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    Report of Investigation Committee into Firefighter Injuries Sustained at 41 Eaton Street

    31 March 201

    Su!mitted to"

    Commissioner of #u!$ic Safet% Steven M& #are

    'ssistant Chief of the (epartment Scott Me$$o

    I'FF )oca$ *++ #resident #au$ (ought%

    Su!mitted !%"

    ,atta$ion -enneth Rainone

    'cting ,atta$ion Chief Stephen Capricotta

    'cting ,atta$ion Chief -evin .utras

    .une 201

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    E/ecutive Summar%

    n 31 March 201 the #rovidence Fire (epartment e/perienced to mu$tip$e

    a$arm ind driven fires that tested the (epartments command and contro$ communications

    strateg% and tactics training operations for $arge sca$e events and mutua$ aid response andcapa!i$ities& hese fire events high$ighted the effects that ind driven fire conditions can have on

    department operations at structure fires the demand for ade5uate and rapid dep$o%ment of

    firefighting resources and the great ph%sio$ogica$ demands p$aced upon firefighters or6ing at

    these t%pes of $ong duration events& ' tota$ of tent% si/ #rovidence Fire (epartment mem!ers

    ere injured& Fourteen mem!ers ere injured at the Eaton Street fire& ' senior fire captain and

    senior firefighter e/perienced critica$ injuries at the Eaton Street& f the tent% si/ injured ten

    #rovidence mem!ers ere treated for presumed c%anide poisoning& he fire event high$ighted

    the comp$e/it% of c%anide issue the dangers of h%drogen c%anide in smo6e the danger to

    firefighters from smo6e e/posure and need for continued education of #rovidence Fire

    (epartment mem!ers and the Rhode Is$and medica$ communit% a!out the dangers of h%drogen

    c%anide poisoning from smo6e e/posure& his fire event provides $earning opportunities

    regarding the need for firefighters to maintain a $eve$ of fitness throughout the course of their

    careers to meet these ph%sio$ogica$ demands during structura$ firefighting7 the need to ensure

    ade5uate trac6ing rotation reha!i$itation and rest of fatigued fire fighters7 $earning

    opportunities regarding the #rovidence Fire (epartment Incident Command S%stem 8ICS9 and

    the command and contro$ of a $arge sca$e emergenc% incident& his fire event high$ighted the

    #rovidence Fire (epartments ina!i$it% to fu$fi$$ ICS Command Staff and :enera$ Staff positions

    ith chief officers ith Fire :round Command e/perience& his fire event a$so high$ighted the

    demands p$aced upon the #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9

    during emergenc% operations of this si;e and demonstrated the cha$$enges for the present on

    dut% staffing $eve$s of the ,C& he universa$ consensus of this committee as that Eaton Street

    fire presented $earning opportunities for the entire (epartment and as such the focus of this

    report is to provide $earning o!jectives for a$$ departmenta$ ran6s&

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    a!$e of Contents

    E/ecutive Summar%

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    Introduction

    8#hoto 1 Side 1 and 2 !efore Fire (epartment arriva$9

    n 31 March 201 the #rovidence Fire (epartment simu$taneous$% e/perienced to

    mu$tip$e a$arm ind driven fires that tested the departments command and contro$

    communications strateg% and tactics training operations for $arge sca$e events and mutua$ aid

    response and capa!i$ities& hese events !egan ith a genera$ a$arm fire during hich a secondthree a$arm fire occurred&

    he #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9 !egan receiving

    phone ca$$s for a report of a house fire in the vicinit% of 41 Eaton Street at 14"04 hours& his fire

    5uic6$% gre to a genera$ a$arm fire& 'ppro/imate$% to and a ha$f hours into the Eaton Street

    fire the ,C as6ed the Incident Commander if he had an% units avai$a!$e to c$ear the first fire

    !ecause the ,C as receiving mu$tip$e phone ca$$s for the second fire&

    't 1"3+ hours the ,C dispatched mutua$ companies a$ong ith #rovidence Fire

    (epartment companies that ere a!$e to c$ear the Eaton Street fire to the area of )aure$ ?i$$

    've& and )a!an Street for reports of mu$tip$e houses on fire& his fire 5uic6$% gre to three

    a$arms&

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    hese ind driven fire events tested the entire +4 mem!er p$atoon of the #rovidence Fire

    (epartment off dut% mem!ers ho returned to or6 on their on initiative as e$$ as

    firefighters of severa$ surrounding communities that provided mutua$ aid to the cit% of

    #rovidence& It as the training dedication and professiona$ism disp$a%ed that da% a$ong ith

    the time tested aggressive interior structura$ firefighting strategies and tactics emp$o%ed !% the

    #rovidence Fire (epartment mem!ers 8for hich the (epartment has traditiona$$% !een

    recogni;ed for9 that 6ept !oth fire incidents from !ecoming major conf$agrations&

    he #rovidence Fire (epartment companies on the scene at 41 Eaton Street and $ater at

    )aure$ ?i$$ 've& faced rapid$% esca$ating e/treme$% fast moving fires that ere enhanced !% the

    effects of the ind& Meteoro$ogist Steve Cascione from $oca$ nes station ',C@es as

    contacted for the recorded ind speeds for the time of the fires& ?e provided the investigation

    committee recorded eather statistics from the e!site &underground&com that shoed

    sustained inds of 20&* to 34&> mph ith the highest gust of ind recorded at 4 mph for the

    five hour period of time during the fire events&1he inds ere !$oing from Side 1 to the Side

    3A4 corner of the origina$ fire !ui$ding for the fire event on Eaton Street&

    hese fire events high$ight the danger of ind driven fires the effects that ind can have

    on department operations at structure fires the demand for ade5uate and rapid dep$o%ment of

    firefighting resources and the great ph%sio$ogica$ demands p$aced upon firefighters or6ing at

    these t%pes of $ong duration events& f the +4 mem!ers or6ing that da% Fift% nine of those

    mem!ers operated at !oth fire events&

    's a resu$t of these to fire events tent% si/ #rovidence Fire (epartment mem!ers ere

    injured& Fourteen mem!ers ere injured at the Eaton Street fire& ' senior fire captain and senior

    firefighter e/perienced critica$ injuries at the Eaton Street fire re5uiring e/tended sta%s in area

    hospita$s& f the tent% si/ injured ten #rovidence mem!ers ere treated for presumed c%anide

    poisoning&

    ,ecause of the num!er of injuries at these fires 'ssistant Chief of the (epartment

    perations Scott Me$$o ordered an investigation into the circumstances surrounding the to

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    incidents& o committees ere formed to investigate the incidents and re$ated injuries and

    prepare reports on each incident&

    ,atta$ion Chief -enneth Rainone 'cting ,atta$ion Chief Stephen Capracotta and 'cting

    ,atta$ion Chief -evin .utras ere assigned the duties of investigating the injuries that occurred

    at 41 Eaton Street&

    '$$ officers ho responded to 41 Eaton Street ere instructed !% 'cting ,atta$ion Chief

    -evin .utras to su!mit a #rovidence Fire (epartment Form 1* regarding compan% actions at this

    incident a$ong ith the names of individua$s ho ere injured and circumstances re$ated to

    those injuries& -e% individua$ mem!ers invo$ved ith the events of this fire ere intervieed !%

    committee mem!ers&

    he intent of the committee as to o!jective$% co$$ect and revie the facts of the

    Eaton Street fire ana$%;e departmenta$ procedures and to ma6e recommendations for

    improvement in departmenta$ po$ic% and procedures&

    he universa$ consensus of this committee as that Eaton Street fire presented $earning

    opportunities for the entire (epartment and as such the focus of this report is to provide $earning

    o!jectives for a$$ departmenta$ ran6s&

    he fire event at 41 Eaton Street once again high$ighted the dangers of h%drogen c%anide

    as a product of com!ustion and the potentia$ danger to firefighters re$ated to h%drogen c%anide

    poisoning from accidenta$ smo6e e/posure& he #rovidence Fire (epartment had !een invo$ved

    in !ringing this danger $ight to the nations fire service e/act$% 10 %ears ago 8to the month9 !ac6

    in March of 200&2he Eaton Street fire event reiterates the need for continued education of

    department mem!ers and the medica$ communit% a!out the dangers of h%drogen c%anide

    poisoning from smo6e e/posure&

    he fire provides $earning opportunities regarding the ph%sio$ogica$ demands p$aced on

    the firefighters& he fire demonstrates the need of firefighters to maintain a $eve$ of fitness

    throughout the course of their careers to meet these ph%sio$ogica$ demands during structura$

    2 (orce%.&&.utras -& Mo$is .& arone .& Darren &Report of Investigative Committee into Cyanide Poisoning

    of Providence Firefighters. Ma% 200&

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    firefighting and $ong duration events& In addition this fire event provides $essons on the need to

    ensure ade5uate trac6ing rotation rest and reha!i$itation of fatigued fire fighters&

    he $arge sca$e fire event at Eaton Street a$so provided $earning opportunities regarding

    the #rovidence Fire (epartment Incident Command S%stem 8ICS9 and the command and contro$

    of $arge sca$e emergenc% incidents&

    Dithin the rea$m of ICS this fire event high$ighted the #rovidence Fire (epartments

    ina!i$it% to fu$fi$$ ICS Command Staff and :enera$ Staff positions ith chief officers ith Fire

    :round Command e/perience&

    his fire event a$so high$ighted the demands p$aced upon the #rovidence Fire (epartment

    ,ureau of perationa$ Contro$ 8,C9 during emergenc% operations of this si;e& his event

    further demonstrated the cha$$enges for the present on dut% staffing $eve$s of the ,C&

    he (epartment can !e ver% than6fu$ that no civi$ian death or firefighter $ine of dut%

    death occurred at 41 Eaton Street& his fact is a testament to the training and professiona$ism

    e/hi!ited !% department mem!ers operating at this cha$$enging fire scene& he cha$$enge for the

