0:31:27 Battalion 5 Lloyd Bill, [inaudible]

19:40:30

0:31:28 Car 1 Thomas 10-4, [inaudible] everybody out of the building. We

still can’t find the Captain on 15.

Channel 2

19:38:28

0:29:26 Engine 7 Harriss Engine 7 to Dispatch on channel 2. We are 10-8 to

Station 13

19:38:33 0:29:31 Dispatch McIver 10-4


Telephone

19:38:58 0:29:56 Dispatch Barrineau [ringing) Charleston Fire, go ahead.

19:39:01 0:29:59 Engine 9

Captain Hess

Hey, I'm going to north bridge, this is #9.

19:39:05 0:30:03 Dispatch Barrineau Going to the north bridge?

19:39:06 0:30:04 Engine 9

Captain Hess

Yeah, I'm going to north bridge around 12's area

unless they call for us.

19:39:10 0:30:08 Dispatch Barrineau Alright, why don't you try to get closer than that?

19:39:12 0:30:10 Engine 9

Captain Hess

Okay, alright

19:39:13 0:30:11 Dispatch Barrineau Alright. Thank you man. Bye, bye.

19:39:14 0:30:12 Engine 9

Captain Hess

Bye

Channel 2

19:38:56

0:29:54 Engine 8

Mobile Radio

Suggs Engine 8, Battalion, ahh Engine 8 to Dispatcher on

Channel 2

Telephone

19:39:26 0:30:24 Dispatch

McIver

[crying] [ringing] Oh shit. Charleston County

EMS shows this time

as 19:30:57 and


is not correct

19:39:32 0:30:30 EMS Dispatch EMS

19:39:34 0:30:32 Dispatch McIver Hey, EMS. This is the Fire Department.

19:39:35 0:30:33 EMS Dispatch Yes




19:39:37 0:30:35 Dispatch

McIver

Ahem, we need some more units over at the Sofa

Super Store. I don't know we've got a whole unit

that is not answering our radio so we don't know if

they are still inside the building or not.

19:39:49 0:30:47 Okay

19:39:50 0:30:48 Dispatch McIver Can you get someone over there, please?

19:39:51 0:30:49 EMS Dispatch We’ll see what we can do.

19:39:52 0:30:50 Dispatch McIver Thank you.

19:39:53 0:30:51 EMS Dispatch Alright.

Channel 1

19:40:41

0:31:39 Engine 13

Captain

Harrison System Watch activation, no audio

19:40:48

0:31:46 Car 11 Shriver Car 11 to Captain Louis Mulkey. PASS in the

background

Channel 1

19:40:59

0:31:57 Ladder 5

Captain

Richardson System Watch activation, no audio

19:41:05

0:32:03 Engine 12

Nozzle

Lemacks System Watch activation, no audio

19:41:11 0:32:09 Car 11 Shriver System Watch activation, no audio


19:41:15 0:32:13 Car 11 Shriver Number 16.

19:41:17

0:32:15 Engine 12

Suction


19:41:18

0:32:16 Car 1 Thomas Car 1 to Battalion 4, stay off the radio, Battalion 4.

Nobody else goes inside.

19:41:25 0:32:23 Battalion 4 Aytes 10-4, Read.

Channel 2

19:41:32 0:32:30 Car 11 Shriver Car 11 to Dispatcher on 2

19:41:38 0:32:36 Dispatch Barrineau Go ahead, Chief

19:41:40

0:32:38 Car 11 Shriver Get #16 to go to Channel 2 for me PASS in the

background

19:41:45

0:32:43 Dispatch Barrineau Chief, you are breaking up. I can't hear you. What

did you say again, repeat?

19:41:49 0:32:47 Car 11 Shriver I need #16 to go to Channel 2 for me.

Channel 1

19:41:48

0:32:46 Engine 3

Mobile Radio

Witt 19, we’ve got to find ourselves a hydrant now.

19:41:53

0:32:51 Engine 16

Engineer

Wittner Engine 16 to Car 11, Channel 2, Chief.

Channel 2

19:42:11

0:33:09 Engine 13

Captain

Harrison 13 to Dispatcher on 2 [inaudible] 13

19:42:14 0:33:12 Dispatch Barrineau 13 we,

19:42:20

0:33:18 Dispatch Barrineau Captain 13 just go to the 76. Stop in front. We

supposed to stay of the radio on Channel 1. You

are not going to have any problem finding where to

go. There are enough Chiefs there to tell you

where to go. Just go to the 76.

19:42:40

0:33:38 Engine 13

Captain



19:42:41 0:33:39 Car11 Shriver System Watch activation, no audio

19:42:42

0:33:40 Engine 13

Captain

Harrison 13 is 10-97 Siren winding down in

the background





19:42:48

0:33:46 Engine 9

Captain


Channel 1

19:42:20

0:33:18 Car 1 Thomas Car 1 to, um, to anyone that’s on the side of the

building, everybody’s outside, correct?

Channel 1

19:42:54

0:33:52 Engine 11

Engineer

Griffin Engineer 16, I need more pressure. PASS in the

background.

19:42:58

0:33:56 Engine 16

Engineer

Wittner 10-4

19:43:02 0:34:00 Car 11 Shriver [Inaudible] ….hear me?

19:43:03

0:34:01 Engine 11

Engineer


19:43:06 0:34:04 Car 11 Shriver Car 11, Engine 16, go to channel 2.

Channel 2

19:43:15

0:34:13 Engine 16

Engineer

Wittner [inaudible] chief. I am sending 225 to him right

now.


19:43:24

0:34:22 Engine 16

Engineer

Wittner Engineer 16 to Car 11, you copy? Pumper running in

the background

19:43:30

0:34:28 Car 11 Shriver Alright, #16, you are pumping, how much are you

pumping to #11 right now?

19:43:36

0:34:34 Engine 16

Engineer

Wittner I've got 225 coming coming to him, Chief. I did my

hose bed plus my two sections of 3-inch

19:43:44

0:34:42 Car 11 Shriver Alright, we not getting anything. I need all you can

give me over here at the fire now, okay?

19:43:49

0:34:47 Engine 16

Engineer

Wittner 10-4, Chief. If we can get these damn cops to stop

these guys running over my supply line. That is

what is killing us. They are parking on the supply

line.


19:44:03

0:35:01 Engine 9

Captain

Hess 9 Dispatcher on 2. We west side. Siren in the

background

Channel 1

19:43:52

0:34:50 Engine 11

Engineer

Griffin 16, is that all you can give me?

Channel 1

19:44:34

0:35:32 Engine 10

Engineer

Butler Radio activated, no transmission

Channel 2

19:44:34

0:35:32 Car 2 Garvin Dispatch on 2 PASS device

sounding in the

background

19:44:39 0:35:37 Dispatch Barrineau Go ahead on 2

19:44:41

0:35:39 Car 2 Garvin Dispatcher, call Waterworks and see if they can get

us more water on Wappoo Road.

19:44:47 0:35:45 Dispatch Barrineau Come back again. I can't hear you.

19:44:50

0:35:48 Car 2 Garvin Call Waterworks. See if they can get us some

more pressure on Wappoo Road.

19:44:57

0:35:55 Engine 11

Engineer

Griffin Go ahead, 16.

19:45:06

0:36:04 Engine 16

Engineer

Wittner Go ahead.




19:45:08

0:36:06 Engine 11

Engineer

Griffin I need more pressure

19:45:11

0:36:09 Engine 16

Engineer

Wittner I am giving you everything I got. I am sitting at 250.

19:45:15

0:36:13 Engine 11

Engineer


Channel 1

19:44:34

0:35:32 Engine 10

Captain


19:44:40 0:35:38 Car 1 Thomas Car 1 to Captain Louis Mulkey

19:44:48

0:35:46 Engine 3

Engineer

Witt Engine 3 to Captain 3, the water’s coming


19:44:54

0:35:52 Engine 3

Captain

Waring 10-4, 3

Channel 1

19:45:20 0:36:18 Car 2 Garvin Radio activated, no transmission

19:45:22 0:36:20 Car 303 O'Donald Radio activated, no transmission

19:45:46 0:36:44 Car 303 O'Donald Radio activated, no transmission

Channel 1

19:45:48

0:36:46 Engine 11

Engineer

Griffin Engineer 6, tell me when you’ve got water coming.

Channel 1

19:46:00 0:36:58 Engine 11 Johnson Captain 11 to Battalion 4

19:46:03 0:37:01 Battalion 4 Aytes Go ahead

19:46:05

0:37:03 Engine 11 Johnson I have 19 on the corner of DuPont & 17, I can take

another line if we need it.

19:46:13 0:37:11 Car 1 Thomas We need that line in the front door.

19:46:13 0:37:11 Battalion 4 Aytes I need another line for Ladder 5


19:46:24

0:37:22 Engine 10

Captain


19:46:28

0:37:26 Engine 12

Engineer

Horn Engine 12 to Battalion 4, I can handle that line.

19:46:33

0:37:31 Battalion 4 Aytes That’s alright, we’ve got it now. 13 is laying a line,

the other line to it.

19:46:37

0:37:35 Engine 10

Captain




19:46:51

0:37:49 Engine 3

Engineer

Witt Engine 3 to Captain 3. Siren in the

background

Telephone

19:46:23 0:37:21 Dispatch Barrineau I'm getting CPW right now. I got it, I got it, yeah, I

got it. Take care of the phone babe. I got Public

Works.

19:46:39 0:37:37 Charleston

Public Works

[ringing] Charleston Water.

19:46:40 0:37:38 Dispatch Barrineau Yes, this Operator 4 with the Charleston Fire

Department. We've got one hell of a big fire on

1807 Savannah Highway, the Sofa Store and we

need you guys to boost up the pressure on the

water off of Wappoo Road area for the engines.

They are having a heck of a time keeping pressure.

Can you take care of that for us?




19:46:58 0:37:56 Charleston

Public Works

Yeah, I will. What is your telephone number and I'll

direct line

19:47:02 0:38:00 Dispatch Barrineau 577-7070. If you could boost up that pressure for

them, we'd appreciate it.

19:47:05 0:38:03 Charleston

Public Works

I'll call the plant, buddy. I'll call them right now.

19:47:07 0:38:05 Dispatch Barrineau Thank you, man. Hurry up if you can for me, Bub.

Telephone

19:46:29 0:37:27 Dispatch McIver ...One

19:46:31 0:37:29 Engine 7 Harriss Yes. We are on the floor Station 13

19:46:33 0:37:31 Dispatch McIver Okay, thank you.

19:46:34 0:37:32 Engine 7 Harriss Uh, huh

19:46:37 0:37:35 Dispatch McIver Charleston Fire Department. Operator 1.

19:46:39 0:37:37 Caller Deanne?

19:46:40 0:37:38 Dispatch McIver Yes

19:46:41 0:37:39 Caller Do we have a fire West Ashley?

19:46:42 0:37:40 Dispatch McIver Yes and we can't talk. I mean it is a major fire.

Okay?

19:46:46 0:37:44 Caller Where's it at?

19:46:47 0:37:45 Dispatch McIver It's 1807 Savannah Highway

19:46:49 0:37:47 Caller Okay

19:46:50 0:37:48 Dispatch McIver Alright, bye. Charleston Fire Department, Operator

1.

19:46:55 0:37:53 Caller Hey

19:46:56 0:37:54 Dispatch McIver Hey

19:46:57 0:37:55 Caller Hey, do you all got a fire somewheres.

19:46:59 0:37:57 Dispatch McIver Yes, 1807 Savannah Highway.

19:47:01 0:37:59 Caller Yes, we are sitting here on Sam Rittenburg and we

see some hell of a smoke over there.

19:47:05 0:38:03 Dispatch McIver Yes, sir. And I really can't talk right now. We are

extremely busy.

19:47:09 0:38:07 Caller Alright

19:47:10 0:38:08 Dispatch McIver Okay, thank you.

19:47:14 0:38:12 Dispatch McIver Charleston Fire Department, Operator 1.

19:47:17 0:38:15 Caller Yes. There's some big fire West of the Ashley.

19:47:19 0:38:17 Dispatch McIver Yes sir, yes sir, we are on it.

19:47:21 0:38:19 Caller What is it?

19:47:22 0:38:20 Dispatch McIver Sir, all I can tell you, it's at 1807 Savannah

Highway.

19:47:26 0:38:24 Caller 1807 Savannah Highway. Okay

19:47:27 0:38:25 Dispatch McIver Yes Sir. Alright, bye.

Channel 2

19:46:42

0:37:40 Engine 9

Captain

Hess Nine to Car 11, we we're West side at #10

Channel 1

Radio activated, no transmission There are a number

of activations in this

period from

Charleston County

Sheriff Units, Engine

13 Captain, Engine

10 Captain, Ladder 5

Captain (James

Richardson), Engine

13 Engineer

Channel 1






period from

Charleston County


13 Captain, Engine


Captain (James

Richardson), Engine

13 Engineer

Channel 1



period from

Charleston County


13 Captain, Engine


Captain (James

Richardson), Engine

13 Engineer

Channel 2

19:47:32 0:38:30 Dispatch Barrineau Car 11, you still on amm, Channel 2?

19:47:38 0:38:36 Car 11 Shriver Car 11

19:47:41

0:38:39 Dispatch Barrineau I talked to the Waterworks and they are going to be

boosting up the pressure. They're trying to get

somebody down there to you right now.

19:47:47

0:38:45 Car 11 Shriver 10-4 PASS in the

background

Channel 1



period from

Charleston County


13 Captain, Engine


Captain (James

Richardson), Engine

13 Engineer

Channel 1

19:48:03 0:39:01 Engine 13 Harrison Engine 3 go to Channel 2

19:48:14

0:39:12 Engine 13

Engineer

Taylor System Watch activation, no audio

19:48:20

0:39:18 Engine 12

Suction


19:48:26

0:39:24 Engine 11

Captain


19:48:36 0:39:34 Car 1 Thomas Car 1 to Dispatcher

19:48:40 0:39:38 Dispatch Barrineau Go ahead, Chief

19:48:42

0:39:40 Car 1 Thomas Alright, send me Ladder 4 PASS in the

background.


19:48:50

0:39:48 Dispatch McIver [dispatch tone] Dispatcher to Ladder 4, 1807

Savannah Highway, 1807 Savannah Highway, time

out 19:49.

19:49:06

0:40:04 Ladder 4 Morley Ladder 4 is 10-8 Savannah Highway Dispatcher. Siren in background

19:49:09 0:40:07 Dispatch McIver 10-4, Ladder 4 19:49




Channel 2

19:48:22 0:39:20 Engine 13 Harrison Captain 13 to Engine 3 on 2

Channel 2

19:48:55

0:39:53 Battalion 4 Aytes Battalion 4 to Engine 3 [inaudible] take another line

19:48:57

0:39:55 Engine 16

Engineer

Wittner System Watch activation, no audio

Channel 2

19:49:26

0:40:24 Battalion 4 Aytes Battalion 4 to the Captain of Engine 3. Engineer 3,

charge that other line


Channel 1

19:49:36

0:40:34 Outside Agency Radio activated, no transmission

Channel 2

19:49:48

0:40:46 Engine 16

Engineer

Wittner Engineer 16, Battalion 4

19:49:51 0:40:49 Battalion 4 Aytes Go ahead

19:49:53

0:40:51 Engine 16

Engineer

Wittner Chief, I am pushing you 250. I can't give you any

more

19:49:57

0:40:55 Battalion 4 Aytes Did 13 just bring you that line to hook to your truck?

19:50:02

0:41:00 Engine 16

Engineer

Wittner Negative Chief. I still got just the single line coming

off.

19:50:07

0:41:05 Battalion 4 Aytes Okay. I go another line coming I need you to

charge.

19:50:12

0:41:10 Engine 16

Engineer

Wittner ,,,10-4

19:50:13 0:41:11 Battalion 4 Aytes Battalion 4 to, umm, Captain Lee

Channel 1

19:50:12 0:41:10 Car 1 Thomas [inaudible] Car 1 to Dispatcher.

19:50:16 0:41:14 Dispatch Barrineau Go ahead, Chief.

19:50:18

0:41:16 Car 1 Thomas Call Mayor Riley at home, or his cell phone number,

and tell him what we got going, and tell him we’ve

got a bad fire at the Super Store right now.

PASS in the

background.

19:50:27 0:41:25 Dispatch Barrineau 10-4, we got you covered, we’ll get him.

19:50:35

0:41:33 Engine 19

Mobile Radio

Johnson Engine 19 to Car 1.


19:50:40

0:41:38 Engine 19

Mobile Radio

Johnson Chief, do you want us to hand stretch another line

down from this hydrant. We’ve got about 80

pounds on it.

19:50:46

0:41:44 Car 1 Thomas Yes sir. We need it for Ladder 4. Where are you

coming from?

19:50:50

0:41:48 Engine 19

Mobile Radio

Johnson Copy, Ladder 4. Got it coming Chief.

19:50:53 0:41:51 Car 1 Thomas I said where are you coming from?

19:50:57

0:41:55 Engine 3

Engineer

Witt Engine 3 to Car 1, it’s on DuPont. Corner of

DuPont and Savannah Highway.

Channel 2




19:51:10

0:42:08 Engine 9

Captain

Hess 9 to Car 1. We're at Station 10.

19:51:16

0:42:14 Engine 13

Captain

Harrison Back down

19:51:23

0:42:21 Ladder 4

Mobile Radio

Morley Ladder 4 to Dispatch on Channel 2. We're west

side

Channel 1

19:51:23 0:42:21 Dispatch Barrineau Dispatch to Car 1. I got #9 at Engine 10.

19:51:27

0:42:25 Car 1 Thomas Alright, tell #9 I said to come to go to umm DuPont

& 17, drop their hose and bring it to me for a supply

line. [inaudible] bring it to me, go to DuPont and 17

hookup and bring it to me because I’m going to

hook it to Ladder 4 when they get here.

PASS in the

background


Channel 2

19:51:44

0:42:42 Engine 9

Captain

Hess 9 copies Chief

Channel 1


19:51:55 0:42:53 Car 1 Thomas Who’s in front of Morris Nissan?

Channel 2

19:51:54

0:42:52 Engine 9

Captain

Hess 9 to Dispatcher, we are in route Siren in the

background

19:51:59 0:42:57 Dispatch Barrineau 10-4 babe, 19:52

Channel 1

19:52:06 0:43:04 Battalion 4 Aytes Battalion 4 to Car 1.

Channel 1

19:52:18 0:43:16 Car 2 Garvin Car 2 to Engine 6.

Channel 1

19:52:28

0:43:26 Engine 16

Captain

Benke System Watch activation, no audio According to

Charleston Police

Department radio

technicians, this

transmission likely

occurred as this radio

was being destroyed.

19:52:31

0:43:29 Car 1 Thomas Move that aerial ladder, move it over towards the

main building.

19:52:40

0:43:38 Engine 15

Nozzle


Channel 1

19:53:03

0:44:01 Engine 10

Captain

Villareal Radio activated, no transmission

Channel 1

19:53:17

0:44:15 Car 1 Thomas Car 1 to Ladder 5. Can you swing your ladder over

toward the main building or not?




19:53:24

0:44:22 Ladder 5

Captain

Richardson Chief, are you talking about the building closer to

Savannah Highway?

19:53:30

0:44:28 Car 1 Thomas Alright, stay where you’re at, stay where you’re at,

I’ll have Ladder 4 come to the front.

19:53:35

0:44:33 Ladder 5

Captain

Richardson Chief, if you want me to, I can get the front and

Ladder 4 can maybe come off Pebble and get the

back because I can’t get this one too far in the

back.

19:53:43 0:44:41 Car 1 Thomas You just keep what you got, keep what you…

19:53:46

0:44:44 Ladder 5

Captain

Richardson 10-4, Sir.

19:53:48

0:44:46 Battalion 4 Aytes Car 1 [inaudible] Engine 10. I got a feeling that

fire’s coming towards it.

19:53:50

0:44:48 Engine 10

Captain


19:53:56

0:44:54 Engine 3

Engineer

Waring Engine 3 to Car 1.

Channel 1

19:54:11 0:45:09 Battalion 4 Aytes Battalion 4 to Captain of Ladder 4

19:54:15

0:45:13 Ladder 4

Mobile Radio

Morley Go ahead Battalion 4 Siren in the

background

19:54:17

0:45:15 Battalion 4 Aytes Cap, I have a 2 ½ waiting on you right here in the

parking lot. If you come down the road, you’ll see

me here, follow me and I’ll back you right in there.

Siren in the

background

19:54:19

0:45:17 Engine 10

Captain


19:54:26

0:45:24 Ladder 4

Mobile Radio

Morley Yes sir, Chief. Siren in the

background

19:54:30

0:45:28 Engine 3

Engineer

Witt Engine 3 to Battalion 4.

19:54:32 0:45:30 Battalion 4 Aytes Go ahead Engine 3.

19:54:35

0:45:33 Engine 3

Engineer

Witt Got St. Andrew’s hooked up down here and they’re

coming to you with a supply line.


19:54:43 0:45:41 Battalion 4 Aytes 10-4

Channel 2

19:54:24 0:45:22 Dispatch Barrineau Captain 9, how close are you, baby?


19:54:33 0:45:31 Dispatch Barrineau Captain Engine 9


19:54:50 0:45:48 Engine 13 Harrison Captain 13 Batallion 4

Channel 1

19:54:47

0:45:45 Engine 10

Captain

Villareal Radio activated, no transmission PASS device in the

background.

19:54:57

0:45:55 Engine 10

Captain


Channel 2

19:55:10 0:46:08 Engine 13 Harrison Captain 13, Battalion 4

Channel 1

19:55:14

0:46:12 Engine 10

Captain


19:55:20

0:46:18 Engine 13

Captain

Harrison Captain 13 to Battalion 4.

19:55:23

0:46:21 Battalion 4 Aytes Go ahead, Cap Backup alarm I the

background




19:55:25

0:46:23 Engine 13

Captain

Harrison The 2 ½ line is in the parking lot waitin’ on Ladder 4

19:55:30

0:46:28 Battalion 4 Aytes I got you, I got him. Siren in the

background.

19:55:33

0:46:31 Car 1 Thomas Chief Buddy, tell them do not charge it until we get

it hooked up.

