Accident Review Factual Report Huntsman Incident

SACRAMENTO FIRE DEPARTMENT SACRAMENTO METROPOLITAN FIRE

DISTRICT

Accident Review Factual Report

Structure Fire-Fall Injury

February 26, 2011

3341 Huntsman Drive

CA-XSA-11-24041

The Board of Review approved this report on July 26, 2011.

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ACCIDENT REVIEW REPORT SACRAMENTO FIRE DEPARTMENT HUNTSMAN DRIVE-XSA 11-24041 SACRAMENTO METROPOLITAN FIRE DISTRICT

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Investigative Team 1 2 3

Kim Iannucci, Assistant Chief 4 Sacramento Fire Department 5

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Team Members 13 14 15

David Baldwin, Captain 16 Sacramento Fire Department 17

18 Rick Lee, Captain 19

Sacramento Fire Department 20 21

Michael Teague, Captain 22 Sacramento Metropolitan Fire Protection District 23

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Technical Specialists 27 28 29 30

Barbra Brenner, Safety Specialist 31 City of Sacramento- Risk Management Division 32

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Board of Review 1

2 Lloyd Ogan 3

Sacramento Fire Department 4 Deputy Chief – Operations 5

6 Brian Rice 7

Sacramento Metropolitan Fire District 8 Deputy Chief – Operations 9

10 John Michelini 11

Cosumnes Fire Department 12 Deputy Chief – Operations 13

14 Jody Gossner 15

California Department of Forestry and Fire Protection 16 Amador-El Dorado-Sacramento-Alpine Unit 17

Deputy Chief 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

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Table of Contents 1 EXECUTIVE SUMMARY ...................................................................................................... 7 2 INTRODUCTION .................................................................................................................. 9 3

Terminology .................................................................................................................... 10 4 Building Layout ............................................................................................................... 11 5 Report Organization: ....................................................................................................... 12 6

DEPARTMENT DEMOGRAPHICS .................................................................................... 13 7 Sacramento Fire Department ......................................................................................... 13 8 Sacramento Metropolitan Fire District ............................................................................. 13 9 Standard Operating Guidelines ...................................................................................... 14 10

STRUCTURAL SUMMARY ................................................................................................ 15 11 Building Construction Features: ...................................................................................... 15 12

Roof Assembly ............................................................................................................ 16 13 Wall Construction ........................................................................................................ 16 14 Floor Assembly ........................................................................................................... 16 15 Windows ..................................................................................................................... 16 16

Exposures: ...................................................................................................................... 16 17 Alpha Side ................................................................................................................... 17 18 Bravo Side .................................................................................................................. 17 19 Charlie Side ................................................................................................................ 17 20 Delta Side ................................................................................................................... 17 21

PRE-INCIDENT INFORMATION ........................................................................................ 19 22 Pre-Incident Company Status and Location ................................................................... 19 23 Weather Conditions ........................................................................................................ 21 24

INCIDENT NARRATIVE & TIMELINE ................................................................................ 23 25 PHOTOGRAPHS & ILLUSTRATIONS ............................................................................... 29 26 FINDINGS .......................................................................................................................... 33 27

Human Findings.............................................................................................................. 33 28 Management Findings .................................................................................................... 35 29 Building Findings ............................................................................................................ 36 30 Equipment Findings ........................................................................................................ 37 31 Communications Findings .............................................................................................. 38 32 Staffing/ Response Time Findings .................................................................................. 38 33

CAUSAL AND CONTRIBUTING FACTORS ...................................................................... 39 34 Causal Factors ............................................................................................................... 39 35 Contributing Factors ....................................................................................................... 39 36

LESSONS LEARNED ........................................................................................................ 41 37 RECOMMENDATIONS ...................................................................................................... 43 38 SIGNATURE PAGE ........................................................................................................... 45 39 APPENDIX A - INCIDENT COMMUNICATIONS ............................................................... 47 40

Radio System Overview ................................................................................................. 47 41 Incident Radio Traffic Transcript ..................................................................................... 49 42

Appendix B - Glossary and TERMS ................................................................................... 57 43 Appendix C - Standard Operating Guidelines .................................................................... 65 44 45 46 47 48


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EXECUTIVE SUMMARY 2

3 The Huntsman Drive fire was reported on February 26, 2011 at 21:09 hours Pacific 4

Standard Time (PST) in the Rosemont neighborhood, located in the un-incorporated 5

section of Sacramento County, California, and within the jurisdiction of the Sacramento 6

Metropolitan Fire Department (SMFD). As part of the long standing “boundary drop” 7

agreement between fire agencies in Sacramento County, a Sacramento Fire Department 8

(SFD) Engine Company was assigned to the incident as part of the first alarm response. 9

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At approximately 21:15 SMFD Engine 54, the second arriving engine, assumed Incident 11

Command, and assigned SFD Engine 60 to conduct vertical ventilation. At the time the 12

order was given to Engine 60 to ventilate there was no truck company on scene. 13

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At 21:19 an “Emergency Traffic” was transmitted informing the Incident Commander that a 15

Firefighter was down after falling from a ground ladder. While attempting to transition from 16

a portable ground ladder to the roof of the structure, the Company Officer from SFD Engine 17

60 fell approximately 8 feet to the concrete driveway below, landing on the SCBA bottle that 18

was attached to his back. The Company Officer received care from on scene medics and 19

was transported to the UC Davis Medical Center with a serious low back injury. 20

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INTRODUCTION 1

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This Accident Investigative Report is a comprehensive and factual review of the response 3

to the February 26, 2011 fire incident on Huntsman Drive. Specifically, the Investigative 4

Team was asked to: 5

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“Obtain all available incident facts/information and communicate a detailed, 7

validated factual incident review report to the Sacramento Fire Department 8

and the Sacramento Metropolitan Fire District. All information contained in the 9

report will be factual documentation of the events leading up to the incident, 10

the incident operation(s), and incident mitigation to include treatment and 11

transport of the injured personnel. The results of the findings and 12

recommendations will be used as lessons learned for Fire Service in 13

Sacramento County.” 14

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Personnel from the Sacramento Fire Department, Sacramento Metropolitan Fire 16

Department, and the City of Sacramento Risk Management Division worked cooperatively 17

to investigate the events leading up to the injuries to the Fire Captain. 18

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Terminology 1 2

All of the times used in this document are expressed using the 24-hour clock. In December 3

2007, the Sacramento Operational Area adopted International Phonetic Alphabet, which 4

assigns a word to each letter of the alphabet, as listed below: 5

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A – Alpha H – Hotel O – Oscar V – Victor 7

B – Bravo I – India P – Papa W – Whiskey 8

C – Charlie J – Juliet Q – Quebec X – X-ray 9

D – Delta K – Kilo R – Romeo Y – Yankee 10

E – Echo L – Lima S – Sierra Z – Zulu 11

F – Foxtrot M – Mike T – Tango 12

G – Golf N – November U – Uniform 13

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These words are used whenever it is necessary to identify any letter of the alphabet over 15

the 800 MHz radio system or refer to the sides and interior divisions of a building (Figure 1). 16

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Building Layout 1 2

Building layout, location, and exposures are commonly identified with a letter (alpha) and a 3

number (numeric) to describe the location of the structure relative to the fire building. The 4

term “exposure” refers to a structure that is attached or adjacent to the fire building. 5

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Alpha Side

Bravo Side

Charlie Side

Delta Side

A/B Corner

B/C Corner

C/D Corner

A/D Corner

Figure 1: The Alpha/Numeric graphic representation of the building sides.


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Report Organization: 1 2

This Report is organized into twelve (12) sections and three(3) Appendices. Each Section 3

is divided into various sub-sections, which include relevant background information, specific 4

discussion pertaining to the incident on Huntsman Drive, and, where applicable, 5

recommendations for future action. The Appendices include a comprehensive post incident 6

analysis of equipment used by the injured personnel, and a glossary of common terms 7

used by the Sacramento Fire Department and the Sacramento Metropolitan Fire District. 8

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DEPARTMENT DEMOGRAPHICS 2

Sacramento Fire Department 3 The Sacramento Fire Department is a full-time paid professional fire department and has 4

been serving the citizens of the city of Sacramento since 1850. The Department provides 5

fire suppression, advanced life support transportation, hazardous materials response, 6

technical rescue operations, fire prevention, and public education to the citizens of 7

Sacramento and to the contract areas of the unincorporated portions of Sacramento 8

County. The Department is also the sponsoring agency for the Sacramento Urban Search 9

& Rescue Team, California Task Force 7. . 10

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Currently the department deploys 23 Engine Companies, 8 Truck Companies, 1 Rescue 12

Company, 13 ALS Ambulances, 4 Battalion Chiefs, covering an area of 99 square miles in 13

the incorporated portion of the city and provides services by contract to 45 square miles of 14

unincorporated Sacramento County. The Department currently serves 530,000 residents 15

and over 500,000 transient workers due to a large state and federal government workforce 16

associated with being a State Capital. The total daily suppression strength is 150 17

members. All suppression companies are staffed with four (4) personnel consisting of: 18

Company Officer (Captain), Engineer, and two (2) Firefighters. The department responds to 19

over 70,000 calls for service annually. 20

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Sacramento Metropolitan Fire District 22 The Sacramento Metropolitan Fire District was created December 1, 2000 when the 23

American River Fire District and the Sacramento County Fire District merged creating the 24