    #rovidence Fire (epartment is to $earn from this incident identif% actions that ma% have

    contri!uted to the event and $earn an% $essons from the injuries that occurred at this fire& he

    u$timate goa$ is to share these $essons ith future generations of #rovidence Firefighters and

    prevent future injuries or deaths&

    ,ac6ground and Significance

    he devastating effect of ind on structura$ firefighting strategies and tactics has !een

    recogni;ed for man% %ears& hrough the investigative or6 of the @ationa$ Institute for

    ccupationa$ Safet% and ?ea$th 8@IS?9 and the scientific research performed !% the @ationa$

    Institute of Standards and echno$ogies 8@IS9 the fire service has !ecome !etter educated a!out

    the devastating effects of ind driven fires&3@IS? has repeated$% identified the effects of ind

    driven fires as a contri!uting factor in man% )ine of (ut% (eaths 8)((9 that this agenc% has

    investigated&

    3 @ationa$ Institute of Standards and echno$og% Firefighting tactics under wind driven fire

    conditions: 7-story buiding e!periments.echnica$ @ote 12+& 200+

    *

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    Most recent$% the @IS? )(( report F2014A0+ on the deaths of to ,oston Fire

    (epartment mem!ers re$eased in March of 201 reiterate the dangers associated ith ind

    driven structure fires& his report stated hen responding to a reported structure fire an

    overriding consideration concerning si;eAup must !e ind conditions and its potentia$ effect on

    the fire& he 6e% to successfu$$% operating at indAimpacted fires in a structure depends on

    recogni;ing the indAimpacted fire conditions that ma% change a seeming$% routine fire into a

    !$otorching fire& ,$otorching is the appropriate description of hat i$$ occur hen fire

    conditions are impacted !% ind conditions&4

    he #rovidence Fire (epartment a$so has e/perienced the effects of ind driven fires in

    the past most nota!$% on 14 'pri$ 2014&> n that da% the #rovidence Fire (epartment

    e/perienced a firefighter near miss event and mu$tip$e ma%da%s ere transmitted hen

    department mem!ers ere over run !% a ind driven fire event&

    's a resu$t of the near miss and ma%da%s on 14 'pri$ 2014 a department investigation

    as conducted& hat report stated"

    In 200= he @ationa$ Institute of Standards and echno$ogies 8@IS9 in

    conjunction ith Fire (epartment of @e Gor6 8F(@G9 #o$%technic Institute of @e

    Gor6 Hniversit% and support from the (epartment of ?ome$and Securit% conducted

    research on the effects of ind driven fires& he o!jective of this stud% as to improve

    the safet% of fire fighters and !ui$ding occupants !% deve$oping a !etter understanding of

    ind driven fires and ind driven firefighting tactics inc$uding structura$ venti$ation and

    suppression 8@IS 200= p& viii9& he research as a$so intended to stud% the effects of

    positive pressure venti$ation fans ind contro$ devices and e/terna$ ater app$ication

    ith f$oor !e$o no;;$es to mitigate the ha;ards of the ind in structure fires 8@IS

    200= p& i9&

    4 @ationa$ Institute of ccupationa$ Safet% and ?ea$th Fire Fighter Fata$it% Investigation Report F2014A0+ Mar

    201

    > ,ates M& Cro$e% (& (ought% #& .utras -& oro '&Report of Investigation Committee

    into Firefighter "ayday and In#uries $ustained at %% Pymouth $treet& 'pri$ 2014

    =

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    's a resu$t of these ind driven e/periments" ' !ase$ine as deve$oped for the

    ha;ards associated ith a ind driven fire and the impact of pressure venti$ation and

    f$o paths ithin a structure& Dind created conditions that rapid$% caused the

    environment in the structure to deteriorate !% forcing fire gases through the apartment of

    origin and into the pu!$ic corridor and staire$$& hese conditions ou$d !e untena!$e

    for advancing fire fighters& Mu$tip$e tactics used in conjunction ith each other ere

    ver% effective at improving conditions for fire fighter operations and occupant egress

    8@IS 200= p& i9&

    From the @IS stud% information has !een gained a!out the understanding of

    f$o paths ithin structure fires and the effects that ind pressure and venti$ation i$$

    have on these f$o paths& he f$o path of the energ% of the fire is inf$uenced !% areas of

    high and $o pressure& Simp$% put ind creates areas of high pressure and i$$ push

    heat smo6e 8un!urned fue$s9 and to/ic products of com!ustion toards areas of $o

    pressure& he ind i$$ push the fire from the room of origin out into areas of $o

    pressure such as adjacent rooms ha$$a%s and staire$$s&

    (epending on the ind ve$ocit% this movement ma% !e ver% e/p$osive and fire

    fighters operating in these areas ma% !e overArun !% intense radiant heat& It is imperative

    that fire fighters !e a!$e to recogni;e these dangers ithin the structure and operate inareas outside of these f$o paths hen ind is inf$uencing the progression of the fire&

    'ppropriate$% app$ied venti$ation tactics are a a% for fire fighters to contro$ these

    f$o paths and ensure their safet%& his re5uires strong 6no$edge of fire !ehavior and

    venti$ation tactics& ,% understanding the effects of ind and !% app$%ing the appropriate

    venti$ation tactics fire fighters can contro$ the fire and these dangerous f$o paths&

    Simp$% c$osing doors is another tactic is to contro$ the f$o path of the fire& his

    can !e accomp$ished !% contro$$ing the door of the room of origin& If this is not possi!$e

    contro$ of other interior doors ma% assist in contro$$ing the f$o path& In highArise fires

    the contro$ of staire$$ doors !ecomes ver% important hen the apartment door is $eft

    open during these t%pes of fire events&

    +

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    In some cases depending on the ind ve$ocit% and pressure head $ong direct

    attac6 ith a hose $ine from the $o pressure area to the high pressure area 8from the

    un!urned to !urned9 direct$% against the f$o path of the fire ma% not !e prudent& Fire

    officers and Incident Commanders need to recogni;e this danger& Standard aggressive

    tactics ma% have to !e a$tered to ensure the safet% of mem!ers&

    Research into ind driven fires provided the $ine of dut% death reports $isted

    a!ove& hese reports are just a sma$$ samp$e of $ine of dut% deaths that indicated ind

    as found to !e a contri!uting factor& he investigations into these events demonstrated

    the effect that ind had on the progression of the fires& he e/tensive documentation of

    these events are indicators for the fire service of the need to incorporate the 6no$edge

    gained from these investigations and the research from the @IS stud% into dai$%

    structura$ firefighting training&

    @IS research has determined that ind speeds as $o as 10 mph 81 6mBhr&9 are

    sufficient to create indAdriven fire conditions if the f$o path is uncontro$$ed& @IS in a

    recent stud% on indAdriven fires in structures has shon that ind speeds as $o as 10

    mph can turn a routine room and contents fire into a f$oor to cei$ing fire storm or

    !$otorch effect generating untena!$e conditions for fire fighters even outside of the

    room of origin& emperatures in e/cess of 00 C 81100 F9 and tota$ heat f$u/es in e/cessof *0 6DBmJ ere measured at 4 ft& a!ove the f$oor a$ong the f$o path !eteen the fire

    room and the donind e/it vent& hese conditions ere attained ithin 30 seconds of

    the f$o path !eing formed !% an open vent on the upind side of the structure and an

    open vent on the donind side of the structure&

    he or6 !% @IS? and @IS indicate that the fire service as a ho$e sti$$ has

    or6 to do understanding the dangers of ind driven fires educating mem!ers on

    identif%ing ind driven fire potentia$ incorporating recognition of ind speeds in initia$si;eAup identif%ing potentia$ e/p$osive f$o paths and choosing the appropriate tactics

    hen com!ating these t%pes of fires&

    ,ates M& Cro$e% (& (ought% #& .utras -& oro '&Report of Investigation Committee into Firefighter"ayday and In#uries $ustained at %% Pymouth $treet& 'pri$ 2014

    10

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    he #rovidence Fire (epartment has in p$ace >0 preAesta!$ished standard operating procedures

    8S#s9& he standard operating procedures are intended to act as decision ma6ing guides for

    compan% officers and mem!ers& hese standard operating procedures are !ased upon nationa$$%

    recogni;ed consensus standards that are intended to ma6e fire ground activities as safe as

    inherent$% possi!$e& here are a num!er of #rovidence Fire (epartment S#s re$ated to

    structure fires most nota!$% perations at Structure Fires 'ccounta!i$it% Ma%da% Fast

    Compan% and Safet% Compan% perations& he department a$so fo$$os the princip$es of

    Incident Command out $ined in a document tit$ed #rovidence Fire (epartment Incident

    Command 81++39& (ecisions officers ma6e and actions that the% ta6e shou$d !e guided and !e

    inf$uenced !% the departments S#s Incident Command document (epartment Ru$es and

    Regu$ations standing :enera$ rders and the officers training and e/perience&

    he #rovidence Fire (epartment ,ureau of perationa$ Contro$ 8,C9 is responsi!$e for

    the dispatch of fire companies to emergencies& he ,C or Fire '$arm 8F'9 receives te$ephone

    ca$$s for emergencies and via the state operated +11 Enhanced S%stem& he department a$so has

    te$egraph fire a$arm street !o/es as e$$ as municipa$ a$arm !o/es in !ui$dings throughout the

    cit% referred to as master !o/es&

    he standard assignment for a master !o/ is three engines to $adders and a chief&

    Dhen !oth chiefs are unavai$a!$e a command compan% i$$ !e dispatched& ' command

    compan% can !e an engine or $adder compan% ith a captain in command of the compan%&

    he standard first a$arm assignment for a !ui$ding fire is three engines to $adders the

    Specia$ ?a;ards a rescue and a chief& Immediate$% fo$$oing the dispatch of the first a$arm

    companies the ,C dispatches a Fast 'ssist Search eam 8F'S9 compan%& he F'S

    Compan% is comprised of a )adder and Engine Compan%& Dhen a or6ing fire is confirmed the

