Charleston Phase II Report

[papacheese]

I'm posting this under the training thread due to the headline:

"Charleston Phase II Report: Poor Training Led to Deaths"

The independent panel created by the mayor of Charleston submitted a 272 page report that, to put it politely, is absolutely stunning as well as scalding. Here's the link:

cms.firehouse.com/content/article/article.jsp?sectionId=56&id=59499

Although supposedly not linked, Chief Thomas submitted his resignation the day before the report was released.

Although very large, the report is perhaps the most substantial and comprehensive one I have ever read; the panel went to great lengths to reconstruct the time line and situations as accurately as possible. I skimmed through the entire document yesterday afternoon and am still stunned by the chain of events, circumstances, and miscues that lead to these tragic deaths.

While understanding the need to respect the familes of those who made the ultimate sacrifice, whether Charleston or anywhere else, it is vitally important that we examine disasters such as this in order to ensure that IT NEVER HAPPENS AGAIN.

Read the report and you'll see the scope of mistakes, from building code violations to inspection indifference, lack of sprinklers and pre-planning, inadequate command and control, poor risk management, outdated tactics, and as the headline suggests, lack of training. To think that this tragedy was just "bad luck" is burying your head in the sand. The accident chain could have been easily broken in many different spots, yet in this case, tradition overpowered reason and logic.

I strongly recommend that every officer and firefighter read through this, at least to recognize the factors that led to the deaths of these brave men. All of us have targets like the Super Sofa Store either in our local or mutual aid response. The construction features and fire loading practically beg for a flashover to occur, especially when committing the ultimate sin of venting behind the attack team. Approximately three or four years ago, NIOSH published a similar report of a fire in Tennesee in which the circumstances were almost identical...further proof that we need to analyze these tragedies and somehow teach our people how to recognize the danger signs.

[thecutman]

Just think!!


If the fire inspectors made them move the dumpster off the building per the code, would this fire have been that bad? Just a thought. It also shows why inspections are a valid part of fire prevention.

[papacheese]

The number of mistakes, miscues, and malfunctions are mind-boggling. I spent the better part of two hours going over the report again, admittedly skipping around a little, but I'll eventually finish it. This is a classic case of culture and tradition overpowering logic and reason. The fact that the Chief of Department defiantly stated in a post-fire press conference stated that he would do the same thing again is truly incomprehensible and proof that our best hope of reducing senseless LODD's rests with the next generation of firefighters.

When you boil things down even more, the critical moment appears to be when the decision is made to vent the front windows...which not surprisingly, there appears to be some confusion as to who ordered.

[WebBoss]

May 17, 2008 4:48:52 GMT -5 papacheese said:

The number of mistakes, miscues, and malfunctions are mind-boggling. I spent the better part of two hours going over the report again, admittedly skipping around a little, but I'll eventually finish it. This is a classic case of culture and tradition overpowering logic and reason. The fact that the Chief of Department defiantly stated in a post-fire press conference stated that he would do the same thing again is truly incomprehensible and proof that our best hope of reducing senseless LODD's rests with the next generation of firefighters.

When you boil things down even more, the critical moment appears to be when the decision is made to vent the front windows...which not surprisingly, there appears to be some confusion as to who ordered.

There does seem to be a degree of inadequate-progressive training, but this is something you will see with most larger departments. There was obviously somethings that were very wrong and could have been corrected long before this incident, but when I read the report, I noticed more lack of good communications and complacency as the two biggest problems they faced. To Charleston's and Chief Thomas's defence, these are 2 areas that they are addressing in the wake of this incident.

[papacheese]

Chief Thomas resigned the day before the report was released, although he claims the two events are not connected. Right.

OK, I'm going to wax cynical here for a moment - please indulge me. Yes, the CFD is making great strides in correcting the host of problems this tragedy uncovered - they've graduated to supply lines bigger than 2 1/2, purchased compliant work uniforms, upgraded their apparatus, strictly enforce new PPE regulations, installed ICS into their operations, and begun an intensive training program both for their firefighters and officers.

So, here's my question: why did it have to take nine preventable LODDs to finally bring them into the 21st century? In this day and age of worldwide connectivity and communications, where a wealth of informtion and data is literally at our fingertips, how one can possibly excuse the fact that despite all the regulations, standards, and experiences in the real world surrounding them, the CFD leadership chose to ignore the hard-earned lessons that are being unfortunately repeated every single day? It's bad enough when some unexpected, unknown circumstance takes the life of a brother or sister firefighter, but why are we dying trying to save merchandise that the owners don't care enough to protect with sprinklers?

The answer is hubris, the Greek word for "ego".

In reading the report, I was struck by the number of obvious reports, situations, and circumstances that demanded a change of strategy....but the department culture, their "default" posture for any fire, proved too difficult to overcome. For a fair-sized city to operate like they did is beyond my comprehension.