19:55:37 0:46:35 Battalion 4 Aytes 10-4, Chief

19:55:38

0:46:36 Engine 13

Captain

Harrison 10-4

19:55:40 0:46:38 Car 403 Roberts System Watch activation, no audio

19:55:45

0:46:43 Battalion 4 Aytes Do not charge those lines for Ladder 4 until it’s

hooked up.

Maybe Shriver?

Siren in the

background.


19:55:49

0:46:47 Ladder 4

Mobile Radio

Morley Ladder 4 to Battalion 4.

19:55:54

0:46:52 Car 1 Thomas Number 9, see if you can turn around down there

and lay me another line to Ladder 4 down here

Siren in the

background.

19:56:01

0:46:59 Battalion 4 Aytes Captain Ladder 4 is that you coming across the red

light right here?

Siren in the

background.

19:56:04

0:47:02 Ladder 4

Mobile Radio

Morley Yes, Sir, where are you at. Siren in the

background.

19:56:10

0:47:08 Engine 9

Mobile Radio

Hess 9 to Car 1


19:56:14

0:47:12 Engine 9

Mobile Radio

Hess Chief, we are right here in front of Dunkin Donuts.

Where do you want the line?

19:56:16

0:47:14 Battalion 4 Aytes See me here in the street, come on. Siren in the

background.

19:56:18

0:47:16 Car 1 Thomas [inaudible] you are probably going to have to lay it

to the pumper that’s down on the corner of Wappoo

& 17

Siren in the

background

19:56:26

0:47:24 Engine 9

Mobile Radio

Hess Okay, 10-4.

19:56:28 0:47:26 Battalion 4 Aytes [Inaudible]


19:56:29

0:47:27 Ladder 4

Mobile Radio

Morley System Watch activation, no audio

19:56:35

0:47:33 Engine 7

Suction

Cypress System Watch activation, no audio


19:56:37

0:47:35 Engine 10

Captain


19:56:37

0:47:35 Car 1 Thomas Car 1 to Dispatcher. See if you can get North

Charleston to cover some of our stations downtown

or Mt. Pleasant or whoever you can call.

Siren in the

background

19:56:41

0:47:39 Outside

Agencies


19:56:45

0:47:43 Dispatch McIver That’s affirmative, Chief. North Charleston’s going

to go to Comings Street.


19:56:50

0:47:48 Car 1 Thomas 10-4, See if you can get James Island to go down to

the station or downtown and also Mount Pleasant.

19:56:57 0:47:55 Dispatcher McIver 10-4

Channel 2

19:55:40 0:46:38 Dispatch Barrineau Dispatcher to Captain 9 where you at?

Telephone




19:57:02 0:48:00 St. Andrews

Fire

Department

[ringing] St. Andrews Dispatch

19:57:08 0:48:06 Dispatch

McIver

Hey, can y'all go over and cover some of our

stations West Ashley?

19:57:12 0:48:10 St. Andrews

Fire

Department

No, ma'am.

19:57:13 0:48:11 Dispatch McIver You can't?

19:57:14 0:48:12 St. Andrews

Fire

Department

You know why I am saying that? No, all of our

stations are out. I just called North Charleston and

St. John's to try to cover us.

19:57:20 0:48:18 Dispatch McIver Oh, jeese. Okay.

19:57:21 0:48:19 St. Andrews

Fire

Department

All our units are out.

19:57:21 0:48:19 Dispatch McIver Okay. Thank you.

19:57:22 0:48:20 St. Andrews

Fire

Department

Sorry about that.

19:57:24 0:48:22 Dispatch

McIver

That's okay. Negative, all I got was an answering

machine and I left a message. Whatever

Channel 1

19:57:08

0:48:06 Engine 10

Captain

Villareal Radio activated, no transmission

Channel 1

19:57:20

0:48:18 Car 1 Thomas Car 1, dispatcher, did you get in touch with the

Mayor?

19:57:24

0:48:22 Dispatch McIver Negative, all I got was his answering machine. I left

a message.

19:57:31

0:48:29 Engine 13

Captain

Harrison Captain 13 to Ladder 4, let me know when you are

ready for that line to be charged

19:57:36

0:48:34 Car 1 Thomas I’ll let you know, Lee. Just hold on. I’ll let you

know.

Telephone

19:57:56 0:48:54 Dispatch McIver North Charleston going to Coming Street

19:58:02 0:49:00 Mt Pleasant FD Communications

19:58:04 0:49:02 Dispatch McIver Hey, this is the City of Charleston Fire Department.

19:58:06 0:49:04 Mt Pleasant FD Uh, huh.

19:58:07 0:49:05 Dispatch McIver Um, can ya'll cover some of our units for us? Are

ya'll…

19:58:11 0:49:09 Mt Pleasant FD In reference to?

19:58:13 0:49:11 Dispatch McIver Well, we have got a major fire West Ashley.

19:58:16 0:49:14 Mt Pleasant FD Oh, you mean a fire. Um, OK, umm, so did you all

do a, umm, did ya'll do a page? Did ya'll page it out

throughout the fire department?

19:58:28 0:49:26 Dispatch McIver No, no, I didn't do that. I, my, my Chief just asked

me to, umm, to call and see if ya'll could cover

some of our units cause, I mean, we don't have, we

have nothing left.

19:58:40 0:49:38 Mt Pleasant FD Okay, okay, cover what area?

19:58:42 0:49:40 Dispatch McIver Um, alright, let me see, umm, like umm, engine 9's

area. Do they know where engine 9 is?

19:58:51 0:49:49 Mt Pleasant FD Well, can you give me that.




19:58:52 0:49:50 Dispatch McIver King and Heriot. Oh, gosh.

19:58:59 0:49:57 Mt Pleasant FD Okay, King and Heriot.

19:59:00 0:49:58 Dispatch McIver Um, alright let me see. Um,

19:59:06 0:50:04 Mt Pleasant FD Well how about this. How about I call my Batt Chief

and tell him to call you directly.

19:59:09 0:50:07 Dispatch McIver Okay, that will be fine.

19:59:11 0:50:09 Mt Pleasant FD What is your number?

19:59:12 0:50:10 Dispatch McIver 577-7070

19:59:15 0:50:13 Mt Pleasant FD Okay

19:59:16 0:50:14 Dispatch McIver Thank you.

19:59:16 0:50:14 Mt Pleasant FD Alright, bye bye.

19:59:17 0:50:15 Dispatch McIver Bye

Channel 1

19:57:56

0:48:54 Battalion 6 Nielson Battalion 6 to Car 1. Engine 7 is heading to #11. If

you need him, call him.

Channel 1


19:58:17

0:49:15 Engine 19

Acting Engineer

Johnson Engine 19 to Battalion, Car 1.


19:58:22 0:49:20 Battalion 4 Aytes …Car One

19:58:23

0:49:21 Engine 19

Acting Engineer

Johnson Chief, umm, is St. Andrew’s hooked up? I’m ready

to charge the supply line [inaudible} have it hooked

up.

Johnson?

19:58:29 0:49:27 Car 1 Thomas Where’s that line going to?

19:58:29

0:49:27 Battalion 4 Aytes Battalion 4 to Car 1, Chief do you need a second

line for Ladder 4?


19:58:38

0:49:36 Engine 10

Captain


19:58:41

0:49:39 Car 1 Thomas #9’s going to lay to me, #9’s supposed to be laying

to me.

19:58:45

0:49:43 Battalion 4 Aytes I got a line coming down the street and they weren’t

sure where it was coming, do you need one

coming?

19:58:50 0:49:48 Car 1 Thomas I need one to Ladder 4 if they can get it to me

19:58:55

0:49:53 Battalion 4 Aytes Chief, they’re coming to where you are right now.

19:58:57

0:49:55 Engine 10

Captain


19:58:59 0:49:57 Engine 13 Harrison 13 to Car 1

19:59:00

0:49:58 Outside

Agencies


19:59:11 0:50:09 Engine 13 Harrison 13 to Car 1

Telephone

19:58:53 0:49:51 City Dispatch [ringing] City Dispatch

19:58:44 0:49:42 Mayor Riley Hi, this is Mayor Riley. How are you?

19:58:57 0:49:55 City Dispatch I'm fine, sir. How are you doing?

19:58:59 0:49:57 Mayor Riley I am fine. I just got in and got a call about the Sofa

Super Store.

19:59:03 0:50:01 City Dispatch Yes, sir.

19:59:04 0:50:02 Mayor Riley How are things going?




19:59:05 0:50:03 City Dispatch Um, right now, um they are trying to out the fire. It's

in full gulf. I am answering the phone for the Fire

Department because they are sort of kind of busy

over there. We got a lot of units on scene and the

fire trucks and I think there were two parties inside

but they got one out but I'm not sure about the other

party cause they wasn't able to answer my question

when I was talking to them so…

19:59:22 0:50:20 Mayor Riley Okay Sound of children in

the background

19:59:23 0:50:21 City Dispatch That's about all I know right now.

19:59:27 0:50:25 Mayor Riley Okay, alrighty, well, thank you.

19:59:28 0:50:26 City Dispatch You're welcome, sir.

19:59:29 0:50:27 Mayor Riley If, ahh, if you hear anything, if you would call me at

XXX-XXXX.

Number deleted by

Kevin Roche during

transript preparation

19:59:33 0:50:31 City Dispatch Okay.

19:59:34 0:50:32 Mayor Riley Thanks a lot.

19:59:35 0:50:33 City Dispatch Alright, Sir. Bye, bye.

Channel 2

19:58:53

0:49:51 Engine 7 Harriss Engine 7 to Dispatcher, Channel 2, we are in route

Station 11

Channel 2

19:59:20

0:50:18 Charleston

County Sheriff's

Office

Radio activated, no transmission

Channel 1

19:59:23

0:50:21 Engine 13

Captain

Harrison 13, Car 2

19:59:27 0:50:25 Car 11 Shriver Go ahead 13

19:59:30

0:50:28 Engine 13

Captain

Harrison We’re working on your second line for Ladder 4.

We’ve almost got it.

19:59:32

0:50:30 Engine 10

Captain


19:59:36 0:50:34 Car 11 Shriver 10-4

Telephone

19:59:28 0:50:26 Dispatch Barrineau [unaudible] Yeah.

19:59:29 0:50:27 Battalion 6 Nielson Geno, I'm sending 7 to 11.

19:59:32 0:50:30 Dispatch Barrineau 7 to 11, okay.

19:59:33 0:50:31 Battalion 6 Nielson Just let James Island know if you got a call, let

them take the calls. Okay?

19:59:37 0:50:35 Dispatch Barrineau Okay.

19:59:38 0:50:36 Battalion 6 Nielson Thank you

19:59:39 0:50:37 Dispatch Barrineau Got you baby

19:59:40 0:50:38 Battalion 6 Nielson Yes sir.

19:59:41 0:50:39 Dispatch Barrineau Bye, bye.

Telephone

19:59:56 0:50:54 Dispatch Barrineau [dial tone] 7 to 11

19:59:56 0:50:54 James Island

Fire

Department

[ringing] James Island Fire Department

20:00:03 0:51:01 Dispatch Barrineau Hey, Buddy. This is Operator 4, Geno.




20:00:05 0:51:03 James Island

Fire

Department

Yeah

20:00:06 0:51:04 Dispatch Barrineau Do me a favor. Umm, we’ve got 7 going to 11.

We’ve got a big fire on Savannah Highway.

20:00:09 0:51:07 James Island

Fire

Department

Yeah, I've been hearing.

20:00:10 0:51:08 Dispatch Barrineau Do me a favor. Whose this, Willie?

20:00:11 0:51:09 James Island

Fire

Department

No, this is Terry.

20:00:12 0:51:10 Dispatch Barrineau Terry, do me a favor. This is Captain Geno.

20:00:13 0:51:11 James Island

Fire

Department

Yes, Sir.

20:00:15 0:51:13 Dispatch Barrineau Anything West of the Ashley, James Island area,

over that way.

20:00:18 0:51:16 James Island

Fire

Department

Yes, Sir.

20:00:18 0:51:16 Dispatch Barrineau Take it for us.

20:00:19 0:51:17 James Island

Fire

Department

Okay. I've talked to our 101 and [inaudible]

20:00:22 0:51:20 Dispatch Barrineau Yeah, just cover for us, doll baby. We appreciate it.

That's one we owe you.

20:00:25 0:51:23 James Island

Fire

Department

We got you.

20:00:26 0:51:24 Dispatch Barrineau Thank you, darling. We appreciate it. Love you,

man.

20:00:28 0:51:26 James Island

Fire

Department

Bye

20:00:28 0:51:26 Dispatch Barrineau Bye, bye.

20:00:31 0:51:29 Dispatch Barrineau [inaudible] take West I, I mean James Island. Yes,

Charleston Fire.

20:00:35 0:51:33 Mount Pleasant

Battalion Chief

Timms Hey, Chief. It's Chief Timms of Mount Pleasant.

What do ya'll need?

20:00:37 0:51:35 Dispatch Barrineau Okay, hold on. We've got the Chief from over there

in Mount Pleasant. Where do you need him at?.

We’ve got James Island taking care of [woman in

background saying: West Ashley and James Island.

King & Heriot) Hold on James. .


Battalion Chief

Timms Okay

20:00:52 0:51:50 Dispatch Barrineau We need somebody at King & Heriott, Chief.


Battalion Chief

Timms King & Harriett station?

20:00:55 0:51:53 Dispatch Barrineau Yeah, we need somebody at that one, yeah, that's

number 9.


Battalion Chief

Timms Alright, I've got Engine 3 headed to you.

20:01:00 0:51:58 Dispatch Barrineau Okay


Battalion Chief

Timms Alright

20:01:01 0:51:59 Dispatch Barrineau Thank you so much, Chief. We appreciate it.

Alright, we're good for right now.





Battalion Chief

Timms Okay, that's good.

20:01:06 0:52:04 Dispatch Barrineau Thank you very much. Yes, Sir.

Telephone

20:00:03 0:51:01 [ringing]

20:00:31 0:51:29 Dispatch Barrineau [inaudible] take West I, I mean James Island. Yes,

Charleston Fire.


Battalion Chief

Timms Hey, Chief. It's Chief Timms of Mount Pleasant.

What do ya'll need?

20:00:37 0:51:35 Dispatch Barrineau Hold on. We've got the Chief from over there in

Mount Pleasant. Where do you need him at?.

We’ve got James Island taking care of [woman in

background saying: West Ashley and James Island.

King & Harriott) Hold on James. .


Battalion Chief

Timms Okay

20:00:52 0:51:50 Dispatch Barrineau We need somebody at King & Harriett, Chief.


Battalion Chief

Timms King & Harriett station?

20:00:55 0:51:53 Dispatch Barrineau Yeah, we need somebody at that one, yeah, that's

number 9.


Battalion Chief

Timms Alright, I've got Engine 3 headed to you.



Battalion Chief

Timms Alright

20:01:01 0:51:59 Dispatch Barrineau Thank you so much, Chief. We appreciate it.

Alright, we're good for right now.


Battalion Chief

Timms Okay, that's good.

20:01:06 0:52:04 Dispatch Barrineau Thank you very much. Yes, Sir.


Battalion Chief

Timms [inaudible] …to Engine 3

Channel 1

20:00:18

0:51:16 Radio activated, no transmission There were several

activations during this

period from Ladder 4

Ladderman 1, Engine

12 Nozzle, and an

outside agency.

Channel 1

20:00:42

0:51:40 Radio activated, no transmission There were several

activations during this

period from Ladder 4

Ladderman 1, Engine

12 Nozzle, and an

outside agency.




Channel 2

20:00:44

0:51:42 Engine 9

Captain

Hess 9 to 3, water's coming.

Channel 1

20:01:04

0:52:02 Engine 12

Engineer

Horn Engineer 12 to Captain 13

20:01:07

0:52:05 Engine 13

Captain

Harrison Go ahead

20:01:08

0:52:06 Engine 12

Engineer

Horn We’re ready to charge the line


20:01:13

0:52:11 Engine 13

Captain

Harrison Repeat

20:01:16

0:52:14 Engine 12

Engineer

Horn We hooked another line, pulled off of 13, where’s it

going to?

20:01:22

0:52:20 Engine 13

Captain

Harrison Is that the second line?

20:01:25

0:52:23 Engine 12

Engineer

Horn That’s affirmative

20:01:26

0:52:24 Ladder 4

Ladderman 1

Turner System Watch activation, no audio

20:01:26 0:52:24 Car 1 Thomas 13, did you lay the line?

20:01:28

0:52:26 Engine 13

Captain


20:01:28 0:52:26 Car 1 Thomas Are you ready to charge the line?

20:01:34

0:52:32 Engine 19

Mobile Radio

Johnson 19 to Truck 4 are you ready for me to charge this

supply line?

20:01:38

0:52:36 Car 1 Thomas That’s affirmative, if you’ve got it going to Ladder 4,

charge it. 13 have you already charged yours?

20:01:44

0:52:42 Engine 19

Mobile Radio

Johnson Water’s coming.

20:01:44

0:52:42 Engine 13

Captain


20:01:46 0:52:44 Car 1 Thomas Alright, 10-4, Give me about 250 pounds

20:01:46

0:52:44 Engine 13

Captain


20:01:52

0:52:50 Engine 9

Captain

Hess 9 to 13 if you need more water, I’m hooked to a

hydrant

20:01:53

0:52:51 Engine 13

Captain

Harrison [inaudible] go ahead and charge both lines.

20:01:59

0:52:57 Engine 12

Engineer


20:02:00

0:52:58 Engine 3

Engineer

Witt 9 you calling me?

20:02:03

0:53:01 Engine 9

Captain

Hess 10-4. We’ve got water coming to you.

20:02:07

0:53:05 Engine 3

Engineer

Witt 10-4, Captain

20:02:13

0:53:11 Engine 19

Mobile Radio

Johnson 19 to truck 4 you got water

20:02:20 0:53:18 Car 303 O'Donald [inaudible] one hooked to the 4 ½, charge it



Telephone

20:01:40 0:52:38 Dispatch Barrineau [ringing] Charleston Fire, Operator 4, how can I

help you?

20:02:00 0:52:58 Summerville

Fire

Department

Haydon Yeah, this is Captain Haydon of the Summerville

Fire Department.

20:02:02 0:53:00 Dispatch Barrineau Yes, Sir.




20:02:03 0:53:01 Summerville

Fire

Department

Haydon Uh, our Chief wanted us to call ya'll and find out if

there is anything we might be able to send down

that way.

20:02:08 0:53:06 Dispatch Barrineau Yeah, if you hold on for me one minute, Chief.

20:02:09 0:53:07 Summerville

Fire

Department

Haydon Okay

20:02:09 0:53:07 Dispatch Barrineau Got Summerville, where do we need another

pumper at? I've got Summerville. Where do we

need another pumper at? We've got one at 9,

we've got somebody, we've got North Charleston at

15. No I've got North Charleston at 15 right now.

How about let's send somebody to ahh, 8?

20:02:30 0:53:28 Summerville

Fire

Department

Haydon I know where 8 is, I know that district.

20:02:32 0:53:30 Dispatch Barrineau 8's home? How about let's send West Ashley then.

We’ll send them to 10. Hey, Chief.

20:02:38 0:53:36 Summerville

Fire

Department

Haydon Yeah?

20:02:38 0:53:36 Dispatch Barrineau Could you send one of them to #10 which is right

down the road from where the fire is

20:02:43 0:53:41 Summerville

Fire

Department

Haydon I know where that is.

20:02:44 0:53:42 Dispatch Barrineau on Highway 17 by Nicholson.

20:02:45 0:53:43 Summerville

Fire

Department

Haydon Okay. How about our Rehab tent or anything like

that to help out, it's air conditioned anything to help

out on the scene?

20:02:51 0:53:49 Dispatch Barrineau That would be great. That would be great, Chief.

This is from Summerville, right

20:02:54 0:53:52 Summerville

Fire

Department

Haydon Right.

20:02:54 0:53:52 Dispatch Barrineau Okay. If you could send, if you could send

somebody to Engine 10 and then the relief truck.

20:03:00 0:53:58 Summerville

Fire

Department

Haydon Okay. We'll do it.


20:03:03 0:54:01 Summerville

Fire

Department

Haydon Alriight, we'll have somebody in route in just a

minute.

20:03:04 0:54:02 Dispatch Barrineau Yeah, yeah, send them, the relief truck – you said

it's got air, O2 and everything?

20:03:09 0:54:07 Summerville

Fire

Department

Haydon Umm

20:03:09 0:54:07 Dispatch Barrineau What's it got on it?

20:03:11 0:54:09 Summerville

Fire

Department

Haydon Well, we’ve got a light and air truck if you need it

where we can fill cascade, you know, we can fill the

air packs. We can do that.

20:03:16 0:54:14 Dispatch Barrineau Okay. That would be fabulous. I know we got an

air truck. I don't even think it's out there but I don't

think we've got anybody that can bring it right now.

20:03:24 0:54:22 Summerville

Fire

Department

Haydon Okay

20:03:25 0:54:23 Dispatch Barrineau So if ya'll could do that, it would be fabulous.

Summerville Fire Department, that's great. And go

to #10 and just stand by for us. We'd appreciate it.




20:03:33 0:54:31 Summerville

Fire

Department

Haydon Okay, then.

20:03:34 0:54:32 Dispatch Barrineau Thanks, Chief. Bye, bye.

20:03:35 0:54:33 Summerville

Fire

Department

Haydon Bye

Telephone Duplicate of the

conversation above,

different recorded line

20:01:53 0:52:51 Dispatch Barrineau [ringing] Charleston Fire, Operator 4, how can I

help you?

20:02:00 0:52:58 Summerville

Fire

Department

Haydon Yeah, this is Captain Haydon of the Summerville

Fire Department.

20:02:02 0:53:00 Dispatch Barrineau Yes, Sir.

20:02:03 0:53:01 Summerville

Fire

Department

Haydon Uh, our Chief wanted us to call ya'll and find out if

there is anything we might be able to send down

that way.

20:02:08 0:53:06 Dispatch Barrineau Yeah, if you hold on for me one minute, Chief.

20:02:09 0:53:07 Summerville

Fire

Department

Haydon Okay

20:02:09 0:53:07 Dispatch Barrineau Got Summerville, where do we need another

pumper at? I've got Summerville. Where do we

need another pumper at? We've got one at 9,

we've got somebody, we've got North Charleston at

15. No I've got North Charleston at 15 right now.

How about let's send somebody to ahh, 8?