    ,C i$$ dispatch Engine > ith the 'ir Supp$% Hnit& he officer of Engine > i$$ !e assigned

    the Incident Safet% fficer duties at the incident&

    Fires !e%ond the capa!i$ities of the first a$arm assignment are 6non as mu$tip$e a$arm

    fires& 'n additiona$ a$arm has to engines and one $adder assigned to it& he #rovidence Fire

    11

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    (epartment has the a!i$it% to assign si/ a$arms after hich the fire ou$d !e referred to as a

    :enera$ '$arm fire&*

    Hpon the announcement of a Ma%da% on a fire ground the department has procedures to

    ma6e the fire and automatic mu$tip$e a$arms ith hat is 6non as a Ma%da% response&

    Ma%da% response is comprised of to engines to $adders and to rescues&

    he #rovidence Fire (epartment changed over to a h%!rid =00 M?; s%stem in 200+&

    his seven channe$ s%stem is a com!ination of digita$ and ana$og radio channe$s& Channe$s 1 >

    and * are digita$& #orta!$e radios on 1 > and * transmit to a series of repeater toers

    throughout the Cit%& Fire ground channe$s 2 3 and 4 are ana$og& #orta!$e radios on 2 3 and 4

    transmit direct$% to one another a$6ie ta$6ie st%$e& ?oever apparatus or mo!i$e radios

    transmit direct$% to the toers on a$$ channe$s& 'pparatus radios i$$ not receive the porta!$es on

    channe$s 2 3 or 4 the a$6ie ta$6ie st%$e un$ess a vehic$e repeater s%stem 8RS9 is manua$$%

    turned on& he RS repeats the ana$og message over the digita$ fre5uenc%& Engines $adders and

    the $ine chief vehic$es are e5uipped ith RS& his is a ver% genera$ e/p$anation of the fair$%

    intricate communication s%stem& #ertinent to this investigation porta!$e radios on channe$s 2 3

    or 4 on$% transmit to other porta!$es or need to !e repeated through a RS on the same channe$&

    If no apparatus radio is on the same channe$ ith a RS the transmission i$$ not reach fire

    a$arm or apparatus&

    his intricate radio s%stem re5uires strict adherence to S# 1* and S# 3> hich dictate the

    procedures for using mu$tip$e radio channe$s for one incident& hese procedures re5uire one RS

    !e sitched to the second radio channe$ assigned for the Rescue Sector during Ma%da% events at

    fires&=

    #rocedures

    he Investigative Committee as se$ected !% 'ssistant Chief of (epartment Scott Me$$o& 'n

    organi;ationa$ meeting as he$d& From this meeting three o!jectives ere set& he first o!jective

    * #rovidence Fire (epartmentRues and Reguations1++

    = #rovidence Fire (epartment"aydays Standard perating #rocedure 3>& 2012

    12

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    as to gather as much data as possi!$e& Second to eva$uate the information co$$ected& )ast$%

    report an% $essons that can !e $earned to prevent injur% or death&

    he data co$$ection !egan ith the retrieva$ of the radio transmissions for the Eaton Street

    Fire Captain .u$ia Rou6e provided the committee a C( audio recording for each radio channe$

    8#rimar% (ispatch Channe$ 1 and Fire ground Channe$ 29& 'cting ,atta$ion Chief -evin .utras

    instructed a$$ compan% officers to su!mit a #rovidence Fire (epartment Form 1* regarding

    compan% actions at this incident a$ong ith the names of individua$s ho ere injured and

    circumstances re$ated to those injuries& #hotos that had !een ta6en at the fire scene !% itnesses

    and provided to Car *+ ere a$so given to the committee& Mem!ers of the committee co$$ected

    data regarding the t%pe of injur% and functions !eing performed that contri!uted to the injur%&

    Incident at 41 Eaton Street

    n 31 March 201 at 14"0* hours the #rovidence Fire (epartment ,ureau of

    perationa$ Contro$ 8,C9 dispatched Engines 12 * 1> )adder 4 and Specia$ ?a;ards 1

    Rescue 4 and ,atta$ion 3 to 41 Eaton Street for a report of a !ui$ding fire&+he ,C a$so

    reported that #rovidence #o$ice ere on the scene and that there as a !rush fire on )eigh Street

    e/tending to a house on Eaton Street&

    Dhi$e responding a$ong (oug$as 'venue to Eaton Street Engine 12 and )adder 3 eredirected to )eigh Street !% civi$ians& Engine 12 reported to the ,C that he as !eing directed to

    )eigh Street and that there as a possi!$e !rush fire on )eigh Street& he ,C radioed Engine

    12 and reiterated that #rovidence #o$ice stated a there as a possi!$e !rush fire !ehind 41 Eaton&

    his radio transmission as immediate$% fo$$oed !% a transmission from Engine 12 stating that

    there as a house fire on Eaton and that Engine 12 ou$d !e !ac6ing don )eigh Street to

    respond to the origina$ address of 41 Eaton Street&

    't appro/imate$% 14"10 hours Rescue 4 as the first fire apparatus to arrive on the scene

    at 41 Eaton Street& Rescue 4 transmitted a Code Red and gave a si;e up that stated there as a

    fu$$% invo$ve house fire ith heav% fire shoing second third and fourth f$oor of a three fami$%

    residentia$ ood frame& his transmission as immediate$% fo$$oed !% Engine * and Rescue 4

    + Recorded 'udio Fi$es #rovidence Fire (epartment 'pri$ 201

    13

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    !oth re5uesting a second a$arm& ,atta$ion 3 arrived on the scene and informed the ,C to

    prepare for a third a$arm&

    he officer of Rescue 4 esta!$ished the EMS sector !ecame the EMS Sector officer& ?e

    !egan assessing the need to e/pand the EMS sector !ased upon the potentia$ for injured mem!ers

    and reha! of mem!ers as the incident progressed& he EMS Sector fficer !egan to re5uest

    additiona$ rescues to ensure that EMS services ere provided on the est and east sides of the

    rapid$% e/panding incident&

    8#hoto 2 Ear$% Stages of peration Side 19

    't 14"11 hours ,atta$ion 3 re5uested a third a$arm& 't 14"12 hours )adder radioed the,C and reported that there as fire in E/posure 4& his transmission as fo$$oed ith a

    transmission from ,atta$ion 3 esta!$ishing Eaton Command& Eaton Command provided the ,C

    ith the first status report hich stated one three and one ha$f stor% ood frame !ui$ding fu$$%

    invo$ved in fire E/posure 4 as on fire ith fire shoing on the second and third f$oors

    E/posure 2 as on fire ith fire in the $oft and that the fire as dou!tfu$ at this time&

    First a$arm companies se$fAdep$o%ed fo$$oing #rovidence Fire (epartment Standard perating

    #rocedures and the departments Incident Command se5uence of preAesta!$ished incident

    priorities si;eAup strategic o!jectives and tactica$ operations out$ined in the departments

    Incident Command S%stem Manua$& he first a$arm compan% officers a$$ recogni;ed the

    esca$ating fire event unfo$ding !efore them and understood the Incident 'ction #$an of riting

    off hat as a$read% $ost 8the origina$ fire !ui$ding9 and focusing actions on e/posure protection

    and fire contro$&

    14

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    Engine * arrived first to the Eaton Street side of the event& Engine 12 esta!$ished a ater

    supp$% to Engine *& Engine * stretched a to and a ha$f inch hand $ine to !egin e/posure

    protection of Side 2 of E/posure 4& he chauffer of Engine * used his dec6 gun to !egin

    e/posure protection on Side 4 of E/posure 2&

    )adder 3 remained on )eigh Street here the% ere origina$$% directed !% !%standers&

    he fire fighters assigned to )adder 3 positioned their apparatus and attempted to provide

    vertica$ venti$ation on E/posure 4 hi$e the officer of )adder 3 contro$$ed the groing !rush

    fire that threatened !ui$dings on )eigh Street& Engine 4 supp$ied )adder 3 ith ater from a

    h%drant on (oug$as 've&

    )adder 4 and )adder arrived and positioned and prepared their apparatus for defensive

    operations on the origina$ fire !ui$ding and e/posure protection of Side 2 of E/posure 4&

    8#hoto 3 )adder 4 Setting up for defensive perations Side19

    Engine 14 fo$$oed )adder in on the origina$ dispatch& Engine 14 positioned their

    apparatus to use the dec6 gun on the third f$oor of E/posure 4 and #rotect E/posure 4'& he

    mem!ers of Engine 14 !egan to prepare feeders to supp$% )adder 4 )adder and $ater )adder 1&

    Engine 3 supp$ied Engine 14 ith a five inch feeder from a6$and 've&

    Engine 1> stretched a three inch attac6 $ine fitted ith a ,$i;tfire no;;$e to !egin

    e/posure protection in the rear of E/posure 2& he chauffer of Engine 1> $ater returned to his

    apparatus to !egin ater supp$% operations to )adder * hich as dispatched on the second

    a$arm and as no positioned in front of E/posure 2&

    1>

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    Mem!ers of Specia$ ?a;ards made entr% into E/posure 4 hich as no on fire& he%

    performed primar% searches on the first f$oor and some areas on the second f$oor that did not

    contain fire& he officer of Specia$ ?a;ards notified the Incident Commander 8IC9 of the search

    resu$ts and informed the IC his mem!ers ere stretching hand $ine into E/posure 4 and ere

    operating on the second f$oor&

    Engine 2 arrived on the second a$arm& he% stretched a hand $ine into E/posure 2 and

    performed a search on f$oors one and to& Engine 2 then informed the IC that the% ere

    operating on the third f$oor Side 4 of E/posure 2& 'fter securing a ater source for Engine *

    Engine 12 dep$o%ed hand $ine into E/posure 2 and made their a% up to the $oft of E/posure 2&

    Dith defensive operations undera% on the origina$ fire !ui$ding and companies moving

    offensive$% into the E/posure 2 and E/posure 4 the IC !egan to sectori;e the incident& he IC

    designated the officer of Specia$ ?a;ards as the E/posure 4 Sector fficer and the IC designated

    the officer of Engine 12 as the E/posure 2 Sector fficer& he IC esta!$ished a third sector on the

    e/terior of Side 3 of a$$ !ui$dings invo$ved& Engine 1> as assigned as the Side 3 Sector fficer&

    he IC then !egan to assign companies to the three sectors no esta!$ished& Engine 14

