Huntingtown VFD Featured In Firehouse Magazine

Firefighters Burned In Mega-Mansion Fire
Part 2 – What the investigative report revealed

By: Chief William Goldfeder & Chief Jonathan Riffe

This is the conclusion of a two-part report on operations at a March 19, 2011, house fire in Huntingtown, MD, at which 10 firefighters were injured, including four who received significant burns. Fire and rescue personnel from the Huntingtown Volunteer Fire Department (HVFD) responded along with other departments from throughout Calvert County and numerous mutual aid departments from Anne Arundel, Charles and Prince George's counties.

As we reported in part one (September 2012), about 15 minutes after interior firefighting operations were begun, conditions on the second floor deteriorated rapidly as the main body of heavy fire in the attic and void spaces dropped down on firefighters. This forced an emergency evacuation of the second floor.

Given the severity of the injuries and magnitude of the event, Chief William Goldfeder was asked by HVFD Chief Jonathan Riffe to assemble an independent investigative team to critically review the incident so others can learn about what happened there and how to prevent injuries in the future. The team consisted of Assistant Chief Donald W. Heinbuch of the Baltimore City, MD, Fire Department; Division Chief Michael W. Robinson of the Baltimore County, MD, Fire Department; Chief Jonathan R. Starling of the Sterling Volunteer Fire Department in Loudoun County, VA; Chief William Corrigan of the College Park Volunteer Fire Department in Prince George's County, MD; Captain Justin L. Green of the Loudoun County, VA, Department of Fire, Rescue and Emergency Management; and Deputy Chief William Goldfeder of the Loveland-Symmes Fire Department in Ohio, who was chairman of the investigative team. The team was assisted with logistics by James W. Richardson, coordinator, and Katie Hanko, both from the Fire-Rescue-EMS Division of the Calvert County Department of Public Safety. Particular thanks to Captain Justin Green, who served as the scribe and the architect of the document as the report was being developed.

As we stated in part one, the investigative report contains the results of the team's comprehensive review and analysis. All of the information presented is factual and, to the greatest extent possible, was validated by multiple sources prior to inclusion in this document. It is important to note that the investigative team had months to examine the incident, form conclusions and develop recommendations. In contrast, the first personnel to arrive on the scene had only seconds to make critical decisions and take action. This column continues a synopsis of the investigative report.

FIRST ARRIVING UNITS:
Chief 6C, the first fire department unit to arrive on scene, based his decision to enter the house on information relayed from Calvert Communications that "(the caller is) advising the fire's now spread to his attic" and the occupant, who arrived at the vehicle and mentioned that someone was still inside. As the first-arriving unit on scene, Chief 6C (who reported "heavy smoke from the attic area, working fire") had the opportunity to establish command, formulate an Incident Action Plan (IAP) and communicate a strategy to incoming units. Instead, Chief 6C asked Chief 6A to take command upon arrival.

Engine 6-2, the first suppression unit to arrive on scene, reported, "6-2 laying out at the end of the driveway, gravel portion."
Chief 6C: "I do not have an all clear, I'm going in."
Chief 6A: "I copy."

Chief 6C exited the vehicle and met the lieutenant, who had arrived before Chief 6C, at the rear of the vehicle where they both donned their personal protective equipment (PPE) and self-contained breathing apparatus (SCBA) carried in Chief 6C's vehicle. Once equipped, they both entered the home via the front door on side Alpha. Chief 6C entered the open door and traveled across the foyer where the stairs to the second floor were visible. Chief 6C reported seeing a haze on the first floor, while light smoke was visible at the ceiling level of the second floor when looking up the stairwell. The lieutenant remained in the foyer while Chief 6C accessed the two-story great room to the rear of the home where he found the fireplace. No fire or signs of fire were visible around the fireplace.

On the way back toward the foyer, Chief 6C met an older occupant of the home who was carrying pictures from a den/office area. The occupant was instructed to exit and Chief 6C quickly checked the remainder of the first floor for occupants before returning to the foyer.

Engine 6-2 arrived on scene with five personnel. After laying out from a position in the driveway where the surface changed from asphalt to gravel, Engine 6-2 laid approximately 800 feet of threeinch supply line. Chief 6C reported that the engine company also stretched a 400- foot, 1¾-inch pre connected attack line to the front door of the house.

00:09:36 – Chief 6C: "Alright, everybody's out the house, (Chief 6A). We're running the 400 right now."
Chief 6A: "Alright, you're reporting an all clear and you're running the 400."
Chief 6C: "Yeah, that's right; we're going to have heavy fire in the attic" and he requested hooks inside immediately.

