Fresno firefighters who responded to a house blaze where Capt. Pete Dern fell through a roof and was severely burned failed to properly assess the fire’s dangers, reflecting a Fire Department in which personnel are “picking and choosing” which procedures to follow, an investigative report says.
The 274-page investigative report on the March 29, 2015, fire in central Fresno makes sweeping recommendations for the Fresno Fire Department – some of which are already being put into place by the department.
Dern was engulfed in flames for more than 90 seconds. He suffered second- and third-degree burns on 70 percent of his body. The incident and his long rehabilitation received national attention. Dern spent 164 days in the burn unit at Community Regional Medical Center.
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Following the incident, Fire Chief Kerri Donis assembled a Serious Accident Review Team and authorized it to investigate the circumstances of the fire and Dern’s injuries. The report was released Tuesday afternoon.
The recommendations issued by the team cover everything from adhering to rules on personal protective gear to altering the fire department’s culture of safety. The eight-member SART team was made up of current and retired fire officials from the Kern County Fire Department, the Modesto Fire Department, the Los Angeles Fire Department and other agencies.
The report said causal factors included fire department culture, risk management identification, ventilation training and water application techniques.
But, the team added, many of the same factors have been found in dozens of other serious firefighting incidents across the country “that the contributory and causal factors were not unique to this incident.”
“We have years of investigative reports with documented factors, recommendations, as well as more scientifically proven, modern firefighting methods, that can and do make this profession safer for our people,” the report states, “yet we continue with business as usual, or simply write firefighting off as just being a dangerous profession.”
Firefighters’ and commanders’ approach to the blaze showed an absence of a standard risk management process developed by the fire department to address hazards in firefighting operations, the report said. It recommended the department develop a vigorous training program with exercises on assessing risk.
“When dealing with department policies and procedures, it is apparent the membership at all levels is picking and choosing which ones they are willing to follow,” SART team members wrote. The report recommended an “imperative for safety” be established within the department.
A firefighting technique called vertical ventilation, which involves cutting holes into a roof to allow heat and smoke to escape, was a causal factor, the report said.
During the March fire, Dern was attempting to perform vertical ventilation when the garage roof collapsed and Dern fell inside. The report recommended a policy be implemented to ensure firefighters are not knowingly attempting vertical ventilation over unprotected spaces.
Nozzles and water-application techniques were another causal factor highlighted in the report. It noted that, in contrast to national standards, Fresno Fire Department had a policy of using 95 gallons per minute. Building materials and furnishings have shifted to plastics and synthetics, which burn hotter and quicker than traditional cellulose-based materials, the report said. It recommended the fire department adopt the National Fire Protection Association standard of 300 gallons per minute, shared between the first and second hose lines at a home fire.
There is no fire department policy on how to battle residential garage fires, the report said. It noted that in 2010, Fresno Fire Department participated in an accident review process for a Modesto Fire Department roof operation that had similar circumstances to the March fire in Fresno. However, there was little or no change in Fresno Fire Department roof operations, the report said.
The report also found that during the March fire and other incidents, personnel sometimes acted independently, without the knowledge or consent of the incident commander. The report suggested a process for fire department vehicles to respond and receive assignments at emergencies.
Fire personnel should consistently conduct a more thorough process of sizing up a fire, the report said. At the March fire, no complete walk-around was done. “Executive staff shall provide and enforce clear expectations to ensure a 360-degree walk-around assessment has been completed or attempted,” the report said.
Fresno Fire Department has numerous policies about personal protective equipment (PPE), but the report found that some department personnel had lax attitudes about following them. The investigation team said they interviewed firefighters who acknowledged that they often didn’t wear seat belts on their way to a fire or accident because they wanted to have all their safety gear on by the time they reached the incident.
“During the rescue attempt of the fire captain, several personnel were not wearing the appropriate PPE, potentially delaying rescue efforts,” the report said. Investigators said an inspection of Dern’s gear indicated that he was not wearing his protective gloves and hood and that his helmet may not have been strapped onto his head.
A news release from the Fresno Fire Department that announced the report said Dern and his family would not comment to the media about the findings.
Donis and Fresno City Fire Fighters union president Carlton Jones said they welcomed the report as a learning opportunity and a springboard for training and policy improvements to ensure firefighter safety.
“This was an opportunity to identify issues not only with the Fresno Fire Department, but with the American fire service,” said Donis, citing the report’s note that some of the same issues were factors in at least 70 other serious incidents in which firefighters were injured or killed over the past 10 years. “These are issues that have been going on for years, and (the industry) has essentially kicked the can down the road. … Now here is a playbook on how to go forward.”
Donis said the mayor and City Council are already taking steps to beef up the department’s training budget and personnel by about $1.7 million for the 2016-17 fiscal year. “And for the council to push forward (this year) with positions that the mayor and city manager recommended is a huge shot in the arm,” she added. The new positions will include two training captains, training officers for engineers and firefighters, and an additional battalion chief for each shift. Donis acknowledged, however, that Fresno continues to have lower minimum staffing than other metropolitan areas.
Jones said that the union was pleased that the city invested in the SART report. While the report may seem harsh on its surface, his firefighters understand that “this is a 200-plus-page snapshot of this one 15-minute incident.” But, he said, “the public doesn’t get to see in this report what led up to it or what steps have already been taken.”
“For us, we look at every incident as an opportunity to improve,” he added. “We can’t lose. We constantly want to get better. … This is a learning tool, something that pretty much says, ‘You have some things to work on.’ ”
Jones said he expects the department to “take all the good information we know will help us, and hopefully convince our city leaders to make the necessary investments” in such factors as more training, improved radio gear and increased staffing.
Donis said one surprise was learning that firefighters said they weren’t wearing their seat belts aboard engines and trucks as they rode to fires. “How did we create this culture of ‘rush, rush, rush at all costs to an event’ at the expense of safety?” she said. “Safety is non-negotiable, and that has improved. … You have to wear your seat belts. You have to button up and wear all the equipment we’re given to be safe. Gather as much information as we can before we enter the building.
“You have to take a little more time, and that’s hard for firefighters to do,” she added. “But we’re no good to anybody if we don’t arrive and function safely.”