Case Study: Publication Manual of the American Psychological Association
Instructions:
All case study reports must comply with the Publication Manual of the American Psychological Association (APA), Sixth Edition for writing conventions, organization, and formatting.
After thoroughly reading the following case study, write a three to four page paper with your analysis of the problem, your conclusions of the cause and your suggestions for how to prevent this from occurring on other similar incidents. The following discussion points should assist you:
What factors/operations contributed to this incident?
As the safety and health program manager, what recommendations would you make in order to prevent similar incidents?
What standards and regulation, if any apply to these types of operations?
Incident Description:
On February 17, 1997, two male firefighters (the victim and injured) were part of a fire company that responded to a single family dwelling fire. When the fire company arrived at the fire scene, the District Major reported heavy smoke emitting from the roof area of the dwelling. The victim and injured pulled two water hoses from the engine they were assigned to and proceeded toward the dwelling. After knocking down a ceiling fire, they entered the dwelling through the front door and both immediately fell through the floor into the basement area. One firefighter was seriously injured while the victim died from asphyxiation.
Incident Analysis:
On February 17, 1997, at 0009 hours, a fire call came into the 911 dispatcher from the occupant of a private residence adjacent to the incident site. The call was immediately directed to the fire station serving the district of the city where the fire was located. The District Major 204, Engine 11, Engine 6, Emergency Medical Service EC6, and Aerial 4 were ordered to respond. Altogether, 5 pieces of equipment and 16 personnel arrived at the fire scene between 0013 hours and 0014 hours. The District Major was first on the scene at 0013 hours and assumed command. All the remaining vehicles and crews arrived seconds behind the District Major.
When the District Major pulled up near the front of the residence where the incident occurred, he reported heavy smoke coming from the structure. He the asked a small group of spectators standing on the street whether anyone might be in the house. A spectator responded that he didn’t think anyone lived there. He then ordered firefighters from Engine 11 to pull two 1 ¾–inch waterlines and approach the front door area. After the lines had been pulled and moved to the door area, it was discovered that the pressure relief valve on the Engine 11 water pump was sticking and could not sustain adequate water pressure.
In the interim, a firefighter attempted to open the front door, but found it was locked. He kicked open the door, which allowed considerable amounts of heavy black smoke and heart to emit from the door opening. He was ordered to close the door and pull two lines from Engine 6. Also, firefighters from Aerial 4 had started a generator and illuminated the area, then carried two positive pressure ventilation (PPV) fans to the front of the residence. The PPV fans were started, by use of the fans was restricted until charged lines were brought to the front door area. Other firefighters had pulled exposure lines and were fighting fires on the opposite side of the structure and protecting an adjacent residence.
While the District Major was working with the engineer from Engine 11, trying to get the pump on Engine 11 functioning, he called for Engine 6 to pull two waterlines. Two firefighters (the victim and inured) pulled two lines from Engine 6 and proceeded to the front door of the residence. The airflow volume of the PPV fans was increased and aimed toward the door opening. The two firefighters from Engine 6 donned their self-contained breathing apparatus (SCBAs) and knocked down some fire in the ceiling area of the structure before making entry (unknown to the firefighters, that three separate fires were burning in the basement—one fire was directly below the entry of the front door).
Shortly thereafter (about 2-3 minutes after donning their SCBAs) the two firefighters entered the house through the front door to attack the interior fire, and immediately fell through the floor into the basement area. Approximately 8 minutes had elapsed and the District Major said “Let’s ease off this thing for a minute,” (pull back and regroup), and then realized two firefighters were missing. A lieutenant, after being advised of the problem, crawled along the ground and discovered hose lines going into the front doorway and down into a hole. A light from a flashlight was seen in the smoke/darkness of the hole and the lieutenant stuck his right hand into the floor opening and was grabbed by one of the firefighters (injured).
At about the same time, firefighters on the outside of the house lowered a 14-foot ladder through the front doorway into the basement; the ladder brushed up against the injured firefighter and he grabbed it. The injured firefighter was pulled from the basement area with the aid of the ladder. The injured firefighter, after being extracted from the basement, advised others that the other firefighter was still in the basement. Numerous search and rescue efforts were make through the hole in the floor and from the back door to the basement.
The victim was eventually located and removed from the basement area, and vital signs were checked at 0118 hours, approximately 53 minutes after the victim and injured were discovered missing. The injured firefighter reported that both he and the victim sprayed water on one another trying to stay cool. It was also reported that the injured firefighter had manually activated his personal alert safety system (PASS) device. However, due to the noise of the engines, pumps, PPV fans, etc., no one heard the alarm. Approximately 8 to 10 minutes after entering the structure, both firefighter’s SCBAs ran out of air and they tried to breathe entrained air from the water spray from their lines.