7th largest fire department in the State of California. Metro Fire represents 16 predecessor 25

agencies. Metro Fire provides fire suppression, fire prevention, advanced life support 26

transportation, technical rescue, and hazardous materials response to 417 square miles of 27

eastern Sacramento County including the incorporated city of Rancho Cordova and Citrus 28

Heights. 29

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Metro Fire responds to 70,000+ requests for service each year from 37 fire stations 31

arranged in 5 battalions. Metro Fire deploys 37 engines, 4 trucks, 1 heavy rescue, 1 32


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hazmat, 1 ARFF and 13 advanced life support ambulances with a daily staff of 168. These 1

stations protect over 650,000 people. The area is composed of residential, industrial, 2

wildland urban interface and rural grass lands. Staffing on Engines is one Captain, one 3

Engineer and one Firefighter. All engine companies have at least one paramedic assigned. 4

Staffing for trucks, hazmat and rescue is one Captain, one Engineer and two Firefighters. 5

Ambulances are staffed with two firefighters, one of which is a paramedic. 6

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Standard Operating Guidelines 8 In 2010, the Sacramento County Operating Area began developing a set of regional 9

Standard Operating Guidelines (SOG). The first set of SOGs including the SOG for 10

residential structure fires were implemented July 1, 2010. 11

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The Regional SOGs required the development of standardized naming of the riding 13

positions on all emergency apparatus. These riding positions are identified by rank and 14

function, with each position having a name and set of basic responsibilities on any given 15

emergency. All company members are identified by their riding position and the company 16

they are assigned to. 17

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On an Engine Company the pre-assigned riding positions are: Officer (Captain), Engineer, 19

Nozzle Firefighter and Back-Up Firefighter. The riding positions identifiers on the Truck 20

Company are: Officer (Captain), Engineer, Saw Firefighter and Tools Firefighter. If a 21

department member is calling a particular company, then the Officer will answer the radio 22

for that company. (e.g. “Engine 1, Engine 2.”) The Officer for Engine 2 would answer the 23

radio). If a one member needs to talk to a particular company member, then that member 24

is identified by their riding position and company identifier. (e.g.: “Truck 1 Captain, Truck 1 25

Saw”). 26

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All references to members involved in this incident will be referred to by their riding 28

positions 29

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STRUCTURAL SUMMARY 4

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The Huntsman Drive incident occurred in a neighborhood known as Rosemont, which is 6

located in an unincorporated section of Sacramento County on the east side of the 7

Sacramento city limits. The basic structural information is a follows: 8

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• One story single family dwelling built in 1974 10

• 3 bedroom, 2 bathroom 11

• 1368 square feet 12

• 45’ wide by 55’ deep 13

• Wood frame (Type V) 14

• Conventionally framed roof assembly with composition shingles 15

• Stucco exterior wall covering 16

• Windows were boarded up at the time of the fire 17

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Building Construction Features: 19

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In the fire service, the term “building construction” refers to the type of construction of the 21

structure, as well as the combustibility and the fire resistance rating of a building's structural 22

elements. To classify buildings consistently, the National Fire Protection Association 23

(NFPA) has developed five “Types” of construction. The structure on Huntsman Drive was 24

of Type V construction, which means that its structural members consisted entirely of wood 25

and is probably more vulnerable to fire, both internally and externally, than any other 26

building type. 27

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This was the second fire in this structure. The previous fire occurred on 02/14/2011with the 29

fire involving room and contents located in C/D corner of the structure. After the fire was 30

extinguished, the windows and the ventilation hole in the roof were covered with plywood 31

by the restoration construction contractor. 32


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Roof Assembly 2 The roof was constructed from 2”X6” rafters that were placed 16 inches on center. The roof 3

was sheathed with ½ inch plywood. There were 2 layers of compositions shingles attached 4

to the roof. On the charlie side, a 4 foot by 4 foot ventilation hole was present from a 5

previous fire. This hole was covered with a 4’ by 8’ piece of ¾ inch plywood secured by 6

decking screws. 7

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Wall Construction 9 All interior and exterior walls were constructed of 2” X 4” wall studs that were 16 inches on 10

center. The interior walls were covered with ½ inch sheet rock. The exterior walls were 11

covered with paper and stucco. There were no shear panels present. The exterior wall void 12

spaces were filled with roll-in fiberglass insulation. 13

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Floor Assembly 15 The floor assembly was composed on 2” X 6” tongue-in-grove subfloor. Most of the floor 16

was covered with carpet. 17

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Windows 19 The windows were single pane aluminum construction. All the window openings were 20

covered with ¾ inch plywood after the building sustained fire damage on February 14, 21

2011. 22

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Exposures: 25

The exposures adjacent to 3341 Huntsman Drive were not a factor and did not play a role 26

in the outcome this incident. (Map 1) 27

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Alpha Side 1 The Alpha exposure was a landscaped front yard and street. At the A/B corner there was 2

six foot wood fence which slightly impeded the movement of the ground ladders down the 3

Bravo side. 4

Bravo Side 5 The Bravo-1 Exposure, located approximately 20 feet away, was a two story single family 6

dwelling of similar construction. The exposed surfaces of the structure consisted of stucco 7

siding. No fire or heat damage was reported for this exposure. 8

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Running along the property line between the two structures is a 6 foot high wood fence. 10

This fence ran from the C/D corner of the Bravo-1 exposure and ran the entire length of the 11

property line and ended in the backyard. There were several aluminum sheds along the 12

fence line. None of the sheds received damage from the fire. 13

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Charlie Side 15 The Charlie Side contained a large concrete patio and a large RV parking pad. The parking 16

pad was access for the delta side on Thilow Dr. There was also a small area of grass. 17

Running along the rear property line was a 6 foot wood fence. 18

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Delta Side 20 The Delta side of the structure was composed of a landscaped side yard that ran along 21

Thilow Drive. The landscaping limited access for ground ladders on this side of the 22

structure. 23

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IMPACT ON INCIDENT 1

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The sheets of plywood on the windows and doors contributed to the delay in horizontal 3

ventilation, which may have been a contributing factor in the buildup of heat conditions that 4

delayed the advancement of the attack hoseline. 5

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Map 1: Aerial view depicting the location of 3341 Huntsman Drive.

Thilow Dr

Huntsman Dr

3341 Huntsman Dr

Alpha Side

Bravo Side

Charlie Side

Delta Side


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PRE-INCIDENT INFORMATION 1

Pre-Incident Company Status and Location 2 At the time of the incident, all of the first alarm companies were available in quarters. 3

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AIQ= Available in quarters 14

AOR= Available on radio 15

Unvail= Unavailable for dispatch 16 17

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Company Status* Staffing Distance to Incident [9]

E 62 AIQ 3 1.1 mi E 54 AIQ 3 1.4 mi E 60 AIQ 4 2.6 mi E 61 AIQ 3 4.4 mi

TR 65 AIQ 4 7.0 mi TR 50 AIQ 4 6.0 mi

Batt 9 (Sta 50) AIQ 1 6.0 mi Batt 14 (Sta 66) AIQ 1 6.2 mi

M 61 AIQ 2 4.4 mi


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3341 Huntsman

3341 Huntsman

Legend

Engine 60 District SMFD Response area 240047-CAD Pick Zones

3341 Huntsman Drive

Map 2: Station locations in relation to incident location.


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Weather Conditions 2 3

Weather conditions at 2109 hours taken at the Sacramento Regional Fire Emergency 4

Communications Center weather station, located 2.45 air miles from Huntsman Drive, at 5

the time of the incident: 6

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8 Temperature: 43.5F 9

10 Humidity: 62% 11

12 Wind Speed: 5 mph 13

14 Direction: 326 degrees 15

16 Sky: Clear 17

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INCIDENT NARRATIVE & TIMELINE 1

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The development of an accurate account of the events as they transpired requires the use 3

of multiple sources including: dispatch logs; radio transmissions; individual statements; 4

interviews; and electronically recorded MDT transmissions. When a specific sequence of 5

events occurred simultaneously, all attempts were made to place them in the best logical 6

order. The names of the Department members involved in this accident have been 7

redacted from this report and they are referred to by their riding/assignment position. The 8

sequences of events are described in the narrative below: 9

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On the evening of February 26, 2011, at 21:09 PST, the Sacramento Regional Fire 11

Emergency Communications Center (SRFECC) begins receiving multiple calls for a house 12

fire located at 3314 Huntsman Drive. The first 9-1-1 caller reported visible flames from the 13

back of the corner house that faces Huntsman Drive, and that the house appears boarded-14

up. 15

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Shortly after the initial call was processed, the SRFECC received five additional 9-1-1 calls 17

reporting the same information as the original caller. 18

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At 21:09:02 (+0:00) the SRFECC dispatched a residential house fire assignment to 3341 20

Huntsman Drive. The assignment included: 4 Engine Companies, 2 Truck Companies, 2 21

Battalion Chiefs and 1 Medic. As part of the assignment, the tactical radio channel of A6 22

was pre-assigned for on scene operations. The companies assigned were: SMFD Engine 23

