Summary On August 25, 2005 a live fire training exercise was conducted at a North Carolina County airport. Personnel involved in the training evolution were three employees of the airport who were employed as airport lineman as well as firefighters. The evolution involved a short classroom session consisting of radio procedures, hose applications, turret operations, and cargo hazards. Following the classroom session the crash truck was taken out to a large open field and positioned approximately fifty feet away from a large pile of approximately 20 pallets. The crash truck s pump was in gear, but no hose lines were pulled initially. None of the three firefighters had turnout gear or SCBA. Approximately five gallons of aviation fuel was applied to the pile. After a brief discussion with one of the two other firefighters, the instructor-in-charge of the evolution bent over downwind of the pile and ignited the fuel. The injury to the instructor-in-charge occurred upon ignition. The other two firefighters did not receive injuries. The burned firefighter had second-degree burns on his hands, arms, and legs, and was transported to the University of North Carolina Burn Center. Introduction On August 25, 2005, a 26 year-old firefighter was burned in a live fire evolution during a training exercise conducted at a County airport. The evolution took place at approximately 2PM. The student received second-degree burns on both hands, his arms, and legs. The firefighter was hired by the airport in June 2001 and began airport firefighter training in 2002. Since that time the firefighter had attended semi-annual airport firefighter training. The Office of State Fire Marshal was requested to investigate the incident by the Airport Authority. On August 28 oral interviews were obtained from the Airport Manager, the Director of Operations, and the two firefighters that were not injured. The investigators made a site visit to the live fire training area with these two firefighters. Training records were obtained from the Director of Operations as well as MSDS sheets on the class B fuel used. Recorded weather conditions were also reviewed. Page 1 of 10
The live fire training area was a large open field surrounded by trees and scrub brush. The class A material to be ignited was a large pile of approximately 20 pallets. Approximately 5 gallons of AVGAS was applied to the pile. No pre-fire plan was available. No burning permits were obtained. The incident did not occur in an ozone action region. Instructor-in-charge's Training History The Instructor-in-Charge is received initial airport line service training in 2002. Since that time he completed the yearly FAA training requirements for responding to aircraft emergencies. The most recent live fore training was completed on April 21, 2005. No North Carolina firefighter certification was obtained. He is not Live Fire Qualified. He is a recent member of a volunteer fire department in the area. Other two firefighter s Training History Both individuals had three years of experience with the airport and had completed the yearly FAA training requirements for responding to aircraft emergencies. The most recent live fire training was completed on April 21, 2005. The individual that was closest to the burn victim is a certified Firefighter I + II, and an EMT. The individual that was with the crash truck has no other firefighter certifications. Turn-out Gear None of the three individuals had turnout gear or SCBA. They were wearing airport uniforms. Page 2 of 10
Investigation The live fire training area is an open grass field near the airport surrounded by trees and scrub brush. The burn pile consisted of approximately 20 pallets three feet high with a circumference of 45 feet (picture #1). The crash truck was located approximately 50 feet downwind from the pile with the pump in gear (picture #2). No hose lines were deployed prior to the injury. There was no pre-fire plan available and no pre-burn briefing was discussed among the three firefighters. Neither the Director of Operations nor the Airport Manager was advised that a burn was to take place. The incident occurred between approximately 2PM and 3PM. Winds were gusting from 10 to 15 mph, and the temperature was between 84 degrees Fahrenheit with a dew point of 61. The instructor-in-charge applied approximately 5 gallons of AVGAS to the pile. As noted by the airport Operations Manager, this is a departure from normal policy. Only small quantities of diesel fuel are to be used (MSDS, 121046-00). One of the firefighter s then suggested lighting the set with some broom straw, but the instructor-in-charge said that the straw was too wet and he could use his lighter to start the set. The individual then kneeled over, downwind of the pallets, to light the fire (picture #3). The injury occurred when the individual sparked his lighter and ignited the vapors of the AVGAS. Discussion The burned firefighter was involved in a live fire training evolution that was to be conducted in a large open field with approximately 20 pallets to be burned. Wind was gusting and the temperature was warm. The individual used an extremely flammable, high hazard class B fuel to ignite the fire. This liquid can release considerable vapor at temperatures below ambient that readily form flammable mixtures. Vapors settle to ground level (MSDS, 51052-00). Some time passed between the time the liquid was poured to the time the liquid was ignited. With the existing air temperature, vapors were readily produced. The individual ignited the fuel in gusty wind conditions downwind of the product, and had no turnout gear on. All burn patterns of the fire set are consistent with the accounts from the individuals interviewed. Char to the natural ground cover was noted on the downwind side of the pile approximately 21 feet from the edge of the pallets and where the individual ignited the fire (picture #4). 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 that Page 3 of 10
