The Texas State Fire Marshal’s Office released their investigative report on the house fire that killed Houston Fire Department Captain James Arthur Harlow, Sr. and Firefighter Damion Jon Hobbs on 12 April 2009. The details of the report reveal a pattern of department errors compounded by the effects of wind on fire behavior. The report reveals individual and collective problems that are not unique to this one fatal fire.
Seat belt – Use of Seat belts is mandatory any time the vehicle is in motion.
Speed – Obey all traffic laws; obey all HFD policies; Do not bust red lights or intersections; Non-emergency response is acceptable.
PPE – Only HFD issued PPE; No extra layers for insulation; weakest part of PPE ensemble is the SCBA face piece.
Size-up – Perform a 360; accurate arrival reports; Use TIC for temperature reading prior to entry, communicate via radio.
Water before you go – Goal to have an uninterrupted water supply before entry.
Low-Low-Low – On entry; inside; on exit.
Ventilation – Goal of first ladder is ventilation; Release heat and smoke to benefit firefighters and survivable victims.
RIT – RIT on every incident; in place ASAP.
Crew Integrity – Not an option; Critical to incident accountability; Call Mayday early.
Communication – Throughout incident; interior and exterior progress reports.
‘Rules’ created after the April 2009 line of duty deaths.
A much earlier, similar fire on 19 February 2005 killed the first arriving engine officer, Captain Grady Burke. While the state reporting style varies greatly between 2005 and 2009, similar problems are noticeable, more so when including the NIOSH investigative report. Following the death of Captain Grady, local news stations and some fire service websites wrote about the notion that Houston’s ‘fast attack strategy’ may be the fault for five deaths between 2000 and 2006.
Each article regurgitated the 2005 NIOSH report highlighting the strategy and noted that a thermal imaging camera was left behind. While the structures in which each death occurred varied greatly (ballroom; fast food restaurant; high-rise; two-story vacant private dwelling; and one –story private dwelling), the tactics used and equipment missing received the greatest scrutiny outside of the investigations.
Unfortunately, this scrutiny was only done as general interviews and genuflection; no serious discussion emerged regarding Houston’s tactics outside of the department. The ‘fast attack’ quickly became a point of blame, much like the ‘aggressive interior attack’, of many who claimed Houston’s fireground operations were reckless. Instead of focusing on the details and eccentricities of each incident, a blanket judgment was accepted that blamed the attack strategy in whole. In order to understand the idea that individual, yet collective, acts are at fault, and not a general tactic, the latest line of duty investigation needs to be compared to the previous ones.
This and other related posts will look at the similarities, differences and communications documented in Houston’s recent line of duty deaths to identify behavioral issues for future consideration. The intent is not to second-guess the actions of the fallen and survivors, but to determine if certain unknowns had effects on the fireground and if the investigative reports call our attention to them. An additional purpose is to determine if investigative reports as well as related news coverage and commentary have caused misconceptions regarding Houston’s ‘fast attack’ strategy.
Similarities between 2005 and 2009 Fires
Each structure was a one-story rancher built in the 1950’s. The first-due engine and ladder arrived together, as well as a chief officer. The department’s electronic accountability system is in place and operating (“Grace” Accountability alerts when firefighter is recorded “inactive” at 20 and 30 seconds) during the initial operations. Despite the difference in conditions upon arrival, each investigative report commented that the initial crews had fire behind them after entering the structure. In 2005, a firefighter from E.46 stated he observed fire appear “behind them again” and banking down . Engine 26, and Engine 36, first and second due in the 2009 fire, had to reposition and attack fire they believed was behind them . Crews at each fire reported a dramatic increase in heat. In 2005 fire, at the same time the evacuation signal was given, a firefighter reports the room he was in “lit up with fire all around me.” In 2009, a firefighter from the second due truck company noted a significant change inside the entrance of the structure.
In each fire, the backup line was stretched off the first due engine. In the 2009 fire three hoselines were stretched off the first due engine at the time of the fire’s rapid growth. The state report reveals that the officer from the second due engine had problems with pressure in his line. As the fire grew and it became initially apparent that firefighters were missing, additional hoselines were placed into service, but still with a lack of pressure.
“The Rapid Intervention Team (Engine 29) attempted to secure a 1 ¾ inch attack line to enter the structure for search and rescue purposes, but was unable to obtain a line with adequate pressure and volume. Engine 29A initially tried to get the dry line charged, but Engine 26 Engineer could not supply the additional line as defensive measures were initiated and the ladder pipe was being supplied. Engine 29A then picked up the line brought out by Engine 36 but the pressure was still inadequate to enter the structure. The volume of fire at this point was beyond the capacity of hand line tactics and Ladder 26 was being set up for master stream operations.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 24
At the time the victims were discovered, the first due engine was supplying five handlines and a ladder pipe. It wasn’t until additional efforts to search and remove the missing firefighters were organized, that two hoselines were deployed, having been supplied by a second hydrant. In the 2005 fire, the crew operating the second line, stretched off the first due engine, encountered a burst length. To correct the problem, a third hoseline was stretched off the first due engine.