20:02:30 0:53:28 Summerville

Fire

Department

Haydon I know where 8 is, I know that district.

20:02:32 0:53:30 Dispatch Barrineau 8's home? How about let's send West Ashley then.

We’ll send them to 10. Hey, Chief.

20:02:38 0:53:36 Summerville

Fire

Department

Haydon Yeah?

20:02:38 0:53:36 Dispatch Barrineau Could you send one of them to #10 which is right

down the road from where the fire is

20:02:43 0:53:41 Summerville

Fire

Department

Haydon I know where that is.

20:02:44 0:53:42 Dispatch Barrineau on Highway 17 by Nicholson.

20:02:45 0:53:43 Summerville

Fire

Department

Haydon Okay. How about our Rehab tent or anything like

that to help out, it's air conditioned anything to help

out on the scene?

20:02:51 0:53:49 Dispatch Barrineau That would be great. That would be great, Chief.

This is from Summerville, right

20:02:54 0:53:52 Summerville

Fire

Department

Haydon Right.

20:02:54 0:53:52 Dispatch Barrineau Okay. If you could send, if you could send

somebody to Engine 10 and then the relief truck.

20:03:00 0:53:58 Summerville

Fire

Department

Haydon Okay. We'll do it.


20:03:03 0:54:01 Summerville

Fire

Department

Haydon Alriight, we'll have somebody in route in just a

minute.

20:03:04 0:54:02 Dispatch Barrineau Yeah, yeah, send them, the relief truck – you said

it's got air, O2 and everything?




20:03:09 0:54:07 Summerville

Fire

Department

Haydon Umm

20:03:09 0:54:07 Dispatch Barrineau What's it got on it?

20:03:11 0:54:09 Summerville

Fire

Department

Haydon Well, we’ve got a light and air truck if you need it

where we can fill cascade, you know, we can fill the

air packs. We can do that.

20:03:16 0:54:14 Dispatch Barrineau Okay. That would be fabulous. I know we got an

air truck. I don't even think it's out there but I don't

think we've got anybody that can bring it right now.

20:03:24 0:54:22 Summerville

Fire

Department

Haydon Okay

20:03:25 0:54:23 Dispatch Barrineau So if ya'll could do that, it would be fabulous.

Summerville Fire Department, that's great. And go

to #10 and just stand by for us. We'd appreciate it.

20:03:33 0:54:31 Summerville

Fire

Department

Haydon Okay, then.

20:03:34 0:54:32 Dispatch Barrineau Thanks, Chief. Bye, bye.

20:03:35 0:54:33 Summerville

Fire

Department

Haydon Bye

Channel 1

20:02:53

0:53:51 Dispatch McIver Dispatcher to Car 1, have you got enough water

pressure? I have the Waterworks on the land line.


20:03:00

0:53:58 Car 1 Thomas Dispatcher, if they can give us some, okay. If they

can’t, don’t worry about it.

20:03:04 0:54:02 Dispatch McIver 10-4

Channel 1

20:03:13

0:54:11 Battalion 4 Aytes Battalion 4 Car 1. St. Andrew’s just got their umm,

aerial up on Pebble Road.

20:03:24 0:54:22 Car 403 Roberts [inaudible]

20:03:26


11 to BC3.

20:03:35


to Car 11.

Channel 1

20:03:46 0:54:44 Battalion 4 Aytes Battalion 4 Car 1.

Channel 1

20:04:00

0:54:58 Dispatch Barrineau Dispatcher to any Chief go to Channel 2 for me,

I’ve got information for one of y’all.

20:04:00


11 to BC3.

20:04:06


to Car 11.

20:04:12


11 to BC3.

Channel 2

20:04:07 0:55:05 Battalion 4 Aytes Go ahead, Geno, what you got?

20:04:09

0:55:07 Car 1 Thomas Go ahead. This is Car 1. PASS device in the

background.




20:04:14

0:55:12 Battalion 4 Aytes Chief, I just talked to man at SCE&G's dispatch

who says there is no gas to any three of those

buildings.

20:04:21

0:55:19 Car 1 Thomas 10-4, Captain Geno. Was it you giving me a

message?

20:04:23

0:55:21 Dispatch Barrineau That's affirmative. I got the Waterworks called,

they supposed to be boosting up the pressure, I got

Summerville Fire Department coming down to

Engine 10 with a relief truck and a pumper. I got

North Charleston at Coming Street. And I got the

closest unit I got engine 7 going to #11. and Mt.

Pleasant's going to #9.

20:04:40 0:55:38 Car 1 Thomas Alright, 10-4. Just keep it coming. That's all.


Channel 1

20:04:28

0:55:26 Engine 10

Engineer

Butler Engine 12

Channel 1

20:04:37

0:55:35 Engine 10

Engineer

Butler You hold that water right there.

20:04:41

0:55:39 Private call to BC3

from Car 11.

20:04:44 0:55:42 Car 602 Winn 602 to Car 1

20:04:46

0:55:44 Ladder 4

Engineer

Land System Watch activation, no audio

20:04:52

0:55:50 St. Andrews

Engine 4

St. Andrew’s Engine 4 on the City [inaudible]

20:04:55

0:55:53 Car 1 Thomas Car 1 to the umm, to the bucket of Ladder 4.

Anthony move it over to your right, [inaudible] to

your right. In the middle of the building, Anthony.

[inaudible] To your right in the middle of the

building. Shoot it down.

20:04:56 0:55:54 Car 602 Winn System Watch activation, no audio

20:05:15

0:56:13 Engine 3

Captain

Waring Captain 3 to Car 1, just wanted to let you know the

roof has fallen in the center


20:05:24 0:56:22 Car 1 Thomas Go ahead whoever’s calling Car 1

20:05:28

0:56:26 Engine 9

Engineer

Seabrook System Watch activation, no audio

20:05:29 0:56:27 Car 602 Winn System Watch activation, no audio

20:05:31

0:56:29 Car 1 Thomas Anthony, can you extend it on out and get over it

some more?

PASS device in the

background.

20:05:32

0:56:30 Engine 3

Captain

Waring System Watch activation, no audio

20:05:41

0:56:39 Car 1 Thomas Shoot it straight down, shoot it straight down when

you get on top of it. That’s right. Now work it to

your right. Keep on going as long as you are safe.

20:05:47 0:56:45 Battalion 5 Lloyd Battalion 5 to Ladder 5.


20:05:59

0:56:57 Ladder 5

Captain

Richardson Go ahead

20:06:02

0:57:00 Battalion 5 Lloyd Put that line, put those lines on the back warehouse

starting from the back, from the back. We already

got four in the front.

20:06:09

0:57:07 Ladder 5

Captain

Richardson 10-4. I don’t have much pressure to reach too far

but I’ll put it back on it.

20:06:18

0:57:16 Ladder 5

Captain

Richardson Battalion 5. See if they can lay me another line if

they have the line, and the pressure to lay me

another line.

20:06:28 0:57:26 Car 1 Thomas [inaudible]

20:06:30

0:57:28 Engine 9

Captain





20:06:34

0:57:32 Ladder 4

Captain

Morley Ladder 4 to Car 1.

20:06:37 0:57:35 Car 1 Thomas Alright, Captain, go ahead.

20:06:39

0:57:37 Ladder 4

Captain

Morley Can we get that other line charged so we can get

this other nozzle going?

20:06:44 0:57:42 Car 1 Thomas 10-4. I’ll try.

Channel 1

20:07:03 0:58:01 Car 403 Roberts 403 to Ladder 4

20:07:07

0:58:05 Ladder 4

Captain

Morley Go ahead

20:07:09

0:58:07 Car 403 Roberts Captain, can you shut your lines down for one

second?

20:07:19

0:58:17 Engine 15

Suction

Walker System Watch activation, no audio

20:07:20

0:58:18 Car 1 Thomas Anthony, we’re trying to get the line layed now,

we’re trying to get it to you, opening up the other

nozzle now, just keep that nozzle in the middle.

PASS device in the

background.

20:07:30

0:58:28 Ladder 4

Captain

Morley It’s coming right up this wall, Chief.

Telephone

20:07:14 0:58:12 Dispatch McIver One

20:07:14 0:58:12 Battalion 3 Ackerman Is North Charleston sending us a unit?

20:07:17 0:58:15 Dispatch McIver Do what?

20:07:18 0:58:16 Battalion 3 Ackerman Is North Charleston sending us a unit?

20:07:19 0:58:17 Dispatch McIver Yes

20:07:20 0:58:18 Battalion 3 Ackerman Mount Pleasant sending one also?

20:07:20 0:58:18 Dispatch McIver Mount Pleasant is, umm, going to #9.

20:07:27 0:58:25 Battalion 3 Ackerman Okay

20:07:27 0:58:25 Dispatch McIver Um, James Island is going to cover West Ashley

and James Island for us.

20:07:31 0:58:29 Battalion 3 Ackerman Okay

20:07:32 0:58:30 Dispatch McIver Summerville is sending one to #10. 7 is at 11.

20:07:35 0:58:33 Battalion 3 Ackerman Thank you very much.

20:07:36 0:58:34 Dispatch McIver Okay. Alright. Goodbye.

Channel 1

20:07:52

0:58:50 Engine 12

Suction

Henry Radio activated, no transmission

Channel 1

20:08:12

0:59:10

Car 1

Thomas Chief Buddy, you got it covered around there? PASS device in the

background.

20:08:16

0:59:14

Battalion 4

Aytes Come back, Chief. I’ve got St. Andrew’s backing

another one down in down here at Pebble and I’ve

got the aerial up there and doesn’t have much

pressure, Ladder 5 doesn’t either.

20:08:20

0:59:18 Charleston

County Sheriff's

Office


20:08:25

0:59:23

Car 1

Thomas Ladder 4’s got pretty good pressure on one line.

Lay as many as we can get.

20:08:30

0:59:28

Battalion 4

Aytes Yeah, I got three hand lines back on Pebble and

I've got St. Andrew’s backing another truck on the

side of this field. Ladder 5 doesn’t have much.

20:08:31

0:59:29 Engine 10

Captain


20:08:31

0:59:29 Engine 10

Engineer

Butler System Watch activation, no audio




20:08:38 0:59:36 Car 1 Thomas 10-4

20:08:43

0:59:41

Car1

Thomas Alright, can you use one of those hand lines

[inaudible] can we use it?

20:08:52

0:59:50

Battalion 4

Aytes When St. Andrew’s comes back down to here

[inaudible] ...to Ladder 5, we'll use it.

20:08:59

0:59:57 Ladder 4

Captain

Morley Ladder 4 to Car 1


Telephone

20:08:58 0:59:56 Dispatch

Barrineau

[ringing] I'm getting the Waterworks again.

[ringing]

20:09:11 1:00:09 Charleston

Public Works

Charleston Water.

20:09:12 1:00:10 Dispatch

Barrineau

Hey, partner. This is Operator 4 again. Did

anybody ever boost up the pressure?

20:09:15 1:00:13 Charleston

Public Works

They did. I called and talked to one of your

colleagues.

20:09:18 1:00:16 Dispatch

Barrineau

We need some more pressure. They are still

complaining about some more water. Is there

anyway we can get anymore pressure built up?

20:09:23 1:00:21 Charleston

Public Works

Like I said, I just now talked to one of your

colleagues.

20:09:25 1:00:23 Dispatch Barrineau Uh, huh.

20:09:26 1:00:24 Caller She said it was okay but they need a little more

pressure.

20:09:29 1:00:27 Dispatch Barrineau Yes.

20:09:30 1:00:28 I told the guys at the plant and they said they are

going to try to pull them up a little more.

20:09:32 1:00:30 Dispatch

Barrineau

Well if you could please do it for us, we'd

appreciate it immensely. Okay?

20:09:34 1:00:32 Charleston

Public Works

[inaudible.]

20:09:35 1:00:33 Dispatch Barrineau Thank you for all your cooperation.

20:09:37 1:00:35 Charleston

Public Works

Thank you.

20:09:37 1:00:35 Dispatch Barrineau Thank you.

20:09:38 1:00:36 Charleston

Public Works

Alright

20:09:38 1:00:36 Dispatch Barrineau Goodbye.

20:09:43 1:00:41 Dispatch Barrineau Car 11. Batallion 4 are you on 2?

20:09:56 1:00:54 Dispatch Barrineau [phone ringing] Charleston Fire, Operator 4

Channel 1




Page C-1

Appendix C – Unit Summaries Car 1 Fire Chief Times: 19:12:31 – Tells Engine 15 to continue to their standby at Fire Station 11 19:14:45 – Directs Engine 6 to stand by at Fire Station 10 and has Engine 19 dispatched to the fire 19:15:31 – Directs Dispatch to ask Saint Andrews Fire Department to cover calls in West Ashley 19:16:32 – On the scene 19:17:25 – Orders Engine 12 to give a supply line to Engine 10 19:19:12 – Orders Engine 6 to respond to the scene 19:19:33 – Requests the power company 19:23:09 – Asks Assistant Chief about interior conditions 19:24:29 – Series of transmissions to Engine 12 Engineer regarding supply line pressure 19:26:40 – Advised by Dispatch of a civilian trapped in the building 19:27:55 – Advises Assistant Chief that he has a stacked tip working in the warehouse 19:31:11 – Requests Engine 3 to the scene to supply Ladder 5 and later provides instructions 19:33:01 – First transmission to Assistant Chief regarding firefighter in distress 19:34:47 – First order to vacate the building 19:35:47 – First call asking for Captain 15 19:37:02 – Call for an additional fire company to be dispatched 19:40:11 – First order for all firefighters to remain out of the building 19:48:42 – Requests Ladder 4 to the scene Summary: The Fire Chief was off-duty and returning from visiting his parents. He was approximately 7.6 miles from the scene at the time of dispatch. The Fire Chief monitored the radio traffic and began his response when Engine 12 was dispatched to the incident (approximately 19:13). When the Fire Chief arrived on the scene, he parked his vehicle in the middle of Savannah Highway and donned his personal protective clothing. As the Fire Chief walked toward the front of the building, Engine 12 was arriving. He told Engineer 12 where the closest fire hydrant was located and assisted Engineer 10 as he connected the lines.


Page C-2

Car 1, continued The Fire Chief met the Assistant Chief at the northwest corner of the fire building. They had a brief conversation and the Fire Chief told the Assistant Chief that he would be in charge of the loading dock area and the Assistant Chief would have the front. Traditionally in the Charleston Fire Department, the Fire Chief takes the side of the incident that has the most active fire. The Fire Chief did not see any smoke at the front of the building before he went to the loading dock area. As the Fire Chief arrived at the loading dock area, firefighters were clamping the 1-1/2 inch handline from Engine 10 that had burned through and were replacing the hose. The Fire Chief conferred with Battalion 4 about the situation. Battalion 4 told him that they had fire in the loading dock. The Fire Chief saw that a handline was in place on the ramp that led to the staging area door. The Fire Chief observed that the walls of the warehouse were cherry red and that there was an obvious working fire inside. Firefighters made up a 2-1/2 inch attack line with a stacked tip as other firefighters forced entry into the warehouse. The Fire Chief ordered firefighters from Engine 10 and Engine 12 who were operating a 1-1/2 inch handline into the loading dock to hold their position at the door. The warehouse was opened and firefighters operated the 2-1/2 inch line into the warehouse from the exterior. The Fire Chief ordered the firefighters on the 2-1/2 inch line to remain outside the building. The Fire Chief was advised by dispatch that a civilian was trapped at the back of the building. At some point, prior to going to the front of the building, the Fire Chief met briefly with the on-duty Saint Andrews Assistant Chief. The Fire Chief assigned the Saint Andrews companies to fight the fire at the back of the warehouse, off of Pebble Road. Car 303 met the Fire Chief near Engine 10’s apparatus. Car 303 advised the Fire Chief that he had heard distress calls from firefighters. The Fire Chief called to the Assistant Chief at the front of the building to advise him of the Mayday. As he walked to the front of the store, the Fire Chief advised the Assistant Chief that all of the firefighters at the loading dock were outside. The Fire Chief does not recall hearing any of the firefighter distress calls.


Page C-3

Car 1, continued The Fire Chief met the Assistant Chief, Battalion 5, and Car 303 at the front of the store. Air horns were sounded to notify firefighters of an evacuation. The Fire Chief did not allow any firefighters to reenter the structure due to fire conditions. The Fire Chief and other chief officers called for Captain 15 because he could not be located after Firefighter 15A emerged from the building and did not know the location of his captain. Although initial accountability efforts concentrated on Captain 15, it soon became apparent that others were missing as well.

The Fire Chief does not recall arranging for a water supply for Ladder 5 prior to coming to the front of the building - he summoned Engine 3 to the scene prior to being aware of the firefighters in distress. The Fire Chief recalled that Ladder 5 was at the front of the building when he came to the front. This is probably mistaken, because Ladder 5 was backing into the lot next door as Car 303 arrived at the scene, prior to making the Fire Chief aware of the distress calls. The Fire Chief does not recall sending any Saint Andrews firefighters into the structure after the distress calls. He does remember Saint Andrews Rescue 1 Driver, SA1, coming out of the structure along with other firefighters. The Fire Chief does not recall giving an order or who might have given an order to remove the windows at the front of the store. The Fire Chief can be heard on the radio seeking Firefighter 15B at 20:26:46. He can be heard seeking Captain 5 and Engineer 5 at approximately 20:37:37. The Fire Chief recalls seeing the following firefighters coming out of the building: Captain 6, Engineer 6, Firefighter 15A, Firefighter 15B, Firefighter 6, and Saint Andrews Rescue Driver (SA1). He was also aware that other firefighters had been inside and had escaped (Captain 11, Firefighter 11, Engineer 15). The Fire Chief was not aware of any reports of firefighters having their hands on any of the firefighters that died in the incident during any rescue attempt.


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Car 2 Assistant Chief Note: The Assistant Chief was working for the Assistant Chief normally assigned to “B” shift. Times: 19:11:11 – Orders Engine 11 to come behind the Sofa Super Store 19:11:35 – Orders Engine 10 to come to his position and back into the alley 19:12:10 – Orders Engine 16 to come inside the building upon their arrival 19:12:49 – Orders the dispatch of Engine 12 to the scene 19:13:31 – Orders Engine 15 to the scene 19:13:46 – Orders Engine 15 to bring a handline into the building upon their arrival 19:14:10 – Tells BC4 that he has fire inside the rear of the building walking its way into the showroom 19:14:23 – Orders the dispatch of Engine 6 to the scene 19:15:05 – Orders the 1-1/2 inch line to be charged 19:15:15 – Orders Engine 16 to stretch a 2-1/2 inch handline into the store 19:17:14 – Orders Engine 12 to lay a line for Engine 10 19:17:36 – Orders Engine 16 to lay to a hydrant for Engine 11 19:20:05 – Tells Engineer 11 not to charge the 2-1/2 until he has a supply line 19:21:26 – Inquires about the supply line from Engine 16 19:23:16 – Tells the Fire Chief that he is assessing the fire conditions (in SCBA) 19:24:22 – Fragment of a transmission about a 2-1/2 (in SCBA) 19:28:03 – Tells the Fire Chief about a civilian trapped in the store 19:28:42 – Calls for help from any available firefighter 19:30:02 – Tells the Engineer 11 that he has the help he needs 19:30:58 – Working to free trapped civilian 19:31:42 – Requests EMS for the injured civilian 19:32:53 – Additional information for EMS 19:33:17 – Tells the Fire Chief that fire crews remain in the building 19:33:52 – Identifies Firefighter 15A as a firefighter that escaped the building 19:34:01 – Tells the Fire Chief that Firefighter 15A did not call the Mayday 19:35:34 – Tells the Fire Chief that Captain 11 has been located


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Car 2, continued Summary: The Assistant Chief had just completing eating dinner with Battalion 4 and the crew of Engine 11. When the Sofa Super Store incident was dispatched, he helped firefighters prepare the engine for response and then watched as Battalion 4 and Engine 11 responded from their quarters. The Assistant Chief heard Battalion 4 report smoke in the area and immediately responded to the incident. As he responded to the scene, he saw a black column of smoke rising from the scene. As he responded, the Assistant Chief saw that Engine 11 had taken the block around to the back of the store and told them to come around. When the Assistant Chief arrived on the scene, he conferred with Battalion 4. Engine 10 was arriving on the scene at that time so he ordered Engine 10 to back down the alley to attack the fire and called fro Engine 12 to be dispatched. The Assistant Chief did not go to the loading dock area until much later in the incident, after fire had taken hold of the building. The Assistant Chief went inside the showroom to assess conditions. The Assistant Chief and two store managers walked into the store through the front entrance and found clear conditions inside. The managers led the Assistant Chief and Captain 11 to the rear of the showroom to a set of double doors that led to the loading dock. As they approached the doorway, the Assistant Chief saw a small puff of smoke above the doors at the level of the dropped ceiling. The door was not hot. The Assistant Chief turned the knob and the door was quickly pulled open by air rushing from the store into the loading dock. Fire could be seen in the loading dock to the right of the double doors, near the exterior wall. Captain 11 closed the door. The Assistant Chief ordered Captain 11 to get a handline. The Assistant Chief called for Engine 15 to respond to the fire and then for Engine 6 to respond. (The Fire Chief directed Engine 19 to respond in place of Engine 6). When he walked back outside, the Assistant Chief was met at the door by Captain 5. Captain 5 and his crew were advancing a handline into the building from Engine 11 which was parked by the door. Conditions inside the showroom were still clear. The Assistant Chief called for Engine 16 to bring a 2-1/2 inch line into rear the showroom on the right side.


