Texas 2010 LODD State Investigation Synopsis

Report on July 2010 fire that claimed a captain identifies seven main errors.

On 3 July 2010 firefighters from Boling and Wharton volunteer fire departments were dispatched to the Maxim Egg Farm for a reported “big fire” in the warehouse section of the structure at 21:41 hours. By 0802 hours the next day the fire was extinguished, two firefighters were transported to Gulf Coast Medical Center and the body of Wharton Captain Thomas Araguz III had been removed from the scene. The following is brief review of the fireground operations contained in the report, SFMO Firefighter Fatality Investigation Case FY 10-01, as well as the seven findings and recommendations.

The report covers the building; fireground operations; origin and cause of fire; PPE evaluation of the victim; and recommendations. There is very little information about fire behavior other than scant descriptions in the fireground operations narrative. The report also contains many post-incident photos as well as building diagrams and a incident timeline. The last firefighter fatality report by the State Fire Marshal’s Office (SFMO) was on the deaths of a Houston captain and firefighter on 12 April 2009.

South aerial view of the egg processing plant

At 2140 hours, the local 911 center received a report of fire, followed by a second report of a “big fire”. The victim’s Assistant Chief was already on the street from an earlier call and had responded. His report of “heavy fire” coming from the roof at the northeast corner is the first on scene sizeup. The first arriving engine followed the assistant chief to a loading dock on the northeast side. Despite mention of doors at the loading dock, a metal panel from the wall was removed and a 1 3/4-inch hoseline was placed into operation. Shortly after this, the deck gun from the first engine was also placed into action. This is the first report of a hoseline stretched to attack the fire. There is no mention of available water supply, however tankers and off-site refill locations are eventually mentioned.

Audio of the incident is stated to reveal difficulties getting to the location of the fire. Firefighters were not familiar with the structure and grounds, there were no preplans and building employees were directing incoming fire companies. Six minutes after the arrival of the Assistant Chief the victim’s Fire Chief arrived, established a command post on the south side (Alpha side), a staging area and a fireground channel for communication. The Incident Commander is met by the plant manager, also the former fire chief of the victim’s department, and is told that the fire is in the boiler room and should be reached by breaching an exterior wall. Also at this time the second engine and a tanker arrived on Side Alpha. Incident Command directed them to set up a portable dump tank, the first report of establishing a water supply.

1130 hose-line up steps into processing room entry door

Firefighters on Side Delta were still having difficulty making entry. A county Deputy Chief arrived, the third chief officer on the scene, and reported fire through the roof over Dry Storage 1, which is located on Side Delta. This is the second report of fire through the roof of the structure. Entry on Side Alpha was made through a keypad access door with the help of an employee. The report make special note that this door was chocked open by a three-ring binder. Once inside, the conditions found are described as “low visibility and moderate heat overhead.” The victim, another captain and a firefighter were directed to advance a hoseline into the building. The trio stretched a dry line into the structure and encountered “numerous obstacles”. With no water in the line, they returned to the doorway to wait. During this time, the engine (1130) was experiencing pump problems identified as a linkage failure in the priming pump. The tanker (1160) connected to the engine and the dump tank and began the initial water supply. The trio then reentered the building, encountering employees who had entered to remove files. This was reported and the incident commander requested the sheriff’s office to secure the scene. With a charged hoseline the victim and other captain proceed, leaving the firefighter at the doorway to feed the line (the report does not state the length of this line). The victim and other captain move along the right side as far as 20 feet. The captain states that he reported via radio “high heat and low visibility” but the transmission is not recorded. This is the second report of conditions inside. In the investigation interview the captain stated that the heat kept him from walking upright, forcing him to “duck walk.” The captain also stated that he “penciled” the ceiling and observed no change in the heat or smoke. The two continued to advance until heat forced the to retreat to the center of the room from which they entered, approximately, as the diagrams in the report are not to scale. At this point, the two decide to advance again but towards the left.