conduct live fire training. These recommendations are intended to help jurisdictions in establishing guidelines for conducting such training. Recommendation #1: NFPA 1403, 7.1.1 states that prior to being permitted to participate in live fire training evolutions, the student shall have received training to meet the performance objectives for FF1 of the following sections of NFPA 1001, Standard for Fire Fighter Professional Qualifications: Safety, Fire Behavior, Portable Extinguishes, Personal Protective Equipment, Ladders, Fire Hose, Appliances and Streams, Overhaul, Water Supply, Ventilation, and Forcible Entry. The AHJ should have documentation that all participants have achieved the minimum level of knowledge in the NFPA 1001 performance objectives as stated in NFPA 1403. Recommendation #2: NFPA 1403, 7.2.2, 7.2.3, 7.2.4, and 7.2.5 states that for outside training, care should be taken to select areas that limit the hazards to both personal safety and the environment. The training area shall be flat with no obstructions that can interfere with firefighting operations, and that ground cover shall be such that it does not contribute to the fire. The ground cover should be impervious. Refer to picture #1. The AHJ should ensure that the training area complies with the NFPA references above. The area should be cleared of debris and the natural vegetation mowed to prevent possible uncontrolled fire spread. Recommendation #3: NFPA 1403, 7.2.10 states that all required permits to conduct live fire training evolutions shall be obtained. North Carolina General Statute Chapter 113, Article 4C: Regulation of Open Fires. 113-60.24 Open Burning in non-high hazard counties requires an open burning permit from the N.C. Division of Forest Resources. North Carolina Administrative Code, Environmental Management Section.1900 Open Burning: 2D.1900(11)(B) requires the regional office supervisor of the appropriate regional office of the Division of Air Quality be notified of this live fire training. The AHJ should develop a policy to ensure all permits on the local and state level are obtained prior to live fire training. Recommendation #4: NFPA 1403, 7.2.20 states that awareness of weather conditions, wind velocity, and wind direction shall be maintained. The instructor-in-charge must be aware of weather conditions and include temperature, wind speed, and wind direction. The AHJ should develop S.O.G.s to ensure the instructor-in-charge monitors the weather before the live fire training evolution as well as just prior to ignition of the fire. Page 4 of 10
Recommendation #5: NFPA 1403, 7.2.21.1 states that consideration shall be given to the control and extinguishments of the fire and the provision of necessary backup lines to protect personnel. NFPA 1403, 7.2.21.2 states that the minimum water supply and delivery for live fire training evolutions shall meet the criteria identified in NFPA 1142, Standard on Water Supplies for Suburban and Rural Fire Fighting. NFPA 1403 7.2.21.3 states that a minimum reserve of additional water in the amount of 50 percent of the fire flow demand in 7.2.21.2 shall be available to handle exposure protection or unforeseen situations. NFPA 1403 7.2.21.4 states that separate sources shall be utilized for the supply of attack lines and backup lines in order to preclude the loss of both water supply sources at the same time. Only one truck was present on site. No hose lines were pulled prior to ignition. Extinguishment was done with a booster line. The AHJ should develop S.O.G.s to ensure that NFPA 1403 water supply requirements are met. A pre-fire plan should be established to clearly state guidelines for conducting live fire training at this site. Recommendation #6: NFPA 1403, 7.2.23 and 7.2.23.1 states that prior to conducting actual live fire training evolutions, a pre-burn briefing session shall be conducted for all participants. All facets of each evolution to be conducted shall be discussed, and assignments shall be made for all crews participating in the training session. No pre-burn session was conducted, nor any objectives of for the evolution stated. The AHJ was unaware that the live burn was taking place. The AHJ should develop S.O.G.s to ensure that, before any live fire training, pre-burn sessions with the participants shall be conducted. Recommendation #7: NFPA 1403, 7.2.23.3 and 7.2.23.4 and states that a pre-burn plan shall be prepared and shall be utilized during the pre-burn briefing sessions. All features of the training areas and structure shall be indicated on the plan. No pre-burn plan was available. A pre-fire plan should be established by the AHJ to clearly state guidelines for conducting live fire training at this site. Schematics of the site as well as truck placement and hose layout should be done. Water supplies should be calculated and guaranteed. Recommendation #8: NFPA 1403, 7.3.1 states that the fuels used in live fire training evolutions shall have known burning characteristics that are as controllable as possible. The class B fuel used as pre-application to start the fire known as AVGAS has known burning characteristics, but is very uncontrollable. It is highly flammable and volatile. Page 5 of 10