62 (1st due Engine); SMFD Engine 54 (2nd due Engine); SFD Engine 60 (3rd due 24

Engine); SMFD Engine 61 (4th due Engine), SMFD Truck 65 (1st due Truck); SMFD 25

Truck 50 (2nd due Truck); SMFD BC 9 (1st due Battalion Chief); SMFD BC 14 (2nd 26

due Battalion Chief); SMFD Medic 61 (1st due Medic) 27

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The 1st due Battalion Chief, Battalion 9, conducted a roll-call on radio channel A6 to ensure 29

all companies were enroute and on the correct radio channel and continued with the roll-30

call process until all companies assigned acknowledged. 31

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21:12:00 (+3:58) SMFD Engine 62 was the first arriving engine and transmitted the 1

following report on conditions: 2

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“62’s arrived. We got a attic fire at the same house we had the fire at about a 4

week ago. Be advised we have an attic fire. Engine 62 is assuming fire 5

attack.” 6

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The Officer and Nozzle Firefighter of Engine 62 stretched the initial attack line and began 8

interior fire attack, while the Engineer assisted with other support functions on the exterior. 9

The Officer reported progress into the structure was slowed due to the heat conditions and 10

ventilation was needed. 11

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21:13:48 (+4:46) SMFD Engine 54 was the second arriving engine and radioed the 13

following: 14

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“We’re at the hydrant at Huntsman and ahh, I can’t remember what it is. I 16

think its Rosemont. We’re laying into the scene. Engine 54 will be assuming 17

Huntsman Command here in just about 30 seconds. We’ll give you an update 18

in a second.” 19

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21:14:08 (+5:06) Battalion 9, not yet on scene, acknowledged Engine 54’s transmission: 21

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“Copy 54’s got water and Command” 23

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21:14:20 (+5:18) Engine 54 replied back to Battalion 9: 27

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“Engine 62 is going to be Fire Attack, Engine 54 is getting water supply. We’ll 29

provide 2 out at this point. And I’ll get some other crews going when they get 30

here.” 31

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Engine 54, approaching from the south, laid in wet, approximately 300 feet of LDH to 1

Engine 62. Engine 54 Nozzle remained at the hydrant during the lay-in. Engine 54 2

Engineer completed the lay and assisted Engine 62 Engineer with the completion of the 3

supply line hook up. The Engine 54 Captain assumed Command. After the water supply 4

was completed, the Engineer and Nozzle Firefighter of Engine 54 stretched the 2OUT line 5

and assumed the 2OUT team. 6

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21:14:39 (+5:37) SFD Engine 60, the third arriving engine, transmitted “On scene” from 8

their MDC, and simultaneously announced on the tactical channel that they were on scene. 9

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After Engine 60 arrived, the Back-Up Firefighter and Nozzle Firefighter retrieved their tools 11

and removed the 14’ roof ladder from Engine 60 and proceeded to the Alpha side of the 12

building where they encountered the Engine 54 Captain, who had just completed a visual 13

inspection of the Bravo and Charlie sides, and were instructed face-to face by the Engine 14

54 Captain (IC) to perform vertical ventilation and remove the plywood sheeting that was 15

covering the previous ventilation holes. At the time the instruction was given, Engine 60 16

Captain was not present, because he was still obtaining this equipment from the engine. 17

The Engine 60 Captain his first knowledge of the ventilation order is when he heard the IC 18

transmit the assignment over the radio: 19

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21:15:48 (+6:46) 21

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“All incoming units, we have Engine 60 taking vertical ventilation. Incoming 23

Engine 60 has vertical ventilation. Firefighter 54 shut off the hydrant. 24

Firefighter 54 shut off the hydrant.” 25

26 The Nozzle Firefighter and Back-Up Firefighter from Engine 60, spotted and raised the 27

ladder to the eve-side of the roof of the garage located at the A/B corner of the structure. 28

The ladder lay resting against a metal rain gutter of the structure. Neither firefighter noted 29

the slope of the concrete driveway, where the ladder was footed. None of the three 30

members of Engine 60 remember exactly how many rungs of the ladder were extending 31

over the roof line, but they estimate it was in the range of two-four rungs. 32

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After the ladder was raised, the Back-Up Firefighter was the first to climb the ladder, while 1

the Nozzle Firefighter footed the ladder. The ladder was footed according to the 2

department standards taught in the recruit academy; the fire firefighter standing on the 3

inside of the ladder, with his back to the building, grasping the beams of the ladder with 4

each hand, and gently pulling the ladder toward his body. After the Back-Up Firefighter 5

reached the top of the ladder he stepped onto the roof, and secured the ladder by holding 6

the tip while the Nozzle Firefighter climbed. Both firefighters reported that the ladder did 7

not move or slip during the climbing process. Once the second firefighter reached the roof, 8

they proceeded to the ridge of the roof and began the ventilation process. 9

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21:16:19 (+7:17) Engine 54 (IC) updated companies assigned to the incident: 11

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“All incoming units, the majority of the fire is going to be on the C side of the 13

building. We gonna have a bedroom fire that appears to have gotten up into 14

the attic. The majority of the fire is coming from the back left window. We 15

have boards over a lot of the windows so RIC company we going to need to 16

pry off all the plywood.” 17

18 Engine 60 Engineer was the third person to reach the ladder. By the time he reached the 19

ladder, the two Firefighters had already climbed and were on the roof performing ventilation 20

operations. The Engineer proceeded to climb the ladder without it being footed, and noted 21

that when he reached the roof there was a rung from the ladder in-line with the gutters 22

edge. The Engineer also noted that when he began to transition from the ladder to the roof 23

that the ladder had “slipped” a bit, but he was able to maintain his balance. The Engineer 24

proceeded up the roof and assisted the two Firefighters. 25

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21:16:46 (+7:44) Engine 54 (IC) assigned the fourth arriving engine, Engine 61 to RIC: 27

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“E61 you’re going to be the RIC Company. I need you to go around the 29

structure once again and pry of plywood and make sure that the interior crew 30

can get out if they need to.” 31

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21:17:34 (+8:32) Battalion 14, the first arriving Battalion Chief, arrives on scene: 33


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“Battalion 14’s on scene. Command can we do a face to face” 1

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21:18:04 (+9:02) The Officer of Engine 54 transmits to all companies operating on scene: 3

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“All incoming units update from fire attack too hot inside they’re unable to 5

interior attack until we get this ventilated. E60 is working on vertical ventilation 6

at this point.” 7

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21:18:31 (+9:29) The Officer of Engine 54 assigned Medic 61 to Fire Attack. He mistakenly 9

believed that is was Medic 64. 10

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Fire Attack Engine 62 I’m sending you Medic 64 crew. 64 crew is coming to you. 12

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Engine 54 Captain walks to the Delta side of the structure to do a face-to-face transfer of 14

command with Battalion 14. 15

21:18:46 (+9:44) Truck 50 marks on scene with the MDC and voices impending arrival on 16

the Tac A6 17

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Command, Truck 50 is about 30 seconds out. 19

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Engine 60 Captain arrived at the ladder. No one was around to foot the ladder. He began 21

climbing the ladder without anyone footing it. He stepped on to the roof with his right foot. 22

The ladder began to slide out. Engine 60 Captain tried to step back onto the ladder but this 23

just accelerated the motion of the ladder. Engine 60 Captain attempted to grab the roof with 24

his right hand but was unable to hold on. Engine 60 Captain fell from the roof landing on his 25

back and SCBA. 26

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Although it was not announced on the Command or Tactical frequencies, Battalion 14 28

assumed Command. 29

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21:19:47 (+10:45) Engine 54 Engineer and Engine 54 Nozzle witness the fall from their 31

position as two out. Engine 54 Engineer transmitted the firefighter down information. 32

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Command, firefighter down A side of the building off a ladder approximately 10 feet. 1

I’ll repeat. Firefighter down out front (Covered). 2

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21:19:57 (+10:54) Battalion 14 acknowledged the emergency traffic and changes the fire to 4

a defensive mode. 5

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Okay all units this is Command with emergency traffic. We are going defensive at 7

this time. All units defensive. I got a firefighter down on the A side the building. I 8

need a medic unit to that location. Medic 61 you will now A side of the building 9

medical group. This is a defensive fire. 10

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All units exit the structure. 12

21:20:23 (+11:20) Battalion 14 notified Fire Dispatch of the firefighter down and the switch 13

to defensive mode. 14

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Fire Dispatch Huntsman Command. I’ve got a firefighter down on the A side of the 16

building, requesting a code 3 medic. Going defensive. 17

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Medic 61 began treating Engine 60 Captain. Engine 61 assisted with removing Engine 60 19

Captain’s PPE. Spinal precautions were applied. 20

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Command requested two (2) additional engine companies and an SFD Battalion Chief from 22

Fire Dispatch. Command began conducting a Personnel Accountability Report (PAR). All 23

interior firefighters were accounted for. 24

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Once all the crews were accounted for, Command began formulating a plan to re-engage 26

the fire offensively. 27

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21:30:21 (+20:58) Medic 61 transported Engine 60 Captain to UC Davis Medical Center 29

code 2. 30

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PHOTOGRAPHS & ILLUSTRATIONS 2

3 The following diagram was created by Denis Murray GIS specialist at SMFD. The 4

measurements utilized in the construction of the diagram were taken by SMFD Captain 5

Teague. Captain Teague compiled these measurements on March 1, 2011, at 3341 6

Huntsman Drive while utilizing a 14 foot straight ladder similar to the ladder utilized on the 7

fire. The photographs utilized herein were taken the same day as the measurements. 8

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The ladder was placed in approximately the same position it was in at the time of the 10

accident. The climbing angle of the ladder was set by using the method outlined in IFSTA 11

