Lesson Not LearnedTexas, Tennessee and EmmitsburgWhy Does Johnny Not Read?

Everyone went home so who the hell cares?

Image above and video below are from a Memphis house fire. Tactics aside, and without full knowledge of operations and actions who can comment with any validity, the roof ventilation is questionable. Not the actual ventilation but the lack of proper SCBA use while on the roof of a burning structure.

The last week of September FireRescue Magazine/FirefighterNation shared the NIOSH firefighter fatality investigation report of a Dallas Fire-Rescue captain who died after falling through a roof while performing vertical ventilation. Among the contributing factors identified was lack of PPE use, as implied in the summary, “His legs went through the ceiling of the second floor apartment while his body remained in the attic. He was wearing his self-contained breathing apparatus (SCBA) but was not wearing his facepiece and was overcome by the products of combustion. He was rescued by crews operating at the scene and transported to a local hospital where he died from his injuries.” [1] The cause of death is listed as asphyxiation from the products of combustion. It becomes more glaring when one reads past the various risk analysis and command recommendations to the point of PPE use, “For unknown reasons, the victim and the T26 fire fighter were not on air at the time the victim fell through the roof. He was not able to don his facepiece after becoming trapped in the attic. The victim may have survived until rescuers were able to free him if he had been on air.” [2] (bold mine)

Wooden soffit above second story window where fire entered the attic from first floor room of origin located directly below. (NIOSH photo.)

While it may seem simple to expect an immediate removal from partially falling through a burning roof, we are reminded that nothing is quite so simple on the fireground, “Within seconds, crews operating inside the structure found the victim's legs protruding through the ceiling and immediately began working to free him from the attic. Members made access into the attic from the bathroom and bedroom directly above the fire in an attempt to assist the victim while crews worked to free him from the ceiling from below. The members in the attic had to abandon this tactic because they found it futile to attempt to pull the victim up. They determined that it was more efficient to free the victim from below. The victim's removal was impeded due to him being caught on wiring and ceiling framing lumber. He was finally removed and rushed to a local hospital where he died from his injuries.” [3]

Captain Todd Krodle's name is at this hallowed circle (author photo)

Move forward to this past weekend and I observed many families, wives, husbands, parents, siblings and friends who were remembering firefighters killed last year and previous years at the National Fallen Firefighters Foundation Memorial Weekend. Each fresh name on the monument told a tale of many subjects, none the least of which is lessons learned. So how do we make the connection between a LODD investigation report, a memorial weekend and a recent house fire? We see it in where there is no connection actually, where there is no recognition of what can happen, what actually has happened, and how it can easily happen to us.

Yes I know that we can dismiss it as luck, and some will dismiss it by cheapening EGH (the job got done, everyone went home, so quit Monday morning quarterbacking), but for those who beat the drum about trying to reduce the line of duty deaths at what point are we going to stop pointing to rules of engagement posters, initiatives and analyses and begin to look at why we are not learning from the deaths of others? The delivery is quite simple; online, on paper. So we must seriously begin to ask where are these disconnects in our learning?


p.s. I'm sure there is also a connection in this question as to why National Fallen Firefighter Near-Miss died a peer review death recently. Think about it.

1. Career Lieutenant Dies After Being Trapped in the Attic After Falling Through a Roof While Conducting Ventilation – Texas (2012) Retrieved 8 October 2012 from http://www.cdc.gov/niosh/fire/reports/face201120.html
2. Ibid, Recommendation #3
3. Ibid, Investigation



Bill Carey is the daily news and blog manager for Elsevier Public Safety (FireRescue Magazine/Firefighter Nation, JEMS and LawOfficer sites.) Bill also manages the FireEMSBlogs.com network and is a former volunteer lieutenant with the Hyattsville Volunteer Fire Department in Prince George's County, Maryland.

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