Texas 2010 LODD State Investigation Lessons Never Learned

Bill Carey draws your attention to the Araguz LODD report and the biggest finding not mentioned.

The first article regarding the line of duty death of Wharton, Texas Captain Thomas Araguz III was a synopsis of the Texas State Fire Marshal’s Office investigation, minus the building construction details. This article will look at the seven findings and their various recommendations.

The Big One

Everyone has that one structure or site where we know the firefight will be difficult and our victory will be marginal at best. Typically we make efforts to preplan such addresses in order to keep our members safe and cut our losses. Our mind’s eye sees the initial operations not one of an aggressive interior attack but one of staging apparatus, setting up complex water deliveries and settling in for a long day of master stream deployments.

Captain Araguz III died on 3 July 2010 in a fire involving an egg production and processing plant. The plant is composed of mixed construction styles, in irregular shape and story, spanning open space over 58,000 square feet. It can be said with good reason that the structure was built to burn. Wharton County, where the plant is located, has no adopted fire codes, no model construction codes and no county fire marshal to conduct safety inspections. The fuel load was composed of packing materials for the eggs. Foam containers, plastic containers, pulp fiber containers, cardboard boxes and wood pallets made the majority of the fuel. There are no hydrants on the grounds and there were no sprinklers in the plant. Portable fire extinguishers were reportedly in place as well as battery operated smoke detectors. According to the code and building classification, there were no fire alarms or fire sprinklers present because the occupancy load was less than 100. During peak operation, the plant contained 35 employees. At the time of the fire 18 employees were present. An evacuation plan was present and reviewed by new employees. There were no regular emergency drills. The fire was noticed by employees who, after a verbal alarm, evacuated the plant and meet at a prearranged location.

The existing water supply infrastructure included two water storage tanks on the property with a capacity of 44,000 gallons. There was no fire department connection available. The nearest hydrants were three miles away and, as the fire developed, 15 miles away. The report reveals that the tanker refill operations early on depleted the water supply of the City of Boling.

Pre-Fire Facts:

  • Large, irregular shaped, mixed construction building
  • Large fuel load
  • No built in fire suppression system
  • No hydrants
  • Insufficient municipal water supply
  • No pre-plans

It is apparent that there was very little chance for success using an aggressive interior attack given the preexisting facts as well as the initial on scene report of fire conditions.

Report Findings and Recommendations

The report identifies seven findings and lists recommendations and references within each finding. The findings on a whole focus on risk; command; communication; rapid intervention and air management. While they do address errors made on the fireground, they fall short of finding realistic faults and ignore other glaring mistakes.

FINDING 1

There were no lives to save in the building. An inadequate water supply, lack of fire protection systems in the structure to assist in controlling the spread of the smoke and fire, and the heavy fire near the windward side facilitated smoke and fire spread further into the interior and toward “A” side operations. Along with the size of the building, the large fuel load, and the time period from fire discovery, interior firefighters were at increased risk.

FINDING 2

Initial crews failed to perform a 360-degree scene size-up and did not secure the utilities before operations began.

It is correct that the preexisting fire protection shortcomings, combined with minimal fire response and significant fire on arrival presented an increased risk to interior firefighters. Unfortunately the finding fails to stress the problems due to a lack or preplan information. Preplanning this structure would have accounted for six of the seven findings regarding failure to perform a 360-degree size-up; span of command; establishment of RIC; and organization of communication/command channels. It is surprising that given the account of initial operations that preplanning is not mentioned anywhere in the recommendations. From the details of the operations and tactics, preplanning could be recommended to improve the following:

  • Initial Assignment. The first due fire department had to request aid from a second department. An automatic dispatch of at least three departments should have been done on the initial alarm.
  • Initial attempt to locate seat of fire. The first arriving chief officer was directed to a loading dock near where fire was reported venting from the roof. After working “several minutes with employees” to gain entry, he was redirected to another location near opposite of the first. The first engine was directed to the corner near the venting fire while the chief officer attempted to locate the seat of the fire by “looking through the doors at the loading dock to Dry Storage 1.” Unable to see visible fire through the smoke a decision was made to breach and exterior wall.
  • Direction and control of incoming companies. The report stated that locating the seat of the fire was made difficult by employees leading apparatus around the structure. Rather than fault the employees, blame should be laid at the first due fire department for not having preplanned the structure. Even a rudimentary preplan would have identified an initial staging area, various points of access and the viability of access, as noted in the report which also blames the weather (rain) for apparatus problems. Likewise, a preplan would have also provided the initial command and sub command levels and kept fire officers and firefighters from being swayed by employee directions. One should also note that it was nearly 10 minutes after the first chief officer’s arrival until additional mutual aid was requested, and 30 minutes when audio first records the setting up of a dump tank for water supply.

Despite a best understanding of risk management and risk analysis, there is a greater chance for firefighter injury and worse when the initiative to establish command is lost and each company is left to create its own strategy and tactic for fighting the fire. Likewise it becomes harder for the incident commander to gain control among a half dozen different fire operations on one scene.

It is obviously correct that a 360-degree sizeup was not done, however without the aforementioned planning it appears that the completion on a 360-degree sizeup would have made very little difference. We should begin to question the ‘off the cuff’ manner in which the 360-degree sizeup is recommended. It does provide a complete exterior view and is proven hindsight valuable in various firefighter fatality reports. Unfortunately the 360-degree sizeup does not do as well with large commercial structures, especially those that are not preplanned. There is little evidence in the report to show how much a difference such a sizeup would have made, if it could have been made at all (weather limited access around the area). Instead of simply saying a 360-degree sizeup should have been done, departments dealing with large, irregular shaped commercial structures should assign other incoming chief officer or apparatus to approach and or initially stage at different building sides in order to give the incident commander a whole picture.

FINDING 3

The Incident Commander failed to maintain an adequate span of control for the type of incident. Safety, personnel accountability, staging of resources, and firefighting operations require additional supervision for the scope of incident. Radio recordings and interview statements indicate the IC performing several functions including: Command, Safety, Staging, Division A Operations, Interior Operations and Scene Security.

Again, when the responsible first arriving incident commander fails to establish command or is not equipped with the tools for command, we should expect company officers to begin deciding for themselves what course of action to take. It is not a mutinous situation, but one where all command actions become reactive not only to the fire but to the companies operating on the fireground.

FINDING 4

The interior fire team advanced into the building prior to the establishment of a rapid intervention crew (RIC).

FINDING 5

The interior team and Incident Commander did not verify the correct operation of communications equipment before entering the IDLH atmosphere and subsequently did not maintain communications between the interior crew and Command. Although Chief Barnett stated he communicated with Captain Cano, there was no contact with Captain Araguz.

Findings 4 and 5 are similar in that lack of initial command was a contributing factor. We are very aware of the ‘2-in, 2-out’ guideline as well as its pros and cons; unfortunately few such recommendations address the true fault. It is not a fault that the interior fire team advanced before a RIC was established, but that a lack of planning allowed such an advance. Consider this; heavy fire is showing through a part of the roof upon arrival. Mutual aid has to be requested, to provide a secure water supply. The seat of the fire is unknown. The layout of the building is unknown. Which of these is made better with the establishment of a RIC before entering – and, may I add, entering with a line not suitable for the fire it is attacking? Consider the communications as well. Had there been a RIC established before arrival, how much of a difference could it have made with the improper communication used? We should begin to question not the validity of having a RIC in place, but if we are bringing additional problems to the fireground that a RIC will not be able to solve.

FINDING 6

The interior operating crew did not practice effective air management techniques for the size and complexity of the structure. Interviews indicate the crew expended breathing air while attempting to breach an exterior wall for approximately 10 minutes, then advanced a hose line into a 15,000 square feet room without monitoring their air supply. During interviews Captain Cano estimated his consumption limit at 15 – 20 minutes on a 45 minute SCBA.

FINDING 7

Captains Araguz and Cano became separated from their hoseline. While it is unclear as to the reason they became separated from the hose line, interviews with Captain Cano indicate that while he was finding an exterior wall and took actions to alert the exterior by banging and kicking the wall, he lost contact with Captain Araguz.