Essentials page 290. The angle of a properly set ladder should be approximate 75°. 12

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As presented in the diagram, due to the slope of the driveway, the measured angle 14

between the driveway and the ladder is 60°. This means that more of the firefighter’s weight 15

is transferred outward overcoming the frictional force that holds the ladder in place. 16

17

Captain Teague had several firefighters climb the ladder on March 1. Each time while the 18

firefighter was stepping on to the roof, the ladder began slipping. 19


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Diagram of the approximate ladder placement. 1

2


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Approximate location of the ladder 1

2 3


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6

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1

FINDINGS 2

3

The following the conclusions of the Accident Review Team based on the chronology of 4

events and factual data, weight of evidence, interviews, and professional judgment. 5

Findings are grouped into the following categories: human, building construction, 6

management, equipment, communications, staffing, response times. 7

8

Human Findings 9 10

H-1 11

All Sacramento Fire Department members assigned to the Huntsman Drive Incident on 12

February 26, 2011 met or exceeded current agency qualifications and training requirements 13

for fire positions held. 14

15

H-2 16

The personnel assigned to Engine 60 had a combined 58 years of experience. Company 17

Officer- 25 Years; Engineer-16 years; Back-Up FF- 12 years; Nozzle FF-5 years. 18

19

H-3 20

Training records indicated that all Sacramento Fire Department members training met or 21

exceeded those recommendations contained in the National Fire Protection Association 22

(NFPA) 1932: STANDARD ON USE, MAINTENANCE, AND SERVICE TESTING OF IN-23

SERVICE FIRE DEPARTMENT GROUND LADDERS 24

25

H-4 26

Training records indicated that all Sacramento Fire Department members training met or 27

exceeded those recommendations contained in the National Fire Protection Association 28

(NFPA) 1001: STANDARD FOR FIRE FIGHTER PROFESSIONAL QUALIFICATIONS 29

30

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1

H-5 2

All Sacramento Metropolitan Fire District personnel assigned to the Huntsman Drive 3

incident met or exceeded agency qualifications and training for the positions assigned. 4

5

H-6 6

Engine 60 crewmembers were not a sleep at the time of the incident. 7

8

H-7 9

The fire occurred during the 37th hour of a 48 hour shift. 10

11

H-8 12

After arrival, Engine 60 Captain was separated from his crew as he finished donning his 13

PPE. 14

15

H-9 16

Engine 60 Firefighters received orders to ventilate from the Incident Commander (Engine 17

54 Captain) without their Engine 60 Captain being present. 18

19

H-10 20

Engine 60 Captain became aware of the order to ventilate by radio transmission. 21

22

H-11 23

Engine 60 Firefighters and Engineer climbed the ladder prior to Engine 60 Captain’s arrival 24

at the ladder. 25

26

H-12 27

Engine 60 Captain ascended the ladder without it being secured. 28

29

H-13 30

During Engine 60 Captain’s transition from the ladder to the roof, the ladder slipped out 31

from under him. 32

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1

H-14 2

The ladder was spotted on the concrete driveway by Engine 60 Firefighters. 3

4

H-15 5

The interior attack crew, Engine 62 was unable to access the seat of the fire due to 6

excessive heat in the structure. 7

8

H-16 9

Engine 60 Captain received prompt medical care from the Medic 61’s crew. 10

11

Management Findings 12 13

M-1 14

The Huntsman Drive fire was located in the jurisdiction of the Sacramento Metropolitan Fire 15

Department. 16

17

M-2 18

Incident Command was established by Engine 54 and was announced over the tactical 19

channel at 21:13:48. 20

21

M-3 22

Some directions were given to the IC by the responding Battalion Chief prior to their arrival 23

on scene. 24

25

M-4 26

Incident Command was transferred to Battalion 14 on his arrival at 21:18:46. 27

28

29

M-5 30

The transfer of command was not announced on the Command or Tactical radio channels. 31

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1

M-6 2

Sacramento Fire Department engine companies are not typically assigned truck company 3

operations, for example, vertical ventilation. 4

5

M-7 6

Metro Fire engine companies are, at times, called upon to perform ventilation. 7

8

M-8 9

The incident commander deviated from the Regional Standard Operating Guideline by 10

assigning Engine 60 to ventilation. 11

12

Building Findings 13 14

B-1 15

The fire building was a single story residence built in 1974 16

17

B-2 18

The fire building was classified as Type V construction. 19

20

B-3 21

The involved building sustained fire damage due to a room and contents fire 12 days prior 22

to this incident. 23

24

B-4 25

A ventilation hole was cut in the roof on the previous fire. 26

27

B-5 28

The windows and the ventilation hole were covered with plywood by a board up contractor 29

after the previous fire. 30

31

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B-6 1

The driveway is made of concrete and sloped away from the structure at a 10○ angle. 2

3

B-7 4

The building was unoccupied at the time of the fire. 5

. 6

Equipment Findings 7 8

E-1 9

The Captain was wearing department approved PPE ensemble. 10

11

E-2: 12

The ladder used was from Engine 60. 13

14

E-3: 15

The ladder used was 14 foots solid beam roof aluminum ladder manufactured by the Duo-16

Safety ladder company. 17

18

E-4 19

The ladder was placed in service with Engine 60 in December 2010. 20

21

E-5 22

This ladder, as well as all ladder used by the Sacramento Fire Department, meet the 23

recommendations set forth in the National Fire Protection Association (NFPA) 1931 24

STANDARD FOR MANUFACTURER'S DESIGN OF FIRE DEPARTMENT GROUND 25

LADDERS 26

27

28

E-4 29

Ladders are tested as required by NFPA 1932. 30

31

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07/28/11 Page 38 of 71

Communications Findings 1 2

C-1 3

The SRFECC assigned tactical channel Alpha 6 (A6) for the Huntsman Drive incident. 4

5

C-2 6

There were no reports of communications problems, or radio failure during the incident. 7

8

C-3 9

The tactical frequency (A6) did not appear congested throughout the incident. 10

11

Staffing/ Response Time Findings 12 13

SR-1 14

All companies responding to this incident were running with their department’s standard 15

staffing levels; four person for SFD; thee on SMFD engines, and four of SMFD trucks. 16

17

SR-2 18

The closest truck company was located at Station 50, six (6) miles from the incident 19

location. 20

21

SR-3 22

The initial engine arrived on scene in 4 minutes 12 seconds after dispatch within the time 23

frame recommended by NFPA 1710. 24

25

SR-4 26

The first truck company did not arrive on scene until 9 minutes 44 seconds after dispatch 27

which is 1 minutes 44 seconds longer than recommended by NFPA 1710. 28

29

SR-5 30

All first alarm units were on scene at 11 minutes 25 seconds after dispatch. 31

32


07/28/11 Page 39 of 71

CAUSAL AND CONTRIBUTING FACTORS 1

Causal Factors 2 3

Causal Factors are any behavior, omission, or deficiency that if corrected, eliminated, or 4

avoided probably would have prevented the injuries. 5

6

Causal Factor 1: 7

Engine 60 Captain ascended the ladder without the ladder being secured. H-8

11, H-12, H13, H-14 9

10

Contributing Factors 11 12

Contributing Factors are any behavior, omission, or deficiency that sets the stage for an 13 accident, or increases the severity of injuries. 14

15

Contributing Factor 1: 16

The ladder was placed on a downward sloping concrete driveway. This placement allowed 17

the ladder to be easily dislodged when transitioning to the roof. E-2, E-3, B-6 18

19


Engine 60’s crew did not maintain crew continuity. H-9, H-11 21

22


The incident commander’s order to firefighters instead of their supervisor interrupted the 24

chain of command. H-9, H-10 25

26


The Sacramento Fire Department and the Sacramento Metropolitan Fire District have 28

cultural differences as to the fireground duties and responsibilities of the engine company. 29

M-6, M-7 30

31


07/28/11 Page 40 of 71


Deployment of truck companies by both agencies has created an area where extended 2

response times are present. SR-2, SR-4, SR-5 3

4


The sheets of plywood covering the windows allowed the structure to retain the heat from 6

the fire, thus making it impossible for the interior fire attack crew to access the seat of the 7

fire prior to ventilation. B-5, H-17 8

9


The delay in the arrival of the truck company coupled with the inability to access the seat of 11

the fire placed pressure on the incident commander to find another course of action. M-8, 12

H-17, SR-2, SR-4, SR-5 13

14


Firefighters acted independently on the fireground without the knowledge of their company 16

officer. H-9, H-11 17

18

19

20

21

22

23


07/28/11 Page 41 of 71

1

LESSONS LEARNED 2

3

As a result of the After Action Incident Analysis, the Serious Accident Review Team has 4

identified some key learning points that will help prevent a re-occurrence of an event of this 5

nature. 6

7

The surface a ladder is placed on directly affects its stability. Ladders placed on sloped 8

surface will slip out more easily that on flat surfaces. Concrete surfaces do not provide 9

adequate friction to keep the ladder in place. 10

11

Maintaining crew continuity is a priority. If all four members of Engine 60 were together, it is 12

unlikely that the accident would have occurred. Captains need to keep their crews together 13

to ensure proper supervision. 14

15

There are cultural difference between the Sacramento Fire Department and the 16

Sacramento Metropolitan Fire District. These differences were made apparent as it relates 17

to the expected duties of engine companies and truck companies. Crews from both 18

agencies must understand these differences to ensure a safe response. 19

20

21

22

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2

3

4

5

6

7

8

9

10

11



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RECOMMENDATIONS 1

2

As a result of the After Action Incident Analysis, the Accident Review Team has 3

identified opportunities for improvement that will decrease the likelihood of a similar incident 4

given similar circumstances could be avoided. 5

6

Recommendation 1 7

Provide training programs that re-emphasize basic firefighting skills including raising, 8

lowering and climbing ladders. The refresher training program should emphasize the safety 9

precautions that need to be taken during the implementation of these skills. 10

11

Recommendation 2 12

Formalize interagency training so that companies along jurisdictional borders understand 13

each other’s capabilities. 14

15

Recommendation 3 16

Develop and implement leadership/followership training and crew resource management 17

training in an effort to have crews maintain cohesiveness during emergency incidents. 18