    !ac6up the mem!ers of Specia$ ?a;ards in E/posure 4 and stretched up the front stairs of

    E/posure 4& he officers of )adder 1 and )adder moved into the E/posure 4 to assist ith

    offensive operations no ta6ing p$ace in that !ui$ding&

    Engine = and the officer of )adder * moved into the E/posure 2 to assist offensive

    operations no ta6ing p$ace in that !ui$ding&

    Car 2 arrived on the scene and at 14"2 hours he re5uested a fourth a$arm just 1+ minutes

    after the dispatch of the first a$arm& en minutes $ater Car 2 re5uested a genera$ a$arm !e struc6

    at 14"3 hours&

    Dith the remainder of avai$a!$e #rovidence Fire Companies arriving on scene the IC

    assigned companies into the e/posure !ui$dings to gain contro$ of the fires in these !ui$dings and

    6eep the incident from groing an% further&

    1

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    Engine 13 and )adder 2 ere assigned to the E/posure 2 Sector and the IC made the

    officer of Engine 13 the E/posure 2 Sector fficer& his a$$oed for Engine 12 to maintain their

    position in the $oft and provided greater supervision of companies operating in E/posure 2&

    Engine 10 Engine 8after providing Engine 14 a second five inch feeder9 and )adder >

    ere assigned to E/posure 4 Sector and the officer of )adder 1 as assigned as the E/posure 4

    Sector fficer& he change in the assignment of the Sector fficer ro$e as made again to gain

    !etter supervision of companies operating in E/posure 4&

    Engine 11 and )adder = ere assigned the duties of the F'S Compan%& Engine 4 and

    )adder 1 ere origina$$% assigned the F'S Compan% duties !ut the rapid$% esca$ating fire

    event re5uired use of these companies !% the IC for tactica$ operations&

    't 14">1 hours the IC provided the ,C ith another incident status update& he IC

    reported that he had one !ui$ding fu$$% invo$ved heav% fire in E/posure 2 and heav% fire in

    E/posure 4 fire sti$$ dou!tfu$& 's the incident duration progressed the IC re5uested an additiona$

    $adder and engine to have in staging& ' @orth #rovidence engine and $adder ere dispatched to

    the scene& he @orth #rovidence )adder as used to re$ieve some of the #rovidence cres in

    E/posure 2 hi$e the @orth #rovidence Engine as used in E/posure 4&

    he mem!ers operating at 41 Eaton Street faced fierce fire conditions as a resu$t of the

    effect that ind p$a%ed upon the incident& he effects of the ind made the tas6s of contro$$ing

    fire spread overhau$ing e/tinguished areas of fire and comp$ete$% e/tinguish poc6ets of fire that

    ou$d f$are up hen inf$uenced !% the ind an e/treme$% arduous time consuming tas6&

    E/posure 2 as the first !ui$ding here head a% as gained and contro$ of the fire in

    that !ui$ding as comp$eted& Cres operating on f$oor to and three performed e/tensive

    overhau$ to comp$ete$% e/tinguish the fire on those f$oors& Cres operating in the $oft of

    E/posure 2 faced an unfinished $oft hich a$$oed them to cover the entire f$oor ith their hose$ine from the re$ative safet% of the rear staire$$& he officer of Engine 12 reported that his cre

    as a!$e to ma6e it up onto the f$oor and s$o$% move toard Side 1 to comp$ete the

    e/tinguishment of the fire in the $oft&

    1*

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    he contro$ of the fire in E/posure 4 as more difficu$t& he $oft of that !ui$ding had

    !een finished into an occupied $iving space& he unit as divided front to !ac6 ith a stair to the

    fourth f$oor on Side 1 and Side 3& ,ecause it as a finished space additiona$ hose as re5uired

    to cover the ha$$a%s and rooms off of the ha$$a% to reach a$$ areas of the f$oor un$i6e the open

    f$oor area in the $oft of E/posure 2&

    he first hose $ine advanced up the rear stairs stretched short& rigina$ heada% into the

    $oft as $ost hen the hose $ine had to !e !ac6ed don to piece in additiona$ hose to ma6e the

    stretch& 't one point during the !att$e to gain the fourth f$oor companies attempting to move up

    to the fourth ere ordered don to the third f$oor !% the IC& he IC as concerned a!out the

    conditions he as itnessing from the e/terior that interior cres ere not aare of& Dhen it

    as confirmed that a$$ mem!ers ere in a safe $ocation on the third f$oor the IC directed )adder

    3 and )adder 1 to p$ace their master streams into the $oft of E/posure 4 to 6noc6 don the

    groing !u$6 of the fire on the fourth f$oor&

    #rior to the use of the master streams on the fourth f$oor mem!ers cou$d dar6en don the

    f$ames on Side 3 and move up the stairs on$% to !e driven don the stairs hen gusts of ind

    ou$d drive hidden fire and heat out of the concea$ed spaces don onto the hose $ine cre& 'fter

    the master streams 6noc6ed don the !u$6 of the f$ames on the fourth f$oor the master streams

    ere redirected !ac6 on the origina$ fire !ui$ding& Cres in E/posure 4 cou$d no move !ac6 up

    to comp$ete the e/tinguishment or the fourth f$oor !% opening up the finished cei$ings and a$$s

    to comp$ete the e/tinguishment of hidden poc6ets of fire&

    he fire as p$aced under contro$ at 1>"41 hours& Some companies remained on the scene

    for appro/imate$% to more hours ith #rovidence Fire (epartment 'rson Investigators

    remaining on the scene unti$ 1+"4> hours&

    (iscussion

    he dangers of acute h%drogen c%anide poisoning from smo6e inha$ation are not ne to

    the #rovidence Fire (epartment& n March 23 and 24 of 200 the #rovidence Fire (epartment

    $earned of the true magnitude of the dangers of c%anide in smo6e as the resu$t of three fires over

    the course of to da%s& In the aftermath of the three fires a tota$ of 2= mem!ers sought medica$

    1=

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    fo$$o up 2* of ho ere tested for c%anide poisoning& 10Eight of those mem!ers ere found to

    have e$evated $eve$s of c%anide&11

    ne mem!er ho had e$evated c%anide $eve$s from an e/posure to smo6e at the second fire

    suffered a heart attac6 at the third fire& Dhi$e the investigation committee as not a!$e to

    conc$ude that c%anide re$ated arrh%thmia $ed to the mem!ers heart attac6 it as determined

    ith certaint% that the mem!er had e$evated $eve$s of c%anide in his !$ood at the time of he

    suffered the heart attac6&12 he investigation did determine that c%anide poisoning can $ead to

    death !% affecting the !od%s a!i$it% to carr% o/%genated to the vita$ organs as e$$ as having the

    a!i$it% to causes heart arrh%thmias and that the arrh%thmias can occur up to to ee6s after the

    e/posure&13

    he investigative report from the events in 200 !rought the dangers of acute c%anide poisoning

    from smo6e inha$ation to the nationa$ $eve$& he investigative report from 200 discovered that

    h%drogen c%anide is produced in significant 5uantities at fires invo$ving materia$s that are

    common$% present in modern !ui$dings such as p$astics s%nthetics and nitri$es&14't that time

    the investigation committee found research that supported the most common cause of c%anide

    poisoning as from smo6e inha$ation&1>

    10 (orce% .&&.utras -& Mo$is .& arone .& Darren &Report of Investigative Committee into

    Cyanide Poisoning of Providence Firefighters& Ma% 200

    11 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma%

    200(orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma%

    200

    12(orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    13 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    14 (orce%.& et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    1+

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    #rior to 200 the C%anide #oisoning reatment Coa$ition 8C#C9 had !een s$o$% raising the

    aareness of the dangers of c%anide in smo6e !ut as a resu$t of the events in #rovidence in

    200 the nations fire service is no great$% aare of the dangers& C%anide is no 6non as one

    of the dead$% to/ic tins a$ong ith Car!on Mono/ide that can have acute affects to

    firefighters from smo6e inha$ation&

    he investigative report in 200 found that the e/posures to c%anide ere a resu$t of

    trained seasoned firefighters misperceiving the ris6 and ma6ing a ca$cu$ated ris6 versus !enefit

    ana$%sis on the fire ground ithout a$$ of the pertinent information&1he 200 report found that

    firefighters are e/pected to ma6e the decision to ear or not ear their SC,' at a variet% of

    incidents from !ui$ding fires to investigations of fa$se or accidenta$ a$arms to investigating

    strange odors or the sme$$ of smo6e to operating at !rush fires ru!!ish fires and car fires&1*he

    200 report a$so stated that the decisions firefighters are re5uired to ma6e re$ated to air use is

    often made re$%ing on their s6i$$ judgement and e/perience in determining hen to mas6 up& 1=

    his decision to mas6 up is inf$uenced !% the potentia$ for the atmosphere to !e ha;ardous the

    $imited air supp$% duration the a!i$it% of the cre to accomp$ish tactica$ assignments and the

    desire of mem!ers not anting to consume air in nonAcontaminated areas so that the% have air

    hen needed to ensure the units tactica$ effectiveness&1+

    1> Ec6stein M and Manisca$co #MFocus on $mo&e Inhaation - 'he "ost Common Cause of (cuteCyanidePoisoning #rehospita$ and (isaster Medicine http"BBpdm&medicine&isc&edu o$& 21@o& 2 8MarA

    'pr 200

    1 (orce%. et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    1* (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    1= (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence Firefighters& Ma% 200

    1+ (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    20

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    he Investigative Committee conducted a $ength% intervie ith the Fire Captain ho as

    hospita$i;ed for c%anide poisoning from the Eaton Street fire& (uring the intervie the Fire

    Captain e/p$ained his air use as inf$uenced e/act$% as as e/p$ained in the previous paragraph&