Once the first floor was checked and no occupants were found, Chief 6C returned to the foyer and met with the lieutenant. As they were ascending the stairs to the second floor, Engine 6-2 arrived in the foyer. Engine 6-2 had stretched the 400-foot, 1¾-inch handline to the front door and proceeded, with the line dry, to the second floor. Upon entering the house, the crew reported there was no sign of smoke on the first floor. In the foyer, they found the stairwell to the second floor, which they ascended, and found light smoke at the ceiling level.

Once at the top of the stairs, Chief 6C checked the side-Delta area of the second floor and the lieutenant turned to the left and moved toward side Bravo over the garage where there was a "bonus room" (a multi-purpose room often found over a garage or in an attic). Chief 6C returned briefly to the top of the stairs and told Engine 6-2 that they "couldn't find attic access and (they) would need to find a way in to the attic."

Upon reaching the second floor, the unit supervisor of Engine 6-2 moved to the Bravo side of the house where the bonus room was over the garage. The intent was that firefighters were "going to go that way and work our way back." In the bonus room, firefighters used pike poles to open inspection holes in the ceiling looking for fire. They did not find any signs of fire and firefighters moved from the Alpha and Bravo quadrants, across the open area and toward a bedroom on side Delta. At this point, the hoseline had still not been charged.

00:10:27 – Chief 6C: "Operations to Command."
Chief 6A: "Go ahead, Chief."
Chief 6C: "I'm doing my 360 right now. I got heavy fire on side Charlie."
Chief 6A: "Alright, get inside with them guys, don't worry about anything else, I will be there in about 30 seconds… get that place opened up. Squad 6, long hooks when you get there…copy, long hooks."

At this point, a large number of firefighters were in the open area with most of them working to find the fire by hooking the ceiling. Several firefighters reported that there was little coordination or direction beyond "bring long hooks" and "hook the ceiling." Units generally stayed together, but eventually spread around the open area. At this stage, numerous personnel were operating inside in an attempt to pull ceilings, find the best access to fire and attack.

THE FIRE EMERGENCY:
00:20:58 – Huntingtown Command (Chief 6A): "6C, I need an update right away, it's not looking good (see Photo 1). About two more minutes and I'm pulling them out."
"(Inaudible)…officer to Command, I need a line to side Alpha."
Chief 6C: "6C to Command. Evacuate the building, evacuate the building, evacuate the building. Calvert, sound the evacuation tone immediately. All units…(covered by tones.)"
At this point, firefighters begin emergency evacuation of the home.

Huntingtown Command reported seeing a flash of light across the large window in the second-floor open foyer concurrent with a rapid increase in fire and smoke issuing from the second floor. On the interior, firefighters operating in the bedroom and firefighters operating in the second-floor open area reported rapidly changing smoke conditions followed by a sudden spike in temperatures that quickly changed to fire progressing from the ceiling level to the floor (see Photo 2).

Chief 6C, at this time positioned in the foyer area assisting with hoseline advancement, observed a rapid increase in smoke visible up the stairwell and then fire in the two-story great room. Chief 6C reported fire was visible to the approximate level of the first-floor ceiling in the great room. Chief 5B, positioned in the great room near the first-floor fireplace, saw fire progress down the stairway and "blow out the front door." On the exterior, Huntingtown Command recognized these conditions and called for an evacuation.

In the second-floor bedroom, the officer from Engine 6-2 became separated from his firefighter on the nozzle and ultimately jumped from the second-floor window, landing on the first-floor overhang before landing on the grassy surface on side Alpha. The firefighter from Engine 6-2 and a firefighter from Squad 6 operating in the bedroom retreated to the stairway. Multiple firefighters operating in the open area on the second floor reacted to the rapid fire progress by immediately implementing survival techniques. Firefighters partnered up with other firefighters by holding onto airpacks and rapidly descended the stairs. At least one firefighter found the hoseline and followed it until the banister surrounding the stairwell was located. Several firefighters, upon locating the banister, jumped or fell to the first floor.

Chief 2, operating as Division 2, on the second floor encountered a rapid heat buildup while standing next to the railing around the stairwell. Chief 2 sounded his PASS (audible warning device) to serve as a beacon for other firefighters on the second floor before following the hose down the stairs. Once in the foyer area, Chief 2 helped pull down hoselines from the second floor and gather equipment. When Chief 2 discovered a helmet from a Company 2 firefighter, Chief 2 conducted a face-to-face accountability check with Engine 2-1 and Tower 2 before confirming all personnel from Company 2 were accounted for with Huntingtown Command.