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Car 2, continued The Assistant Chief donned his turnout coat, helmet and SCBA backpack and went back into the store. The Assistant Chief observed light smoke in the showroom. He was able to see firefighters in the doorway applying water to the fire in the loading dock. He did not observe any fire in the retail area of the store. While he was inside the showroom, the Assistant Chief received a call regarding the trapped civilian. He met Captain 19 and the crew from Engine 19 who were on the way into the showroom as he was headed out and directed them toward the double doors. The Assistant Chief then spoke with the store managers about the report of the trapped civilian and determined that the civilian was most likely trapped in a workshop area of the building that was not accessible from the showroom due to the fire. When he emerged from the store, the Assistant Chief spoke with the Fire Chief on the radio about the trapped civilian. The Assistant Chief and two store managers walked around the east end of the store and encountered a locked wooden fence. The Assistant Chief walked back to the front of the building and yelled to Battalion 5 who had just arrived on the scene. Battalion 5 brought a crew of firefighters from Saint Andrews Fire Department Engine 2 and Rescue 1 around to the side of the building. Battalion 5 borrowed an axe from the Saint Andrews firefighters and opened the wooden fence gate. The Saint Andrews firefighters, two managers, and two chiefs walked behind the building. One of the store managers directed the firefighters where to hit the wall. A firefighter put a Halligan tool through the wall and a hand immediately emerged from the hole. Firefighters widened the hole and the trapped civilian came out through the opening. As firefighters walked the injured civilian around the front of the building, bystanders applauded. The injured civilian was propped up against a truck and EMS was notified of his location. When the Assistant Chief came back around the front of the building, he could see that conditions inside the showroom had changed dramatically. He was joined at the front of the building by the Fire Chief, Car 303 and the Training Chief.

The Assistant Chief does not recall donning the facepiece of his SCBA at any point. (There are at least two radio transmissions by the Assistant Chief that sound as if they were spoken through an SCBA facepiece.) He does recall doffing the SCBA backpack when he went around to the rear of the store to help with the rescue.


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Car 2, continued The Assistant Chief believes that Captain 15 reached out from the store and borrowed his handlight after he came around the front of the building. The review team could not support this assertion based on our interviews. The Assistant Chief does not recall giving an order to break the windows at the front of the store.


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Battalion 4 Battalion 4 Notes: Fire Station 11 – 1517 Savannah Highway – approximately .9 miles from the Sofa Super Store Battalion 4 and Engine 11 are housed at Fire Station 11. Times: 19:09:02 – Dispatched from quarters 19:09:44 – Reports smoke in the direction of the Sofa Super Store 19:10:46 – On-scene reporting trash and debris fire 19:10:56 – Informs dispatch that the fire may be in the building 19:11:13 – Directs the placement of Engine 11 19:12:43 – Informs Car 2 that he believes fire is in the building 19:13:10 – Orders Engine 12 to lay a line 19:17:07 – Directs the movement of Engine 12 19:34:27 – Requests a pumper for Ladder 5 19:35:08 – Identifies Engineer 5 Summary: Battalion 4 was in quarters at Fire Station 11 at the time of dispatch. As he was responding, he reported smoke in the area of the incident. Battalion 4 was the first Fire Department unit on the scene. He was able to drive his sedan down the alley to the loading dock area. Upon his arrival at the scene at 19:10:46, Battalion 4 reported a trash and debris fire up against the building. After making his arrival report, Battalion 4 backed his car out of the alley and parked it in front of the store to allow for access to the fire by the first arriving engine company. At the time of Battalion 4’s arrival, the flames were taller than the loading dock area. Battalion 4 saw a window leading into the staging area but did not initially see fire in the building. Moments later he reported that the fire may have gotten into the building. When Engine 10 arrived on the scene, Battalion 4 walked with Captain 10 as the engine backed down the alley to the loading dock area. When Battalion 4 and Captain 10 arrived at the loading dock area, flames were visible inside of the staging area.


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Battalion 4, continued When Engine 12 was dispatched, Battalion 4 ordered them to lay a line for Engine 10. When Engine 12 arrived on the scene, Battalion 4 again ordered them to lay a supply line for Engine 10 and helped Engine 12 locate Engine 10. Engine 10’s position was blocked by the store and a fence. Battalion 4 ordered a Firefighter 12A to force entry into the warehouse and ordered a fire department mechanic that had arrived on the scene to retrieve a power saw and bring it to the loading dock area. Firefighter 12B arrived and the man door to the warehouse was opened. Battalion 4 observed fire inside of the warehouse to the left of the door. He ordered firefighters to remain outside of the warehouse. Battalion 4 ordered two off-duty firefighters that had responded to the incident to move Ladder 5 from the front parking lot of the store to the field adjacent to the Sofa Super Store. The Fire Chief arrived in the loading dock area and took command of operations in that area. Battalion 4 helped set up Ladder 5 in the field next to the Sofa Super Store. He assisted in securing a water supply for the ladder, first from a Saint Paul’s Fire Department tanker and then from Engine 3. Battalion 4 also coordinated with Saint Andrews Fire Department command officers and firefighters on their work fighting the warehouse fire from Pebble Road.


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Battalion 5 Battalion 5 Note: Fire Station 7 – 1173 Fort Johnson Road - approximately 7.8 miles from the Sofa Super Store. Times: 19:15:30 – Responding to the Sofa Super Store 19:24:09 – Arrives on the scene 19:31:19 – Reports that the civilian has been rescued from the store 19:37:18 – Orders the dispatch of Engine 13 to the scene Summary: Battalion 5 was conducting an SCBA drill at Fire Station 7. Engine 13 also attended the training session. Firefighters monitored the radio and heard the initial dispatch to the Sofa Super Store. The arrival report at the fire did not indicate a working fire so the drill continued. Once additional units were summoned to the scene, Engine 13 was directed to return to their station and Battalion 5 began his response to the Sofa Super Store. Battalion 5 observed smoke in the air as he responded to the scene. As he arrived on the scene, he passed Engine 16 at a hydrant. The supply line that was being pumped by Engine 16 had been charged. Battalion 5 parked his vehicle in the center of Savannah Highway and observed Engine 11 in the front parking lot of the store and three engines in the street (E6, E15, and E19). He observed Ladder 5 in the leftmost lane of the highway, past the Sofa Super Store. Battalion 5 donned his protective clothing and proceeded to the front door of the store. Battalion 5 met the Assistant Chief at the front door of the store and requested orders. Battalion 5 observed that the front door of the store was propped open and that a charged 1-1/2 inch line, an uncharged 2-1/2 inch line, and a booster line were through the door. Battalion 5 observed smoke inside the store from floor to ceiling with limited visibility at the floor level for the first few feet into the store. He was able to see through the windows of the store and did not observe any soot or condensation on the windows. Smoke was emanating from the doorway but did move with much force.


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Battalion 5, continued The Assistant Chief reported the he was going to around to the rear of the building based on a report of a civilian trapped in the store. Battalion 5 was not aware of the trapped civilian until he was advised by the Assistant Chief. Battalion 5’s attention was temporarily drawn to Engine 11 as the engineer was experiencing water supply problems. Moments later, the Assistant Chief called to Battalion 5 and requested firefighters with tools to assist him. Several firefighters from the Saint Andrews Fire Protection District approached the front of the store. Battalion 5 ordered them to gather tools and come with him. The Assistant Chief, Battalion 5, and two store managers encountered a locked wooden gate and fence at the rear of the structure. Battalion 5 tried unsuccessfully to open the gate with the axe he had carried. The Saint Andrews firefighter arrived and opened the gate. The Assistant Chief, Battalion 5, the three Saint Andrews firefighters, and the two store managers proceeded to the rear of the building. They located the room where the civilian was trapped after hearing banging on a wall. The metal side of the building was cut open by Battalion 5 and a Saint Andrews firefighter and the civilian was removed. The civilian was brought to the front of the building by the Saint Andrews firefighters; the Assistant Chief and the store managers also returned to the front of the store. Battalion 5 remained at the rear of the store for a short time. He called out for others that might have been trapped in the structure but got no response. As he left the rear of the store, he observed smoke pushing with some force from holes that had been cut into the metal building walls. He reported the rescue of the civilian at 19:31:19. When Battalion 5 returned to the front of the store he met the Fire Chief, the Assistant Chief, and other firefighters. He learned that firefighters were in trouble and was directed by the Assistant Chief to break out some of the windows at the front of the store. Battalion 5 broke out two large windows to the left of the front door. A third window blew out as he approached it. After fire emerged from the front of the structure, Battalion 5 moved the Assistant Chief vehicle away from the building. He directed Captain 11 to lay an additional supply line with Engine 19’s apparatus, and made his way to the west side of the building to supervise operations on that side.


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Battalion 5, continued Firefighters on the west side of the building fought fire in the loading dock and warehouse as well as cutting a number of holes into the metal wall of the west showroom to apply water to the fire. Battalion 5 later participated in body recovery efforts.


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Car 303 Car 303 Notes: Car 303 was off-duty, cooking for a charity golf tournament in far northwest Charleston, West of the Ashley River, approximately six miles from the Sofa Super Store. Car 303 had been in public areas of the Sofa Super Store to purchase furniture for the fire department within two years of the fire. Times: 19:30:27 – Car 303 attempts to call Car 1 19:32:19 – Car 303 attempts to call Car 1 19:32:33 – Car 303 on the scene (approximate) Summary: Car 303 was cooking at a golf charity event to honor a firefighter who had been killed in an off-duty car crash. He was monitoring his portable radio and heard the original dispatch. When Battalion 4 arrived on the scene and reported a trash fire, Car 303’s attention was drawn away from his radio for a time. Car 303 received a phone call from another firefighter advising him that there was a working structural fire at the Sofa Super Store. Car 303 and his son immediately left the golf course and proceeded in the direction of the Sofa Super Store. About half way to the scene, smoke from the fire was visible. During the drive, Car 303 monitored incident radio traffic on his portable radio. He heard several transmissions that sounded like firefighters in distress and made several unsuccessful attempts to contact the Fire Chief at the scene over the radio. The first transmission from Car 303 that is captured on the communications recording is at 19:30:27. When he arrived at the scene at approximately 19:32:33, Car 303 parked his personal vehicle and ran to the Fire Chief’s location to inform him of what he had heard. He found the Fire Chief directing operations on the west side of the building near the loading dock. He told the Fire Chief that he had heard a firefighter in distress. The Fire Chief asked Car 303 who had called the Mayday but Car 303 had not recognized the voice of the firefighter(s) in distress.


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Car 303, continued The Fire Chief called the Assistant Chief on the radio and informed him of the Mayday. The Fire Chief said that all of the firefighters in the area that he was working were outside and asked the Assistant Chief about the status of his crews. The Assistant Chief responded that crews were still inside and then advised that one firefighter had just come out of the store. The firefighter was identified as Firefighter 15A. The Fire Chief and Car 303 knew the identity of the Captain of Engine 15. They headed toward the front of the store. At the front of the building the Fire Chief proceeded to the front door of the retail area of the building and Car 303 ran to his vehicle to retrieve his personal protective clothing. Car 303 met back up with the Fire Chief at the front door of the store. As Car 303 approached the front door, the front windows were being removed. The Fire Chief told Car 303 that they could not locate Captain 15. At that point, Captain 15 was the only firefighter that was known to be missing so efforts concentrated on finding him. Car 303 donned an SCBA and made contact with Captain 6 and Engineer 6. Captain 6 and Engineer 6 had just left the structure. Car 303 asked them if they knew the location of Captain 15 - they did not know. Saint Andrews Firefighters SA1 and SA2 exited the structure shortly thereafter and told Car 303 that they had made contact with two lost firefighters inside of the building. Firefighter SA1 indicated that the firefighters were in the main retail area of the store, straight in from the front door. Car 303 requested and was handed the rescue rope by Engineer 11. He brought it to the door with the intention of making entry to perform a search. Car 303 entered the building breathing air from his SCBA and crawled about 15 feet into the building when he began to receive burns to his hands. He had neglected to don gloves on his way into the building. Car 303 returned to the exterior and donned his gloves. He reentered the structure and made it approximately 10 feet inside when he was driven back out by fire conditions. As he withdrew, he could see a wall of flames across the store and going over his head. When Car 303 reached the exterior he saw fire venting from several windows on the front of the store. At that point, Car 303 conferred with the Fire Chief and they decided that there was nothing more to be gained from interior operations. Their efforts concentrated on defensive operations to bring the fire under control. Car 303 assisted with the location, recovery, and removal of the deceased firefighters from the building.


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Engine 6 Crew: Captain 6 Engineer 6 Firefighter 6 in the suction position Times: 19:13:59 – Relocating to the West side 19:14:23 – Requested to the scene by the Assistant Chief 19:14:45 – Redirected to Fire Station 11 by the Fire Chief 19:16:09 – Reports arrival on the west side of the Ashley River Bridge 19:19:12 – Ordered to the scene by the Fire Chief 19:21:50 – Arrives on the scene Summary: Engine 6 was in quarters when the Sofa Super Store incident was initially dispatched. Based on standard protocols, Engine 6 began to relocate to the West Ashley district of Charleston when a working fire was reported. As Engine 6 was enroute, they were requested to respond to the scene by the Assistant Chief. Engine 6 was redirected to cover at Fire Station 11 by the Fire Chief and Engine 19 was dispatched to respond to the scene of the incident. As Engine 6 was passing Fire Station 10 enroute to Fire Station 11, they were ordered by the Fire Chief to respond to the scene, park the truck in the middle of Savannah Highway, and come into the store through the front door. The Fire Chief told Captain 6 after the fire that he summoned Engine 6 to the scene when he saw the volume of fire in the loading dock and warehouse area to the rear of the store. Engine 6 arrived at the scene at 19:21:50, approximately twelve minutes and 48 seconds into the incident. As they arrived on the scene, Engineer 6 remarked to Captain 6 that this was looking like it was going to be a difficult incident.


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Engine 6, continued Captain 6 and Firefighter 6 Upon their arrival, Captain 6 and Firefighter 6 ran to the front door of the store, donned their SCBA facepieces, and made entry. Near the entrance they encountered Captain 11 and Firefighter 11. Captain 6 asked Captain 11 where the nozzle was located and Captain 11 replied that they needed a larger line. Captain 6 and Firefighter 6 followed the 1-1/2 inch hose line toward the rear of the showroom. As they proceeded, they had no visibility in the heavy smoke, although they could walk upright and did not encounter any significant heat. Captain 6 followed the 1-1/2 inch handline back into the showroom until he found the nozzle on the floor. He ordered Firefighter 6 to pull the hose to provide him with additional line. Captain 6 found a large volume of fire and flowed water into a room from the doorway. He believes that he was at the double doors leading to the loading dock. Captain 6 heard the voices of other firefighters in the smoke, but did not make close contact with any of them. Captain 6 flowed the handline for approximately five minutes. He temporarily shut the nozzle when the fire appeared to darken down. As the fire flared up again, he reopened the nozzle to apply water but found that he had little pressure and minimal flow. He attempted to contact the Fire Chief by radio but was unsuccessful. His portable radio may have been turned off or a knob may have been broken. Heat conditions in Captain 6’s position worsened rapidly. Captain 6 began to feel burns on his wrists. He attempted to reposition himself into a more defensive position but the heat conditions continued to worsen. He decided to abandon his position. Captain 6 followed the line back into the main showroom area of the store, noting that heat conditions improved. He found that the handline was looped around and did not provide a clear path to the exit. His Vibralert was activated and he did not hear any other firefighters in the area. He guessed at the direction of the front door and climbed over piles of furniture to move in that direction. Captain 6 fell off of a piece of furniture and made contact with Firefighter 6. Captain 6 told Firefighter 6 that he was nearly out of air; his face piece began to suck to his face with every breath. Captain 6 followed the line and encountered Engineer 6. The three firefighters followed the lines back to the main entrance and emerged at approximately 19:35:14.


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Engine 6, continued Firefighter 6 did hear distress calls from firefighters while he was inside of the building. Engineer 6 Engineer 6 donned his personal protective clothing and SCBA upon arrival, took a pike pole off of the apparatus, and approached the front of the store. He neglected to carry his portable radio with him. As he arrived at the front door, he saw Captain 11 leaving the store. Engineer 6 was also advised by a store manager that someone was trapped at the back of the building. The manager had thought that everyone was out of the building, but saw one worker’s vehicle in the parking lot. Engineer 6 donned his face piece and entered the showroom through the front door. As he entered, he observed an area clear of smoke, like a tunnel, that extended about five feet into the store from the entrance. Black smoke obscured vision on both sides of the “tunnel”. A large volume of air was being drawn into the store from the exterior. He dragged his foot on the hose and then picked up the hose to guide him to the back of the store. Engineer 6 encountered a firefighter in the smoke near the rear of the store. He believes that this firefighter was Firefighter 6. Sensing that there were enough firefighters on the handline, Engineer 6 moved to the left away from the handline. He moved about 10-20 feet and encountered a wall. Engineer 6 struck the wall with his pike pole several times. Smoke conditions in the area were heavy and Engineer 6 could sense heat from the fire. The aisles of the store had begun to become congested due to the movement of furniture that was entangled with the hoses. An unknown firefighter grabbed Engineer 6 and told him that he was lost and about to run out of air. Engineer 6 grabbed the firefighter’s coat as a second, third, and fourth firefighter arrived. Engineer 6 heard the vibra-alerts on the SCBA’s of the firefighters, indicating that they were low on air. The firefighters were in obvious distress. One firefighter dropped to the floor and crawled under Engineer 6 and disappeared. The other three firefighters in distress also turned away and disappeared. The entire exchange occurred in a very short period of time. Engineer 6 believes, but cannot be certain, that these firefighters were Captain 19, Captain 16, Engineer 9, and Firefighter 19. By this time, Engineer 6 had lost track of the handline and was disoriented. He circled around approximately five times in growing circles until he came into contact with the hose.


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Engine 6, continued Immediately upon contacting the hose, Engineer 6 encountered Firefighter 15A. Firefighter 15A was disoriented and low on air. Engineer 6 followed the hose line, dropped his pike pole, and led Firefighter 15A to the front building exit. Engineer 6 removed his facepiece once he reached the exterior and asked Firefighter 15A if he was okay. Once confirming that Firefighter 15A was alright, he donned his facepiece and reentered the store. He made his way to the back of the showroom where he encountered Captain 6 and Firefighter 6. Captain 6 was nearly out of air and Engineer 6 led him to the exit. Firefighter 6 followed the pair to the exit. The three firefighters made their way to the exterior and emerged at approximately 19:35:14. Engineer 6 checked the pressure on his SCBA and found that he had 600 psi remaining. Engineer 11 changed Engineer 6’s SCBA cylinder. When he stood back up after the cylinder change, Engineer 6 observed fire emitting from the front of the store. Engineer 6 and other firefighters operated a 2-1/2 inch handline into the store. Car 303 entered the store briefly but was driven from the building by fire conditions. Initially, water supply on the 2-1/2 was sufficient but soon the line was not getting enough water to have any effect. Engineer 6 joined other firefighters, including the Training Chief, on another handline to the right of the store entrance. Engineer 6 rejoined his crew and assisted other firefighters in cutting holes into the right hand wall of the store, along the alley near Engine 10. He also removed panels from the rollup door on the warehouse. The crew of Engine 6 made up part of the first search team sent into the building to search for the remains of the missing firefighters. They located and recovered the remains of several firefighters. After midnight, the crew of Engine 6 left the building and found their apparatus near Pebble Lane. All of the supply line had been laid but the apparatus was not being utilized.


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Engine 10 Crew: Captain 10 Engineer 10 Firefighter 10 in the suction position Notes: Firefighter 5 was assigned to Engine 10, working for another firefighter. He switched positions with Firefighter 10 on Ladder 5 to allow for Firefighter 10 to participate in driver and pump operations training. Captain 5 was normally assigned as the Engineer of Engine 10. On the day of the fire he was Acting Captain of Ladder 5. Engineer 10 was working the first part of the shift for another Assistant Engineer Fulmer. Times: 19:09:02 – Dispatched 19:09:37 – Responding 19:11:03 – Acknowledges Battalion 4 arrival report 19:11:40 – On the scene and ordered to back down the alley by the Assistant Chief 19:23:49 – Engineer 10 requests additional water from E12 Summary: Engine 10 was in the parking lot of a grocery store on Savannah Highway when the incident was initially dispatched. They had just pulled into the parking lot to shop for supper and the full crew was on board. This placed Engine 10 closer to the Sofa Super Store than if they had been in quarters. Engine 10 responded immediately upon dispatch. The crew had been engaged in driver and pump operator training. The left-hand preconnected 1-1/2 inch handline was in its bed. The second pre-connected line had been stretched and charged during the training session and the hose was rolled on the tailboard.


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Engine 10, continued Engineer 10 saw Engine 11 pull out of their station and turn toward the fire as they approached. As the apparatus approached the scene, Engineer 10 and Captain 10 could see a black plume of smoke rising from the scene. The plume was narrow, straight up, and very dark. As the units got closer to the scene, Engine 11 turned onto a side street to access the back of the store. Engine 10 was the first engine on the scene. The Assistant Chief ordered Engine 10 to come to his location and back down the alley leading to the loading dock area where the fire was located. Captain 10 and Engineer 10 both independently recall being able to see customers or civilians inside the store as they pulled up into the parking lot and prepared to back down the alley. They both assumed that they would be backing down to lay a line for an engine that was already at the rear of the building. Battalion 4 walked with Captain 10 as the engine backed down the alley to the loading dock area. Captain 10 initially observed a debris fire outside the building. He also observed smoke and flames inside the loading dock. Once the apparatus was in position, Captain 10 pulled the booster line and attacked the fire from the exterior. Firefighter 10 pulled the 1-1/2 inch preconnected handline. Captain 10 and Firefighter 10 opened the sliding door leading into the loading dock at the top of a ramp. The door was not locked. They found active fire in the room. They advanced the 1-1/2 inch handline 15-20 feet into the area and flowed water on the fire. The room seemed to the firefighters to be one open area with fire involving almost every part of the room. The fire appeared to Captain 10 to be burning gasses at the ceiling level rather than burning contents of the room. Captain 10 recalls one brief instance while he was inside when it seemed that the fire was being pushed in his direction by another handline. Engineer 10 stretched a 2-1/2 inch supply line by hand out to Savannah Highway. He was met at the street by the Fire Chief. The Fire Chief told him to stand by for a moment and await the arrival of an engine. Engine 12 pulled up and laid a line away from the scene. Engineer 10 returned to his apparatus. When he arrived at the apparatus, Captain 10 and Firefighter 10 were coming out of the structure. Fire conditions in the loading dock had changed rapidly. Captain 10 and Firefighter 10 reported that the heat increased dramatically, to the extent that the facepiece worn by Firefighter 10 melted and crazed. The firefighters were surrounded by flames. At the same time, the hose line burned through and both firefighters were able to abandon their interior position and get back outside. The spray of water created by the burned section of hose created a “water curtain” that protected them as they exited.