**Captain Cano credits his survival to the actions he learned from recent Mayday, Firefighter Safety training.

There’s very little to say regarding Finding 6 and the practice of air time management, except that the report appears almost preposterous in mentioning this separate from lack of and span of command. It should be expected that members will exhaust their SCBA when there is very little oversight in their sectors or other areas of operation. It surprising to see that with as much mention about the lack of command, there is no mention of firefighters freelancing.

Finding 7, the final and second most important finding, sparingly mentions that the hoseline is vital for our survival. The addition of Captain Cano’s training credit appears to placate the issue of saving our own when in fact it highlights a question raised by many; is our survival training allowing us to get deeper into trouble? It is a credit to his survival that he kept his perspective and never gave up in attempting his own rescue. It is unfortunate though that team integrity and training for self rescue are recommended while fire behavior is not.

During the interior movements by Captain Cano, the victim and a third firefighter, Cano gave information that stated the fire was well beyond the attack of their 1 ¾-inch handline,

“Captain Cano was first with the nozzle and described making it 20 feet into the building. Cano states in his interview that he advised Command over the radio that there was high heat and low visibility, although the transmission is not recorded. Cano also reported in his interview, he could not walk through the area and had to use a modified duck walk. Cano projected short streams of water towards the ceiling in a “penciling” motion and noted no change in heat or smoke conditions. They advanced until the heat became too great and they retreated towards the center of the processor. Cano stated that they discussed their next tactic and decided to try a left-handed advance.”

Within 14 minutes, the recorded description on conditions inside goes from “– moderate heat overhead” to “- high heat, low visibility; could not walk.” 20 feet in and the heat has bowed them over. “Penciling”, an often misunderstood nozzle tactic, provides no change in the heat conditions, which forces them to retreat. After regrouping, the nozzle team decides to make another attempt, the only difference being the direction of approach.

Logic would dictate that the increasing heat, coupled with no change after water (a poor attack as well) and no visible fire would lead us to withdraw from the fire building and reconsider a second attack involving a larger line coupled with ventilation. It can be said that the limited water supply may have precluded the use of larger attack hoselines, however, when discussing fire attack in conjunction to saving our own and self preservation, indications that the current method of attack having no effect are just as important as staying in physical contact with a hoseline and signs of building collapse.

Lost from the Beginning

It is fortunate that we have responsible parties in the local, state and federal levels that can investigate incidents where firefighters have lost their lives. It is also unfortunate that the fallen such as Captain Thomas Araguz III and others personify the countless and repeated lessons to be learned. Some reports provide incredible insight into personal acts and the fire’s behavior. Others leave us having to be gleaners, gathering some value from the pages. While the Texas State Fire Marshal’s report provides facts and lessons to learn, it omits a highly valuable one. Preplanning would have highlighted the resources needed to fight a fire in this structure as well as provided an initial script for incoming chiefs and fire companies. It would have also addressed difficulties inherent in the facility itself and would have made the risk management process a much easier path to follow.

We all have places like the Maxim Egg Farm. They may be commercial structures or private dwellings that we simply look at and acknowledge there will be no saving that structure.

It is a tragedy that for lack of planning we would lose a member in such buildings.

References
Texas State Fire Marshal’s Office, Firefighter Fatality Investigation, Investigation Number FY 10-01
“Pre-Planning: An Important Part of Fire Prevention”, Everyone Goes Home, Andy Marsh
Training Officer, Mount Oliver Fire Department
“Pre-Incident Planning in the 21st Century”, USFA/Battalion Chief David L. Bullins, Greensboro (NC) Fire Department
Photos courtesy of Texas State Fire Marshal’s Office



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1 Comment

  • John R says:

    Patrick Mahoney wrote a similar column on FireGeezer http://firegeezer.com/2011/04/12/what-about-fire-flow-and-ventilation/
    I have been fuming for some time about NIOSH reports following a cookie-cutter approach without actually touching on the root causes of the incident. My concern is that people are useing the flawed findings of these reports to make policy changes.
    Perhaps you and Patrick could team up and start a much needed discussion about the weeknesses of these reports and what needs to be done to strengthen them

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