    Dhi$e operating on the third f$oor of E/posure 4 the Captain removed his face piece once the

    fire on the third f$oor as comp$ete$% 6noc6ed don a$$s ere opened up and chec6ed for

    hidden fire and indos ere ta6en out to venti$ate the third f$oor& he Captain did

    ac6no$edge that mem!ers did operate in and out of smo6e for sma$$ periods of time due to the

    sir$ing ind conditions& 't times it as accepta!$e to remove face pieces on$% to have the ind

    change direction and push smo6e don from the fourth f$oor onto their position& he Captain

    and other compan% officers operating in that sector 6ne that the% ou$d have to push up the

    rear stairs to the fourth f$oor to contro$ and e/tinguish the fire on the fourth f$oor in E/posure 4&

    he first hose $ine !rought up the rear stairs to the third and fourth f$oor stretched short

    hen mem!ers attempted to push up to the fourth f$oor& he mem!ers of )adder 3 had attempted

    to venti$ate the roof on E/posure 4 !ut ere pushed off of the roof !ecause of the radiant heat

    from the origina$ fire !ui$ding and the sir$ing fire coming up Side 2 of E/posure 4& 's the

    mem!ers ere $eaving the roof the% ere on$% a!$e to venti$ate an e/isting s6% $ight opening on

    the roof of E/posure 4& he $ac6 of enough hose to reach the fourth f$oor the ind driven fire

    conditions that da% and the ina!i$it% of the mem!ers of )adder 3 to ade5uate$% venti$ate

    E/posure 4 made the push up to the fourth f$oor a difficu$t ph%sica$$% demanding and time and

    air consuming tas6&

    hose mem!ers not on the rear stairs and or6ing on the third f$oor aiting to move up

    to the fourth f$oor removed face pieces !e$ieving the atmosphere as safe on the venti$ated third

    f$oor& he Fire Captain stated during his intervie that he had operated that da% 8March 31

    2019 just as he had done for ever% other fire he had operated at during his thirt% one %ear

    career& ?e perceived the atmosphere on the third f$oor to !e safe !ecause of the strong inds

    !$oing in from Side 1 toards Side 3 of E/posure 4& ?e a$so anted to conserve his air for

    hen his cre moved up the rear stairs to the fourth f$oor& he Fire Captain a$so stated that his

    cre as mas6ed up hen the% ere on the rear stairs to the fourth f$oor and hi$e on the fourth

    f$oor !efore !eing re$ieved&

    21

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    Fo$$oing the events in 200 the #rovidence Fire (epartment imp$emented severa$

    changes to attempt to address the c%anide issue& he first change as to assess the presence of

    c%anide at fire scenes and assist department officers in identif%ing unsafe Immediate$%

    (angerous to )ife and ?ea$th 8I()?9 atmospheres and ma6e correct ris6 versus !enefit

    ana$%sis& he second change as to move to a $onger duration air supp$%&

    In 200 the #rovidence Fire (epartment or6ed ith one manufacturer of gas

    monitoring devices& his compan% partnered ith the #F( and provided 23 sing$e gas meters&

    he c%anide gas meters ere p$aced on a$$ compan% officers air pac6s& he idea as to turn on

    the devices hen entering structure fires to a$$o the devices to a$ert compan% officers of the

    presence of c%anide&

    'fter the imp$ementation and use of the detectors it !ecame apparent that the gas meters

    ere not !ui$t to meet the rigors of structura$ firefighting& he fi$ters on the gas meters as e$$ as

    other components are on$% rated for temperature environments of one hundred and tent%

    degrees Fahrenheit or $oer& Soon meters ere !eing damaged !ecause the meters ere !eing

    used in e$evated temperature environments& 'fter !eing damaged the meters ere returned to

    manufacturer for repairs& he manufacturer anted to !e paid to repair or rep$ace the meters& he

    #rovidence Fire (epartment made a fisca$ decision to move aa% from air monitoring for

    c%anide& Compan% officers no $onger carr% the c%anide sing$e gas meters&

    Dhat did !ecome readi$% apparent as the preva$ence of c%anide at fire scenes& Dhen the

    meters ere in service the% cou$d !e heard a$arming at man% t%pes of fire events that #F(

    mem!ers responded to& #rior to the presence of the meters mem!ers performing a ris6 versus

    !enefit ana$%sis at simi$ar t%pes of fire events assumed the atmospheres ere safe&

    'ir monitoring of fire environments after the fire has !een 6noc6ed don has no

    !ecome a standard operating procedure for some fire departments around the countr%& he

    #rovidence Fire (epartment no $onger emp$o%s air monitoring procedures for fire scenes&

    he idea !ehind air monitoring is to provide officers ith additiona$ information a!out

    the atmosphere as to hether it is safe to remove face pieces or not& 'ir monitoring is a

    procedure that the #rovidence Fire (epartment shou$d consider to incorporate !ac6 in to

    22

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    department procedures& ' compan% at each fire cou$d !e assigned the responsi!i$it% of providing

    air monitoring once the fire is under contro$&

    Dith respect to air monitoring not a$$ the dangers associated ith the to/ic products of

    com!ustion can !e monitored for& he gas detection e5uipment can on$% provide information

    ith respect to the t%pe of gas !eing monitored& Car!on mono/ide and c%anide $eve$s cou$d !e

    monitored for !ut other 6non dangerous carcinogens present in smo6e cannot !e monitored

    for& Firefighters need to !e educated and understand that other dangers are present in smo6e and

    it is not accepta!$e to !reathe smo6e even hen the gas meters are not a$arming for car!on

    mono/ide or c%anide&

    ' recommendation from the 200 investigation as for the #rovidence Fire (epartment

    to investigate the idea of comprehensive air management&20't that time four mem!ers of the

    Seatt$e Dashington Fire (epartment had !een moving to educate the 'merican fire service of the

    need for firefighters to !etter manage air use& he motivation for !etter air management !% the

    Seatt$e mem!ers as the resu$t of firefighter near misses and severa$ )ine of (ut% (eath

    8)((9 incidents e/perienced !% the Seatt$e Fire (epartment& he )((s ere the resu$t of

    firefighters running out of air in I(?) atmospheres&21

    In 200= the #rovidence Fire (epartment moved to a $onger duration air supp$% c%$inder&

    he Seatt$e Fire (epartment and other departments around the countr% had moved to the $onger

    duration c%$inders to com!at the issue of firefighters running out of air in an I()? atmosphere

    and !eing e/posed to smo6e& he move to the $onger duration c%$inders as done to a$$o fire

    fighters to mas6 up ear$ier enter or6 and e/it the Immediate$% (angerous to )ife and ?ea$th

    8I()?9 atmosphere hi$e sti$$ !eing on air&

    20 (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    21 ,ernocco S& :ag$iano M& .ose #& #hi$ips C&(ir "anagement for the Fire $ervice 200=

    #enne$$ #u!&

    23

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    his method of 6noing ho much air %ou have upon entering monitoring that air hi$e

    in the I()? atmosphere and e/iting the I()? atmosphere !efore the $o air a$arm indicator

    !egins to sound has !ecome 6non to the fire service as the Ru$e of 'ir Management22

    Since 2013 the princip$e of the Ru$e of 'ir Management a$ong ith the re5uirement of

    training mem!ers on individua$ consumption rates and the re5uirement to manage air

    consumption as part of a cre has !een incorporated into the @ationa$ Fire #rotection

    'ssociation 8@F#'9 Standard 1404 $tandard for Fire $ervice Respiratory Protection 'raining.

    Dhen the #rovidence Fire (epartment moved to the $onger duration air supp$% the intent

    of getting mem!ers to go on air sooner and sta% on air $onger as not conve%ed to a$$ mem!ers

    of the department& he training on the intent and purpose of the $onger duration air supp$% as

    presented as a point schoo$ presentation& Chiefs officers and firefighters not needing or not

    interested in receiving a ha$f a point toard promotion did not attended&

    he department did not revise its Standard perating #rocedure 8S#9 2 to ref$ect the

    intent of the change to the $onger duration air supp$%& In 2010 a draft revision of the

    (epartments S# 2 as su!mitted to the administration upon their re5uest& he draft S#

    incorporated the Ru$e of 'ir Management and out$ined the necessar% resources needed to meet

    the tenants of the Ru$e of 'ir Management& his draft as not adopted nor has the S# !een

    revised since !eing esta!$ished in 1+++&

    he administration at that time as main$% concerned ith the aspects of the draft S#

    that out$ined hat is 6non as three deep dep$o%ment resource a$$ocation mode$& he three

    deep dep$o%ment mode$ is descri!ed in the !oo6 'ir Management for the Fire Service 23his

    dep$o%ment mode$ had !een used primari$% in the past for high rise t%pe fires as e$$ as $ong

    duration events here mem!ers ere re5uired to remain on air hi$e in the I()? atmosphere&

    he #rovidence Fire (epartment S# 2+ ?igh Rise Fires recommends incident commanders use

    this method of resource a$$ocation for re$ief trac6ing and reha!!ing of cres&24#rogressive

    departments around the countr% have !een moving to this t%pe dep$o%ment mode$ for ever% da%

    22 ,ernocco S& et a$&(ir "anagement for the Fire $ervice 200= #enne$$

    23 ,ernocco S& et a$(ir "anagement for the Fire $ervice 200= #enne$$ #u!