If I sound bitter and sarcastic, it's only because it seems like a macabre version of the movie "Groundhogs Day"...the same thing keeps happening, over and over again. I guess there's always a price to pay for knowledge and change....I just happen to think its far too steep.

We can mourn and vow to "Never Forget", but the more important thing we should do is swear "Never Again".

[thelurker]

Allow me to wax cynical for a minute also....
You can vow "Never Again," but as with every NIOSH report, there is a common thread. Say what you want, but mark my words, it WILL happen again. It might not me 9 more brothers, but the changes that are being made will be localized to the CFD and maybe a few of their neighbors. However, across the nation, the majority of "powers that be" will either not read or disregard this report with the old "well we're not Charleston" excuse. I appreciate what you are saying Papa, but nothing will change across the nation. There is too any politics, too much money involved, and too much home rule for anything to ever change as it should. The fire service is reactionary, and will continue to be so until.....well, I don't know until when, but as long as the we've always done it that way, and the we have to do whats best for the company, guys are around, the fire service won't have a culture shift.

[papacheese]

Wow...I though I was cynical! LOL

Lurker, I can't disagree with your opinion, for it seems like no matter what happens, there's always that group "out there" who, for whatever reason, chooses to bury their heads and ignore the real world around them.

But here's the thing....

Twenty years ago we would have eventually heard a little about the incident and thought "Wow...bad karma"; today we get ALL the info. Twenty years ago we would have given the subject maybe ten minutes of thought, then moved on because "tradition" stated that we will lose firefighters. Today, we question, analyze, review, and identify what went wrong.

The change will not happen soon, but (I hope) it will eventually take root, not with my generation, but with yours. I read the comments and thoughts of a lot of the younger brothers and sisters on this forum and in person and I detect a slightly different mind set than what I'm used to. Politics WILL be politics, that's for sure...politicans don't have to crawl down smoke-filled hallways. Somewhere on this forum, there are future chief officers reading and thinking about what we post here. They may not agree with everything we say, but at least they're THINKING, something that unfortunately was almost non-existent years ago. Somewhere in the back of their mind, they're filing away the information and items we discuss and will hopefully trot them out when the time comes.

[thelurker]

I hope you're right Papa....I hope you're right

[chief3102]

I agree with what papa, lurker and webboss have said. Each has its own merits. Here’s my waxing:

I think that Chief Thomas was doing what “he” thought was right for his department. In today’s day and age however, he should be tried criminally for what “he” though t was right. There is absolutely no reason on God’s earth that in today’s world they would walk into a tinderbox with a damn booster line. There is no reason that they used such shitty supply lines. There is no reason for a whole lotta shit that took place other that their leader had his head up his ass. I’m personally sick and tired of chief’s of departments not stepping up to the plate and doing what is right. I have no doubt that old Rusty loved his men and his department. I have no doubt that he thought it could never happen there. But does that excuse the out right negligence. I DON’T THINK SO !!!
There but for the grace of God goes a whole lot of old time Chiefs who love their departments and their men. Does that magically bring them back to life to sit with their wives and children, NO!! These same good old Chiefs are the same ones that will complain that the report is “Monday morning quarterbacking”. I know that the department is now going through some major changes to bring about change in the way they do thing and is buying new equipment. But why does it take nine dead brothers to bring about change. I would have no problem with Old Rusty if he was banging down the Mayor’s door asking for funding for equipment and training for his men and was being denied. He would have a track record of trying to do what was right. I’m sure Good Old Rusty had all the latest and greatest bells, whistles and blinky lights on his Fire SUV, but was basically sending his men into the fires of hell with their d*&ks in their hands.

Shame on Chief Rusty Thomas and any other Chief who does not demand that his men and department keep up on the training and education to fight today’s fires. Shame on them, for not demanding that their departments be equipped properly.

[papacheese]

Chief...you managed to find the words that were eluding me...my outrage sometimes can't be channeled correctly.

Is it any wonder why there has been an increase in criminal charges being levied against IC's who fail to do their job properly? Again, we have no one to blame but ourselves. Hoot and hollor about government sticking their noses in our business all you want...it will be as effective as howling at the moon. The handwriting is on the wall: the "old school" brand of firefighting might have been a lot more fun, but it was also far more deadlier to a few unfortunate brothers and sisters.

Earlier this year I had to present anti-discrimination and anti-harassment training to my department members, never an enjoyable class to teach or sit through. In trying to summarize a confusing array of procedures and policies so that everyone understood the situation, I told them the easiest and simplest course of action is to ask themselves: "Am I prepared to defend my words or actions?"

The same goes for ICs and officers. It is not longer a viable defense to say "That's how we've always done it", or "I never considered the possibilty", "We didn't adopt that standard" or "Nothing like that has ever happened before". It is no longer possible to claim ignorance or brush aside regulations we don't agree with. Like it or not, our little secluded world is changing, ever so slowly but surely.

