Summary On March 8, 2006, a North Carolina Fire Department conducted Fire Ground Operations training under Live Fire Conditions at a 9600 cubic foot, 4 story fire training facility owned by the local community college. There is confusion between the community college and fire department in question in reference to who was the Authority Having Jurisdiction. There were two North Carolina Fire & Rescue Commission (NCFRC) Qualified Live Fire Instructors employed by the community college who where instructed by both the community college and the fire department that their responsibility was to set and monitor the fire props only. Two training staff members of the fire department were responsible for developing the training scenarios. Students consisted of line members of the fire department in question who rotated through the training evolutions in companies. Class A materials were used for setting the fires in three different burn pans in the structure. Two burn pans were on the first floor, and the third burn pan was in the basement. The basement consisted of normal construction features of the burn building and several additional props made by the fire department. These props consisted of two temporary walls made of pallets and one consisting of several old couches made of wood, fabric and foam. During the afternoon exercise, fire extended out of the basement burn pan and ignited several of the couches used as props. During this evolution three firefighters were inside the building on the first floor and received minor burns to there facial area. Introduction On March 8, 2006 three career firefighters received minor burns while participating in fire ground operations training under live fire conditions. The three firefighters were all performing search and rescue drills as part of the fire department training scenario being conducted at a North Carolina community college burn building when they received minor burns around their facial area. The injured firefighters were of various ages and experience levels as noted later in this report. The Office of State Fire Marshal was requested to investigate the incident by Deputy Director Steve Sloan in accordance with the North Carolina Fire and Rescue Commission (NCFRC). Interviews were conducted with two Live Fire Qualified Instructors employed by the community college involved in the incident, as well as the three burned firefighters, the community college coordinator, and a training officer with the fire department in question. A sketch of the building layout as drawn by one of the LFQ instructors and written statements from the injured firefighters was also obtained.
Injured Firefighter #1 Relevant Training History The burned firefighter #1 is a 35 year old male with 21 years of fire service experience. The firefighter serves in a leadership role in the department and holds FFI & II certifications as well as qualifications in FFI & II and Live Fire. The firefighter was functioning as part of a search and rescue crew on the first floor. Injured Firefighter #2 Relevant Training History The burned firefighter #2 is a 27 year old male with 12 years of fire service experience. The firefighter holds FFI & II certification, and qualification as a FFI & II instructor. Firefighter #2 was serving on a hoseline assigned to search and rescue on the first floor. Injured Firefighter #3 Relevant Training History The burned firefighter #3 is a 25 year old male with 8 years of fire service experience. The firefighter is FFI & II certified. Firefighter #3 was assisting in search and rescue activities on the first floor. Ignition Officer #1 Relevant Training History Ignition officer #1 has over 15 years of fire service experience and carries certifications and/or qualifications in FF I & II, Haz-Mat, Live Fire, and is a Fire Officer I. Ignition Officer #2 Relevant Training History Ignition officer #2 has over 16 years of fire service experience and carries certifications and/or qualifications in FF I & II, and Live Fire. Fire Department Training Officer Relevant Training History The FD training officer interviewed has over twelve years of fire service experience and carries certifications and/or qualifications in FF I & II, and Driver Operator. Injured Firefighter #1 Turn-out Gear The turnout gear of firefighter #1 consisted of 1.5 year old Globe PBI Matrix Gold/Cross Tech MB coat and trousers in good condition. The helmet consisted
of a 4 year old Cairns N6A Leather that was reported in good condition before the training exercise. Firefighter #1 reported that the helmet did suffer some damage including cracked paint, and bubbles all over and underneath. No other damage noted to gear. Injured Firefighter #2 Turn-out Gear The turnout gear of firefighter #2 consisted of 3 year old Globe GX-7 coat and trousers in good condition. The helmet consisted of a 6 year old Cairns 1010 that was reported to be in excellent shape before the training evolution. Firefighter #2 reported that the helmet did suffer some damage including discoloration of reflective tetrahedrons. Injured Firefighter #3 Turn-out Gear The turnout gear of firefighter #3 consisted of unknown age Jamesville PBI Gold Fabric coat and trousers in good condition. The helmet consisted of a 2 month old Cairns Metro N660C that was reported to be in excellent shape before and after the training evolution.