EMERGENCY TRANSMISSIONS:
The following radio transmissions outline the emergency:
Huntingtown Command: "6C, come in and I need accountability right away."
Chief 6C: "(Vibralert sounds)…I am still trying to verify that everyone has come out…(Vibralert sounds)…start a few ambulances, I know we've got people hurt."
Huntingtown Command: "I cannot, can't copy a word you're saying, Chief."
Chief 6C: "(Vibralert sounds)…I am still inside on Division 2, trying to verify that everyone is out…start an ALS unit and a few ambulances. (Chief 6A) I know we've got people hurt."
Huntingtown Command: "Alright, the only thing I got is that you got a couple
people hurt, they're in the front yard. Your mask is going off. I can't understand a word you're saying."
Chief 6C: "(Vibralert sounds)…I'm inside verifying that everyone is out."
Chief 6C and 5B remained in the first floor foyer area for a few minutes to ensure all firefighters were accounted for and had exited the home. "Start me three ambulances for now, Calvert. I'll get back to you in a minute."

Medic 102 had requested aero medical evacuation resources in the form of helicopters from Maryland State Police as soon as firefighters appeared in the doorway evacuating the house.

Huntingtown Command: "Please somebody get on the handlines."
Chief 6C: "(Vibralert sounds)...(unreadable transmission)."
Huntingtown Command: "Safety Officer 6, come in. Safety Officer 6, come in."
Unknown unit: "Engine 2, I need water."
Huntingtown Command: "I need to know if we're all clear. I still see people coming out that front door."
Duty Chief: "Duty Chief, Chief 2 and Chief 6C, we're all here making sure everybody's out."
Huntingtown Command: "Alright, now I want one of you to let me know who's hurt, how many guys and the severity of injuries immediately."
Duty Chief: "I'll get that to you in one second."
Tower 2 Portable: "Be advised that when I was coming out, the homeowner was inside. You need to make sure that homeowner got out."
Huntingtown Command: "Yeah, I think he dove out that window, I think I saw him come out the front."
Duty Chief: "Duty Chief to Command."
Unknown unit: "Command, I got that second supply line coming back. I'm not going to be able to make it duals with 2-2. I'm going to have to lay their thousand out and then use their LDH (large diameter hose)."
Huntingtown Command: "Alright, standby with that real quick. Calvert, my Safety Officer is going to have the EMS sector on Tac 3, OK? He's going to take care of that, he does need two helicopters."
Calvert Communications: "OK."
Duty Chief: "Alright Command, I've got two injured."
Huntingtown Command: "Chief 6C, come in."
Chief 6C: "Go ahead (6A)." Huntingtown Command: "Alright, I need to know if everybody is out of this house immediately."
Chief 6C: "I know this. As soon as I can get a line I'm going back to the second
floor."
Huntingtown Command: "Uh, I don't think you can make that second floor, Chief, from where I'm standing. Get me an accountability, now."
Chief 6C: "You're going to have to call the individual officers, (6A). I don't know who was in charge of 6-2. OK, Calvert. I'm going to have to bug you for one minute. Calvert, get me Engine 6-2's officer.
Calvert Communications: "6-2."

After no success, Engine 6-2's driver/operator is asked, "Who was on your fire truck?" There was no recorded response and there is no further mention on TAC 1 regarding accountability of firefighters or EMS resources. The remainder of the radio traffic concerns logistics and suppression efforts to combat the remaining fire. Accountability of Engine 6-2 was accomplished through face-to-face communications.
Injured firefighters were treated on-scene before transport to area and regional hospitals by both ground and air resources. Firefighters remained on-scene for several hours before the fire was fully extinguished.

LESSONS LEARNED AND RECOMMENDATIONS:
It was clear that following this fire, the incident would become a culture-altering event as the HVFD had committed to change so that it never experiences an event like this again. The request for an outside, independent review of this fire and actions taken since this event is indicative of that commitment. To be clear, the fire could have absolutely resulted in the line-of-duty death of one or more firefighters. The following are some of the recommendations based on the most significant issues at the fire.

PRE-INCIDENT INFORMATION:
There is a need to have pre-incident building information available to responding firefighters for a variety of situations, including residential structures. While time consuming, it is a part of any fire departments responsibility to know what it will potentially be dealing with before it must deal with it. In as much as a football team studies the other team before the game, firefighters must fully understand what they may encounter be before hand as well. Capturing data and organizing information for ready reference by responding firefighters can greatly improve effectiveness of operations. In some cases, it can be done by recording details on specific buildings such as size, hazards and layout and in others, recording general neighborhood layouts with driveway lengths for hoselays and water-supply locations can be sufficient. Information can include anything a fire command officer and firefighters would want to know before a fire occurs. There was no pre-incident planning on this fire.