    24

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    fire events of shorter durations& he intent of the use of this dep$o%ment mode$ as to com!at the

    dangers of mem!ers !eing e/posed to smo6e&

    he practice of adhering to three deep dep$o%ment mode$s is resource dependent& ' $ot of

    resources 8i&e& engine and $adder companies9 are re5uired to meet this dep$o%ment mode&

    Essentia$$% for ever% hose $ine dep$o%ed there is one engine compan% on the $ine one engine

    compan% on dec6 and one engine compan% in staging to re$ieve the mem!ers on the $ine hen

    their air supp$% !egins to !ecome $o& he on dec6 cre can move up and re$ief the initia$ hose

    $ine cre !efore their $o air a$arms activate if their tactica$ assignment and position re5uires

    them to !e continua$$% on air& hen the cre in staging ou$d move up& his same process for

    $adder companies ou$d need to !e used for those $adder compan% tactica$ assignments and

    positions that re5uire the cre to !e on air continua$$%&

    'n a$ternative to the three deep dep$o%ment resource a$$ocation mode$ for shorter

    duration events is the staffing of engine and $adder companies ith one officer and three

    firefighters& Four person cres hen operating in the I()? atmospheres re5uiring air use have

    the a!i$it% to sp$it the cre and operate in the I()? in teams of to or more&2>Dhen the need

    for rep$acing air supp$ies !ecomes apparent the officer can sp$it his cre and send to mem!ers

    out to rep$ace their air c%$inders hi$e to remain in the I()?& Dhen the first to mem!ers

    sent to rep$enish their air supp$% return the ne/t to mem!ers can rotate out for ne air

    c%$inders& his procedure of air management and sp$itting the cre a$$os the compan% to

    maintain their tactica$ assignment ithin the I()? atmosphere ithout the need for additiona$

    cres&

    hree person engine and $adder companies cannot fo$$o the same procedure for

    rep$enishing their air supp$% as four person companies& hree person companies do not have the

    a!i$it% to sp$it the cre and maintain tenants of the to in to out ru$e found in the

    (epartments standard operating procedures&

    2

    24 #rovidence Fire (epartment Standard perating #rocedure 2+)igh Rise Fire1++>

    2> #rovidence Fire (epartment Standard perating #rocedure 32 *perations at $tructure Fires

    1+++

    2>

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    Since 200 there have !een five $ess high profi$e fire events here an individua$

    mem!er of the department as treated for c%anide poisoning as a resu$t of e/posure to smo6e

    from structura$ firefighting& he events of March 31 2001 and the previous e/posures to

    c%anide indicate that more education and training of department mem!ers is re5uired&

    C$ear$% the continued e/posure of mem!ers to c%anide indicate the pro!$em for the

    #rovidence Fire (epartment is hat has !ecome 6non as an adaptive cha$$enge and not a

    technica$ cha$$enge for the department&2*he department has continued to address the c%anide

    issue and air use ith technica$ so$utions !ut the pro!$em of mem!ers !eing e/posed to c%anide

    continues to occur&

    's as found in 200 this Investigation Committee finds that characteri;ing the pro!$em

    strict$% as a discip$inar% issue ignores the comp$e/it% of the pro!$em&2='$so simp$% changing

    tactica$ operations of the #rovidence Fire (epartment ou$d not address the issue of continued

    e/posures to smo6e& his t%pe of change i$$ re5uire the t%pe of transformationa$ $eader that

    ?eifet; and )ins6% rite a!out in the !oo6 )eadership on the )ine&2+

    he issue is e/treme$% comp$e/ re5uiring strong transformationa$ $eadership support

    throughout the department 8!oth po$itica$$% and administrative$%9 continued education and

    training of a$$ mem!ers and ran6s of the department&

    here has !een much research of the ph%sio$ogica$ demands p$aced upon firefighters

    during structura$ firefighting& he persona$ protective firefighting gear re5uired for therma$

    2 #rovidence Fire (epartment Standard perating #rocedure 32 *perations at $tructure Fires

    1+++

    2*?eifet; Rona$d '& and Martin )ins6%+eadership on the +ine: $taying (ive through the

    ,angers of +eading& ,oston M'" ?arvard ,usiness Schoo$ 2002& #rint&

    2= (orce% . et a$&Report of Investigative Committee into Cyanide Poisoning of Providence

    Firefighters& Ma% 200

    2+ ?eifet; Rona$d '& and Martin )ins6%+eadership on the +ine: $taying (ive through the

    ,angers of +eading& ,oston M'" ?arvard ,usiness Schoo$ 2002& #rint&

    2

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    protection the se$fAcontained !reathing apparatus carried on the !ac6s of firefighters necessar%

    e5uipment needed to perform inside the fire environment and the ph%sio$ogica$ and emotiona$

    stress a$$ have a s%nergistic effect p$acing e/treme ph%sio$ogica$ demands on the firefighters

    !od%& 'ccording to information provided !% the Hnited States Fire 'dministration 8HSF'9 the

    $eading cause of fata$ities to firefighters is heart re$ated medica$ emergencies and HSF' data

    a$so indicates that after age 3> the proportion of deaths due to traumatic injuries decrease and

    the proportion of deaths due to medica$ causes steadi$% increase&30

    ' stud% found that the provision of fire suppression and emergenc% medica$ services

    entai$s sporadic high $eve$s of ph%sica$ e/ertion uncontro$$ed environmenta$ e/posures and

    ps%cho$ogica$ stress from o!serving intense human suffering&31Firefighters e/perience inordinate

    num!ers of $ineAofAdut% deaths deaths due to occupationa$ diseases forced retirements and $ineA

    ofAdut% injuries&32Firefighter fata$ities and injuries occur at a rate one and one ha$f times those of

    po$ice officers&33

    ften firefighter heart rates i$$ go from norma$ resting rates to e$$ a!ove age re$ated

    ma/imum heart rates& his ph%sio$ogica$ demand can occur ith $itt$e or no arning as e$$ as

    ith $itt$e or no arm up due to the nature of emergenc% response& Research has found that the

    pattern of sedentar% periods interrupted !% catecho$amine surges and heav% ph%sica$ e/ertion has

    30 Stoe$$ Frederic6 M& Chief *fficer& Sti$$ater -" Fire #rotection #u!$ications 6$ahoma

    State H 2004& #rint&

    31 MooreAMerre$$ )& 'inong K& Mc(ona$d S& Moore .& Fisher E&Reducing Firefighter

    ,eaths and In#uries: Changes in Concept Poicy and Practice Contributing Factors to

    Firefighter +ine-of-,uty ,eath in the nited $tates&

    32 MooreAMerre$$ )& et a$Reducing Firefighter ,eaths and In#uries: Changes in Concept

    Poicy and Practice Contributing Factors to Firefighter +ine-of-,uty ,eath in the nited

    $tates&

    33 MooreAMerre$$ )& et a$Reducing Firefighter ,eaths and In#uries: Changes in Concept

    Poicy and Practice Contributing Factors to Firefighter +ine-of-,uty ,eath in the nited

    $tates&

    2*

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    !een suspected to put firefighters at an increased ris6 for acute heart attac6s&34' danger of

    e/ceeding the ma/imum heart rate is the !od%s ina!i$it% to carr% o/%genated !$ood to vita$

    organs of the !od%&

    From the investigation of the events at the Eaton Street fire it is 6non that the

    firefighter ho as critica$$% injured suffered a heart re$ated medica$ emergenc% that as

    diagnosed as demand ischemia& (emand ischemia is a t%pe of heart re$ated event for hich

    !$oc6ages in the arteries ma% not !e present& It occurs hen a patients heart needs more o/%gen

    than is avai$a!$e in the !od%s supp$% and ma% occur in patients ith tach%arrh%thmias

    8a!norma$$% fast heart rates9&3>,$ood tests i$$ sho the presence of en;%mes that indicate

    damage to the heart musc$e&

    he activities at the emergenc% scene of the critica$$% injured firefighter and su!se5uent

    injur% high$ight the e/treme ph%sio$ogica$ demands p$aced upon firefighters during the

    performance of their duties& he critica$$% injured firefighter as assigned to an engine compan%

    for the fire on Eaton Street& ?is engine compan% staffed ith an officer and to firefighters as

    dispatched upon the genera$ a$arm& he initia$ assignment for the engine compan% as to secure

    an additiona$ ater source& he engine compan% $aid a one thousand foot five inch feeder from

    the h%drant $ocated at the corner of Chad ,ron Street and a6$and 'venue&

    he critica$$% injured firefighter as responsi!$e for turning in this h%drant and then ran

    up to the fire scene& nce at the scene he retrieved his air pac6 and too$s and as instructed !%

    his officer to assist the other firefighter in dep$o%ing an attac6 hose $ine into E/posure 4& he

    cres assignment from the Incident Commander as to ta6e the $ine to the fourth f$oor and

    re$ief cres a$read% operating on the fourth f$oor& Dhen intervieed the critica$$% injured

    firefighter reported that he had moved up and don the four f$ights of the rear stairs severa$

    times to ensure ade5uate hose as stretched up to the fourth f$oor& hese actions ere necessar%

    to a$$o for the hose $ine to cover the entire foot print of the fourth f$oor&

    34 ?a$es &)eart ,isease in the Fire $ervice: Cause for Concern 2011

    3> http"BB&secondscount&orgBheartAconditionAcentersBinfoAdetai$A2Bt%pesAofAheartAattac6s

    2=

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    Dhat needs to !e remem!ered is that this firefighter as carr%ing si/t% pounds of

    persona$ protective e5uipment and too$s necessar% to perform safe$% and effective$% hi$e

    performing these assigned tas6s& 'dditiona$$% this as a three person engine compan%& he

    officer as needed on the fourth f$oor to supervise and direct the activities of the no;;$e man in

    the ;ero visi!i$it% I()? atmosphere& )eaving a$$ of the or6 of stretching the hose $ine into

    position on the shou$ders of the critica$$% injured firefighter&

    'fter comp$eting duties as the !ac6up firefighter the critica$$% injured firefighter joined

    his cre on the fourth f$oor& Short$% after reaching the fourth f$oor and ith improvements of

    conditions on the fourth the injured firefighter informed his officer of the need to ta6e a 5uic6

    !rea6& he firefighter ent outside to an area of Sector 3 here cou$d remove his SC,' and

    persona$ protective e5uipment& ?e as given a !ott$e of ater !% mem!ers operating in that

    Sector& 'fter drin6ing the ater and catching his !reath he then donned his persona$ protective

    e5uipment and SC,' and joined his cre on the fourth f$oor& he cre remained on the fourth

    f$oor unti$ the f$oor as comp$ete$% overhau$ed and the fire comp$ete$% e/tinguished&