Radio channel/operating problems plagued both fire scenes. Manual dexterity appears to be the main problem. In 2005, one radio was dropped while the member reported he was trapped. One victim in the 2009 fire had left his radio on the engine, the other had his radio, but it was found switched to the wrong channel and turned off. The City of Houston purchased 270 portable radios so that each firefighter would have a radio on the fire ground. This was recommended by NIOSH following the McDonald’s fire in February 2000 that claimed the lives of two Houston firefighters. All firefighters have portable radios while on duty. It appears that one reason for the dexterity problems may be the way the department carries radios on the fireground. The front chest radio pocket appears to be the preferred method. Firefighters utilizing radios not equipped with speaker microphones have to remove the radio to communicate, as well as switch channels. Most any fine motor skill with hands is complicated when wearing gloves.
In the 2009 fire, number 3 in the list of the immediate finding was the lack of a thermal imaging camera. Although conditions upon arrival may have led to rash acts that could be construed as being ‘caught up in the moment’ this is not the first time that Houston has suffered a line of duty death where a thermal imaging camera was left behind.
“A thermal imaging camera (TIC) was available on the scene but was not used during the initial entry into the burning building, as required by departmental SOG, which states, “the TIC will be utilized in every structure fire” with priority given to search and rescue operations followed by the fire attack and rapid intervention teams.” SFMO Firefighter Fatality Investigation # 05-218-02 Page 14
“At the time of the incident, the department did not have any SOPs regarding the use or application of thermal imaging cameras for search-and-rescue operations; however, thermal imaging cameras were assigned to all ladder trucks. Thermal imaging cameras with transmitters were assigned to rescue trucks, hazmat units, and the command van.” NIOSH: High-Rise Apartment Fire Claims the Life of One Career Fire Fighter (Captain) and Injures another Career Fire Fighter (Captain) – Texas
Although there was no standard operating procedure for thermal imaging cameras in place, the department did carry them, as evidenced in the 2001 high-rise fire report.
“Senior Captains/Captains will be responsible to ensure that the TIC is removed from their assigned apparatus and deployed on every dispatched structure fire and other identified situations that will enhance the safety of the firefighting personnel or rescue operations.” Houston Fire Department Operating Procedures, Subject: Thermal Imaging Camera, Volume No. II, Reference No. II-43, Command: Emergency Operations Sections 1.01-6.03E.5.01
This follows the earlier line of duty death report from the McDonald’s fire in 2000 and was a recommendation,
“The use of a thermal imaging camera may provide additional information the Incident Commander can use during the initial size-up.” NIOSH: Restaurant Fire Claims the Life of Two Career Fire Fighters – Texas
Unfortunately, nine years and six deaths later, the thermal imaging camera is still identified as an important tool found lacking on the fireground. The next post related to the Houston line of duty deaths will look at the differences between the 2009 and 2005 fires.
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1. “Firefighter Pate stated he observed fire appear behind them again, banking down from the ceiling in a rolling motion.” SFMO Firefighter Fatality Investigation # 05-218-02 Page 6
2. “Both crews originally fought fire ahead of their lines, but had to turn their attention to fire that had developed above and possibly behind them at this point.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 21
3. SFMO Firefighter Fatality Investigation # 05-218-02 Page 6
4. “Hawkins (Ladder 29A) stated that conditions deteriorated rapidly and visibility went down from a couple of feet from the floor, to floor level.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 21
5. “- Captain Alcazar of Engine 36 had difficulties with both pressure and volume as reported by the officer.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 21
6. “Captain Currie radioed that they were “trapped” and “need help” on his handheld radio. He then dropped the radio while trying to change channels because burns to his hands affected his manual dexterity.” SFMO Firefighter Fatality Investigation # 05-218-02 Page 8
7. “Captain Harlow reported over the radio that there was “heavy smoke coming from a one-story wood frame, Engine 26 will be making a fast attack,” and left the truck without his radio.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 18
8. “Firefighter Hobbs did have his radio and it was determined to have been in working condition but was not operating on the frequency used on the fire scene and it was in the OFF position.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 34
9. “Restaurant Fire Claims the Life of Two Career Fire Fighters – Texas” NIOSH
10. “Although the Thermal Imaging Camera was removed from Engine 26, it was found in the front yard. There is no indication that it was utilized.” SFMO Fire Fighter Fatality Investigation Case FY 09-01 Page 37
“Houston’s ’10 Rules of Survival’ After LODDs” FireRescue1
“Houston Fire Department 2007 Annual Review” Houston Fire Department
“Is the ‘fast attack’ firefighting strategy worth the risk?” KHOU 11 News
“Career Fire Captain Dies When Trapped by Partial Roof Collapse in a Vacant House Fire – Texas” NIOSH
“High-Rise Apartment Fire Claims the Life of One Career Fire Fighter (Captain) and Injures Another Career Fire Fighter (Captain) – Texas” NIOSH
“Restaurant Fire Claims the Life of Two Career Fire Fighters – Texas” NIOSH
“Investigation Number FY 09-01 Captain James Arthur Harlow, Sr. Firefighter Damion Jon Hobbs Houston Fire Department April 12, 2009” Texas State Fire Marshal’s Office
“Investigation Number 05-218-02 Captain Grady Burke Houston Fire Department February 19, 2005” Texas State Fire Marshal’s Office
“Investigation Number 02-50-10 Captain Jay Jahnke Houston Fire Department October 13, 2001” Texas State Fire Marshal’s Office