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Engine 10, continued Captain 12 and Firefighter 12A joined the crew of Engine 10 at the loading dock area and pulled the nozzle outside to replace the burst section of hose. While the burned section was being replaced, Firefighter 10 applied water to the fire on the interior of the staging area with the booster line. The interior fire grew in intensity. The Fire Chief arrived at the loading dock area at approximately the same time the section of hose was being replaced. He assumed command of the fire fighting operations in the loading dock area. Once the water supply to Engine 10 was established, Firefighter 12B arrived to assist. When the 1-1/2 inch line was recharged, Captain 10, Captain 12, and Firefighter 12A operated the line from the doorway leading into the loading dock. The firefighters were ordered by the Fire Chief not to go back inside to fight the fire. Engineer 10 experienced water supply problems and was assisted by the Fire Chief in having Engine 12 increase the pressure in the supply line. The water supply to Engine 10 from Engine 12 was frequently interrupted by cars driving over and parking on the supply line on Savannah Highway. After approximately five minutes of flowing water into the staging area through the doorway, the Fire Chief ordered Captain 10 to work on the fire in the warehouse. Captain 10 entered the man door of the warehouse and saw a large amount of fire in every area of the warehouse. An interior attack was not appropriate. A 2-1/2 inch attack line was stretched from and charged by Engine 10. The line was used to apply water to the interior of the warehouse once access was made through the man door and the rolling door. At some point, Firefighter 15B joined firefighters in the loading dock area. The crew of Engine 10 remained in the dock area and also fought fire through holes cut into the wall of the right-hand retail area addition.


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Engine 11 Crew: Captain 11 Engineer 11 Firefighter 11 in the suction position Notes: Fire Station 11 – 1517 Savannah Highway – approximately .9 miles from the Sofa Super Store Battalion 4 and Engine 11 are based at Fire Station 11. Captain 11’s normal assignment was as the Engineer of Engine 11. Engineer 11’s normal assignment is Engine 3. The Sofa Super Store was his first fire as an Acting Engineer. Captain 11 had been part of a walk through of the Sofa Super Store and had shopped in the store. Engineer 11 was generally familiar with the store having been raised in the area. Firefighter 11 had also been inside of the store and had previously discussed fire and water supply issues at the store with other firefighters. Times: 19:09:02 – Dispatched as a part of the initial response 19:09:51 – Responding 19:11:23 – On-scene (approximate) 19:13:17 – Captain 11 calls for an attack line to be brought inside 19:15:56 – Engineer 5 calls for E11 to charge the 1-1/2 inch line 19:16:23 – Firefighter 5 calls for E11 to charge the 1-1/2 inch line 19:22:41 – Engineer 11 calls for his supply line to be charged 19:26:17 – Engine 11’s supply line is charged by E16 19:29:02 – Engineer 11 charges 2-1/2 inch handline 19:38:14 – Engineer 11 calls for additional pressure on the supply line 19:42:54 – Engineer 11 calls for additional pressure on the supply line 19:45:08 – Engineer 11 calls for additional pressure on the supply line 19:46:00 – Captain 11 discusses additional water supply with Battalion 4


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Engine 11, continued Summary: Engine 11 was in quarters at the time of the original dispatch. The Assistant Chief was visiting Fire Station 11 for dinner and was present at the time of the dispatch. The firefighters had just completed dinner and were washing the engine at the time of dispatch. They quickly returned equipment into the apparatus compartments and readied the apparatus for response. When Engine 11 turned left out of quarters, the black smoke column from the Sofa Super Store was immediately visible. The dispatch message indicted that the fire was behind the Sofa Super Store. In order to access the rear of the structure, Engine 11 turned left on Wappoo Road and right on Pebble Road. Realizing that the fire could not be accessed from that side, Engine 11 continued on Pebble Road, turned right on Stinson Drive, right again on Savannah Highway, and arrived at the front of the Sofa Super Store. Engine 10, Car 2, and Battalion 4 were all on the scene by the time Engine 11 arrived at the front. Engine 11 stopped in the front of the Sofa Super Store on Savannah Highway as Engine 10 was backing into the alley on the west side to access the fire. Captain 11 was wearing his personal protective clothing. He dismounted the apparatus and told his crew to lay a supply line for Engine 10. Ladder 5 was approaching the scene at that time. Captain 11 had heard the radio report that the fire may be inside the building. He went inside the showroom to assess the situation. Captain 11 did not see any smoke in the showroom, but was concerned about the spread of fire from the back of the building into the retail area. As he walked through the store, Captain 11 met the Assistant Chief. They walked to the rear and turned right, then went through a doorway framed by a block wall into another retail area (west showroom). As the firefighters passed through the door, they observed a set of double door to their left. The double doors led to the loading dock. Captain 11 noted a small amount of grayish colored smoke at the suspended ceiling above and to the left of the doors. The Assistant Chief turned the knob and the door was quickly pulled open by the air rushing from the store into the loading dock. Captain 11 observed a couch on fire, heavy black smoke, and an orange glow inside the loading dock. Air continued to be drawn into the loading dock from the showroom. Captain 11 reached in and closed the door. The Assistant Chief ordered Captain 11 to get him an attack line.


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Engine 11, continued Captain 11 departed immediately for the front of the store. As he proceeded, he called on the radio for a 1-1/2 inch handline to be brought into the building. The time was 19:13:17. Captain 5 directed Engineer 11 to move his apparatus to the front door of the store. They guided him to position Engine 11 near the front door and told him that they were going to pull the right-hand preconnected handline. When Captain 11 went into the store, Firefighter 11 took the soft suction and hydrant wrench from Engine 11 and began to walk in the direction of a fire hydrant near Morris Nissan. Firefighter 11 doffed his SCBA backpack and left it on the street. When he reached the intersection of Wappoo Road and Savannah Highway he observed that Engine 11 was being repositioned near the front door of the store. He returned to the apparatus, dropped the soft suction by the pump panel and donned another SCBA. When Captain 11 emerged from the front of the store, he saw Captain 5 stepping up onto the back of Engine 11 to deploy a 1-1/2 inch handline. Captain 11 asked Captain 5 why Engine 11 was not laying the line for Engine 10. Captain 5 told him that another engine was going to lay a line for Engine 10. Captain 5 advanced the hose line into the showroom. Captain 11 grabbed several loops of hose and followed Captain 5 and Engineer 5 into the store. Captain 11 pulled hose to the rear of the main aisle of the store and realized that Captain 5 would need additional hose to reach the loading dock. Captain 11 returned to the exterior, removed the nozzle from the other 1-1/2 inch preconnected attack line and connected the two lines together. This action increased the overall length of the attack line to 500 feet, providing sufficient hose to reach the fire. Captain 11 removed the second preconnected line from the hose bed and advanced the additional hose into the structure. Firefighter 11, who had arrived back at the apparatus, removed the remainder of the hose from the hose bed and flaked out the line to ensure that it would not kink. Firefighter 11 followed the hose line into the building and joined Captain 11 and the other firefighters near the double doors. As he proceeded to the rear, he passed civilians leaving the store. The atmosphere was clear until he reached the area where the other firefighters were operating. He observed smoke in this area and donned his face piece.


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Engine 11, continued The 1-1/2 inch handline had not been charged. Captain 11 sent Firefighter 11 back to the engine to check and see why the line was not charged. A few moments later, with no water yet in the line, Captain 11 went back to Engine 11 to determine why the line was not charged. When he arrived at the engine, Engineer 11 told him that he could not get the truck into pump gear. Captain 11 was familiar with an idiosyncrasy with the pump engagement for this particular piece of apparatus1. He engaged the pump, charged the 1-1/2 inch handline, and returned to the interior of the store. Captain 11 reentered the store and began to proceed to the double doors. As he reached the rear part of the showroom he encountered smoke and stopped to don his SCBA face piece. When Captain 11 rejoined the crew of Ladder 5 at the double doors they had also donned their face pieces. The 1-1/2 inch handline had been advanced into the loading dock through the double doors and was flowing water. Engineer 5 was at the doorway and he believed that Captain 5 was inside the loading dock operating the nozzle. Captain 11 backed them up on the line. Captain 16 and Firefighter 16 arrived at the double doors with a 2-1/2 inch handline. The 2-1/2 inch line was uncharged and was placed on the floor near the door. Captain 16 made a comment to Captain 11 stating that they would be in trouble if the fire got behind them. After two requests had been made to charge the 2-1/2 inch line, Captain 11 started back to Engine 11 to determine why the 2-1/2 inch handline had not been charged. As he walked through the middle showroom the atmosphere was filled with black smoke and the heat had markedly increased. As he proceeded to the exit, Captain 11 recognized the voices of Engineer 19 and Firefighter 19. Once outside, Captain 11 found that Engine 11 did not have a charged supply line and was still using tank water. The 2-1/2 inch line would not be charged until Engine 11 had a more reliable supply of water. The supply line was charged soon after Captain 11 came outside.

1 The throttle control on the pump panel on Engine 11 would not operate unless it was set to its lowest position when the pump was engaged. If the hand throttle control on the pump panel was in any position other than its lowest position, the pump would engage when the controls in the cab were activated, but the hand throttle on the pump panel would not operate.


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Engine 11, continued Firefighter 11 and Engineer 11 had changed air cylinders for two firefighters outside the building. Firefighter 11 then reentered the store and followed the hose line to the back of the showroom. At some point he encountered other firefighters inside the showroom. He heard a number of transmissions on the radio about getting out of the store. Heat levels were increasing. Firefighter 11 and the other firefighters began to crawl along the hoseline toward the exterior. Heat levels increased to the point that Firefighter 11 received burns and visibility was near-zero. The air horns were blowing when he was exiting. Firefighter 11 became ill, drank some water, and then joined other firefighters on an exterior 2-1/2 inch hand line. While he was at Engine 11, Captain 11 realized that he could not account for Firefighter 11, who he had sent to investigate the delay in charging the 1-1/2 inch handline. Captain 11 went to the exterior loading dock area looking for Firefighter 11. At that time he observed that the interior of the warehouse was well involved. By the time Captain 11 returned to the front of the store, conditions had changed significantly and he did not reenter the structure. Battalion 5 directed Captain 11 to take Engine 19 and lay another supply line for Engine 11. The left hand booster line from Engine 11 was pulled by a fire department mechanic on the scene and placed under the engine compartment to cool the pavement and the engine. The right hand booster line was pulled by Firefighter 15B and advanced into the interior of the store.


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Engine 12 Crew: Captain 12 Engineer 12 Firefighter 12A in the nozzle position Firefighter 12B in the suction position Note – This was the first fire for Firefighter 12A. Times: 19:12:49 – Dispatch of Engine 12 requested by the Assistant Chief 19:12:53 – Dispatched to the incident 19:13:10 – Order from Battalion 4 to lay a line to Engine 10 19:13:35 – Responding from quarters 19:17:07 – Battalion 4 directs Engine 12 to lay a supply line for Engine 10. 19:17:39 – On-scene (approximate) 19:20:31 – Engineer 12 reports water coming to Engine 10 19:20:55 – Engineer 12 reports cars driving over the supply line 19:24:29 – Requests for more pressure on the supply line from the Fire Chief 19:46:28 – Engineer 12 offers to pump another supply line 20:01:04 – Engineer 12 discusses charging additional supply line Summary: Engine 12 was in quarters at the time of the original dispatch to the Sofa Super Store. The crew was in the process of washing the apparatus and cleaning up after dinner. Firefighters heard the dispatch and monitored the radio. Captain 12 told Engineer 12 to check the map to determine the location of fire hydrants in the area in case Engine 12 was dispatched to the scene. The firefighters heard the arrival report of Battalion 4 indicating an exterior fire and assumed that they would not be summoned to the scene. About two minutes later, Engine 12 was dispatched to the incident at the request of the Assistant Chief. Immediately after Engine 12 was dispatched, Battalion Chief 4 called on the radio with instructions to lay a supply line for Engine 10. As Engine 12 arrived on the scene, they saw heavy smoke from the rear of the structure. From Savannah Highway Engineer 12 was able to see clearly into the store through the front windows as they arrived. Engine 12 was directed by Battalion 4, by the Assistant Chief, and by the Fire Chief to lay a supply line to a hydrant for Engine 10. As Captain 12 dismounted the engine, he met with the Fire Chief. The Fire Chief directed Engine 12 to a nearby hydrant that was known to Captain 12. The hydrant was located at Blitchridge and First.


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Engine 12, continued Engineer 10 and Engineer 12 met in the parking lot and connected the supply line from Engine 12 to a line from Engine 10. Firefighter 12B headed to the hydrant on foot to prepare for the arrival of Engine 12. Once the connection was made, Engine 12 laid a single 2-1/2 inch supply line 850 feet to the hydrant. Captain 12 and Firefighter 12A went to the loading dock area behind Engine 10. Firefighter 12A was ahead of Captain 12. Firefighter 12A met Battalion 4 and was directed to clamp a 1-1/2 inch attack line from Engine 10 to remove a section of hose that had burst. Once this task was completed, he was directed to break into the man door that led into the large warehouse. When Captain 12 arrived at the rear, Engine 10 already had a 2-1/2 inch handline with a stacked tip on the ground. Battalion 4 ordered Captain 12 to help fight the fire in the loading dock area. Captain 12 helped operate a 1-1/2 inch line that was advanced into the loading dock doorway. When Firefighter 12B finished helping Engineer 12 hook-up to the hydrant, he took a pike pole from Engine 12 and proceeded to the loading dock area. He joined Firefighter 12A at the warehouse door using a Halligan tool from Engine 10 and a flat headed axe to force the door open. A 2-1/2 inch line was brought to the doorway and firefighters flowed water into the warehouse. Firefighter 12B used a rotary saw to attempt to cut through the large roll-up door that led into the warehouse. The saw bogged down and was unable to complete the cut. An axe was later used by a fire department mechanic to cut a hole into the rolling door into the warehouse. The firefighters continued to flow handlines and fight fire in the loading dock and warehouse area. The firefighters reported losing water on several occasions. Captain 12 observed the compound gauge on Engine 10 at some point and saw that it read zero. The firefighters did not hear any of the trouble or mayday reports from the interior. Engine 12’s crew continued to utilize handlines to fight fire in the loading dock and warehouse, and through holes that were cut into the west showroom walls. Captain 12 and his crew became aware that firefighters were missing as they encountered other on-duty and off-duty firefighters at the scene. Firefighter 12B assisted with the recovery of the deceased firefighters.


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Engine 15 Crew: Captain 15 Engineer 15 Firefighter 15A in the suction position Firefighter 15B in the nozzle position Notes: Fire Station 15 – 162 Coming Street – approximately 5.5 miles from the Sofa Super Store. June 18th was Firefighter 15B’s first on-duty shift with the Charleston Fire Department. Firefighter 15B had previous fire service experience in Maine and in South Carolina. Times: 19:10:32 – Moving to Fire Station 11 19:12:31 – Ordered to continue to Fire Station 11 by the Fire Chief 19:13:31 – Ordered to respond to the fire scene by the Assistant Chief 19:13:46 – Ordered to bring a 2-1/2 inch line to the interior by the Assistant Chief 19:17:30 – Engine 15 arrives on the scene 19:21:21 – Captain 15 attempts to communicate with the Assistant Chief 19:30:22 – Last transmission, inaudible, from Captain 15’s radio Summary: In accordance with Charleston Fire Department procedures, Engine 15 began to relocate to Fire Station 11 when the Sofa Super Store incident was dispatched. The Assistant Chief ordered Engine 15 to respond to the scene three minutes later. Firefighters could see smoke as they drove and then responded to the scene. The apparatus was parked in the median of Savannah Highway in front of the Sofa Super Store. Captain 15, Firefighter 15A, and Firefighter 15B donned their SCBAs, secured tools, and ran to the front of the building. Engineer 15 donned his protective clothing at the scene and followed a short distance behind the others.


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Engine 15, continued Captain 15 Captain 15 conferred briefly with Engineer 11. The crew stowed some of their equipment by the front door, and then proceeded into the store. They encountered light smoke near the door and observed heavier smoke conditions deeper into the interior of the store. A short distance into the building, Captain 15 ordered Firefighter 15B to return to the exterior of the store and bring a hose line inside. Captain 15 also ordered his firefighters to don their SCBA facepieces. Captain 15 and Firefighter 15A advanced deeper into the interior of the structure together, following the path of two hoselines, a 1-1/2 inch line and a 2-1/2 inch line. As they advanced, smoke conditions worsened markedly. Firefighter 15B obtained a booster line from Engine 11 and advanced it into the structure. He was unable to locate Captain 15 and Firefighter 15A in the smoke. Engineer 15 When Engineer 15 arrived at the front door of the store he noted that visibility was limited to approximately ten feet inside. He helped an unknown firefighter maneuver a 1-1/2 inch hose line inside the showroom. Shortly after entering the store, Engineer 15’s Vibralert2 began to function. He left the building to replace his cylinder and then reentered the building. He followed the hoseline back and noted that the rear of the store had become hotter and darker since his first trip to the area. Engineer 15 attempted to locate Captain 15 but was unsuccessful. Conditions were worsening and Engineer 15 noted a reddish glow to the rear of the store. Engineer 15 encountered Engineer 6. They heard air horns sounding on the exterior and followed the booster line out to the door. Once outside, Engineer 15 assisted with fire fighting operations on the exterior of the structure.

2 Low air pressure alarm.


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Engine 15, continued Firefighter 15A As Engine 15 arrived on the scene, Firefighter 15A observed Engine 16 dropping the supply line to Engine 11 in front of the store. Firefighters donned their protective clothing and SCBA, secured hand tools, and ran to the front door of the store. Firefighter 15A recalls hearing a report of someone trapped at the rear of the building over his portable radio shortly after the crew entered the structure. While Captain 15 and Firefighter 15A waited for Firefighter 15B to return with the handline, conditions continued to worsen. Captain 15 told Firefighter 15A that he hoped to contain the fire to the right rear of the store by working in the left rear area of the store. They saw or were aware that other firefighters were working to the right rear of the store. Captain 15 ordered Firefighter 15A to go and get a handline. Firefighter 15A found a 1-1/2 inch nozzle and hoseline on the floor near a doorway and tried to move it to the area where he and Captain 15 had been working. Firefighter 15A was unable to locate Captain 15, despite shouting for him and searching the immediate area. Firefighter 15A observed that there was little pressure in the hoseline and that it was difficult to maneuver. The line was entangled with a large amount of dislocated furniture in the area. Firefighter 15A’s Vibralert activated. He turned to walk or crawl out of the structure. As he proceeded, heat conditions markedly worsened. Thinking that he was headed into the fire, he turned 180 degrees trying to find a way out of the building. He crawled and fell over furniture for a short distance and again encountered high temperatures. Firefighter 15A stopped to listen for the sounds of apparatus, but was unable to hear due to high noise levels. Disoriented, he decided to move in one direction. He stumbled over some furniture and looked upward. Through the smoke, Firefighter 15A saw the flashing lights of a PASS device. Firefighter 15A moved rapidly toward the lights and encountered Engineer 6. Engineer 6 guided Firefighter 15A toward the front door of the building. As they neared the exit, Firefighter 15A was able to hear apparatus noise and moved rapidly to the exit.


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Engine 15, continued Once outside, Firefighter 15A took off his facepiece. Engineer 11 replaced his air cylinder with a full cylinder. As he replaced Firefighter 15A’s cylinder, Engineer 11 told Firefighter 15A that a bunch of people were lost in the building. Once the new cylinder was in place, Firefighter 15A reentered the store. Once Firefighter 15A reentered the store, he encountered the crew of Engine 6 who were exiting. A large body of fire was visible in the interior and it was spreading toward the entrance. Firefighter 15A exited the building for the second time through a broken window to the left of the front door (from an exterior perspective). Firefighter 15A did not recall being in the building for very long on his second entry. Firefighter 15A was directed by an officer to be evaluated by emergency medical workers and was then transported to the hospital. Firefighter 15A’s personal protective clothing sustained significant thermal damage while he was inside of the structure and was removed from service. Firefighter 15B Firefighter 15B encountered another firefighter in the smoke, but was unsure of the identity of the firefighter. Firefighter 15B and the other firefighter moved deeper into the store, tripping over items on the floor and in proximity to other firefighters. They were able to walk upright as they moved. Firefighter 15B did not recall making a turn while advancing the booster line. Heat conditions in the store were worsening. Alone by this time, Firefighter 15B observed a red glow though the smoke in the area of the ceiling above his head and flowed water from the booster line in the direction of the fire. He remained in that area and operated the nozzle for several minutes but did not encounter any other firefighters. The Vibralert low air alarm in Firefighter 15B’s SCBA began to activate and he made the decision to leave the structure. He estimates that he had been in the building for approximately 15 minutes at this point. Firefighter 15B dragged the booster line and nozzle toward the exit and then dropped the nozzle and followed the hose line to the exit. As he exited the structure, heat conditions worsened and Firefighter 15B had to crawl. He encountered another exiting firefighter and directed him to his hoseline as a means of finding the exit. As he neared the exit, Firefighter 15B encountered Engineer 15 and both exited from the interior of the store.


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Engine 15, continued After exiting the store, Firefighter 15B changed his air cylinder, taking a full cylinder from Engine 11. He reentered the store, following the booster line for approximately 20 feet. He encountered other firefighters who were rapidly exiting the structure. Firefighter 15B reported that heat conditions increased markedly on his second trip into the structure. Firefighter 15B left the structure a second time and observed fire to the right rear of the structure, over the roof line. He ran around to the right rear of the structure and participated in fire fighting operations in the warehouse and loading dock areas near Engine 10. The remains of Captain 15 were found in a small office area at the back of the main body of the store (the original supermarket space). Captain 15 was found on his back, his carboxyhemoglobin level was 37 percent. Captain 15 unsuccessfully attempted to communicate with the Assistant Chief at 19:21:21. The last recorded activation of his portable radio, with no discernable voice message, was at 19:30:22.