    Hpon e/iting the !ui$ding the entire cre reported to the EMS Sector for reha!i$itation& It

    as there that the critica$$% injured firefighters vita$ signs ere discovered not to !e ithin

    accepta!$e $eve$s& ?is pu$se rate as initia$$% recorded at 1>4 !eats per minute& 'fter

    appro/imate$% fifteen minutes of continued rest and o!servation his pu$se rate remained at 13>

    !eats per minute& 't this point the EMS Sector fficer made the decision to have the firefighter

    transported the hospita$& he other firefighter assigned to this engine compan% as a$so

    transported to the hospita$ for overe/ertion and e/haustion re$ated s%mptoms&

    he @ationa$ Fire #rotection 'ssociations 2014 Firefighter Injur% Report $isted that there

    ere 33>0 firefighter injuries for 2014&3Strain sprain and muscu$ar pain resu$ted in more than

    3 ?a%nes :& .& ?%$ton and .& Mo$is&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire

    #rotection 'ssociation 2014& #rint&

    2+

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    ha$f the major t%pes of injuries received during fireground operations&3*vere/ertion ran6ed

    second at 2>L for the $eading cause of injuries&3=

    'n investigation into the injuries at Eaton Street found that the majorit% of the injuries

    ere overe/ertion& here ere fourteen origina$ injures from the Eaton Street fire& Dhen

    c$assif%ing the t%pe of injuries sustained aside from to hand injuries 8one crushing one !urn9

    and one e%e injur% the remaining e$ven injuries can !e c$assified as overe/ertion fatigue t%pe

    injuries& hese injuries comprised strains and sprains of various !od% parts 8he Fire Captain

    treated for c%anide poisoning as origina$$% transported for a 6nee injur%9&

    ne da% fo$$oing the Eaton Street fire si/ additiona$ firefighters sought medica$ fo$$o

    up& Four of the si/ mem!ers had operated at !oth the Eaton Street fire and the )aure$ ?i$$ 'venue

    fire on March 31 201& '$$ of these mem!ers ere s%mptomatic ith overe/ertion and fatigue

    t%pe injuries&

    Dhen e/amined the injuries at the Eaton Street fire corre$ate ith research that has !een

    done that identifies the major contri!uting factors for firefighter injuries& he contri!uting factors

    are cre si;e standard operating guide$ines and hea$th e$$ness fitness and medica$ status of

    firefighters&3+

    Cre si;e has !een researched !% @ationa$ Institute of Standards and echno$ogies

    8@IS9&40he @IS research addressed the effects that cre si;e has on firefighter safet% and

    3* ?a%nes :& et a$&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire #rotection

    'ssociation 2014& #rint&

    3= ?a%nes :& et a$&Firefighter In#uries /012& Rep& ,oston" @ationa$ Fire #rotection 'ssociation 2014& #rint&

    3+ MooreAMerre$$ )& et a$&Reducing Firefighter ,eaths and In#uries: Changes in Concept

    Poicy and Practice Contributing Factors to Firefighter +ine-of-,uty ,eath in the nited

    $tates&

    40 'veri$$ (& MooreAMerre$$ )& ,aro% '& Santos R& #eacoc6 R& @otarianni -&

    Disso6er (&Report on Residentia Fireground Fied 3!periments.@IS echnica$ @ote 11&

    2010

    30

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    effectiveness& he research 5uantified the effectiveness of cre si;e firstAdue engine arriva$

    time and apparatus arriva$ stagger on the duration and time to comp$etion of tent% to 6e%

    fireground tas6s and the effect on occupant and firefighter safet%&41he research from @IS

    e/periments su!stantiated the re5uirements in the @F#' 1*10 Standard for the rgani;ation and

    (ep$o%ment of Fire Suppression perations Emergenc% Medica$ perations and Specia$

    perations to the #u!$ic !% Career Fire (epartments&

    In 200* @IS? pu!$ished a @IS? '$ert for the service re$ated to cardiovascu$ar

    disease and other sudden cardiac events& he @IS? '$ert provided recommendations to

    minimi;e the ris6 of injur% and death to fire fighters from cardiovascu$ar events& ne of the

    recommendations ca$$s for fire departments to ensure ade5uate staffing $eve$s for emergenc%

    operations to prevent overAe/ertion injuries42&

    Dhat is interesting a!out the num!er and t%pes of injuries recorded of the fourteen

    injuries nine of those mem!ers ere from three person cres hi$e the remaining five injuries

    ere from four person cres& Research has demonstrated that cre si;e of four persons versus

    three persons reduced the ris6 of injuries and improved overa$$ firefighter safet%&

    's mentioned a!ove standard operating guide$ines have !een identified as a contri!uting

    factor for firefighter injuries& he research cited a!ove particu$ar$% ref$ects the $ac6 of standard

    operating guide$ines or fai$ure to fo$$o esta!$ished standard operating guide$ines as a

    contri!uting factor for injuries&

    he #rovidence Fire (epartment ICS provides for ensuring that mechanisms for trac6ing

    and reha!i$itating personne$ are in p$ace and !eing used&43he #rovidence Fire (epartment ICS

    a$so states that personne$ must !e a$so monitored for signs of ph%sica$ or emotiona$ e/haustion

    41 'veri$$ (& et a$&Report on Residentia Fireground Fied 3!periments.@IS echnica$ @ote

    11& 2010

    42 @IS?&Preventing Fire Fighter Fataities ,ue to )eart (ttac&s and *ther $udden

    Cardiovascuar 3vent.#u!$ication @o& 200*133& 200*

    43 #rovidence Fire (epartment Incident Command $ystem1++3

    31

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    indications of e/posure to smo6e ha;ardous materia$s or eather e/tremes&44he command

    matri/ for trac6ing the $ocation and status as in p$ace and !eing used on March 31 201& he

    EMS sector as esta!$ished and in p$ace to provide EMS and reha! to firefighters or6ing at the

    scene&

    Fo$$oing a discussion and revie of the num!er of overe/ertion and fatigue t%pe

    injuries at the Eaton Street fire the IC ac6no$edged that the activation of additiona$

    intermediate command $eve$ positions of the #rovidence Fire (epartment ICS ou$d have

    improved direct supervision of mem!ers or6ing at the scene& he IC further ac6no$edged that

    the additiona$ intermediate command $eve$ positions cou$d have assisted the IC in maintaining a

    proper span of contro$ as out$ined in the (epartments ICS document&4>,% !ui$ding a proper

    command structure the IC cou$d have improved the span of contro$ hich ou$d have improved

    the monitoring of cres or6ing in the to e/posure !ui$dings as e$$ as monitoring the

    amount of time these cres or6ed in the those I()? atmospheres& he intermediate command

    $eve$ positions cou$d have or6ed more c$ose$% ith the compan% officers identif%ing those

    mem!ers needing re$iefs& hen re$iefs cou$d have !een provided in a more time$% fashion to

    prevent mem!ers from overe/erting themse$ves&

    he injuries from the Eaton Street fire ref$ect the dangers associated aggressive interior

    structura$ firefighting& he injuries further high$ight theph%sio$ogica$ demands p$aced upon

    firefighters& he nature of the or6 performed and injuries sustained at the Eaton Street fire

    ref$ect the need of firefighters to maintain $eve$s of fitness that invo$ve the components of cardio

    vascu$ar strength and conditioning and f$e/i!i$it% training throughout the course of their careers&

    It is important to note that rest is an important component of the aspects of fitness hea$th

    and e$$ness for com!ating the ph%sio$ogica$ and ps%cho$ogica$ stressors of firefighting& Dhen

    performing an o!jective revie of the injuries that occurred at the Eaton Street fire the recent

    reorgani;ation of the p$atoon structure of the #rovidence Fire (epartment cannot !e over$oo6edhen e/amining the overe/ertion and fatigue re$ated injuries sustained !% department mem!ers&

    44 #rovidence Fire (epartment Incident Command $ystem1++3

    4> #rovidence Fire (epartment Incident Command $ystem1++3

    32

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    he reorgani;ation to the Fire (epartment invo$ved no input from fire department

    officia$s& ?ad the po$itica$ administration consu$ted the fire department mem!ers the

    administration ou$d have !een informed of the impact that this t%pe of change ou$d have on

    the overa$$ safet% of the firefighters&

    @IS? through the Center for (isease Contro$ 8C(C9 has performed research that

    identifies the impact of increased hours or6ed ith a decrease in the amount of time off for

    recuperation&4' @ationa$ Response eam technica$ report found that fatigue i$$ !e a greater

    impact on overa$$ safet% hen responders are or6ing $ong shifts and the tas6s are ver%

    demanding such as high$% cognitive or emotiona$$% intense or6 ph%sica$ e/ertion e/treme

    environments or e/posure to other hea$th or safet% ha;ards&4*hese findings suggest that

    firefighters ho fre5uent$% or6 $onger shifts com!ined ith $onger or6 ee6s and night

    shifts ma% !e at a higher ris6 of injur% and reduced performance&4='nother report found $onger

    and more stressfu$ the or6 shiftBee6 the greater the need for recuperative time off&4+

    he present or6 schedu$e does not provide ade5uate rest or recuperation for maintaining

    proper fitness hea$th and e$$ness $eve$s to meet the ph%sio$ogica$ and ps%cho$ogica$ demands

    of the jo!&

    he Eaton Street fire provides $earning opportunities ith respect to the #rovidence Fire

    (epartment ICS and command and contro$ of $arge sca$e emergenc% incidents& he #rovidence

    Fire (epartment ICS provides a professiona$ approach to emergenc% management& ICS can

    enhance the a!i$it% of fire officers to organi;e and contro$ resources and activities at the incident

    4http"BB&cdc&govBnioshBemresB

    4* @ation Response eam 4uidance for "anaging 5or&er Fatigue during ,isaster Response

    200+

    4= @ation Response eam 4uidance for "anaging 5or&er Fatigue during ,isaster Response

    200+

    4+ Sonnentag N Kij$stra 2007 .ohnson 2007 otterde$$ et a$ 1++>7 HS('BForest Service&