19

Recommendation 4 20

Evaluate the location of truck companies county-wide to ensure a timely response to all 21

incidents. Consider placing a truck company in the Rosemont area to reduce the response 22

time for first alarm units. 23

24

Recommendation 5 25

When the assigned medic crew is given a fire suppression assignment consider requesting 26

second medic crew to handle medical emergencies on scene. 27

28

Recommendation 6 29

Require incident commanders to maintain the chain of command when giving fireground 30

assignments. 31

32


07/28/11 Page 44 of 71

Recommendation 7 1

Crewmembers should not accept orders on behalf of their company officer. 2

3

4

5

6

7

8

9

10

11

12

13

14


16


07/28/11 Page 45 of 71

1

2

SIGNATURE PAGE 3

4

5 6 Respectfully Submitted by Incident Review Team, 7 (listed alphabetically by last name, room left for signatures) 8 9 10 11 David Baldwin, Captain Sacramento Fire Department 12 13 14 15 Kim Iannucci, Assistant Chief Sacramento Fire Department 16 17 18 19 Rick Lee, Captain Sacramento Fire Department 20 21 22 23 Michael Teague, Captain Sacramento Metropolitan Fire Department 24 25 26 27 28 29 Date 30 31 32 33 34


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1

APPENDIX A - INCIDENT 2

COMMUNICATIONS 3

4

5

6

Radio System Overview 7 8

The Sacramento County Fire Service Agencies operate on a county-wide public 9

safety and local government 800 MHz trunked radio system. The system consists of ten 10

(10) different zones, with each zone assigned to a specific agency or liked agencies. Each 11

zone contains 16 different radio channels. This system allows for county wide inter-agency 12

communications by simply switching zones and selecting the proper channel. Each zone is 13

formatted to fit the needs of that specific agency. However, all radios used by the various 14

agencies operating on trunked system are programmed the same. 15

16

The Sacramento Regional Fire/EMS Communications Center (SRFECC) is the third 17

largest fire dispatch center in the State of California dispatching over 150,000 incidents 18

annually. They are organized as a Joint Powers Authority (JPA) and are supported by the 19

fire agencies we serve. Together with these agencies, they provide fire protection and 20

emergency medical service (EMS) dispatching for nearly all of Sacramento County and 21

parts of Placer County covering over 1,000 square miles and serving over 1.3 million 22

residents. The SRFECC provides dispatching services for eight (8) different fire agencies 23

in Sacramento County. The county-wide trunked system has been operational since 1995. 24

25


07/28/11 Page 48 of 71

The Sacramento Fire Department operates on the Bravo or “B” Zone of the 800 MHz 1

trunked radio system and Sacramento Metropolitan Fire Department operates on the Alpha 2

“A” zone. The jurisdiction that the incident occurs in will dictate what zone the incident will 3

operate on. The radio programming for the Bravo zone is: 4

5

6

Sacramento Fire Department Radio Channel Template

Channel Display Description Use

1 FDSPB Dispatch Channel Dispatching incidents only

2 FCOMB2 Operational Dispatch to Field/Field to Dispatch

3 FCOMB3 Tactical Command Level Tach Channel



6 FT B6 Tach B6 Fire ground tactical operations









15 Dir 15 Direct 15 Non-trunked direct channel

16 Dir 16 Direct 16 Non-trunked direct channel

7

The Radio Channel template layout for Sacramento Metropolitan Fire Department is 8

the same, with the exception that the letter “A” would be substituted for the letter “B”. For 9

example FCOMA2 would be used to communicate between the dispatch center and field 10

units. 11

12


07/28/11 Page 49 of 71

1

Incident Radio Traffic Transcript 2

3 4

The development of an accurate timeline requires a multiple of sources including: 5

dispatch logs; radio transmission voiceprints; individual statements; and interviews; At the 6

height of the incident, there were two (2) different radio channels being utilized for this 7

incident. There are several occurrences of radio transmissions occurring simultaneously 8

on different channels. All efforts were made to place those transmissions in the best logical 9

order as possible. Some situations, time estimations were necessary because personal 10

observations and radio transmissions were made without a time record/reference or source 11

time references conflicted. When a specific time could not be determined, a best estimate 12

of time was provided. Events that occurred sometime between established time references 13

are indicated by asterisks (*). The time in pretences is the running time from time of 14

dispatch 15

16

In an effort to help eliminate confusion regarding the radio transcriptions, the radio 17

channels on the transcription table have been color coded. The assigned color code is as 18

follows: 19

9-1-1 Call Taker Radio Channel A3 20

Main Dispatcher Radio Channel A6 (Tactical) 21

CAD entries 22

MDT transmissions 23

Channel Time Unit Transcription 21:10:09 BC9, BC14, E62, E54, E60, E61, M61, TR65, TR50 Dispatched to S3 to Huntsman and Thilow A3 21:11:02 Dis. Battalion 9, Fire Dispatch A6 21:11:50 BC14 Battalion 14 on is Tac A6 21:11:54 BC9 Copy B14, Battalion 9 roll call. Engine 62, Engine 54, Engine 60 A6 21:12:05 E62 Engine 62 A6 21:12:07 E54 Engine 54 A6 21:12:10 E60 Engine 60 A6 21:12:15 BC9 Engine Medic 61 A6 21:12:18 E61 Engine 61 A6 21:12:21 M61 Medic 61 A6 21:12:25 BC9 Truck 65 and 50 A6 21:12:29 TR65 65 A6 21:12:37 TR50 Truck 50 A6 21:13:00 E62 62’s arrived. We got a attic fire at the same house we had the fire at about a week ago. Be advised

we have an attic fire. Engine 62 is assuming fire attack. A6 21:13:18 BC9 I copy 62 got a working fire in the attic from previous, previous fire. A3 21:13:29 BC9 Fire Dispatch, Battalion 9 A3 21:13:33 Dis. Fire Dispatch A3 21:13:36 BC9 62 on scene reporting a working attic fire. Could you please notify Arson 5 that this is the same

residence we had last week. A6 21:13:48 E54 We’re at the hydrant at Huntsman and ahh, I can’t remember what it is. I think its Rosemont. We’re

laying in to the scene. Engine 54 will be assuming Huntsman Command here in just about 30 seconds. We’ll give you an update in a second.

A3 21:13:50 Dis. Copy Battalion 9 Engine 62 on scene with a working attic fire, advise Arson 5 same residence as last week.

21:13:14 E62 marks on scene (4:12) A6 21:14:08 BC9 Copy 54’s got water and Command. (E54 did not mark on scene) A6 21:14:20 E54 Engine 62 is going to be Fire Attack, Engine 54 is getting water supply. We’ll provide 2 out at this

point. And I’ll get some other crews going when they get here. A6 21:14:34 BC9 Sounds good thanks. 21:14:39 E60 marks on scene (5:37)


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Channel Time Unit Transcription A6 21:14:41 E60 Engine 60 on scene. A3 21:14:47 Dis AMR108 Fire Dispatch A3 21:14:55 E23 Fire Disptatch Engine 23 can you send a code 2 medic here A3 21:14:58 Dis. Engine 23 requesting code 2 medic. AMR108 Fire Dispatch A3 21:15:10 Unk Medic its that building to your left. A6 21:15:48 E54 All incoming units, we have Engine 60 taking vertical ventilation. Incoming Engine 60 has vertical

ventilation. Firefighter 54 shut off the hydrant. Firefighter 54 shut off the hydrant. A3 21:15:52 AMR28 Fire Dispatch AMR28 go ahead and give us the call please for Medic 21. They’re unaware. A3 21:16:01 Dis. Copy AMR28 to handle in place of Medic 21. It will be code 2. A3 21:16:08 AMR28 Copy. A6 21:16:12 Unk We’re shut down. A6 21:16:19 E54 All incoming units, the majority of the fire is going to be on the C side of the building. We gonna

have a bedroom fire that appears to have gotten up into the attic. The majority of the fire is coming from the back left window. We have boards over a lot of the windows so RIC company we going to need to pry off all the plywood.