Investigation The training was conducted at a 9600 cubic foot, 4 story fire training facility owned by the local community college. There was confusion between the community college and fire department in question in reference to who was the Authority Having Jurisdiction. There were two North Carolina Fire & Rescue Commission (NCFRC) Qualified Live Fire Instructors employed by the community college who where instructed by both the community college and the fire department that their responsibility was to set and monitor the fire props only. Two training staff members of the fire department were responsible for developing the training scenarios. Students consisted of line members of the fire department in question who rotated through the training evolutions in companies. Class A materials were used for setting the fires in three different burn pans in the structure. Two burn pans were on the first floor, and the third burn pan was in the basement. The basement consisted of normal construction features of the burn building and several additional props made by the fire department. These props consisted of two temporary walls made of pallets and one consisting of several old couches made of a wood frame with fabric and foam cushions. The training scenario was designed by the fire department training staff. The students were on their apparatus, stopped away from the burn building, and given dispatch instructions. The scenario consisted of search and rescue drills under live fire conditions. Fire department apparatus were to stop at a predetermined location with the intent of making crews add additional hose to there attack lines. Special nozzles provided by the community college were to be used instead of traditional nozzles. It is unsure what the flow of these nozzles were, however it is estimated to be approx. 20 to 30 gallons per minute. After the fires were set, approximately ten minutes passed between the beginning of the evolution and the time that the apparatus and crews were in place and ready to enter the structure due to organization and adding additional lines. The two instructors employed by the community college noticed extreme smoke conditions consisting of heavy black smoke that was not normal for the building and requested over the radio for the training evolution to stop while they investigated the fire props. When they entered, the instructors found high heat conditions coming from the basement. Upon entering the basement the fire had spread from the burn pan and ignited several of the couches nearby. The instructors dragged the couches out the basement door and requested a hoseline from the exterior of the basement. An engine was sent to the back of the building and a hoseline deployed from the exterior of the basement and all fire with the exception of fire in the burn pan was extinguished. The two community college instructors determined that the building was safe and a radio call was issued advising that the training could continue. Fire department 4
training staff then advised crews to enter the building and start there assignments. There is confusion in exactly when in the evolution the injuries occurred. According to injured firefighter #1, he and his crew were assigned to assist with search and rescue operations on the first floor. Approximately 2-3 minutes after entering the structure on the first floor, emergency radio traffic advising that a fire was burning out of control in the basement was heard. Firefighter #1 advised investigators that he thought this was part of the drill. In addition, he advised that he and his crew remained inside at the front door of the first floor until radio traffic stated that the fire in the basement was under control. Upon completion of the evolution, he and two other firefighters observed that they were experiencing pain in the facial area around where there SCBA mask was worn. No blisters were observed at this time. Students were asked by the fire department training officer and the community college instructors if they were injured and at the time no firefighter reported an injury. Later in the day after returning to the station, it was determined by firefighter #1 that he had received minor burns to the facial area. According to injured firefighter #2 he and several other firefighters had entered the structure to perform search and rescue duties. Several minutes after entering firefighter #2 heard emergency radio traffic advising that a fire was out of control in the basement. He advised that he could tell in the tone of voice in the call that it was not part of the drill. He moved with his crew to the exterior door on the first floor until they were advised that it was safe to continue the training operation. After the evolution was over he did feel discomfort in the facial area but did not report an injury. Later in the day after returning to the station, he noticed two small blisters had developed on his face around where the SCBA face piece was worn. Injured Firefighter #3 entered the structure to perform search and rescue duties. After being in the structure for several minutes, firefighter #3 advised that the inside of the building was extremely hot and he exited the building. After exiting, he heard emergency radio traffic advising there was a fire out of control in the basement and that a hoseline was needed. After the evolution was over, the firefighter did not report an injury. Later in the day, firefighter #3 discovered that he was experiencing discomfort to his facial area around where he was wearing his SCBA mask. When interviewing one of the fire department training officers, he advised that no firefighters had entered the burn building prior to the two community college live fire instructor s radio call for the training scenario to halt due to the excessive smoke. After interviewing the three injured firefighters, it was apparent that they 5