    33

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    scene to hand$e the situation in the most effective manner possi!$e&>0ICS can increase the overa$$

    effectiveness of command officers hi$e at the same time ma6ing their jo! easier and $ess

    stressfu$&>1

    ,ecause of the ever%da% use of the ICS the first arriving compan% officers a$ong ith the

    first arriving ,atta$ion Chief ere a!$e to coordinate the activities of the units dispatched on the

    first a$arm& Command as esta!$ished the command se5uence !egun incident priorities

    identified si;e up performed strategic o!jectives esta!$ished and tactica$ operations assigned&

    In an effort to maintain proper span of contro$ the IC 5uic6$% recogni;ed the need to

    divide the scene into managea!$e units& he IC esta!$ished E/posure 4 as one sector and

    E/posure 2 as a second sector and assigned the first compan% officers into these !ui$dings as the

    sector officers& nce these sectors ere esta!$ished and resources assigned to each sector the IC

    esta!$ished the Side 3 Sector to manage the companies operating on e/terior of Side 3 of the

    incident&

    he ICs span of contro$ as e/ceeded even ith esta!$ishment of the sectors and the

    EMS sector !eing esta!$ished !% the officer of the first arriving rescue& (uring the course of the

    fire the IC as responsi!$e for the accounta!i$it% of trac6ing of and assigning time$% re$iefs of

    mem!ers assigned to tent% to #F( fire units si/ #F( ')S rescue units to @orth

    #rovidence Fire units and four out of ton ')S rescue units&

    he $esson to share from an o!jective revie of the command structure for this fire

    event is the need to esta!$ish additiona$ intermediate command $eve$ positions to improve the

    overa$$ safet% and accounta!i$it% of mem!ers operating at the scene& he IC shou$d have

    considered assigning an perations Chief& 's e$$ the geographica$ area of the incident justified

    the esta!$ishment of to (ivision Chief positions one (ivision Chief for contro$ of activities in

    each of the to e/posure !ui$dings& he (ivision Chiefs cou$d then assign sector officers for

    each f$oor of the e/posure !ui$dings improving direct supervision accounta!i$it% and overa$$

    safet% of mem!ers or6ing in those !ui$dings&

    >0 #rovidence Fire (epartment Incident Command $ystem1++3

    >1 #rovidence Fire (epartment Incident Command $ystem1++3

    34

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    he revie of the events of the Eaton Street fire high$ight the #rovidence Fire

    (epartments ina!i$it% to fi$$ ICS Command Staff :enera$ Staff and intermediate command $eve$

    positions ith chief officers ho have Fire :round Command e/perience&

    ?istorica$$% chief officers of the department ou$d promote up through the ran6s& hese

    chief officers ou$d have had e/perience as Fire )ieutenants and Fire Captains& he Fire

    Captains ou$d promote to Fire ,atta$ion Chiefs 8,C9& he ,Cs cou$d promote to (eput%

    'ssistant Chief 8('C9 positions and the ('Cs ou$d move on to the 'ssistant Chief of the

    (epartment 8'C(9 Staff positions or Chief of the (epartment 8C(9&

    Since 200= the #rovidence Fire (epartment has moved to e$iminate severa$ Chief fficer

    Staff positions& he Fire Marsha$$ and (irector of the (ivision of raining ere once Chief

    fficer positions& he duties of these positions have since !een assigned to the Captains of those

    respective divisions& In 2010 a reorgani;ation of the num!er of Chief fficer )ine positions

    e$iminated a !atta$ion chief position from each of the four p$atoons& '$so since 2010 the

    (epartment Safet% fficer position has !een vacant& his position traditiona$$% had !een a

    ,atta$ion Chief ran6& In 201 the (epartment as once again reorgani;ed& he restructuring of

    the num!er of p$atoons e$iminated to more Chief fficer )ine positions 8one ('C one ,C9&

    More recent$% the unfi$$ed C( 'C( perations and the unfi$$ed ('C )ine

    positions have reduced the num!er of #rovidence Fire (epartment Chief fficers ith fire

    ground command e/perience&

    ?istorica$$% hen the (epartment has had fires of the si;e and comp$e/it% of the Eaton

    Street fire hether during the da% or night upon the occurrence of a mu$tip$e a$arms the C(

    'C( Fire Marsha$$ (irector of (ivision of raining (epartment Safet% fficer EMS ,C

    and Superintendent of 'utomotive Repair ou$d respond to the scene of the a$arm and carr% out

    their assigned duties&>2he return of these chief officers to the mu$tip$e a$arm fires provided the

    IC ith chief officers so that if the ICS command structure re5uired these chiefs cou$d !e

    assigned ICS Command Staff ICS :enera$ Staff positions or intermediate command $eve$

    positions&

    >2 #rovidence Fire (epartmentRues and Reguations1++

    3>

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    Dhen o!jective$% revieing the events surrounding the injuries at the Eaton Street fire

    discussion of the unfi$$ed (epartment Safet% fficer position cannot !e over$oo6ed& 's

    mentioned a!ove this position has !een $eft unfi$$ed since 2010& Since 2012 four (epartment

    investigations and reports have !een done !ecause of fire events invo$ving ma%da%s firefighter

    near miss events and fires resu$ting in serious injuries to firefighters& Each of these previous

    reports has recommended the reAactivation of the (epartment Safet% fficer and ,atta$ion 2

    Chief fficer positions&

    he intent of these recommendations as to improve overa$$ firefighter safet%& he

    (epartment Safet% fficer position had !een responsi!$e for the management of (epartment

    ccupationa$ Safet% and ?ea$th program& he (epartment Safet% officer maintained a thorough

    6no$edge of current and changing Federa$ State and $oca$ $as regu$ating safet% in the

    or6ing environment app$ica!$e to the fire department& he Safet% fficer as responsi!$e

    identif%ing and causing the correction of safet% and hea$th ha;ards& It as the Safet% fficers

    responsi!i$it% to investigate a$$ occupationa$ injuries i$$nesses e/posures and fata$ities invo$ving

    fire department personne$ and a$$ accidents invo$ving fire department vehic$es apparatus

    e5uipment and faci$ities& he Safet% fficer managed the co$$ection and ana$%sis of the records

    and data pertaining to apparatus accidents deaths injuries i$$nesses and e/posures of fire

    department personne$& he Safet% fficer responded to emergenc% incidents that invo$ved a high

    degree of ris6 to personne$ and integrated into the #rovidence Fire (epartment ICS to serve as

    the incident safet% officer&

    he repeated recommendation for the reAesta!$ishment of the ,atta$ion 2 Chief fficer

    )ine position to each or6ing p$atoon as a$so intended to improve firefighter safet%& he

    present structure of to Chief fficers per p$atoon ma6es each chief responsi!$e the direct

    persona$ command contro$ and supervision over the personne$ of fifteen companies assigned to

    each of the to !atta$ions& Each chief is re5uired to ma6e month$% inspection of the 5uarters and

    a dai$% inspection of personne$ assigned to the !atta$ion&>3

    Dith the present organi;ationa$ structure of to Chief fficers per p$atoon one Chief

    fficer is responsi!$e for nine companies during the initia$ stages of a fire incident& he first

    >3 #rovidence Fire (epartmentRues and Reguations1++

    3

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    a$arm for a structure fire is three engines to $adders one heav% rescue one ')S rescue&

    Immediate$% fo$$oing the dispatch of the first a$arm companies and engine and $adder is

    dispatched as the Fast 'ssist Search eam 8F'S9 companies& his !rings the first a$arm

    comp$iment to nine companies& he Internationa$ Fire Service raining 'ssociations Chief

    fficer !oo6 states that the standard span of contro$ for an incident commander is three to seven

    ith five !eing the optima$ num!er for appropriate span of contro$&>4he #rovidence Fire

    (epartment ICS a$so states that this is the standard for span of contro$& Current$% the second

    chief if avai$a!$e is !eing dispatched to fire incidents to assist ith managing a fire incident

    $eaving no supervisor for the remaining nineteen companies in the cit%&

    he decimation of the Chief fficer positions !% past and present administrations a$ong

    ith the unfi$$ed e/isting chief officer positions has created a situation that prevents the

    #rovidence Fire (epartment from fo$$oing command contro$ procedures out$ined in the

    (epartments Ru$es and Regu$ations Incident Command S%stem and various Standard

    perating #rocedures& 's stated previous$% $ac6 of fo$$oing standard operating guide$ines as

    identified !% research as a contri!uting factor to firefighter injuries&

    his fire event a$so high$ighted the demands p$aced upon the #rovidence Fire (epartment

    ,ureau of perationa$ Contro$ 8,C9 during emergenc% operations of this si;e& his event

    further demonstrated the cha$$enges for the present on dut% staffing $eve$s of the ,C&

    (uring the Eaton Street fire hich re5uired a$$ avai$a!$e #rovidence Fire (epartment

    units he ,C as coordinating the re5uired mutua$ aid coverage throughout the remainder of

    the cit% monitoring the primar% dispatch radio channe$ and continued to anser routine and

    emergenc% te$ephone ca$$ vo$ume&

    It as fortunate that the Eaton Street fire occurred during da% time operations for the

    ,C& he Captain of the ,C ho norma$$% or6s da% time hours stepped in to assist the

    norma$ on dut% staff of one Fire )ieutenant and to civi$ian dispatchers to meet the demands of

    cha$$enges faced !% the ,C& In addition to persona$$% assisting the on dut% staff the Captain of

    >4 Internationa$ Fire Service raining 'ssociation Chief *fficer& Sti$$ater -" Fire #rotection

    #u!$ications 6$ahoma State H 2004& #rint&

    3*

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    the ,C immediate$% recogni;ed the need of additiona$ staff& he Captain of the ,C ordered

    to civi$ian dispatchers to remain on dut% hen their re$iefs arrived for the change of shift&

    'ppro/imate$% to hours and thirt% five minutes into the Eaton Street fire the ,C

    !egan receiving phone ca$$s for a second ind driven fire on )aure$ ?i$$ 'venue& he ,C as

    no monitoring to fire events and simu$taneous$% monitoring the radio channe$s assigned for

    eac