A6 21:16:42 E61 E61 is arriving from the north. A6 21:16:46 E54 E61 you’re going to be the RIC company. I need you to go around the structure once again and pry

of plywood and make sure that the interior crew can get out if they need to. A6 21:16:57 M61 Medic 61 on scene. Assignment. A6 21:17:02 Unk Hydrant we’re ready for water. A3 21:17:05 M21 AMR28 Medic 21 Are you closer to the call with TR23? The one you just jumped? A6 21:17:06 E61 61 copies we’re assuming RIC. 21:17:11 M61 marks on scene (8:09) A3 21:17:11 AMR28 Yeah Probably. We are already at Greenback and Mariposa. We take that one. Fire Dispatch AMR23

go ahead and put on that call with Truck 23. A6 21:17:12 E54 61 copy you have RIC 60’s doing the vertical ventilation at this point. A3 21:17:22 Disp. Copy AMR28 and M21 exchanging calls A3 21:17:27 AMR108 Fire Dispatch AMR108 we handle the call off of Ranger. Go ahead and cancel Engine 108. A3 21:17:30 Disp. Copy Engine 108 Fire Dispatch you copy Cancel. 21:17:31 BC14 marks on scene. (8:27) A3 21:17:27 E108 We’re copy could you put us AIQ please.


07/28/11 Page 52 of 71

Channel Time Unit Transcription A6 21:17:34 BC14 Battalion 14’s on scene. Command can we do a face to face. A6 21:17:37 E54 Affirmative. I’m meeting up with 62 year quick. I’ll be over there in about a minute. A6 21:17:42 BC14 Copy, I’ll be located on the D delta side of the fire. A6 21:17:48 E54FF Command Nozzle 54 you gonna want this hydrant charged. A3 21:17:50 Disp Truck 23 now responding with AMR28. Patient’s a 90 year old female with chest pain and rapid

respirations is clammy code 3 both units. A6 21:17:53 Unk Go ahead and charge it. A6 21:18:04 E54 All incoming units update from fire attack too hot inside they’re unable to interior attack until we

get this ventilated. E60 is working on vertical ventilation at this point. A6 21:18:31 E54 Fire attack Engine 62 I’m sending you Medic 64 crew. 64 crew is coming to you. 21:18:46 TR50 marks on scene (8:29) A6 21:18:46 TR50 Command Truck 50 is about 30 seconds out. A6 21:18:53 BC14 Truck 50 it looks like 60’s might be working vertical vent. I would like for you to assume roof

division. A6 21:18:59 TR50 Truck 50 copies assuming roof division. A6: 21:19:02 E62 Engine 62 A6 21:19:05 BC14 Go ahead 62. A6 21:19:09 E62 Be advised it’s too hot to move in we get a ventilation hole. A6 21:19:17 BC14 Okay. Go ahead and … (Covered by other traffic) 12:19:17 BC9 marks on scene (10:25) A6 21:19:20 Unk Unintelligible A6 21:19:27 BC14 … 54 A6 21:19:47 E54 Command Firefighter down A side of the building off a ladder approximately 10 feet. I’ll repeat.

Firefighter down out front (covered) A6 21:19:57 BC14 Okay all units this is Command with emergency traffic. We are going defensive at this time. All units

defensive. I got a firefighter down on the A side the building. I need a medic unit to that location. Medic 61 you will now A side of the building medical group. This is a defensive fire.

A3 21:20:07 TR23 AMR28 Truck 23. A3 21:20:12 AMR28 AMR28 Go ahead. A3 21:20:13 TR23 Your best access to this place is actually going to be off of Luce. There is a little alley back there

behind the house.


07/28/11 Page 53 of 71

Channel Time Unit Transcription A6 21:20:19 M61 Medic 61’s with the patient. A3 21:20:23 BC14 Fire Dispatch. Huntsman Command. I’ve got a firefighter down on the alpha side of the building.

Start an additional code 3 medic and we are going defensive. 21:20:27 TR65 marks on scene (11:25) A6 21:20:30 TR65 Command Truck 65 on scene. A3 21:20:32 Disp. Copy Huntsman Command. You have a firefighter down on the A side of the building requesting a

code 3 medic going defensive. A6 21:20:34 BC14 Truck 65 I would like you to come to the C side of the building and assume division Charlie and let’s

start looking at defensive operations. A6 21:20:43 TR65 Copy Division Charlie. Defensive. A6 21:20:50 BC14 Engine 61 you’re going to be medical group and the medic will be working for. A3 21:20:55 AMR28 Truck 23 AMR28 we copy thank you A3 21:21:01 Disp. Huntsman Command Fire Dispatch A6 21:21:03 BC14 Engine 54 Command you’re designator will be Division Alpha and Engine 62 is assigned to you. A6 21:21:13 E54 54 copy Division Alpha 62 is assigned to me and we are defensive posture at this point. A3 21:21:17 E53 Fire Dispatch Engine 53 AOR A3 21:21:23 Disp. Engine 53 AOR A6 21:21:24 TR50 Command Roof Division A3 21:21:29 E53 Fire Dispatch Engine 53 is there a call in our first in we can handle A6 21:21:30 BC14 Okay all units I need a quick PAR. A quick PAR. Division Alpha do you have Engine 62 and Engine 54

out of the building. A3 21:21:26 Disp. Engine 53 negative. A6 21:21:41 E54 That is affirmative. The downed firefighter is from E60 the captain. He was not inside the structure.

The ladder kicked out and he fell. A3 21:21:46 Unk Medic 109 pull up to the covered entrance in front of the fire lane. A6 21:21:51 BC14 Okay. Copy that. Advise if you still think we can do a combination attack at this time. I’m going

defensive flames are through the roof and the C side is well involved. A3 21:21:54 Unk. The far covered entrance. A6 21:22:09 TR50 Command Truck 50 A6 21:22:12 BC14 Go ahead 50 A3 21:22:13 Arson 5 Fire Dispatch Arson 5 add me to B9’s call please


07/28/11 Page 54 of 71

Channel Time Unit Transcription A6 21:22:16 TR50 You don’t want us on the roof any more do you? A3 21:22:17 Disp. Copy Arson 5 Operations A6. Other unit with traffic go ahead. A3 21:22:26 Disp. Other unit with traffic go ahead. A6 21:22:18 Bc14 That’s negative. Go ahead and hook up with Division Alpha (covered) on this for the time being A6 21:22:27 TR50 10-4 A6 21:22:32 E54 If you’re still okay with that we will do interior firefighting from the A side of the structure A6 21:22:46 BC14 Okay. All units this is Command have coordinated with Battalion 9. Battalion 9 is going to assume

Division Alpha. Front door and go in after the fire. A6 21:23:02 E54 This is Engine 54 who was Division Alpha just confirming that you understand that we have crews

going interior. A6 21:23:12 BC14 That’s affirmative. Assigning Battalion 9 to Division Alpha. He’ll be working for you. A6 21:23:19 E54 Awesome A3 21:23:27 BC14 Fire Dispatch, Huntsman Command, give me two additional code 3 engines. A3 21:23:31 Disp. Copy Huntsman Command requesting 2 additional code 3 engines. Your code 3 medic is Medic 65. A3 21:23:43 BC14 Could you also send a Sac City battalion chief to my location. I got a captain off Engine 60 that got

injured. A3 21:23:51 Disp. Copy requesting a Sac City BC A3 21:23:59 E65 Fire Dispatch Engine 65 A3 21:24:03 Disp. Fire Dispatch A3 21:24:06 E65 Would be we on the pick for an additional engine for that fire. A6 21:24:07 TR50 Command Truck 50 A6 21:24:11 BC14 50 A6 21:24:12 TR50 Utilities are secured. A3 21:24:12 Disp. Standby A6 21:24:16 BC14 Repeat your last. A3 21:24:24 Disp. Engine 65 Negative. A6 21:24:25 BC14 Okay Truck 50 I’m going to assign you ventilation group and I’ll have Truck 65 hook up with you now

as ventilation. Both units will be ventilation. Truck 50 in charge. A3 21:24:28 E65 Copy thank you. A3 21:24:34 Unk. E23 do you need a backboard in there. A6 21:24:48 Command this is RIC


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Channel Time Unit Transcription A6 21:24:48 BC14 … you’re assigned to ventilation group which is now Truck 50. A6 21:24:59 Command this is RIC A6 21:25:02 BC14 Go ahead RIC A6 21:25:05 The building has been softened the utilities have been secured. A6 21:25:12 BC14 Copy that. A6 21:25:17 TR65 Command Division Charlie Truck 65 are we being reassigned? A6 21:25:22 BC14 That’s affirmative. I’m going to make Truck 50 ventilation group. I would like you to work for him.

Truck 50 do you copy. A6 21:25:31 TR50 We’re you talking to me? A6 21:25:35 BC14 Truck 50 you are now, your designator is ventilation group and 65 truck is working for you. A6 21:25:43 TR50 Truck 50 copies ventilation group. Truck 65 working for me. A6 21:25:52 TR65 Ventilation Group Truck 65 what do you need? A6 21:25:59 TR50 Nothing at this time. Just meet me at the front of the building. A6 21:26:20 TR65 Copy A6 21:26:58 BC14 Division Alpha Command A6 21:27:12 BC14 Division Alpha Command Battalion 9 Command A6 21:27:30 BC14 Engine (covered) Firefighter Command, are you on the tac? A6 21:27:43 E105 Command Engine 105’s on A6. A6 21:27:49 BC14 Yeah on your arrival I would like for you to take 2 out. Coordinate with Division Alpha. A6 21:27:58 E105 Copy. A6 21:28:04 E54 Command Engine 54. Engine 54 was assigned by Division Alpha to be 2 out. We have the full 54

crew is 2 out alpha side of the building at this point. A6 21:28:17 BC14 Okay. Copy that. 105 I would just like you to stage out on the street at this time. Battalion 9 Division

Alpha Command. A6 21:28:33 BC14 Engine 54 Command A6 21:28:37 E54 Command 54 go ahead. A6 21:28:40 BC14 Yeah, I like to account for the remainder of Engine 60’s crew. Can we do that? A6 21:28:44 E54 Affirmative. The captain Engine 60, Engineer Engine 60 are on their way towards the ambulance.