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Engine 16 Crew: Captain 16 Engineer 16 Firefighter 16in the suction position Notes: Fire Station 16 – 81 Ashley Hall Plantation Road – approximately 3.3 miles from the Sofa Super Store. Engine 19 was also housed at Fire Station 16 pending the completion of Fire Station 19 later in 2007. Engineer 5 was normally assigned as the Assistant Engineer of Engine 16 but was detailed to drive Ladder 5 the day of the fire. Times: 19:10:26 – Moved up for standby upon initial dispatch 19:11:09 – Captain 16 acknowledges BC4 arrival report 19:12:10 – Pre-arrival order from the Assistant Chief to enter the building upon arrival 19:15:15 – Order from the Assistant Chief to bring a 2-1/2 inch handline to the interior upon arrival 19:15:19 – On the scene 19:17:36 – E16 ordered to go to a hydrant by Car 2 19:19:36 – Captain 16 requests that the 2-1/2 inch line be charged 19:21:41 – Engineer 16 tells the Assistant Chief that he is seeking a hydrant 19:22:44 – Engineer 16 tells Engineer 11 that he is seeking a hydrant 19:26:17 – Engineer 16 tells Engineer 11 that water is coming 19:29:00 – Firefighter 16 asks “Which way out?” and begins a series of distress calls and radio activations with no audio that end at 19:37:23 Summary: Engine 16 was in quarters at the time of the initial dispatch and started out as a standby company, following the established Charleston Fire Department protocol. Upon the report of a working fire, Engine 16 began their response to the scene of the fire according to departmental procedures.


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Engine 16, continued At 19:12:10, the Assistant Chief ordered Engine 16 to the interior of the building upon their arrival. At 19:15:15, the Assistant Chief ordered Engine 16 to bring a 2-1/2 inch handline into the store upon their arrival. Captain 16 reported the arrival of Engine 16 on the scene at 19:15:19. As Engine 16 arrived, the apparatus was parked in the center of Savannah Highway. Captain 16 and Firefighter 16 headed for the front entrance as Engineer 16 dressed. Captain 16 and Firefighter 16 began to pull 2-1/2 inch hose from the rear of Engine 11 to advance the line into the building. When Engineer 16 reached Engine 11, Engineer 11 told him that he did not have a supply line. Captain 16 directed Engineer 16 to lay a supply line for Engine 11. The Assistant Chief ordered Engine 16 to start out toward the hydrant at 19:17:36. As he walked to the door, Captain 16 yelled encouragement to Engineer 16. Captain 16 and Firefighter 16 stretched a 2-12 inch attack line with a stacked tip nozzle from Engine 11 into the showroom. The nozzle was positioned near the double doors that led to the loading dock. Surviving firefighters reported that Captain 16 made a comment upon his arrival at the door to the effect that firefighters would be in trouble if the fire got behind them. At 19:19:36, Captain 16 called for the 2-1/2 inch attack line to be charged by Engine 11. Captain 16’s voice indicated that he was wearing his SCBA facepiece at the time of this transmission. The Assistant Chief instructed Engineer 11 not to charge the attack line until the supply line was charged. Engine 16 laid a single 2-1/2 inch supply line headed East on Savannah Highway toward Wappoo Road. Engineer 16 was planning to turn north on Wappoo Road to reach a hydrant that was north of the intersection. When he reached the intersection he discovered that the hydrant had been removed. He dismounted the apparatus at Wappoo Road to search on foot for a hydrant south of the intersection. After searching unsuccessfully he returned to the apparatus and continued to lay the line east toward a hydrant that was near a car dealership. Engineer 16 used his entire bed of 2-1/2 inch supply line and added 100 feet of 3 inch hose that was rolled in a compartment to make up the supply line. The supply line from Engine 16 to Engine 11 consisted of 35 lengths of 2-1/2 inch hose and two lengths of 3 inch hose, 1,850 feet total. At 19:26:17 he called Engineer 11 to advise that the line was being charged.


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Engine 16, continued Engineer 16 reported that civilians were driving over his supply line until the street was closed by the Charleston Police Department. Prior to the arrival of the police department, civilian bystanders made a wall to prevent cars from driving over the supply line. The supply line was pressurized to over 300 psi in an attempt to push water to the scene over such a long distance. The 2-1/2 inch attack line was charged at approximately 19:29:02, after Engine 11 received a water supply. The nozzle was found after the fire in the area in front of the double doors. The position of the nozzle suggested that it never flowed water. Captain 16 and Firefighter 16 were last reported to be in the area where the nozzle was found, waiting for the line to be charged. For unknown reasons, Captain 16 and Firefighter 16 left this area and became disoriented in the smoke. Their remains were discovered with the remains of Engineer 5 in the west showroom, approximately 50 feet from the front of the store. Captain 16 was found face down, his carboxyhemoglobin level was 22 percent. Firefighter 16 was found on his right side, his carboxyhemoglobin level was 66 percent. Firefighter 16’s portable radio was activated a number of times, beginning at 19:29:00. He transmitted a number of distress messages indicating that he was lost and seeking a way out of the building. The recording system also captured activations of his portable radio where no voice communication was recorded. His last discernable transmission was a prayer spoken at 19:32:40. His last system activation was at 19:37:23 although there was no discernable audio recorded at this time. Captain 16’s portable radio was last activated at 19:30:20 although no voice communication was recorded. This may have been an unintentional activation of the radio.


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Engine 19 Crew: Captain 19 Engineer 19 Firefighter 19 in the suction position Notes: Based at Fire Station 16 – 81 Ashley Hall Plantation Road – approximately 3.3 miles from the Sofa Super Store, until the completion of Fire Station 19 later in 2007. Times: 19:14:45 – Dispatched from quarters - requested by Car 1 19:16:01 – Responding 19:20:08 – On the scene Summary: Engine 19 was in quarters at the time of dispatch. The Assistant Chief requested the dispatch of Engine 6 to the scene at 19:14:23. The Fire Chief, who was responding to the scene, ordered Dispatch to send Engine 19 in place of Engine 6 at 19:14:45. Very little is known about the activities of the crew of Engine 19 at the scene. The unit arrived on the scene and parked on Savannah Highway. Captain 19 spoke briefly with the Assistant Chief near the main entrance to the showrooms as they were entering. Captain 19 asked the Assistant Chief where the fire was located and was told to follow the line back into the building and to the right. Engineer 19 and Firefighter 19 were close behind Captain 19. All three firefighters carried their portable radios into the structure. Captain 19’s portable radio was not activated after Engine 19 arrived on the scene. Engineer 19’s portable radio was activated at 19:20:46 and 19:23:35 although no voice communication was recorded. These may have been unintentional activations of the radio.


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Engine 19, continued Firefighter 19’s portable radio was activated on channel 2 at 19:31:55 although no voice communication was recorded. This may have been an unintentional activation of the radio. Later in the incident, around 20:00, Engine 19’s apparatus was used to supply water to Ladder 4 from a hydrant. This initially led to some confusion about the status of Engineer 19. It was assumed that he was at the hydrant pumping the truck. The remains of Engineer 19 and Firefighter 19 were found near one another near the center of the main showroom, just over 40 feet from the front of the building and to the left of the main entrance doorways. Engineer 19 was found face down, his carboxyhemoglobin level was 12 percent. Firefighter 19 was found face down, his carboxyhemoglobin level was 39 percent. Captain 19’s remains were discovered just over 100 feet from the front entrance, at the rear of the main showroom. Captain 19 was found face down, his carboxyhemoglobin level was 48 percent.


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Ladder 5 Crew: Captain 5 Engineer 5 Firefighter 5 in the ladderman one position Notes: Fire Station 10 – 1 Nicholson Drive – approximately 2.3 miles from the Sofa Super Store. Ladder 5 and Engine 10 are housed in Fire Station 10. Firefighter 5 was working for another firefighter on Engine 10 but transferred temporarily to Ladder 5 to allow for driver and pump operations training for Firefighter 10. Captain 5 was normally assigned as Engineer of Engine 10. On the day of the fire he was Acting Captain of Ladder 5. Times: 19:09:02 – Dispatched from quarters 19:09:51 – Responding 19:11:07 – Acknowledges arrival report by BC4 19:12:25 – On the scene 19:15:56 – Engineer 5 calls for the 1-1/2 inch line to be charged 19:16:23 – Firefighter 5 calls for the 1-1/2 inch line to be charged 19:30:15 – Firefighter 5 transmits a distress message 19:32:15 – Engineer 5 transmits a Mayday message 19:34:18 – Engineer 5 identifies himself as the firefighter transmitting the Mayday 19:34:35 – Emergency button activation by Engineer 5 19:38:23 – Radio activation by Engineer 5 in the emergency mode Summary: Ladder 5 was in quarters at the time of dispatch. Captain 5 radioed Dispatch to advise that his unit was responding at 19:09:51. Upon their arrival on the scene at 19:12:25, Ladder 5 parked in the parking lot near the entrance of the Sofa Super Store. All three firefighters dismounted the apparatus.


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Ladder 5, continued Captain 11 radioed from the interior of the store that a handline was needed at 19:13:17. Upon learning that a handline was needed in the interior, the crew of Ladder 5 summoned Engine 11 to the front door of the store. The crew stretched a 250 foot 1-1/2 inch handline through the front door of the store. After an additional 250 feet of line was added, the nozzle ended up at the set of double doors that led from the right-hand showroom addition to the staging area. At the time of the fire, the standard Charleston Fire Department engine carried two preconnected handlines. Each line was composed of 250 feet of 1-1/2 inch hose with an Akron Turbojet nozzle, without pistol grip. The standard setting for these nozzles for the Charleston Fire Department was 60 gpm. At 19:15:56, Engineer 5 called for the line to be charged. This was followed by a call from Firefighter 5 for the line to be charged at 19:16:23. An abnormality with the pump engagement for Engine 11 delayed the charging of the 1-1/2 inch handline. Based on reports from surviving firefighters, the crew of Ladder 5 operated the 1-1/2 inch handline into the staging area. The water stream was being used to control the fire in the staging area and attempt to prevent the spread of the fire into the retail area of the store. Some time after the hoseline was charged, the crew of Engine 16 arrived with a 2-1/2 inch handline. For unknown reasons, the Ladder 5 crew left their operating position and became disoriented in the building. Captain 5 was not equipped with a portable radio while inside of the Sofa Super Store. His radio was found on the apparatus and utilized by firefighters that moved Ladder 5 into a field adjacent to the store to operate as a water tower. Engineer 5 transmitted a Mayday message at 19:32:15. At 19:34:18, he identified himself as the firefighter that had called the Mayday. At 19:34:35, he depressed the orange emergency button on his portable radio. The activation of the emergency button sounds an audible alarm in the dispatch center and alerts the dispatcher to the emergency. At 19:34:40, a dispatcher alerted firefighters on the scene of the fire that Engineer 5’s emergency button had been activated. At 19:38:23, Engineer 5 pressed the transmit button on his portable radio. This action sounded an alarm in the dispatch center for the second time. The emergency signal was cleared from dispatch at 19:40:09.


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Ladder 5, continued Firefighter 5 activated his radio a number of times, some without a discernable voice message. These may have been inadvertent activations. Firefighter 5 transmitted a distress message at 19:30:15 identifying himself and requesting help for himself and other firefighters. Captain 5’s remains were found approximately 100 feet inside of the main showroom of the Sofa Super Store, directly at the back of the store from the main entrance. Captain 5 was found face down, his carboxyhemoglobin level was 65 percent. Engineer 5’s remains were found in the right-hand retail area addition approximately 50 feet from the front of the store. He was found in close proximity to Captain 16 and Firefighter 16. Engineer 5 was found face down, his carboxyhemoglobin level was 58 percent. Firefighter 5’s remains were found in an office or storage space at the very rear of the original supermarket structure. Firefighter 5 was found face down in a kneeling or crawling position, his carboxyhemoglobin level was 31 percent.


Page C-42

Saint Andrews Engine 2 and Rescue 1 Crew: Engine 2 - Captain Saint Andrews Engine 2, Firefighter Saint Andrews Engine 2 (SA2) Rescue 1 – Saint Andrews Rescue 1 Drive (SA1), Saint Andrews Rescue 1 Firefighter Saint Andrews Assistant Chief Times: 19:25:18 – Saint Andrews Engine 2 calling Charleston dispatch (on Charleston channel 1) Summary: Engine 2, Rescue 1, and the Saint Andrews Assistant Chief were celebrating the birthday of Captain Saint Andrews Engine 2. The firefighters were at an Asian restaurant near the intersection of 526 and Savannah Highway, approximately one half mile from the Sofa Super Store. The Saint Andrews Assistant Chief received a telephone call from an off-duty Saint Andrews Fire Department captain asking if they were enroute to the fire on Savannah Highway. Expecting to be called for mutual aid, the Saint Andrews Assistant Chief told his firefighters to get ready to get toned out for the fire. The firefighters paid for their meal and made their way outside to their apparatus. When firefighters left the restaurant and got outside, they were immediately able to see the smoke plume from the fire. The firefighters got into their vehicles and headed for the scene. While enroute to the scene, Captain Saint Andrews Engine 2 radioed Charleston dispatch but did not receive a response. The Saint Andrews Assistant Chief, Engine 2, and Rescue 1 parked at the scene of the fire. As the Engine and Rescue firefighters dressed, the Saint Andrews Assistant Chief went out ahead of the firefighters and met the Fire Chief in the alley leading to the loading dock area.


Page C-43

Saint Andrews, continued Saint Andrews Assistant Chief The Saint Andrews Assistant Chief met up with the Fire Chief in the alley on the west side of the fire building. The Saint Andrews Assistant Chief told the Fire Chief that he had firefighters on the scene and responding and asked how he could help. The Fire Chief initially declined his offer of help. A moment later he assigned Saint Andrews to fire fighting duties for the warehouse and exposures off of Pebble Road. As the Saint Andrews Assistant Chief was driving around to Pebble Road, he received a call from Captain Saint Andrews Engine 2 requesting a thermal imaging camera. The Saint Andrews Assistant Chief drove back to the scene, assuming that the camera had been requested by the Fire Chief. When he arrived back at the scene, the Saint Andrews Assistant Chief made contact with the Fire Chief and offered him the thermal imager. The Fire Chief told him that he did not need the imager and had not called for it. The Saint Andrews Assistant Chief returned to Pebble Road to supervise operations at that location. Saint Andrews firefighters (Engine 1) forced a door on the North side of the warehouse and entered to make an assessment with a thermal imaging camera. They determined that the warehouse was well involved with fire and that a defensive approach was appropriate. On the order of the Saint Andrews Assistant Chief, evacuation air horns were sounded by apparatus on Pebble. Horns were also heard sounding from the front of the fire on Savannah Highway. Engine 2 and Rescue 1 The engine and rescue crews received orders from the Saint Andrews Assistant Chief on the Saint Andrews radio channel to report to the loading dock. As they walked toward the loading dock, a police officer told them that his dispatcher had notified him of a civilian trapped in the building. At the same time, Battalion 5 walked up to the crew and they discussed the trapped civilian. The Saint Andrews firefighters ran across the front of the fire building and down the alley on the east side to a wooden fence gate that blocked their access to the rear of the building. Captain Saint Andrews Engine 2 called the Saint Andrews Assistant Chief and requested the thermal imager that was in the Saint Andrews Assistant Chief’s vehicle.


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Saint Andrews, continued The Saint Andrews firefighters, the Assistant Chief, Battalion 5 and two store managers gained access to the area behind the store and listened for banging. The store managers indicated the area where the trapped civilian would be located. They located the room where he was trapped after hearing banging on a wall. The metal side of the building was cut open by Battalion Chief 5 and a Saint Andrews firefighter and the civilian was removed. The civilian was brought around to the front of the building by Saint Andrews Firefighters SA1 and SA2 and turned over to an off-duty paramedic. EMS was notified of the person’s location. The Saint Andrews firefighters went to the front door of the store seeking an assignment. The Fire Chief and Car 303 were at the front door when the firefighters arrived and there were discussions going on that involved firefighters in distress and Maydays. Firefighters were exiting the building at the same time. The Fire Chief and the Assistant Chief ordered the removal of all of the glass from the front of the store. Captain Saint Andrews Engine 2 and Firefighter SA1 removed the glass from the windows to the right of the entrance. In the process, Captain Saint Andrews Engine 2 received a cut to his hand. As the windows were broken, air was drawn into the building. After the windows were broken, the Fire Chief ordered the Saint Andrews firefighters to enter the building and search for the firefighters in distress. Firefighter SA1 and Firefighter SA2 donned their SCBA facepieces and entered the front of the store. They followed a hose line straight back into the building. Firefighters SA1 and SA2 encountered Car 303 on their way in to the structure. Captain Saint Andrews Engine 2 established accountability for his personnel at the entrance and called for the RIT equipment to be brought to that location from his apparatus. Firefighters SA1 and SA2 reported that they encountered high heat conditions inside the main showroom. They also reported that they encountered other firefighters, at least one of whom was in distress and was not wearing a helmet. They stated that they attempted to pull the firefighter in distress toward the front exit. Heat conditions worsened markedly as the fire began to advance toward them and both Saint Andrews firefighters began to receive burns. Firefighter SA1 reported that he lost his hold on the firefighter in distress. Firefighters SA1 and SA2 then exited the building via the main entrance. As they exited the building, they observed fire coming across the store from the general direction of the loading dock. As they emerged, air horns were being sounded for evacuation.


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Saint Andrews, continued Firefighter SA1 was treated for his burns. All of the Saint Andrews firefighters joined the other members of their department and assisted with fire fighting operations on Pebble Road through the completion of the incident.


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Page D-1

Appendix D - Detailed Timeline


Page D-2

Timeline 19:09:02 – Initial Dispatch 19:10:46 – Battalion 4 arrives 19:11:35 – Car 2 on the scene (first portable radio transmission) 19:11:40 – Engine 10 on the scene 19:12:22 – Ladder 5 on the scene 19:13:17 – Engine 11 Captain requests an attack line

1-1/2 inch handline from E11 advanced into the retail area of the store by L5

19:15:19 – Engine 16 on the scene

Engine 16 advances a 2-1/2 inch attack line into the interior of the store

19:16:32 – Car 1 on the scene 19:17:30 – Engine 15 on the scene

Interior of the store filled with smoke (reports from E15 crews) 19:17:39 – Engine 12 on the scene 19:20:08 – Engine 19 on the scene 19:20:31 – Water supplied by E12 to E10 19:21:50 – Engine 6 on the scene ~19:22:31 - Flames seen from the roof of the retail area from the perspective of the field to the right of the store. 19:24:09 – Battalion 5 on the scene 19:26:17 – Water supplied by E16 to E11 19:26:35 – Dispatcher advises Car 1 of a report of a civilian trapped in the building


Page D-3

19:27:44 – First indication of trouble from inside the store 19:29:02 – Engine 11 charges the 2-1/2 inch handline 19:29:27 – Saint Andrews E4 on the scene 19:30:15 – Firefighter inside the store reports that he needs help. 19:31:19 – Battalion 5 reports that the civilian has been rescued. 19:33:01 – First indication from Chief Thomas that firefighters are in trouble 19:33:43 – Ladder 5 is moved from the front of the store and backs into the lot to the right of the store 19:34:18 – Last word from a firefighter in trouble in the interior of the store 19:34:40 – Ladder 5 Engineer’s emergency alarm received ~19:34:40 – Chief Thomas orders an evacuation 19:34:55 – Chief Thomas arrives at the front of the store 19:35:14 – Engine 6 exits the building 19:35:25 – Windows at the front of the store broken 19:37:37 – Fire appears at the front windows of the store 19:37:51 – Air horns sounding 19:38:21 – Saint Andrews firefighters exit the building


Page E-1

Appendix E – Communications System Information Introduction The Charleston Fire Department utilizes an analog trunked radio system with a single tower site for signal reception and transmission. The system is a 16 channel Motorola SmartNet Type II system. The same system is used by the Charleston Fire Department, the Charleston Police Department, and other city departments. Each fire apparatus is equipped with a mobile radio and every on-duty firefighter and command officer on each engine, ladder, and command unit is provided with a portable radio. A number of firefighters and officers have personally assigned radios that they carry while off-duty. At the time of the Sofa Super Store fire, most firefighters were not equipped with a lapel microphone and firefighters generally carried their portable radio in a breast pocket on the exterior of their protective clothing, or in another exterior pocket. Trunked Radio Systems Trunked radio systems are repeater-based radio communications systems that are composed of multiple radio frequencies controlled by a central system computer controller. The controller assigns radio frequency pairs to conversations as needed, when needed. Trunked radio systems assign a frequency pair as it is needed rather than permanently dedicating a frequency pair for each “channel”. This reduces the number of radio frequencies needed to operate a system and generally increases the utilization of each frequency. Especially in developed areas, the demand for radio frequencies is high. In non-trunked radio systems, a frequency pair is essentially reserved for the exclusive use of one channel. For all trunked and many non-trunked fire service radio communication systems, every radio channel on the radio uses two radio frequencies, a pair, to communicate. The user sends information to the radio system on one frequency and the radio system repeats the transmission back to the radios on that channel through another frequency. Trunking assigns frequencies as needed while non-trunked radio systems reserve frequencies for the use of one channel. Trunked radio systems use the term “talkgroup” to replace the term “channel” as the frequency pair assigned to a work group. For example, a talkgroup could be designated for fire dispatch, another for fireground operations, and others for police, utility services, etc. On the Charleston Fire Department standard portable radio, the talk group was selected by the user utilizing a rotating knob on the top of the portable radio. The radio essentially looks the same to the user but channel utilization differs from non-trunked to trunked systems.