North end of Dry Storage 3 where Captain Cano was rescued

The victim takes the nozzle and along with the captain advances left along the southern wall. It is at this point that they become separated from their hoseline. The investigation reports that a coupling between the first and second lengths was found caught on a threaded floor anchor. The captain states that the victim told him to call a mayday. He was “confused by the request, but after sometime it became apparent they lost the hoseline.” The captain transmitted a mayday but there was no record of it. He may have inadvertently switched channels during his first transmission of interior conditions. Four minutes after the hoseline was reported advanced inside via Side Alpha, the county deputy reported to the Incident Commander that the wall was breached on Side Delta. Incident Command acknowledged with a report of a hose team already inside. Five minutes later the Incident Commander calls the victim and captain with no success. Five more minutes, after six repeated calls, the Incident Commander directs the engine (1130) to sound its air horns while the commander announces a mayday for “unlocated fireman in the building.” and orders “all firemen exit the building.”

While the report does not provide specific detailed movement of groups of firefighters it appears that the initial actions on Side Delta, (the loading dock near Dry Storage 1) where Engine 1134 was positioned, have shifted towards Dry Storage 3 and Side Alpha. This would correspond with the later accounts and photos.

Disorientation and Self Rescue Attempt
The captain states in the interview that he and the victim “made several large circles in an attempt to locate the hoseline.” He became entangled in wire and had to remove his SCBA. After donning it again, he discovered he lost his radio. The captain’s low air warning sounded as he and the victim located an exterior wall and began trying to breach the wall. While doing this, the captain lost contact with the victim. After having run out of air, he removed his mask and continued trying to breach the wall.

Mayday Failure
While the report indicates that there are many fire companies on the scene at this time, there are no indications of the assignment of a rapid intervention crew (RIC) until after the captain is removed. The victim and captain have not been heard from by the Incident Commander since the report of employees inside (22:23). For 12 minutes, Incident Command has called for the victim and captain 10 times. During this Incident Command had asked any inside teams if they located the missing duo, presumably not remembering that he had ordered all firefighters to evacuate the building. Incident command then switches fireground radio traffic to another channel. An unknown firefighter reports hearing tapping on the south wall. This would be somewhat near Side Alpha. Incident Command then directs the missing duo to activate their PASS devices and that “- have teams coming” although no one has been directed to search for the missing. The chief on Side Delta directs and engine to bring manpower and tools to breach the wall. Another call for the missing duo goes unanswered.

Incident Command calls 1502 (mutual aid assistant chief) inquiring about manpower to send through Side Alpha as a rescue team. 1502 complies. Incident Command asks 1502 for accountability of the victim, captain and firefighter by name. 1502 reports that they have removed one member and requests and ambulance. In the next four minutes, a second breach is being done, Incident Command requests personnel with SCBA to the command post and the mayday channel (TAC 2) becomes cluttered with incoming mutual aid companies.

Note: Since the initial indications that the trio were missing there is no record of either a specific RIC or loose band of firefighters, following the hoseline in from the Side Alpha doorway to tray and locate the missing trio or at a minimum the firefighter who was initially positioned in the doorway to advance the hoseline.

RIC Deployments
The tapping heard earlier by firefighters leads them to make two openings in the wall. After the first cut, the captain was located and removed. According the the report he was left to his own care, by which he placed himself into a dump tank to cool down. Although the captain stated the victim was approximately 15 inside, the first RIC made their entrance via the doorway where the firefighter mentioned above was found. Once he was removed, an evacuation was sounded and that initial RIC, first mentioned in the report, abandoned their search. A second RIC made another opening. After entry they faced worsening fire conditions and were withdrawn after an evacuation signal. At this point in the report, the first written indication of the fire’s behavior is noted, “As the fire extended south toward Dry Storage 3,”

“Rescue Operations” talks with Incident Command after this point and additional personnel are requested to the command post. 1502 reports that no entry has been made; waiting on water in a hoseline.

23:10. Ten minutes after Incident Command transmits the mayday a rescue team attempts entry, location not stated. 1502 questions the action, asking Incident Command “how bad is the roof? there is a lot of popping up there” and does not want rescue team to enter. Incident Command redirects the rescue team to another point of entry on the loading dock. During the subsequent minutes, the rescue team reports they “hear something” and additional personnel are sent in. Wind and worsening smoke conditions cause Incident Command to relocate the command post. 1502 reports that firefighters are still inside the building.

Almost ten minutes later Incident Command calls for an evacuation of the fire building. Defensive operations continue. The report notes that a total of four RIC’s made entry over a period of 45 minutes. None of the diagrams provided indicate points of entry and paths of movement. As operations continued in the night and early morning, command of various sectors and the incident was transferred.

Next…”Texas 2010 LODD State Investigation, Lessons Never Learned”

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