The engineer just as an escort. Two crew members for Engine 60 are interior with Engine 54 pardon me, Engine 62 and BC9 Division A.

A6 21:29:03 BC14 Okay copy. If you can I don’t need to talk to Battalion 9 but can you confirm that we get him up on


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Channel Time Unit Transcription the tac channel so I can get a hold of him.

A6 21:29:12 E54 Will do shortly. He’s interior right now. A6 21:29:24 M65 Command Medic 65 on scene. A6 21:29:28 BC14 Medic 65 You would just for like you to stage out on the street with Engine 105. A6 21:29:54 BC9 Command, Interior. A6 21:29:59 BC14 Is this Division Alpha or Interior go ahead. A6 21:30:05 BC9 Division Alpha We need a second line with a fresh crew in here. A6 21:30:11 BC14 Extremely hard to hear. Did you say you need a second line? A6 21:30:17 BC9 Second line. Fresh crew. 21:30:21 M61 marks T2 to UCD. A6 21:30:23 BC14 Okay a fresh crew. I go ahead and assign that to Division Alpha. Engine 105 Command did you copy? A6 21:30:30 E105 105 A6 21:30:35 E105 Engine 105 copies. We’re still about 1 to 2 out. A6 21:30:40 BC14 I’ve got 54 engine doing two out. I’d like for you to hook up as the relief crew for one of the interior

ones. You’re gonna assigned to Division Alpha which is Battalion 9. A6 21:30:52 E105 Copy that. A6 21:30:56 E54 Command, this is Engine 54 at the direction of Division A. A6 21:31:04 E54 …(covered) Because Engine 62 exited the building (covered) another crew (covered) A6 21:31:20 BC14 Okay 54 Just confirming that you are replacing Engine 62 that’s coming out of the building, Correct? A6 21:31:27 E54 That’s affirmative at the direction of Division A. A6 21:31:32 BC14 Okay I copy that. Engine 105 I need you now to assume 2 out outside the door. A6 21:31:42 E105 105 copies. A6 21:31:54 E54 Command 54. Just updated from 62. We’re going to need an air rig here if you don’t have one

coming already. A6 21:32:03 BC14 Start that one more time. An air rig? A6 21:32:12 BC14 Last unit with traffic repeat. A6 21:32:15 E54 Command that was 54. Engine 62 told us they need bottles topped off. We may need an air rig here. A6 21:32:23 BC14 Copy. I’ll get you rolling, one rolling. I think the trucks got some extra bottles at this time. 1

2

Appendix B - Glossary and TERMS 1

2 3 2201 Chief of the Department radio identifier. 4 5 2203 Deputy Chief-Operations radio identifier. 6 7 2208 Assistant Chief-Fire Marshall radio identifier. 8 9 2210 Assistant Chief-Operations radio identifier. 10 11 2216 Captain-Public Information Officer radio identifirer. 12 13 2240 Assistant Chief-Training/Department Safety Officer radio identifirer. 14 15 2241 Captain-Training Division radio identifirer. 16 17 2242 Captain-Training Divison radion identifier. 18 19 2280 Battalion Chief-Reserve coordinator radio identifier. 20 21 2290 Assitant Chief-Special Operations. 22 23 2292 Firefighter-Special Operations Haz-Mat Divsion 24 25 2293 Captain-Special Operations-Haz-Mat Division 26 27 2408 Assistant Chief Metro Fire 28 29 2417 Captain-Sac Metro Safety Officer. 30 31 4680 Fire Chapalin radio identifier. 32 33 4681 Fire Chaplain radio identifier. 34 35 4682 Fire Chaplain radio identifier. 36 37 9901 Communincatons Center Manager. 38 39 9903 Communications Center Operatoins Manager. 40 41 42 Acting Captain: A firefighter who has taken the Captain’s promotional exam, but who has 43

not been promoted to Captain and is filling in for a full time Captain on a 44 short or long term basis. The Acting Captain has the same duties and 45


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responsibilities as a promoted Captain. Or the senior Firefighter who has 1 not taken the exam but is filling in for the regular Captain for a short term 2 (less than 4 hours) while the Captain is temporally out of the station or 3 unavailable. Often referred to as “Sitting in the Seat”. 4

5 Agency 6 Administrator: Managing officer of an agency, division thereof, or jurisdiction having 7

statutory responsibility for incident mitigation and management. Example: 8 Fire Chief. 9

10 A.I.Q.: An acronym meaning Available in Quarters. When a fire company is in 11

quarters and available for dispatch. 12 13 Air-Pak: See SCBA. 14 15 Alarm: A pre-designated set of fire companies and command staff that is 16

assigned to certain or particular situations or calls for service. As an 17 incident escalates additional alarms can be requested. 18

19 Alpha side: Geographical designation that refers to the sides of a building, clockwise 20

from the front. The Alpha side is the front or address side of a structure. 21 22 A.O.R: An acronym meaning Available on Radio. When a fire company is out of 23

the station in their 1st due district and available for calls via the radio. 24 25 Back-Up FF: A member of an Engine Company, who’s primarily responsibility is to 26

assist the Nozzle FF with the stretch of the attack line, help with the 27 movement of the hose, and assist with forcible entry. 28

29 Back-Up Line: A secondary hose line that remains outside and is used to protect crews 30

operating on the inside, and meets the intent of two in/two out. 31 32 33 BARB: An acronym standing for Box Area Response Builder. BARB is a 34

computer program that is part of the CAD system that determines the 35 district boundaries for engine companies based on such factors as: driving 36 distance, surface street speed limits, access problems and stations 37 locations. Although a station may be physically closer to an area, it may 38 be slower getting to that location because of traffic patterns, speed limits, 39 etc, so BARB will pick the next closest engine because it can get there 40 faster. 41

42 Battalion: A geographical response area. 43 44 Battalion Chief: A command level supervisor who oversees a geographical area in which 45

there are engine and truck companies assigned to it. 46 47


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Bravo Side: Geographical designation that refers to the sides of a building, clockwise 1 from the front. The Bravo side is the left side (clockwise rotation) of the 2 house if one is standing and facing the Alpha Side of the house. 3

4 Burnover: A situation where personnel or equipment is caught in an advancing flame 5

front. 6 7

CAD: An acronym for Computer Aided Dispatch: A combination of hardware 8 and software that provides data entry, makes resource recommendations, 9 notifies and tracks those resources before, during, and after alarms, 10 preserving records of those alarms and status changes for later analysis 11 12

C.A.N. An acronym meaning Conditions, Actions, Needs report. An update or 13 progress report requested from the IC to companies operating on the 14 scene of an emergency to the Incident Commander identifying the current 15 conditions, what actions they are taking and if there is a need for further 16 help. 17

18 Captain: See Company Officer 19 20 Causal Factors: Any behavior, omission, or deficiency that if corrected, eliminated, or 21

avoided probably would have prevented the injuries. 22 23 Charlie Side: Geographical designation that refers to the sides of a building, clockwise 24

from the front. The Charlie side is the back side or the side opposite of the 25 Alpha side of a structure. 26

27 Command: Position within the Incident Command System that is responsible for the 28

overall management of the incident. Synonymous with the term Incident 29 Commander. 30

31 32

Company Officer: The immediate supervisor of an engine or truck company members and is 33 usually a Captain or Acting Captain. The Officer is responsible for 34 selecting the initial strategies and tactics at a working fire. 35

36 Contributing 37 Factors: Any behavior, omission, or deficiency that sets the stage for an accident, 38

or increases the severity of injuries. 39 40 Delta Side: Geographical designation that refers to the sides of a building, clockwise 41

from the front. The Delta side is the right side of a structure, or to the right 42 of the Alpha Side. 43

44 Engine Company: A fire suppression apparatus with a staffing of four (4) personnel and 45

carries 500 gallons of water, fire hose and a fire pump who’s primary 46 mission is to, extend hose to the seat of the fire for extinguishment. The 47


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Engine Company is staffed with four (4) personnel and includes: 1 Company Officer, Engineer, Nozzle Firefighter and Back-Up Firefighter 2

3 Engineer: A member of an Engine or Truck Company whose primary responsibility is 4

to safely drive the apparatus and operate the apparatus at the scene of an 5 emergency. Their duties including operating the fire pump or operating 6 the aerial ladder. 7

8 Entrapment: A situation where personnel are unexpectedly caught in a fire behavior 9

related, life-threatening position where planned escape routes or safety 10 zones are absent, inadequate, or compromised. These situations may or 11 may not result in injury. They include "near misses." 12

13 Escape Route: A preplanned and understood route firefighters take to move to a safety 14

zone or other low-risk area. 15 16 Extreme 17 Fire Behavior: "Extreme" implies a level of fire behavior characteristics that ordinarily 18

precludes methods of direct control action. One or more of the following is 19 usually involved: high rate of spread, prolific crowning and/or spotting, 20 presence of fire whirls, strong convection column. Predictability is difficult 21 because such fires often exercise some degree of influence on their 22 environment and behave erratically, sometimes dangerously. 23