My reaction to Chief Thomas's situation is very mixed; as 3102 stated, he probably had become very comfortable with the way things were going in his department....why upset something that's going good? Until that fateful evening, the CFD had been doing things the way they wanted, thumbing their collective noses at the world around them. In the immediate aftermath of this tremendously heartbreaking loss, I remember that his initial reaction was one of arrogance and defiance, stating that they would continue doing things the same way and that OSHA didn't apply to the CFD. I remember shaking my head in disbelief and chalking up his statements to shock.

One only has to read through the report to fully appreciate the sheer senselessness of this tragedy.

Officers: it isn't always the most popular thing to do, but sometimes you have to care enough about your people to keep them away from situations which are obviously detrimental to their life and health.

[chief3102]

Amen Brother Rick, Amen.

My outrage is boiling also, and I haven't done more that a cursory glance through the report. I too had the hairs on the back of my neck standing up at the arrogance of Chief Thomas' remarks. I remember you and I having the discussion and trying to find a reason for him making such statements. We agreed that the statements had to be because he was in shock, because no one could possibly be that arrogant. Well,
dip me in shit and call me stinky because he sure as hell was that much of a bombastic a-hole. His callous disregard for the safety of his men is beyond comprehension. For any Chief's or Officers out there who think that NFPA is just a guideline, do yourself and the future of the fire service a favor and retire immediately. I am tired of shedding tears because of you and your kind.

I will now go soak my head.

Thank you.

[papacheese]

How many "out there" have actually taken the time to read the report?

That wasn't meant to poke or prod, but simply find out. Many may be put off by the sheer length of the report (272 pages), but it's well indexed so you can immediately find the parts that interest you.

Here's a recommendation: if nothing else, take a couple of minutes to read or thumb through the radio transcript which begins with the 911 phone call and ends well after the collapse. Ask yourself if it all seems very familiar....do we sound like that? My personal horror is the amount of radio traffic going on before and after the interior crew begins calling for help - radio chatter about increasing pressure because the supply hose is so woefully inadequate, or the miscommunication/misunderstanding between the Chief and Assistant Chief regarding interior conditions. Bear in mind that no one on the actual incident scene ever heard a call for help - only an off-duty BC with a portable did, who then had to drive directly to the scene because he couldn't break through the ceaseless chatter to tell the Chief there were firefighters calling for help inside.

The more I read, the more appalled I become. Ladies and gentlemen: do not pass this one up - make time to read it; it's that important.

Move over Chief, I need to soak my head too....

[thelurker]

I'm working on reading it now actually.....

[Bossa]

Well, I finished reading this and it is just sad that this happened in todays times.

The tactics employed were archaic so to speak and I am still having problems understanding the idea behind 2 1/2 inch supply lines.
I remember this chief spouting off about how he wouldnt have done anything different if he had to do it all over again and reading this made me want to hit him upside the head with a baseball bat.

I think reveiwing this report with all our members is important. Maybe this will sink in and they can understand why freelancing is such a bad thing, because when you really look at this incident, thats basically what it was... A big freelance party!

What makes it even sadder is we have certain famous fire companies in PG Maryland that have the some things in common with this department... small supply lines, "Pride in aggressive interior attacks", John Wayne style tactics.... It makes me sad knowing not if this will happen again, but when!

[thelurker]

Over 100 years of tradition un-impeded by progress.....

[papacheese]

I have a basic philosophical problem with any department that outright declares itself as "aggressive"...exactly what does that mean? That no matter what, they'll make an interior push just to keep their "tradition" alive?

Judging from my posts, more than a few of you probably think I'm against interior attacks, but nothing could be farther from the truth...I just believe in choosing my battles, especially in this day and age. What we seem to be lacking is an intensive course in the basics of risk assessment and management, especially for officers. To some degree that's being addressed through a greater emphasis on learning more about building construction, a key element in the decision-making process. But there's much more to the process than just how the target was built. Fire involvment, growth, rescue profile, resources, weather, water......all these have to be factored and decided upon before committing to a strategy. This can't be a 100% "instinctive" thing...we have to use our heads when making a decision that could affect lives.

Bossa's comment about freelancing hit the nail exactly dead center...it was pretty much a "do whatever you want" event from the get-go. Like most tragic events, there wasn't just one specific misjudgment, but a whole series of them strung together.

I also focused on the exchange between the Chief and Assistant Chief right before the event occurred, when the lack of clear communication about the situation on Division A no doubt painted a very different picture in the Chief's mind...what if the AC had said "Heavy smoke in the showroom", or "Our guys are still in there"? The mere fact that a HUGE showroom is filled, top to bottom, with thick, ugly smoke is by itself a warning that there's a whole lot of fire somewhere, trying to find it's way out. To be perfectly blunt, that alone is reason enough to call an evac, regroup, reassess, and change tactics.