were in the structure when the basement fire extended to the couches. This would account for their statement of intense heat build-up inside the structure. It is unclear how they were not accounted for at that time from the investigation. 6
Recommendations In order to minimize the risk of the above incident happening again, the North Carolina Office of State Fire Marshal provides the following recommendations to facilities and instructors who provide live fire training in burn buildings. Recommendation #1: NFPA 1403, 3.2.1 defines the Authority Having Jurisdiction (AHJ) as the organization, office, or individual responsible for approving equipment, materials, an installation, or a procedure. When interviewing both fire department personnel and community college personnel, there was confusion to who the AHJ actually was. Before any live fire training is conducted, the AHJ must be clearly identified because 1403 specifically gives the AHJ authority to appoint positions such as the lead instructor, instructor, and safety officer. Recommendation #2: NFPA 1403, 3.3.5 defines an instructor as an individual qualified by the AHJ to deliver firefighting training, who has the training and experience to supervise students during live fire training evolutions. NFPA 1403, 3.3.6 defines the instructor-in-charge as an individual qualified as an instructor and designated by the AHJ to be in charge of the live fire training evolution. Because it was unclear who the AHJ was, no one was clearly identified as an instructor or instructor-in-charge. The two community college instructors who are NCF&RC Qualified Live Fire Instructors believed that the fire department training staff were serving as lead instructors because the two community college instructors were told specifically by both the community college director and the fire department training staff that they were to monitor the fires only, and not be included in actual live fire training and evaluations. The fire department training staff believed that the two community college instructors were in charge because they were agents of the college and carried a NCF&RC live fire qualification. It is clear to the investigation team that the training scenario s were developed and implemented by the fire department training officer. Recommendation #3: NFPA 1403, 6.2.13 states that the water supply for any individual live fire training evolution shall be assessed based on the extent of the evolutions to be performed. 7
NFPA 1403, 6.2.13.1 states consideration shall be given to the control and extinguishment of the fire and the provision of necessary backup lines to protect personnel. NFPA 1403, 6.2.13.2 states that the minimum water supply and delivery for live fire training evolutions shall meet the criteria identified in NFPA 1142. NFPA 1403, 6.2.13.3 states a minimum reserve of additional water in the amount of 50 percent of the fire flow demand determined in accordance with 6.2.13.2 shall be available to handle exposure protection or unforeseen situations. The Lead instructor shall ensure that water supply calculations have been assessed in accordance with the above mentioned standards and this information should be documented on the pre-fire plan. Although it does not appear water supply contributed to these injuries, they are required per NFPA 1403. No one interviewed could produce a pre-fire plan with this information. Recommendation #4: NFPA 1403, 6.2.15 states that prior to conducting actual live fire training evolutions, a pre-burn briefing session shall be conducted for all participants. NFPA 1403, 6.2.15.1 states that all features of the training area and structure shall be indicated on the pre-burn plan. NFPA 1403, 6.2.15.3 states that a pre-burn plan shall be prepared and shall be utilized during the pre-burn briefing sessions. NFPA 1403, 6.2.16 states that prior to conducting any live fire training, all participants shall be required to conduct a walk-through of the structure in order to have a knowledge of and familiarity with the layout of the building and to facilitate any necessary evacuation of the building. The AHJ should prepare a pre-burn plan that all instructors have access to that cover all features of the training area, location of any on-site medical needs, and all other required details of the training structure and fire ground as taught in the LFQ course. This plan should cover all emergency evacuation signals and procedures during the activation of such a signal. No plan was provided to the investigation team. In addition, according to the injured firefighters, a walkthrough of the structure was not conducted prior to live fire training evolutions. Recommendation #5: NFPA 1403, 6.2.18 states that all possible sources of ignition, other than those that are under the direct supervision of the person responsible for the start of the training fire, shall be removed from the operations area. In this case, couches were used for forming a prop wall and were not intended for use as a fuel source, however they were sources of ignition and should have been removed from the structure prior to burning on the floor involved. 8