DISPATCHING AND RESOURCE ALLOCATION:
There is a need to conduct a comprehensive review and assessment of dispatch procedures for all emergency incidents. This should include the dispatching of apparatus based on the pre-determined need and worst-case scenario. For example, if a building has a required fire flow of 2,000 gpm, then – especially in the non-hydrant areas – the first-alarm assignment should include the minimum amount of apparatus necessary to establish and maintain a minimum, uninterrupted and consistent water flow of 2,000 gpm. Additionally, the county should ensure that successive alarms are equal, in terms of resources, to the previous alarm and that the first alarm has resources that will allow numerous tasks to be conducted simultaneously based on water supply, construction type, square footage, access, staffing, etc.

Simply put, when there is a verbal report of a building fire to a dispatcher, the department should send what may be needed (what matches that type of building and life risk) with the assumption that it will be a fire, before it has to be confirmed by arriving units. This fire did not have a response plan that matched the potential fire risks or the conditions that the firefighters encountered upon arrival.

INITIAL ON-SCENE ACTIONS:
Policy should be established that requires a 360-degree size-up prior to conducting interior, offensive operations. Incident Commanders must understand that while certainly committed to saving lives, they are also equally responsible to protect the lives of the firefighters under their command. This fire was not effectively sized up until after the fireground emergency.

We cannot emphasize enough the critical importance of establishing command by the first-arriving officer and communicating (and leading) the strategy to responding or on-scene units. An initial radio report should include relevant information (fire/life conditions, actions, needs, etc.), a strategy statement and direction so that units and personnel understand what they are to do and what they are not to do. It is also important that all Calvert County companies/departments follow the same procedure for initial actions as the volunteer departments, to their credit, operate as one countywide fire system when responding. Responding units to this fire did not have a clear understanding of the fire conditions and the tactical strategies.

INCIDENT COMMAND AND ACCOUNTABILITY:
More and more departments understand the proven need for command support roles by trained and qualified officers responding on the first-alarm assignment. Roles such as command, commandsupport aide, accountability, rear (Charlie) division, rapid intervention team supervisor and safety officer should be performed by command level officers arriving separate from the apparatus. Officers riding on apparatus are just that, company officers, and should be part of that unit during operations. If an officer on apparatus is "pulled" to provide one of the above roles, that unit or company loses that supervision.

The county does have a volunteer "duty officer" response plan that sends an extra chief on building fires, but it is based on availability and does not ensure the response of other chiefs to ensure adequate command leadership and support. This fire did not have an adequate number of responding command-level support officers to assist the incident commander.

WATER SUPPLY:
One of the greatest challenges firefighters can be faced with is operating in developed areas that do not have adequate municipal water supply. While new construction should not be permitted without a municipal water supply system, the reality is that it happens all over the U.S. and Canada. If there is no requirement for municipal water, then a plan to ensure adequate water to fight fires must be developed.

One solution is to require fire sprinkler systems in all future built structures. However, since buildings already exist in numerous non-hydrant areas in Calvert County, we recommended that they seek out a subject matter expert to be contracted to conduct a rural water supply evaluation and develop a plan in cooperation with county departments and companies. The plan should include a requirement to analyze the current resources, develop training for Calvert County firefighters in rural water supply, implement upgrades to all apparatus supply hose to LDH and the development of additional rural water supply sites. This fire did not have an adequate water supply.

COMMON POLICIES AND PROCEDURES:
The volunteer fire and rescue companies in Calvert County are understandably very proud of and dedicated to their organizations. One of the challenges when multiple volunteer fire and rescue companies operate on one incident scene is the independent policies, procedures and equipment specific to each organization. These may conflict and can interfere with what is best for the firefighters and the communities they serve.

In some cases where firefighters also work or serve in other jurisdictions, learned strategies, tactics and procedures from that jurisdiction may conflict with what is appropriate for operations in Calvert County. In so many areas of the U.S. and Canada, fire departments now run a lot more mutual aid as well as automatic mutual aid. In that case, common policies and procedures are essential to increase the chances of success on the fireground. This fire demonstrated the need for all companies and departments to have common policies and procedures that are trained on and enforced with mutual agreement.

CONCLUSION:
The potential of this fire to have lost some firefighters is very real. What is also real is that homes like this, large lightweight woodtruss "mega-mansions," barely held together with glue and gusset plates exist in so many areas where there is no municipal water. Fire departments that protect areas like this have just a few options:
1. To not allow the building (by ordinance) to be built without an applicable municipal water supply.
2. To not allow buildings to be build without requiring standalone, self-sufficient residential sprinkler systems (that use a water tank stored on the property)
3. To get ahead of the building and plan well ahead exactly how much water may be needed (worst-case scenario) and develop a rural water supply response plan that puts that water on the road as a part of the initial dispatch of the fire. If the fire turns out to be minor, simply send the additional companies home. However, you have a working fire, you will be glad to know that water is on the way in a planned and organized manner.