24 Exposure: Refers to a structure in the vicinity of the fire building. Exposures are 25

commonly identified with a letter and a number to describe the location of 26 the structure relative to the fire building (e.g., Bravo-3 Exposure, Charlie-1 27 Exposure). 28

29 Fire: Rapid oxidation, usually with the evolution of heat and light; heat fuel, 30

oxygen and interaction of the three. 31 32 Fire Behavior: The manner in which a fire reacts to the influences of the environment. 33 34 Flash Over: The simultaneous ignition of all of the combustible contents in a space 35

with an average temperature range of 900F to 1,200F. 36 37 Fuel: Any combustible material, especially petroleum-based products. 38 39 GPM: An acronym for Gallons Per Minute: A unit of measurement that describes 40

the rate of fluid flow. Typically used to refer to the amount of water flowed 41 through a hoseline or the capacity of a pump. 42

43 Halligan Bar: A forcible entry tool used for prying open doors and windows. The 44

Halligan bar has three operating features: Fork, Adz, and pike or point. 45 46


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HUD An acronym for Heads Up Display. A HUD is a series of LED lights 1 located in the SCBA mask indicating the air remaining in the SCBA bottle. 2 2 Green lights=Full; 1 Green light=3/4; Yellow light= ½; Red light = ¼. 3

4 IDLH: An acronym for Immediately Dangerous to Life or Health: An atmosphere 5

that poses an immediate threat to life, would cause irreversible adverse 6 health effects, or would impair an individual’s ability to escape from a 7 dangerous atmosphere. 8

Incident 9 Commander: This ICS position is responsible for overall management of the incident 10

and reports to the Agency Administrator for the agency having incident 11 jurisdiction. 12

13 Initial attack: A planned response to a wildfire given the fire's potential fire behavior. 14

The objective of initial attack is to stop the spread of the fire and put it out 15 at least cost. An aggressive suppression action consistent with firefighter 16 and public safety and values to be protected. 17

18 Irons: A set of tools used for forcible entry, usually consisting on a Halligan Bar 19

and Flat head axe. 20 21 Jurisdiction: The range or sphere of authority. Public agencies have jurisdiction at an 22

incident related to their legal responsibilities and authority for incident 23 mitigation. Jurisdictional authority at an incident can be 24 political/geographical (e.g., city, county, state or federal boundary lines), or 25 functional (e.g., police department, health department, etc.). 26

27 LDH: An acronym for Large Diameter Hose. LDH is 4” or larger in diameter and 28

is used to transport water from a supply (hydrant) to an engine. 29 30 MAY-DAY: A radio transmission to report firefighters who are trapped, lost, 31

disoriented, or in a life threatening situation and are in need of immediate 32 assistance. 33

M.D.C.: An acronym for Mobile Data Computer. A MDC is the latest onboard 34 computer system used to transmit the status (AOR, enroute, AIQ, etc) of 35 the company, or to send messages to another company or dispatch. 36 Additionally, MDC’s have mapping programs available for use. 37

38 M.D.T.: An acronym for Mobile Data Terminal. A MDT is an onboard computer 39

system used to transmit the status (AOR, enroute, AIQ, etc) of the 40 company, or to send messages to another company or dispatch. MDT’s 41 are an older technologically, and have limited capabilities. 42

43 Medic: An EMS transport unit that provides Advance Life Support (ALS) care to 44

patients. Or a Firefighter/Paramedic assigned to a Medic unit. 45 46 Mode of 47


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Operation: A strategic plan for the initiation of operations based on size up of incident 1 conditions. The three modes of operation are: Investigation, Fire Attack or 2 Command. 3

4 Nomex ®: Trade name for a fire resistant synthetic material used in the 5

manufacturing of flight suits and pants and shirts used by firefighters. 6 Aramid is the generic name. 7

8 N.F.P.A.: An acronym meaning the National Fire Protection Association. The NFPA 9

is a national organization comprised of firefighters, private sector 10 manufactures representatives, safety organizations, and other interested 11 parties, that establishes guidelines the equipment used, the manufacturing 12 specifications or equipment and testing procedures for evaluating the 13 equipment used by the fire service. The NFPA publishes bulletins 14 containing the information and requirement for the various equipment. For 15 example, NFPA 1951 is the bulletin that contains the specifications for 16 production, use and testing of fire service ground ladders. 17

18 Nozzle FF: A member of an Engine Company who’s primarily responsibility is to 19

extend the initial attack and operate the nozzle at the direction of the 20 Officer. 21

22 P.A.R.: An acronym meaning Personnel Accountability Report. A PAR is initiated 23

by the IC when a May-Day or other emergency exists on the fire ground to 24 account for all company members, their location, and their status. During 25 PAR checks, company officers report the total number and accountability 26 of members assigned to their company, the area they are operating in, 27 and indicate the number of people operating outside of the hazard zone 28 and the status of their SCBA air supply. 29

30 31 PASS: Acronym for a Personal Alert Safety System. A device that senses 32

movement and is designed to automatically activate an alarm signal 33 indicating the wearer is in need of assistance. The device can also be 34 manually activated to trigger the alarm signal. PASS devices may be 35 integrated into the SCBA or a standalone device. 36

37 Personnel 38 Accountability 39 System: A system that readily identifies both the location and function of members 40

operating on an incident scene. 41 42 Pocket Tools: A set of tools carried in the turnout pocket of firefighters. These tools may 43

include: Crescent Wrench; Screw Driver set; Allen wrenches; Vice-Grips, 44 Etc. 45

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P.P.E.: An acronym meaning Personal Protective Equipment: That equipment and 1 clothing required mitigating the risk of injury from or exposure to 2 hazardous conditions encountered during the performance of duty. PPE 3 includes but is not limited to: fire resistant clothing, helmets, goggles, 4 gloves, respirators, foot wear. 5

6 Primary: A Primary Search is a rapid search of the structure for trapped or missing 7

civilians or occupants. 8 9 Riding Positions: A pre-designated assignment and responsibilities on a fire company 10

based on equipment type and seat assignments. On an Engine company 11 the riding positions are: Officer, Engineer, Nozzle Firefighter, and Back-12 Up Firefighter. No a Truck Company the riding positions are: Officer, 13 Operator, Tools Firefighter and Saw Firefighter. 14

15 Roll Call: A procedure that occurs on the radio tactical channel and is conducted by 16

the Battalion Chief to ensure that all companies are enroute. During this 17 procedure, all Company Officers are to voice if they are responding with 18 reduced staffing levels. 19

20 Scan: Refers to a mode by which personnel can monitor multiple radio channels 21

simultaneously. 22 S.C.B.A.: An acronym meaning Self-Contained Breathing Apparatus Portable air 23

(not oxygen) tanks with regulators which allow firefighters to breathe while 24 in toxic smoke conditions. Usually rated for 30 minutes of service. Used 25 primarily on fires involving structures or hazardous materials. 26

27 S.R.F.E.C.C. An acronym for the Sacramento Regional Fire Emergency 28

Communications Center also referred to as: Comm Center of Fire 29 Dispatch. 30

31 32 Situational 33 Awareness: The knowledge of being aware of a situation as it actually exists. 34 35 SOG: An acronym for Standard Operating Guidelines. Standard Operating 36

Guidelines outline general practices used on emergency incidents and 37 special situations and outline of basic roles for Engine Company 38 members, Truck Company members, Medics, Battalion Chiefs, and Staff 39 Officers during fire operations. 40

41 Suppression: All the work of extinguishing or confining a fire beginning with its 42

discovery. 43 Tank Line: A pre-connected fire hose line with a nozzle attached, usually located in 44

the cross-lay bed. A typical SFD engine company has two tanklines: 1- 45 150’ 1 ¾” and 1-200’ 1 ¾”. A majority of the time, the tankline is the 46 preferred choice by the Officer for initial fire attack. 47


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1 2 Technical 3 Specialists: Personnel with special skills that can be used anywhere within the ICS 4

organization. These personnel may perform the same duties during an 5 incident that they perform in their everyday job. 6

7 T.I.C.: An acronym for Thermal Imaging Camera. A TIC is an electronic hand 8

held device that uses the infrared spectrum of light to detect heat or 9 temperature changes in an area, and displays the readings on and LCD 10 screen. 11

12 Travel Channel: An additional tactical channel that is used by 2nd alarm companies to 13

conduct roll call. This channel will eventually become the staging channel. 14 This channel keeps all unnecessary radio traffic off the primary tactical 15 channel. 16

17 Truck Company: A fire suppression apparatus with a crew of four (4), and an aerial ladder. 18

The primary mission of the truck company is to support the engine 19 company during suppression operations and to search and rescue trapped 20 or missing civilians. Truck Companies carry all of the tools and equipment 21 for their mission including: Chain Saws, Ventilation fans, forcible entry 22 tools, and specialized rescue equipment. The Truck Company staffing 23 includes: Officer, Engineer, Saw Firefighter, and Tools Firefighter. 24

25 Type V 26 Construction: As defined by the National Fire Protection Association, a form of 27

construction where structural members consist entirely of wood. 28 29 Union Time: An agreement between management and the local bargaining unit 30

allowing department members, who are union officers, out of the fire 31 station to attend to union related business or issues. 32

33 Walk Around: The act of walking around an emergency incident to conduct a scene size 34

up. 35 36

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Appendix C - Standard Operating Guidelines 2

3

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Documents

Accident Review Factual Report Huntsman Incident