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In a trunked radio system, when a firefighter presses the push-to-talk button on a portable radio to transmit on a talkgroup, a request is made to the trunked radio system on the control channel. The control channel essentially listens for radios that want to transmit and then tells all of the radios that are on the same talkgroup as the radio requesting to speak which frequency pair will be used. This action happens instantaneously and is generally barely noticed by the radio user. Once assigned to a frequency pair, the firefighter transmits a voice message to the system on one of the two assigned frequencies. The radio system repeats the voice transmission back to all of the other radios on the same talkgroup through the second assigned frequency so that the voice message is heard by all others that have the same talkgroup selected. Charleston Fire Department Radio System Configuration The Charleston Fire Department radio system was configured in a way that allowed more than one firefighter to speak at one time. This type of configuration is called a “message trunking operation”. In many trunked radio systems, the system locks out all other system users once someone starts to speak and only allows others to speak when the first person is done. This second type of configuration is called “transmission trunking operation”. The Charleston configuration allowed firefighters transmitting at the same time to “walk over” one another. If another firefighter on the same talkgroup transmits at the same time that the first firefighter is transmitting, both firefighter’s radios transmit simultaneously. This leads to transmissions “walking” over one another. In some cases, this produces partial transmissions or unintelligible noise due to an interference effect called heterodyning. Heterodyning can sound like a buzzing noise, clicking, or a hum that changes in pitch over a few seconds. In other cases only one transmission will be received by the system and will be retransmitted correctly. Due to the fact that portable radios transmit to the radio system on one frequency and receive on a separate frequency, all system users on one talk group hear the same transmission from the repeater assigned to the talkgroup regardless of the number of radios transmitting at the same time. In general, the radio system repeats the strongest signal that is received at the radio tower. There is one exception. Transmission by a dispatcher from the radio console takes precedence over any other received signal.


Page E-3

System Activity Logging The Motorola SmartNet Type II system keeps track of the activity on the trunking system with a computerized logging application called System Watch. This log contains an activity time stamp, the identity of the radio making the request for transmission, the talkgroup, the type of transmission, the physical repeater channel assigned and the duration of the transmission. System Watch also logs other activity such as radio power on/off, talkgroup (channel) changes, as well as other system activity. Emergency Alarm and Emergency Call activations, and radio console resets of the alarms are logged in the System Watch logs. For the Sofa Super Store incident, the time recorded by the System Watch log is 2 minutes and 2 seconds ahead of actual time. All System Watch times in this report have been corrected to actual time. If more than one firefighter transmits simultaneously and “walks over” firefighter(s) that are already transmitting, the System Watch configuration in use for the Charleston Fire Department may not capture the information from both radios. There are several instances related to the Sofa Super Store incident, especially during the time when firefighters are in distress, when the identity of those speaking cannot be confirmed without a doubt. When the identity of who is speaking can be confirmed with reasonable certainty, the name of the transmitter is included in the radio log that is a part of this report. When the identity of the transmitter is uncertain, the transmitter is listed as “unknown”. Voice Logging Recorder The Charleston Fire Department dispatch center also uses a voice logging recorder to record voice transmissions handled by the trunked radio system and the phone system in dispatch center. These voice recordings are the basis for the transcription generated for this report. System Emergency Features All transmissions on the radio system are shown on the dispatcher’s console with the identity of the last several radio transmitters displayed. The dispatcher can glance at this rolling log if he or she misses the identity of a transmitter. As additional transmissions are received, the oldest transmitter identification scrolls off of the screen. The data for this listing is from the same source as the data that is recorded by System Watch. The trunked radio system has two features related to emergency transmissions. The first, Emergency Alarm, transmits an alarm message to the system when the orange emergency button on a portable radio is pressed. The message is transmitted over the control channel, not the assigned voice channel, so it can be activated when there is voice activity on the talkgroup selected on the radio. When the Emergency Alarm is received by the system, it activates an audible


Page E-4

alarm and displays the identity of the unit that activated the alarm at the radio console position in the dispatch center. The dispatcher can mute this alarm using a button on the console display. The second feature related to emergency transmissions is the Emergency Call. Emergency Call is activated when a firefighter transmits on a talkgroup using a radio that has transmitted an Emergency Alarm and has not been reset. When an Emergency Call is received by the system it puts the talkgroup into Emergency Call mode. This mode causes the repeater assigned to the talkgroup to remain assigned to the talkgroup for an extended time and causes activation of the Emergency Alarm alert at the radio console if it is not already active. Once an Emergency Call is received by the system, all firefighter’s transmissions on the talkgroup will be considered Emergency Calls until the Emergency Call is reset by the radio console operator (dispatcher). If the Emergency Call has been reset at the console, further Emergency Call transmissions by the radio in emergency will reactivate the alarm. The radio can only be reset from Emergency mode by holding the orange button in for an extended (programmable) period of time. At the Sofa Super Store fire, the Ladder 5 Engineer, Michael French, activated his orange emergency button at 19:34:35. A dispatcher announced this event on the radio. The emergency mode was reset at dispatch at 19:35:34. Ladder 5 Engineer Michael French pressed his push-to-talk button at 19:38:23. Since his portable radio had not been reset, the emergency mode was reinstated. The emergency mode was reset at dispatch for a second time at 19:40:09. System Interference “Skip” or “ducting” are phenomena where a radio transmission can travel over long distances and be received by another radio system utilizing the same radio frequency. Some skip incidents have been reported where a transmission is received hundreds of miles from where it originates. Radio systems have measures in place to prevent “skip” from interfering with communications. Despite these measures, radio transmissions from outside of the immediate network do make it through. During the Sofa Super Store incident there is a transmission on the logging recorder that appears to involve police activity. The transmission has been tracked to the police department in Saint Simons Island, Georgia. A search of the FCC license database shows licenses to the Glynn-Brunswick 911 center that appears to serve the Saint Simons Island area. Saint Simons Island is in Glynn County, Georgia. The “skip” or “ducting” occurs at approximately 19:22:28.


Page E-5

The license shows one frequency pair 866.0375 MHz/821.0375 MHz that apparently matches a frequency in the city of Charleston trunked radio system. Saint Simons Island is approximately 144 miles from Charleston, over water, and the transmitter location may be closer. A plausible explanation for the interference is that at the same time that the frequency was assigned by the Charleston trunked radio system to a firefighter’s call, the frequency was in use by a Glynn County user as well. The Charleston trunked radio system could have received this spurious transmission and retransmitted it in place of or in addition to the correct transmission. The transmission must have been received by the Charleston system, or it would not have been recorded by the voice logging recorder. Operational Specifics Each fire apparatus is equipped with a mobile radio and every on-duty firefighter and command officer on each engine, ladder, and command unit is provided with a portable radio. A number of firefighters and officers have personally assigned radios that they carry while off-duty. At the time of the Sofa Super Store fire, most firefighters were not equipped with a lapel microphone and firefighters generally carry their portable radio in a breast pocket on the exterior of their protective clothing, or in another exterior pocket. Dispatch, non-emergency administrative, and emergency operations are generally conducted on a single talkgroup designated CFD-1. Three additional talkgroups, designated CFD-2, CFD-FG1 and CFD-4, are available but are rarely used. There were reports from firefighters in Charleston that they heard transmissions from firefighters inside of the Sofa Super Store that cannot be heard on the recordings of radio transmissions made at the dispatch center. Considering the design of the system, this is not possible if the firefighters were on a trunked talkgroup, as it is technically impossible for a receiving radio to receive a transmission directly from the radio.


Page E-6

Charleston Fire Department Dispatch System The Charleston Fire Department utilizes a dispatch operation that is co-located with the Charleston Police Department in the police headquarters building. 911 callers speak first with a Police Department call taker. Calls for the Fire Department are transferred to a Fire Department dispatcher. At the time of the Sofa Super Store incident, two fire dispatchers were on-duty. At the time of the fire, on-duty dispatcher staffing varied from one to two dispatchers on-duty. The dispatchers utilize a computer aided dispatch system to select units for response. The Charleston Fire Department responds to selected types of emergency medical incidents based on criteria worked out collectively with Charleston County EMS (CCEMS). The emergency medical ambulance system for the entire county is operated by CCEMS. On-duty firefighters monitor channel one at all times for dispatch. A pre-alert message is transmitted by dispatch, followed by tones, and a repeat of the dispatch information. All communications are conducted by voice. At the time of the Sofa Super Store fire, the standard response to a structural fire was two engine companies, a ladder company, and a command officer. Depending upon the area of the city where an incident occurred, engine companies would automatically move up to areas vacated by responding units. Some move ups occurred upon dispatch and some upon the report of a working fire. Generally, units from the city’s center move to peripheral areas as units based in those areas respond to emergency incidents. This coverage routine also occurs to cover vacancies created by non-emergency activities such as training. The response of additional units past the initial response and automatic move ups are dispatched upon the specific request of the officer in command of an incident. Greater alarm assignments, where multiple units are dispatched as a group to an incident, are not utilized.


Page F-1

Appendix F - Hydraulic Calculations and Water Flow Analysis

The Charleston Fire Department Standard Operating Procedure called for booster lines to be operated at 40 gpm. Preconnected 1-1/2” hand lines were equipped with combination fog nozzles, set to deliver 60 gpm at 100 psi nozzle pressure. If a higher flow rate was required, the firefighter was permitted to switch the nozzle to the 95 gpm setting and direct the pump operator to increase the pressure accordingly.

The Standard Operating Procedure called for 2-1/2” hand lines to be equipped with either combination fog nozzles or straight bore “stacked” tips:

Combination nozzles were to be set to deliver 150 gpm at 100 psi nozzle pressure. If a higher flow rate was required, the firefighter was authorized to switch the nozzles to the 200 gpm or 250 gpm settings and direct the pump operator to increase the pressure accordingly.

Straight bore (stacked tip) nozzles were to be carried with the 1” tip in place and operated at 75 psi nozzle pressure to deliver 256 gpm. If a higher flow rate was required, the firefighter could switch to a 1-1/8” tip to deliver 290 gpm at 60 psi nozzle pressure or to a 1-1/4” tip to deliver 310 gpm at 45 psi nozzle pressure.

The 2-1/2” line that was taken through the front of the building as well as the two 2-1/2” lines that operated into the warehouse were all equipped with stacked tips. Each of these lines was expected to flow 256 gpm. None of the firefighters or officers who were interviewed reported any request to increase the flows on any of the attack lines. The Charleston Fire Department Standard Operating Procedure called for water to be delivered from engines at hydrants to engines in attack positions through single 2-1/2 inch supply lines. The supply line was to be pumped at a maximum of 200 psi by the engine at the hydrant. Both Engine 16 and Engine 12 exceeded the 200 psi recommendation in response to requests for more pressure in the supply lines to Engine 11 and Engine 10. The following calculations show that the single 2-1/2 inch supply lies were incapable of delivering the flows required by the hose lines that Engines 10 and 11 were attempting to operate. Increasing the pressure beyond the maximums recommended for safety could not overcome the friction loss in the supply lines.


Page F-2

UEstimated Flow Requirements: Engine 10:

1” 40 gpm 1-1/2” 60 gpm 2-1/2” 256 gpm U2-1/2” 256 gpm Total 612 gpm

Engine 11:

1” 40 gpm 1-1/2” 60 gpm U2-1/2” 256 gpm Total 356 gpm

USupply Line Friction Loss Calculations E12 (to E10): 850 ft of 2-1/2’ hose @ 200 psi working pressure Friction loss at 300 gpm = 8.5 X 19.5 = 165.8 psi

350 gpm = 8.5 X 26.5 = 225.3 psi 400 gpm = 8.5 X 34.6 = 294.1 psi 500 gpm = 8.5 X 54.1 = 459.9 psi 600 gpm = 8.5 X 77.9 = 662.2 psi

E16 (to E11): 1750 ft of 2-1/2” hose + 100 ft of 3” hose @ 200 psi working pressure Friction loss at 200 gpm = (17.5 X 8.7) + 3.4 = 155.6 psi 250 gpm = (17.5 X 13.5) + 5.4 = 241.6 psi 300 gpm = (17.5 X 19.5) + 7.7 = 360.7 psi 350 gpm = (17.5 X 26.5) + 10.5 = 474.7 psi


Page G-1

Appendix G: Building and Code Enforcement Information Building Classification

The Sofa Super Store building was classified under the Standard Building Code 1991 – 1994 editions. It was classified as follows: Construction Type - IV Occupancy Type - Mercantile

Building History

The original building was annexed into the City of Charleston on August 22, 1990. The following additions were subsequently made to the original structure:

• The western addition was permitted in December 1993 and required fire rated doors to maintain access and fire separation according to the Standard Building Code 1991-1994.

• The eastern addition was permitted in March 1995 and required fire rated doors to maintain access and fire separation according to the Standard Building Code 1991-1994.

• The east and west additions were considered as separate buildings according to the Building Code due to the construction of the walls of the original building and the installation of fire rated doors.

• The floor area of each individual building was less than the maximum area permitted without sprinklers.

• The rear warehouse addition was permitted in January 1996. It was of non-combustible construction and designed to meet loads in accordance with the provisions of the 1986 MBMA Building Code. It was also designed in accordance with the 1989 AISC (with 1989 amendments) and codes specified.

• This warehouse building was 120’x130’x29’ in size. The floor area of 15,600 square feet was less than the maximum area permitted without sprinklers.


Page G-2

• When the warehouse was constructed, the owner requested two variances from Table 600 of the SBC and from the Code of the City of Charleston, Section 7.1.1:

o To omit the required 2 hour fire rating for the west wall. (Code

requires a wall within 30’ of a property line to have a 2 hour fire rating.)

o To omit the required 2 hour fire rating for the north wall. of the

building to omit the required fire rating. (Code requires a wall within 30’ of a property line to have a 2 hour fire rating.)

• The two variances were granted under the following conditions:

o The owner agreed to abandon the property line between the warehouse and the main building, eliminating the need for the north wall to be fire rated

o A 3 hour fire rated door was required at the point where the

connecting corridor was attached to the existing building

• The record shows that the owner did not apply for any additional construction permits after January 1996.


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Figure 16: Fire Inspection Report, dated March 10, 1998


Page G-4

Information Learned from Investigation

The following information was obtained by the City of Charleston Building Inspections Division during the investigation of the Sofa Super Store fire:

• Between 1996 and the time of the fire, additions were constructed in

the area between the warehouse and the showroom buildings, including the enclosed loading dock.

• After the fire the City’s GIS division examined aerial photos taken between 1998 and 2007. The photos showed creeping construction beginning with a shed roof and small enclosed structures. These photos also showed the progression of the construction including a completely enclosed loading dock and other rooms added to the rear of the building.

• The building owner was apparently aware of the City of Charleston’s permit process, due to the fact that he applied for permits and variances for various projects from 1991 – 1996. These permits were for projects as small as a fence and signage as well as larger projects such as building modifications, renovations and additions.

• The City of Charleston removed the requirement for annual fire inspections of mercantile occupancies from its code in 2000.

• The building was last inspected by a City of Charleston fire inspector on March 30, 1998. At that time the building owner was cited for the following violations:

o exit light violation o aisle space violations o unsatisfactory exit signs

• The following notations were included in the 1998 inspection report: o no chemical or flammable liquid storage was found on the

premises o all electrical and mechanical systems including the roll-up fire

doors were in satisfactory condition o there were no housekeeping issues

• Charleston Fire Department personnel visited the store on multiple occasions between 1998 and 2007 for pre-fire planning purposes. A Sofa Super Store employee noted that they made some safety and prevention suggestions during their visits.


Page G-5

• Roll-down doors designed for fire separation were made by two different manufacturers.

o Each roll-down door had two fusible links.

• The following uses were not permitted in the building: o Hazardous Materials storage o Spray paint/finish application o Combustible liquid storage

• Smoking was common in and around the store. Code Violations The analysis of the Sofa Super Store performed by the City of Charleston Building Inspections Division identified the following potential or suspected code violations at the time of the fire.

• The “in-fill” construction that occurred after 1996, including the enclosed loading dock, occurred without building permits and without the knowledge of the City of Charleston.

• The construction of the “in-fill” additions was not consistent with the classification of the existing buildings. (The additions were wood frame construction.)

• The construction of the “in-fill” additions did not comply with the building code.

• The additions negated the agreed-upon conditions of the variances that had been granted.

• The additions negated the effectiveness of the required fire separations between the pre-existing structures. (In the absence of the required separations, automatic sprinklers would have been required.)

• Large quantities of flammable liquids such as naphtha; cleaning and finishing chemicals; fabric surface coatings and aerosol containers of flammable finish products were stored and used on the premises. Quantities of these materials were found in the area of the loading dock.

• Roll-down fire doors in required fire separations did not operate properly.

• When the illegal modifications to the buildings were made, required exits were eliminated.


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• There were exits through storage areas.

• Some of the exit doors were illegally locked.

• It was reported that non-permitted electrical work was done by employees who were not licensed electricians.

South Carolina Code of Laws (Unannotated)

Current through the end of the 2007 Regular Session

SECTION 6-9-130.

Codes applicable to building inspections.

(A) Buildings must be inspected in accordance with the codes in effect for the locality on the date of the issuance of the original building permit, except that:

(1) If no date of issuance of original building permit can be found, the date of submission of the completed application to the local authority must be used.

(2) If no date of application for, or date of issuance of, building permit is available, the director of the applicable county planning and development service (or similar agency) shall determine the nearest possible date by using available documents, such as transfer of property records, mortgage records, tax records, or rent records.

(B) A building inspection conducted in conjunction with any change in structure must be performed in accordance with the applicable code in effect on date of application or date of permit.

(C) A building inspection conducted in conjunction with a change of use for the building or space must be performed in accordance with the applicable code in effect on the date of the inspection. This inspection should be done with the intention of avoiding extreme hardship to the owner whenever practical.


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City of Charleston Municipal Code

ARTICLE II. BUILDING CODE*

*Cross references: Electrical code, § 12-16 et seq.; fire prevention code, § 13-76 et seq.; plumbing code, § 24-16 et seq.

Sec. 7-26. International Building Code--Adopted. The International Building Code, 2000 Edition, published by the

International Code Council, Inc., including appendices A, B, C, E, F, H, I, and J only, is hereby adopted so that hereafter all building construction, reconstruction, alteration and repairs and all materials and appliances used in connection with building work shall conform thereto; provided however, that A101.4 in Appendix A is hereby deleted and the following shall be substituted in its place and stead: "The City of Charleston hereby avails itself of the exemptions as set forth in S.C. Code Ann. § 6-9-50 and 60 as it pertains to the qualification, removal, dismissal and administrative procedure for personnel employed by the City to enforce its construction codes, it being the intent of the City that such persons hold their employment positions in accordance with the general law of South Carolina.

Sec. 13-80. Licensing. No person shall engage in the business of installation, alteration or

repair of fire protection systems in the city unless he shall have first secured an installation of fire protection systems license and shall have otherwise complied with the requirements for securing such license as the same may, from time to time, be promulgated by the city council.

Section 105.1 Permit Application Any owner, authorized agent, or contractor who desires to

construct, enlarge, alter, repair, move, demolish, or change the occupancy of a building or structure, or to erect, install, enlarge, alter, repair, remove, convert or replace any electrical, gas, mechanical or plumbing system, the installation of which is regulated by the technical codes, or to cause any such work to be done, shall first make application to the building official and obtain the required permit for the work.

EXCEPTION: Permits shall not be required for the following mechanical

work:

1. any portable heating appliance;


Page G-8

2. any portable ventilation equipment;

3. any portable cooling unit;

4. any steam, hot or chilled water piping within any heating or cooling equipment regulated by this code;

5. replacement of any part which does not alter its approval or make it

unsafe;

6. any portable evaporative cooler;

7. any self-contained refrigeration system containing 10 lb (4.54kg) or less of refrigerant and actuated by motors of 1 horsepower (746 W) or less.

Section 105.2 Repairs

Application or notice to the building official is not required for ordinary repairs to structures, replacement of lamps or connection of approved portable electrical equipment to approved permanently installed receptacles. Such repairs shall not include the cutting away of any walls, partitions, or portions thereof, the removal or cutting of any structural beam, load bearing support, or the removal or change of any required means of egress, or rearrangement of parts of a structure affecting the means of egress requirements; nor shall ordinary shall ordinary repairs include addition to, alteration of, replacement or relocation of any standpipe, water supply sewer, drainage, drain leader, gas, soil, waste, vent or similar piping, electrical wiring or mechanical or other work affecting public health or general safety.

Section 105.2.1 Work Authorized

A building, electrical, gas, mechanical or plumbing permit shall carry with it the right to construct or install the work, provided the same are shown on the drawings and set forth in the specifications filed with the application for the permit. Where these are not shown on the drawings and covered by the specifications submitted with the application, separate permits shall be required.

A permit issued by the building official shall be construed to be authorization to proceed with the work in accordance with all the building codes of the City of Charleston. The omission of information on the plans or permit application shall not be construed as authority to violate, cancel, alter, or set aside any of the provisions of the Code, the compliance of which shall remain the responsibility of the applicant and or owner. The Building Official retains the right after issuance of the permit to require a correction of errors in plans or in construction, or correction of violation of the Codes of the City of Charleston.


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International Fire Code

SECTION 107 MAINTENANCE 107.1 Maintenance of safeguards. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, or otherwise installed, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with this code and applicable referenced standards. 107.5 Owner/occupant responsibility. Correction and abatement of violations of this code shall be the responsibility of the owner. If an occupant creates, or allows to be created, hazardous conditions in violation of this code, the occupant shall be held responsible for the abatement of such hazardous conditions. Hazards related to use and occupancy, and not those related to fixed equipment or installations, fall within the scope of the occupants’ responsibility. Owners, however, may become liable if they allow the unlawful operation or continuation of a public nuisance on a property under their control, especially if they knowingly or willfully lease the property in violation of fire, zoning or building regulations. The simple rule for determining what constitutes an owner’s, rather than the occupants’, responsibility is whether or not the issue involves fixed equipment installations or if the structure is separate from those items related to occupancy. The owner is usually responsible for the physical maintenance of the building or structure and its utilities and appurtenances (that is, building services and systems). 703.4 Testing. Horizontal and vertical sliding and rolling fire doors shall be inspected and tested annually to confirm proper operation and full closure. A written record shall be maintained and be available to the fire code official. _Annual tests are intended to determine that required fire and smoke-barrier doors operate freely and close completely. Where fusible links are used as the releasing mechanism, the link may be temporarily removed rather than activated during testing. Fusible links in poor condition must be replaced as part of the maintenance of fire-resistance components. Smoke detectors and heat detectors other than fusible links must be tested as required by the manufacturer’s instructions (see NFPA 72 for recommended testing procedures for various fire


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detectors). Written records must indicate the date, time, test method and person conducting the test for each opening protective. These records must be maintained by the owner and made available to the fire code official for review. This requirement relieves the fire code official of the administrative burden of maintaining test records. 704.2 Opening protectives. When openings are required to be protected, opening protectives shall be maintained self-closing or automatic-closing by smoke detection. Existing fusible-link-type automatic door-closing devices are permitted if the fusible link rating does not exceed 135ºF (57ºC). This section requires that fire door assemblies provided for protection of openings in vertical enclosures be self-closing or automatic closing in order to maintain the integrity of the vertical opening enclosure. This section also recognizes that some opening protectives in existing buildings may already be equipped with heat-actuated closing devices rather than the smoke-detector-actuated devices otherwise required by the section. Such devices are allowed to continue in service, provided that the temperature rating of their fusible element is as low as is available [i.e., 135°F (57°C)] to provide the fastest possible operation in the event of a fire. In the event that an existing fusible link on an opening protective is rated higher than the maximum 135°F (57°C) allowed by this section, it would need to be removed and the door maintained as self-closing or be replaced with a smoke-detector-actuated closer in accordance with this section. New opening protectives must comply with Section 715 of the IBC and closing devices with 715.4.7 of the IBC. See the commentary to those sections for further information. 704.3 Buildings on the same property and buildings containing courts. For the purposes of determining the required wall and opening protection and roof-covering requirements, buildings on the same property and court walls of buildings over one story in height shall be assumed to have a property line between them. Exceptions: In court walls where opening protection is required, such protection is not required provided:

1. Not more than two levels open into the court; 2. The aggregate area of the building, including the court, is within the

allowable area; and 3. The building is not classified as Group I.