The AHJ should develop S.O.G.s as what type and how much class B fuel can be used in the pre-application phase of starting the fire. Flammable liquids should not be used. Recommendation #9: NFPA 1403, 7.3.3 states that fuel materials shall be used only in the amounts necessary to create the desired fire size. It was reported that approximately 5 gallons of class B fuel was used as pre-application to start the fire on approximately 20 pallets. The AHJ should develop S.O.G.s as what type and how much class B fuel can be used in the pre-application phase of starting the fire depending on the fire set. Recommendation #10: NFPA 1403, 7.3.5 states that the instructor-in-charge shall assess the selected fire environment for factors that can affect the growth, development, and spread of the fire. Refer to picture #3. Air temperature, wind speed, and direction were important parameters that increased the risk to the firefighters. The AHJ should ensure that the instructors used for live fire training are familiar with importance of noting weather conditions. Recommendation #11: NFPA 1403, 7.4.1 states that a safety officer shall be appointed for all live fire training evolutions. There was no Safety Officer in place during this exercise. It is suggested that the AHJ adopt the policy of having a designated Safety Officer during all burn building live fire training evolutions. Recommendation #12: NFPA 1403, 7.4.6 states that backup lines shall be provided to ensure protection for personnel on training attack lines. Only one truck was present. There were no attack or backup lines deployed prior to ignition. The AHJ should develop S.O.G.s to ensure compliance with the above stated objective to ensure safety of all personnel during a live fire training evolution. Recommendation #13: NFPA 1403, 7.4.7 and 7.4.1 states that the instructor-in-charge of the live fire training evolutions shall determine, prior to each specific evolution, the number of training attack lines and backup lines that are necessary. Each hose line shall be capable of delivering a minimum of 95 gpm (360 lpm). A minimum of 95 GPM should be used on both the attack and backup lines. After ignition a booster line was used to extinguish the fire. The AHJ should develop S.O.G.s to ensure compliance with the above stated objective to ensure safety of all personnel during a live fire training evolution. Page 6 of 10
Recommendation #14: NFPA 1403, 7.4.10 states that emergency medical services shall be available on site to handle injuries. One of the firefighters present was an EMT B. No medical gear was available on the training site to assist the injured firefighter. The AHJ should adopt the policy of providing adequate emergency medical care on the training ground for all live fire exercises. Recommendation #15: NFPA 1403, 7.4.12 states that one person who is not a student shall be designated to control the materials being burned and to ignite the training fire in the presence of and under the direct supervision of a safety officer. No Safety Officer was present. It is suggested that the AHJ adopt the policy of having a designated Safety Officer during all burn building live fire training evolutions. Recommendation #16: NFPA 1403, 7.4.12.1 states that the person designated to control the materials being burned and to ignite the training fire shall wear full protective clothing including selfcontained breathing apparatus. The individual igniting the fire did not have on turnout gear or SCBA. None was present at the training site. The AHJ should develop S.O.G.s requiring full PPE and SCBA be worn by participants of any live fire training exercises. Recommendation #17: NFPA 1403, 7.4.15 states that the training session shall be curtailed, postponed, or cancelled, as necessary, to reduce the risk of injury or illness caused by extreme weather conditions. The air temperature was warm and the winds were gusting. The fire was ignited downwind from the fire set. The AHJ should ensure that the instructors used for live fire training are familiar with importance of noting weather conditions. Recommendation #18: NFPA 1403, 7.4.16 and 7.4.16.6 states that each participant shall be equipped with and wear full protective clothing and SCBA whenever they are involved in any evolution or fire suppression operation during the live fire training evolution.. None of the three firefighters had on turnout gear or SCBA. None was present at the training site. The AHJ should develop S.O.G.s requiring full PPE and SCBA be worn by participants of any live fire training exercises. Recommendation #19: NFPA 1403, 7.5.1 states that all instructors shall be qualified to deliver firefighter training according to the AHJ. Page 7 of 10
The AHJ was unaware that the live fire evolution was taking place. S.O.G.s should be developed to ensure that only Qualified Live Fire Instructors conduct live fire training exercises. Recommendation #20: NFPA 1403, 7.5.5 states that prior to the ignition of any fire, instructors shall ensure that all protective clothing and equipment specified are being worn. None of the three firefighters had on turnout gear or SCBA. None was present at the training site. The AHJ should develop S.O.G.s requiring full PPE and SCBA be worn by participants of any live fire training exercises. Page 8 of 10
References 1. Material Safety Data Bulletin, 51052-00 AVGAS 100LL, ExonMobil. 2. Material Safety Data Bulletin, 121046-00 MOBIL JET A (-40), ExonMobil. 3. NFPA 1403, Standard on live fire training evolutions. 1997 edition, Quincy, MA: National Fire Protection Association. 4. North Carolina Live Fire Instructor Qualification Course, North Carolina Office of State Fire Marshal. 5. North Carolina General Statute Chapter 113, Article 4C: Regulation of Open Fires.. 113-60.24 Open Burning In Non-high Hazard Counties, Permits Required; Standards. 6. North Carolina Administrative Code, Environmental Management Section 2D.1900(11)(B) Open Burning. Investigator Information This incident was investigated by Chris Best and Derrick Clouston, Fire and Rescue Training Specialists, North Carolina Department of Insurance, Office of State Marshal. Page 9 of 10
Picture #1: burn pallets on left. Debris pile on right. Picture #2: Crash truck and burn pallets. Wind direction Picture #3: Where individuals were standing during ignition. Picture #4: Burn pattern on ground. Page 10 of 10