Influential Fire ReportsUnderstanding the Routine Fire

The following is Guest Contributor Dave LeBlanc's contribution to the 2nd Ed. First Due Blog Carnival.

This is my first entry to the Carnival. I can’t think of a better topic as a jumping off point. When I think back over the countless reports that I have read, there are certainly more than a few that stand out. I think the reports prepared by Departments, as an internal review tend to have the most impact. Certainly there are things to be learned from the NIOSH reports, but for a Department to look inside itself and come out with an honest critique of what went right and what went wrong, well I think that just has more impact.

To choose just a couple reports as standout is difficult. I think that we should read every report, looked at the lessons learned and the mistakes made, and apply what we have learned to our training. We have an obligation to learn from the sacrifices of our Brothers. I think that it is also important that we put what we learn into perspective to our own surroundings and Departments. There are some events or problems that may never be an issue in Small Town USA vs. Da’ Big City. This doesn’t mean we can’t learn from the report, only that not all the lessons will apply. As a side note I think that is also an important lesson for a lot of training items and issues. Departments need to train and develop policies, procedures and skills that work for them, their manpower and their situations. The reports that I picked to discuss for this article stand out in mind for a variety of reasons. A common thread to all of them is how such a routine fire can end in the death of one of our own. Maybe that isn’t right; maybe it is more of how a fire that seemed so routine at the outset in reality was very far from routine.

The first report that comes to mind is the on the fire at 400 Kennedy Street NW in Washington DC. In 1997 a basement fire in a grocery store claimed the life of Sergeant John Carter.  There is a great set of pictures from the fire here, Dave J. Iannone pictures on the Hyattsville VFD site. Sergeant Carter was killed when he fell into the basement while the companies were abandoning fire attack. It wasn’t immediately reported that he was missing, and from the investigation, he survived the fall into the basement and ultimately drown in the water from the fire attack. Several things contributed to his death, but to me the significant issues are equipment related. Sergeant Carter’s mask and radio were both defective. No one could hear him call for help and his mask let the water in. These finding often make me wonder if he would still be with us today.

On March 24, 2004 Oscar Armstrong III paid the ultimate price at 1131 Laidlaw Avenue. The report that was generated was far reaching and well written, perhaps one the best prepared reports I have seen. The link to the enhanced version is here, 1131 Laidlaw Avenue. While this report wasn’t an internal review, it was done by an independent committee with the cooperation of the Department. The events that led Firefighter Armstrong’s death were so rapid and so violent and again it seemed like such a routine fire. The rapid fire event that killed Firefighter Armstrong is an example of how much has changed with the fires we are fighting. The Heat Release Rates today are much different than yesterday and proper hoseline choice and deployment are critical to proper fire attack and control.

The 2007 Line of Duty Death of Prince William County Firefighter Kyle Wilson is another standout (LODD Report – Technician Kyle Wilson) It is probably the first time that I have read about “wind driven” fires in a single family residential setting, now it is something we consider on a regular basis. Another typical story of firefighters searching for someone who isn’t there and then getting separated and cut off. What isn’t typical is that everyone knew where Kyle Wilson was and there was nothing they could do to get to him. (Additional information from

The death of Firefighter Bret Tarver in Phoenix prompted a sweeping training program and a reevaluation of how Rapid Intervention should be set up and carried out (Southwest Supermarket Fire – 2001) Firefighter Tarver became disoriented and was lost in what started out as an exterior fire at 35th Avenue and McDowell Rd. This fire is probably the beginning of the thinking that Rapid Intervention isn’t rapid. After this fire Phoenix did what they do best, they examined the problem and then came up with a solution. They tested and trained until eventually every firefighter went through their program. There have been several excellent articles written that detail the training.

“On May 25, 2008, fire and rescue personnel from Loudoun County responded to a structure fire at 43238 Meadowood Court in Leesburg, Virginia. During the course of the incident, seven responders were injured. Of those injured, four firefighters received significant burn injuries, two firefighters sustained orthopedic injuries, and one EMS provider was treated for minor respiratory distress. To date, five of the injured personnel have returned to duty. Two firefighters continue to recover from their injuries, including one who was severely burned.”

This is an excerpt from the fact sheet from the Loudoun County, 43238 Meadow Court Significant Injury Report. The fire that caused these injuries was determined to have been caused by a cigarette on the back deck. No one was home at the time of the fire. These firefighters ended up above the fire on the first floor and were cut off from escape. While one firefighter was forced to jump, several others were rescued by the heads up placement of a ground ladder.

As I began trying to piece together this article, I looked at the folder on my hard drive where I keep these reports. There were 151 reports in that folder. Those are just the reports that I have saved because I felt there was something worth going back to. It is only a fraction of the total number of reports that I have read. What a sad, cold and sobering thought that is.

Many of these reports will detail a variety of things that we could have done better. From accountability to crew integrity to size up and better tactics, there are lots of things that can go wrong. Rarely is one failure, one mistake, enough to cause the death of our brothers. Often it is a confluence of events. It seems as though we don’t learn enough from these fires. I recently had the opportunity to read a department’s investigative report that could have been a carbon copy of a report I read from that same department 10 years ago. Does that mean the department is unaffected, or doesn’t care? Not at all. Possibly we are not using the information from these reports correctly.

In a recent discussion with a brother firefighter that has lived through a triple LODD the following opinion was offered. Often the fire service reacts in a knee jerk fashion and the pendulum swings well into the safety zone. Then we find that this is an area where we cannot operate and do our job effectively. So gradually the pendulum swings back and we find ourselves operating as we always have.

Until the next time.


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  • Jason says:

    Great post. Good to see you hear Dave, the examples are ones we should all remember and take a good hard look at. Thanks for linking those stories as well, nice job.

  • Jeff Schwering says:

    Nice post Brother, as usual! The links should be used by many of us, for the training purposes we all need, reminders are a good thing!

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