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Where a new building is to be erected on the same property as an existing building, the location of the assumed property_ line with relation to the existing building shall be such that the exterior wall and opening protection of the existing building meet the criteria as set forth in Sections 704.5 and 704.8.

Exception: Two or more buildings on the same property shall either be regulated as separate buildings or shall be considered as portions of one building if the aggregate area of such buildings is within the limits specified in Chapter 5 for a single building. Where the buildings contain different occupancy groups or are of different types of construction, the area shall be that allowed for the most restrictive occupancy or construction.

704.5 Fire-resistance ratings. Exterior walls shall be fire-resistance rated in accordance with Tables 601 and 602. The fife-resistance rating of exterior walls with a fire separation distance of greater than 5 feet (1524 mm) shall be rated for exposure to fire from the inside. The fire-resistance rating of exterior walls with a fire separation distance of 5 feet (1524 mm) or less shall be rated for exposure to fire from both sides. 704.6 Structural stability. The wall shall extend to the height required by Section 704.11 and shall have sufficient structural stability such that it will remain in place for the duration of time indicated by the required fire-resistance rating. 704.8.1 Automatic sprinkler system. In buildings equipped throughout with an automatic sprinkler system in accordance with Section 903.3.1.1, the maximum allowable area of unprotected openings in occupancies other than Groups H-1, H-2, and H-3 shall be the same as the tabulated limitations for protected openings. 704.8.2 First story. In occupancies other than Group H, unlimited unprotected openings are permitted in the first story of exterior walls facing a street that have a fire sep-aration distance of greater than 15 feet (4572 mm), or facing an unoccupied space. The unoccupied space shall be on the same lot or dedicated for public use, shall not be less than 30 feet (9144 mm) in width, and shall have access from a street by a posted fire lane in accordance with the International Fire Code. 714.1 General. Opening protectives required by other sections of this code shall comply with the provisions of this section.


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714.2 Fire door and shutter assemblies. Approved fire door and fire shutter assemblies shall be constructed of any mate-rial or assembly of component materials that conforms to the test requirements of Section 714.2.1, 714.2.2 or 714.2.3 and the fire-protection rating indicated in Table 714.2. Fire door assemblies and shutters shall be installed in accordance with the provisions of this section and NFPA 80.

Exceptions: 1. Labeled protective assemblies that conform to the requirements of this

section or UL 10A, UL 14B and UL 14C for tin-clad fire door assemblies. 2. Floor fire doors shall comply with Section 711.4.6.

714.2.4 Doors in exit enclosures. Fire door assemblies in exit enclosures shall have a maximum transmitted tem-perature end point of not more than 450°F (232°C) above ambient at the end of 30 minutes of standard fire test exposure.

Exception: The maximum transmitted temperature end point is not required in buildings equipped throughout with an automatic sprinkler system installed in accordance with Section 903.3.1.1 or 903.3.1.2.

714.2.7.2 Automatic-closing fire door assemblies. Automatic-closing fire door assemblies shall be self-closing in accordance with NFPA 80. 715.3 Fire door and shutter assemblies. Approved fire door and fire shutter assemblies shall be constructed of any mate-rial or assembly of component materials that conforms to the test requirements of Section 714.2.1, 714.2.2 or 714.2.3 and the fire-protection rating indicated in Table 714.2. Fire door assemblies and shutters shall be installed in accordance with the provisions of this section and NFPA 80.

Exceptions: 1. Labeled protective assemblies that conform to the requirements of this

section or UL 10A, UL 14B and UL 14C for tin-clad fire door assemblies. 2. Floor fire doors shall comply with Section 711.4.6.


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715.3.7 Door closing. Fire doors shall be self-closing or automatic-closing in accordance with this section. Exception: Fire doors located in common walls separating guestrooms in Group R-1 hotels and motels shall be permitted without automatic-closing or self-closing devices. 1008.1.8 Door operations. Except as specifically permitted by this section egress doors shall be readily openable from the egress side without the use of a key or special knowledge or effort. _ When installed for security purposes, locks and latches can intentionally prohibit the use of an egress other operating devices on doors required to be accessible by Chapter 11 of the International Building Code shall not require tight grasping, tight pinching or twisting of the wrist to operate. _ Any doors that are located along an accessible route for ingress or egress must have door hardware that is easy to operate by a person with limited mobility. This would include all elements of the door hardware used in typical door operation, such as door levers, locks, security changes, etc. This requirement is also an advantage for persons with arthritis in their hands. Items such as small, full-twist thumb turns or smooth circular knobs are examples of hardware that is not acceptable. 1008.1.8.2 Hardware height. Door handles, pulls, latches, locks and other operating devices shall be installed 34 inches (864 mm) minimum and 48 inches (1219 mm) maximum above the finished floor. Locks used only for security purposes and not used for normal operation are permitted at any height. Exception: Access doors or gates in barrier walls and fences protecting pools, spas and hot tubs shall be permitted to have operable parts of the release of latch on self-latching devices at 54 inches (1370 mm) maximum above the finished floor or ground, provided the self-latching devices are not also self-locking devices operated by means of a key, electronic opener or integral combination lock.


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_ The requirements in this section place the door hardware at a level that is usable by most people, including a person in a wheelchair. The exception allows security locks to be placed at any height. An example would be an unframed glass door at the front door of a tenant space in a mall that has the lock near the floor level. The lock is only used when the store is not open for business. Such locks are not required for the normal operation of the door. The exception permits a special allowance for security latches at pools, spas and hot tubs. The concern is that the 48-inch (1219 mm) maximum height would place the security latch within reach of children. The 54-inch (1372 mm) maximum height is intended to override the maximum 48-inch (1219 mm) reach range in ICC A117.1. This compromise addresses both concerns for children’s safety and still maintain accessibility to a reasonable level. 1008.1.8.3 Locks and latches. Locks and latches shall be permitted to prevent operation of doors where any of the following exists: 1. Places of detention or restraint. 2. In buildings in occupancy Group A having an occupant load of 300 or less, Groups B, F, M and S, and in places of religious worship, the main exterior door or doors are permitted to be equipped with key-operated locking devices from the egress side provided: 2.1. The locking device is readily distinguishable as locked, 2.2. A readily visible durable sign is posted on the egress side on or adjacent to the door stating: THIS DOOR TO REMAIN UNLOCKED WHEN BUILDING IS OCCUPIED. The sign shall be in letters 1 inch (25 mm) high on a contrasting background, 2.3. The use of the key-operated locking device is revocable by the fire code official for due cause. 3. Where egress doors are used in pairs, approved automatic flush bolts shall be permitted to be used, provided that the door leaf having the automatic flush bolts has no doorknob or surface-mounted hardware. 4. Doors from individual dwelling or sleeping units of Group R occupancies having an occupant load of 10 or less are permitted to be equipped with a night latch, dead bolt or security chain, provided such devices are openable from the inside without the use of a key or tool.


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Where security and life safety objectives conflict, alternative measures, such as those permitted by each of the exceptions, may be applicable. Exception 1 is needed for jails and prisons. Exception 2 permits a locking device, such as a double-cylinder dead bolt, on the main entrance door. Such locking devices must have an integral indicator that automatically reflects the “locked” or “unlocked” status of the device. In addition to being an indicating lock, a sign must e provided that clearly states that the door is to be unlocked when the building is occupied. The sign on the door not only reminds employees to unlock the door, but also advises the public that an unacceptable arrangement exists if one finds the door locked. Ideally, the individual who encounters the locked door will notify management and possibly the fire code official. Note that the use of the key-locking device is revocable by the fire code official. The locking arrangement is not permitted on any door other than the main exit and, therefore, the employees, security and cleaning crews will have access to other exits without requiring the use of a key. This allowance is not limited just to multiple-exit buildings but also to small buildings with one exit. This option is an alternative to the panic hardware required by Section 1008.1.9 In Exception 3, an automatic flush bolt device is one that is internal to the inactive leaf of a pair of doors. The device has a small “knuckle” that extends from the inactive leaf into an opening in the active leaf. When the active leaf is opened, the bolt is automatically retracted. When the active leaf is closed, the knuckle is pressed into the inactive leaf by the active leaf, extending the flush bolt(s), in the head or sill of the inactive leaf (see Figure 1008.1.8.3). Automatic flush bolts on one leaf of a pair of egress doors are acceptable, provided the leaf with the automatic flush bolts is not equipped with a door knob or other hardware that would imply to the user that the door leaf is unlatched independently of the companion leaf. Exception 4 addresses the need for security in residential units. The occupants are familiar with the operation of the indicated devices, which are intended to be relatively simple to operate without the use of a key or tool. Note that this exception only applies to the door from the dwelling unit. 1008.1.8.4 Bolt locks. Manually operated flush bolts or surface bolts are not permitted. Exceptions: 1. On doors not required for egress in individual dwelling units or sleeping units. 2. Where a pair of doors serves a storage or equipment room, manually operated edge- or surface-mounted bolts are permitted on the inactive leaf.


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_ This section is applicable to doors that are intended and required to be for means of egress purposes or are identified as a means of egress, such as by an “Exit” sign or other device. Doors, as well as a second leaf in a doorway that is provided for a purpose other than means of egress, such as for convenience or building operations, should be arranged or identified so as not to be mistaken as a means of egress. This section prohibits installation of manually operated flush and surface bolts except in an individual dwelling or sleeping unit. Even then, such bolts may only be used on doors not required for egress (see Section 1008.1.8.3, Exception 4 for security of doors from individual dwelling and sleeping units). Flush and surface bolts represent locking devices that are difficult to operate because of their location and operation (see Figure 1008.1.8.4). The exceptions provide for edge-mounted or surface-mounted bolts on the inactive leaf of a pair of door(s) from these limited use areas. 1008.1.8.5 Unlatching. The unlatching of any door or leaf shall not require more than one operation. Exceptions: 1. Places of detention or restraint. 2. Where manually operated bolt locks are permitted by Section 1008.1.8.4. 3. Doors with automatic flush bolts as permitted by Section 1008.1.8.3, Exception 3. 4. Doors from individual dwelling units and sleeping units of Group R occupancies as permitted by Section 1008.1.8.3, Exception 4.

The code prohibits the use of multiple locks or latching devices on a door, which would be a safety hazard in an emergency situation. The exceptions address locations where multiple locks or latching devices are acceptable. 903.2.6 Group M. An automatic sprinkler system shall be provided throughout buildings containing a Group M occupancy where one of the following conditions exists: 1. Where a Group M fire area exceeds 12,000 square feet (1115 m2); 2. Where a Group M fire area is located more than three stories above grade plane; or 3. Where the combined area of all Group M fire areas on all floors, including any mezzanines, exceeds 24,000 square feet (2230 m2). The sprinkler threshold requirements for Group M occupancies are identical to those of Group F-1 and S-1 occupancies (see commentary, Section 903.2.3). Automatic sprinkler systems for mercantile occupancies are typically designed for an Ordinary Hazard Group 2 classification in accordance with NFPA13. If high-piled storage (see Section 903.2.6.1) is anticipated, however, additional levels of fire protection may be required.


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Also, some merchandise in mercantile occupancies, such as aerosols, rubber tires, paints and certain plastic commodities, even at limited storage heights, are considered beyond the standard Class I through IV commodity classification assumed for mercantile occupancies in NFPA 13 and may warrant additional fire protection. 903.2.6.1 High-piled storage. An automatic sprinkler system shall be provided as required in Chapter 23 in all buildings of Group M where storage of merchandise is in high-piled or rack storage arrays. Regardless of the size of the Group M fire area, an automatic sprinkler system may be required in a high-piled storage area. High-piled storage includes piled, palletized, bin box, shelf or rack storage of Class I through IV combustibles to a height greater than 12 feet (3658 mm) and certain high-hazard commodities greater than 6 feet (1829 mm). Storage of combustible materials to heights more than that noted above must meet the requirements of Chapter 23 and referenced standard NFPA 13.

NFPA – 80

GENERAL REQUIREMENTS FOR FIRE DOORS

Section 5.1.3.1 of NFPA-80 states that fire doors should be operable at all times. Section 5.2.14.1 of NFPA-80 states that self-closing devices (i.e. door closers) should be kept in working condition at all times.

REQUIREMENTS FOR MAINTENANCE OF FIRE DOORS

Section 5.1.5.1 of NFPA-80 states that fire door repairs should be made, and defects that could interfere with operation should be corrected without delay.

Section 5.2.12.1 of NFPA-80 states that guides and bearings should be kept well lubricated to facilitate operation.

Section 703.2 of the IFC states that fire doors should be maintained in an operative condition in accordance with NFPA-80.

Section 703.2.2 of the IFC states that hold-open devices and automatic door closers, where provided, should be maintained. During the period that such a device is out of service for repairs, the door it operates should remain closed but operable.


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REQUIREMENTS FOR INSPECTING AND TESTING FIRE DOORS

Section 5.2.1 of NFPA-80 states that fire door assemblies should be inspected and tested not less than annually, and a written record of the inspection should be signed and kept for inspection by the AHJ.

Section 5.2.2.1 of NFPA-80 states that as an alternate means of compliance with 5.2.1, subject to the AHJ, fire door assemblies should be permitted to be inspected, tested, and maintained under a written performance-based program.

Section 5.2.2.2 of NFPA-80 states that goals established under a performance-based program should provide assurance that the fire door assembly will perform its intended function when exposed to fire conditions.

Section 5.2.2.3 of NFPA-80 states that technical justification for inspection, testing, and maintenance intervals should be documented.

Annex J. and J.2 of NFPA-80 state that equivalent levels of performance can be demonstrated through quantitative performance-based analyses, subject to the approval of the Authority Having Jurisdiction, e.g. fire marshal. The concept of a performance-based program is to establish the type and frequency of inspection to demonstrate that the assembly is operational. The goal is to balance the inspection frequency with proven reliability of assembly. (For additional information on performance-based programs please see annex J of NFPA-80).

Section 5.2.3.1 of NFPA-80 states that functional testing of fire doors should be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Section 5.2.3.2 of NFPA-80 states that before testing, a visual inspection should be performed to identify any damaged or missing parts that could create a hazard during testing or affect operation or resetting.

Section 5.2.4.2 of NFPA-80 states that as a minimum, the following items should be verified for swinging doors with builders hardware or fire door hardware:

1. No open holes or breaks exist in surfaces of either the door or frame.

2. Glazing, vision light frames, and glazing beads are intact and securely

fastened in place, if so equipped.

3. The door, frame, hinges, hardware, and noncombustible threshold are

secured, aligned, and in working order with no visible signs of damage.


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4. No parts are missing or broken.

5. Door clearances at the door edge to the frame, on the pull side of the

door, should not exceed the following clearances:

a) The clearance under the bottom of a door should be a maximum of 3/4 inch.

b) Where the bottom of the door is more than 38 in. above the finished floor, the maximum clearance should not exceed 3/8 inch or as specified by the manufacturer's label service procedure.

c) The clearance between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, should be 1/8 inch +/- 1/16 for steel doors and should not exceed 1/8 inch for wood doors.

6. The self-closing device is operational, that is, the active door

completely closes when operated from the full open position.

7. If a coordinator is installed, the inactive leaf closes before the active leaf.

8. Latching hardware operates and secures the door when it is in the closed position.



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B.5 Three Fire Fighter Fatalities, Pesticides Repackaging Facility, Arkansas, 1997.

The building involved was approximately 2 years old and of unprotected noncombustible construction. Mostof the building’s area was used for storage of product. However, in one small production area, wherepesticides were repackaged, there were several offices. The building was served by a wet-pipe sprinklersystem.

Facility personnel discovered greenish-yellow smoke coming from a 725 kg (1600 lb) intermediate bulkcontainer (IBC) containing azinphos methyl in the facility’s receiving area and called the fire department at1:02 p.m. In response, the fire department sent an engine and additional fire fighters. The fire chief reportedyellow-colored dust or smoke showing upon arrival and requested a full response, including mutual aid.

The incident commander was provided MSDS on material in the facility by employees and was advised thatthe material was not explosive and that the primary hazard was inhalation. The MSDS were provided to themutual aid chief officer for a more detailed review, and fire fighters were advised to don SCBAs prior toapproaching the structure. As four fire fighters approached the building to conduct a more thorough size-up,an explosion occurred, and a huge ball of fire and smoke mushroomed from the building. The four firefighters were struck by flying masonry blocks and other debris and were buried under the material. Otherfire fighters on the scene began rescue operations, during which smaller explosions occurred. One of thefour trapped fire fighters was successfully rescued, and it was determined that the other three fire fighterscould not be uncovered without the use of power equipment. It was also reported that vital signs could notbe found on any of the buried fire fighters. Considering this information, the severity of the still growing fire,and the information obtained from the MSDS, the incident commander ordered all personnel to evacuatethe fire area and to withdraw to a distance he believed would be safe.

Hazmat team assistance was requested, and an area within a 2-mile radius on the downwind side of thescene was evacuated. One of the many facilities in the evacuation zone was the local hospital. Oncehazardous materials specialists arrived on the scene, it was determined that the most prudent plan of actionwould be to allow the fire to burn itself out, and the hazmat team personnel focused on recovering the firefighters’ bodies.

A more detailed review of the MSDS sheets at the start of the incident by the mutual aid chief indicatedthat, the material involved posed primarily toxicological hazards for which the fire fighters were not properlyprotected, and one of the sheets indicated that, if the product were ignited, it would emit yellow smoke. Themutual aid chief believed that withdrawal of the fire fighters was appropriate and was approaching theincident commander to inform him of this when the explosion occurred. A formalized pre-plan of the facilityhad apparently not been conducted — incident engagement into the hazard area was initiated whileinformation gathering on the situation was still being conducted

CHURCH ROOF COLLAPSE, IN, 2011

On June 15, 2011, an Indiana firefighter was killed by a structural roof collapse while fighting a working firein a church. Multiple reports began pouring into the local dispatch center around 15:49 that heavy smokewas coming from the roof of a church. Though there were multiple 911 calls reporting the incident, no onewas able to provide the dispatchers with an actual address, requiring firefighters to search a general areafor the fire. Eight minutes after the initial 911 call, the first fire department unit arrived on scene to findsmoke and flames showing from a 4,200-square foot church that was constructed of a wood frame, built ona concrete slab, and had a veneer masonry wall.

Smoke and flames became increasingly evident to firefighters operating on the exterior of the structure, butinterior crews only experienced light smoke conditions. Since the church sanctuary’s open design andelevated ceilings, the fire intensified within the attic space as firefighters struggled to gain access to it. Once firefighters were able to begin opening the ceiling, they quickly realized the extent of the fireprogression and began to prepare for retreat. It was at this time that the roof began to collapse, forcing asignificant amount of smoke, heat, and debris onto the firefighters below. As the roof structure began tocollapse, firefighters aided each other as they scrambled to exit the structure. Firefighters desperatelysearched for any window or doorway to escape through was they felt their way through the sanctuary inzero visibility. All exiting firefighters immediately reported to the command post where it was quicklydetermined that one of them was not accounted for. Though additional arriving companies were taskedwith search and rescue, the complete collapse of the roof structure made these efforts impossible toperform. The firefighter was located in the structure by a news helicopter almost one hour after he wentdown.

Proper pre-incident planning had not been conducted for this structure, so its layout and design was notreadily known to incident commanders during the incident. The structure was also located in a rural area,so there were not any fire hydrants within the vicinity. This problem was not identified until after initial units


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were on the scene and started mutual aid units for water tenders. A pre-incident plan could have helpedidentify this problem sooner and aided responders in starting water tenders sooner. A neighbor of thechurch also called 911 to advise them that she had a pond available for the fire department to use as awater source. The pre-incident plan also could have identified these alternative water supplies within thearea and planned for their use .


Submitting on behalf of NFPA 1620 Technical Review Committee Task Group




Affilliation: Appendix B Task Group

Street Address:

City:

State:

Zip:



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Public Input No. 22-NFPA 1620-2016 [ Section No. D.1 ]


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Revise the Site Data Collection Card and Facility Data Record examples to match the data that NFPA1620 states should be collected.

D.1 Sample Forms.


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Figure D.1(a) shows a blank pre-incident plan field collection card, and Figure D.1(b) shows a completedpre-incident plan facility data record.

Figure D.1(a) Site Data Collection Card.


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Figure D.1(b) Facility Data Record.


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The two examples of documents in this appendix do not match the data collection fields that NFPA 1620 specifies should be collected. If we are going to provide examples for individuals completing pre-incident plans, those examples should match the data collection fields that NFPA 1620 requires. If there is information on the forms that the TC feels is valuable to collect, but it not required in the standard, it should be included in the standard. If there is information that is not on the form, but is required in the standard, the form should be revised to include such fields. Regardless if the form or the standard changes, the bottom line is the example forms should match the requirements of the standard...no more or no less.




Street Address:

City:

State:

Zip:



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NFPA Technical Committee on Pre-Incident Planning

Documents

Transcript of NFPA Technical Committee on Pre-Incident Planning