Recommendation #6: NFPA 1403, 6.4.7.2 states that each hoseline shall be capable of delivering a minimum of 360/Lmin (95gpm). The hoselines used were capable of flowing 95gpm; however the nozzles that were required by the community college reduced the flow below 95 gpm. This could be corrected on each nozzle by removing the tip, however not all personnel were advised of this until after the injuries occurred. Anytime hoselines or nozzles are set to flow below 95 gpm, the method for changing the flow should be explained to all participants prior to conducting live fire training evolutions. Recommendation #7: NFPA 1403, 6.4.7.3 states that the instructor-in-charge shall assign the following personnel: (1) One instructor to each functional crew, which shall exceed five students (2) One instructor to each backup line (3) Additional personnel to backup lines to provide mobility (4) One additional instructor for each additional functional assignment It is unclear from the interviews if any instructors were actually assigned to students performing in the training scenario. When the injured firefighters were asked who the instructor-in-charge was, they all answered that the fire department training staff was in charge of the training evolution. When the fire department training staff was asked who the instructor-in-charge was, he answered that it was one of the instructors provided community college. It must be made clear, before any live fire training evolutions begin who is the AHJ, the instructor-in-charge, and the assigned instructors as defined in NFPA 1403. Recommendation #8: NFPA 1403, 6.5.4 states that the instructor-in-charge shall be responsible for full compliance with this standard. NFPA 1403, 6.5.9 states where concurrent, multiple, live fire training evolutions are being conducted in a specifically designed burn building, the identity of the instructor-in-charge shall be clear to all participants. Due to the instructor-in-charge not being clearly identified, confusion arose involving all parties present on the fire ground. In this case, there was no one identified as the instructor-in-charge. The AHJ must ensure that the instructor-incharge has been designated and is qualified in accordance to NFPA 1403. Recommendation #9 NFPA 1403, 6.5.6 states instructors shall take a head count when entering and exiting the building during an actual attack evolution conducted in accordance with this standard. 9
After conducting interviews with the injured firefighters, community college instructors, and fire department training staff, it is clear that firefighters were in the structure unaccounted for while the fire was burning out of control in the basement. A clear identification of who is the instructor-in-charge or who is in charge of accountability would keep this from happening in the future. General Recommendations: Recommendation A: It is recommended that any delivery agency allowing live fire training to be conducted on their premises should understand that they are the AHJ unless it is clearly expressed otherwise in writing. This places all responsibility of identifying instructors and safety officers on the delivery agency. Recommendation B; It is recommended that delivery agencies should establish Standard Operating Procedures(SOP s) detailing how outside agencies can use their facility including responsibilities of both the delivery agency and the outside agency requesting training. Recommendation C: It is recommended that all agencies conducting live fire training should fully understand NFPA 1403, and ensure compliance with the standard while conducting such training. Recommendation D: The North Carolina Fire and Rescue Commission provides a Live Fire Qualification course to ensure instructors understand compliance with NFPA 1403. It is recommended that any instructor performing as a live fire instructor be qualified by the NCF&RC as a Live Fire Qualified Instructor. 10
References 1. NFPA 1403, Standard on Live Fire Training Evolutions. 2001 edition, Quincy, MA: National Fire Protection Association. 2. NFPA 1403, Standard on Live Fire Training Evolutions. 1997 edition, Quincy, MA: National Fire Protection Association. 3. NFPA 1142, Standard on Water Supplies For Suburban and Rural Fire Fighting. 2002 edition, Quincy, MA: National Fire Protection Association. 4. North Carolina Live Fire Instructor Qualification Course, North Carolina Office of State Fire Marshal. Investigator Information This incident was investigated by Chris Best, Derrick Clouston, and Carnie Hedgepeth, Fire and Rescue Training Specialists, North Carolina Office of State Fire Marshal. 11