Baltimore LODD Preliminary Findings

[Remember585 815]

I came across the Baltimore City Fire Department's Preliminary Findings into the death of trainee Racheal Wilson, the mother of two who was only 29 on 2/9/07. The information that I found and have read, which is an internal finding and not even that of an outside group such as NIOSH or OSHA, is startling.

To summize, here is a brief view at what was discovered.

11:35 AM - Fires were lit on all three floors of the building.

11:39 AM - A simulated dispatch was made for the units participating.

12:00 PM - EMS leaves the scene with recruit Wilson who is in cardiac arrest.

12:50 PM - Recruit Wilson is pronounced dead at the hospital.

The building that was used is a brick row house, and the unit used was an end of the row unit. This building was used for non-live fire training a couple weeks earlier where many of the wall coverings and ceilings were stripped exposing joists and framing in various parts of the dwelling.

Units participating in the drill were an IC, Safety Officer, E1, E2, T1, T2, T3 and a RIT. Radios were only given to the Team Leaders of all 3 Trucks, the RIT, S.O. and IC. The two Engine Companies had no radios. A total of 11 Training personnel were on hand. (3 BCFD and 8 Adjunct Instructors).

Wilson was on E1 and that crew took a 1 3/4" line to the 2nd floor and extinguished MOST of the fire, then advanced up to the 3rd floor. While on the 3rd floor the crew noticed an increasing amount of heat and smoke coming from the 2nd floor. One crew member started to experience burns to her legs while in the stairwell. The Instructor with the crew took this FF out a window on to the 2nd floor roof. When the Instructor looked, Wilson was in the window in apparent distress and attempting to escape as well. Due to the unusual height of the window (41") she was struggling to get out and could only do so enough for the upper body to get out. When she was eventually pulled from the window, now unconscious, she was missing a boot, which is believed to have been caught in the wire mesh in the wall below the window sill, which may be why she was stuck.

Several NFPA 1403 Standards were not complied with including:

- Multiple fires set

- Lack of Safety personnel / properly staged Safety personnel

- Lack of radio communications

- Failure to conduct a walk-through of building beforehand.

- Lack of pre-burn plan and pre-burn briefing.

Other contributing factors:

- Misunderstanding of verbal communications between the IC and E1 Team Leader.

- Wilson's SCBA facepiece was either removed or knocked off.

- The unusual height of the window hampered rescue / escape efforts.

- Improperly equipped and manned RIT

- Lack of a charged hoseline for the RIT

- Lack of radios for Engine crews

Here's what concerns me. Baltimore is a well-organized, fully career fire department that obviously has greater training and experience then most of us in Westchester County (speaking of course of the volunteer side, being I can't comment on what I am not a part of). But the overall picture here, and the things missed / overlooked and/or not emphasized are the same things we see all too often here. Look at the time frame for example, in only a matter of MINUTES, the INITIAL MINUTES things went mortally down hill. MORTALLY, people. Why are we still waiting until we are on scene to start out a FAST or RIT? Are we conducting a walkaround at least before sending our troops in? Are we pre-planning, do we have code enforcement to tell us of key hazards? Are we giving our people radios and TRAINING them HOW TO USE THEM? Do we have competent Officers / leaders taking personnel into these fires? Are our FASTs / RITs equipped to do the job, trained to do the job and most importantly, READY TO DO IT? We need to stop the smoke and mirrors bullshit where just because you called for a FAST you are "covered." We need to end the crap where Departments send a FAST which consists of people not trained enough, not experienced enough and not strong enough to get our brothers and sisters out when we need to. I can't help but wonder what would of happened in this case, in a "controlled" TRAINING SCENARIO if the RIT was staffed and equipped properly and contacted in time if this recruit would have lived? Aside from all the misdeeds of the Instructors who did not heed to NFPA 1403 and their own FD policy which could of prevented this, but what if, WHAT IF the RIT was able to make a rescue and not have a recovery which wound up being the sad, sad case here.

Does anyone else get what I am saying? Am I off base or misreading what happened?! As a trained Instructor and as a member of a FAST I am concerned for all of us - this can and obviously DOES HAPPEN! This death should not have happened and we have got to police ourselves better if we are ever going to reduce the number of times a year we bury one of our own.

The entire report can be found here:

Preliminary Report

[ex-commish 490]

Does anyone else get what I am saying?  Am I off base or misreading what happened?!  As a trained Instructor and as a member of a FAST I am concerned for all of us - this can and obviously DOES HAPPEN!  This death should not of happened and we have got to police ourselves better if we are ever going to reduce the number of times a year we bury one of our own.

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One would think after what happened in upstate NY where a chief did time in jail for his role in the death of a probie in an acquired structure that every law and standard would be followed yet they are not. I believe it has to do with the belief that NFPA standards are not a factor in our business because they are not regulatory yet at times what is overlooked is NFPA is a leading standard that is referenced to in court and blatant violation of the standard will bite you in the end.

I also feel complacency is a factor. So is pressure to make things realistic.

All I can say is follow the law, follow the standards and if something goes wrong at least you covered your tracks. Baltimore probably is a well trained department. So is Pheonix Az and they had a live fire accident where the members were allowed to participate wearing only partial PPE.

[Guest Chip025]

One would think after what happened in upstate NY where a chief did time in jail for his role in the death of a probie in an acquired structure that every law and standard would be followed yet they are not. I believe it has to do with the belief that NFPA standards are not a factor in our business because they are not regulatory yet at times what is overlooked is NFPA is a leading standard that is referenced to in court and blatant violation of the standard will bite you in the end.

I also feel complacency is a factor. So is pressure to make things realistic.

All I can say is follow the law, follow the standards and if something goes wrong at least you covered your tracks. Baltimore probably is a well trained department. So is Pheonix Az and they had a live fire accident where the members were allowed to participate wearing only partial PPE.

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Welcome to the culture of playing the odds. This culture must change and its up to EVERYONE to try and change it. It is very difficult to change an inbred idea that " if we haven't needed it in 100 years we dont need it now" attitude. The culture of pushing the limits because as officers and trainers and FF's we know better then all the standards and LAWS that are accepted. Unfortunately it is left up to the FEW who are willing to fight for a new attitude and culture. But with the MANY more concerned about their careers and advancement the FEW get little support. There is nothing more frustrating then" Fighting " for safety and and accountabilty. It shouldn't be a battle with the leaders or are trying to comply with standards. The war should be on those that do not. But I know I will continue to fight beacause I never want to hear that I let one of our members down, and because of it he and his family paid the ultimate price. And the least fulfilling words at that time are "I told you so"

[hudson144 150]

smoke screens are everywhere in the fire service! career,volunteer,military, private- usually things get corrected after the tragic incident such as this happens and yes it is usually too late! some depts. pick up and learn from others and some just act as if things didn't happen< be safe!

[RWC130 594]

I am just speechless....

LODD in Training and all the SAFETY VIOLATIONS!

Why?????

Live Burns are very DANGEROUS as with ANY Fire.

Yes, it's "TRAINING" but all to often we overlook it's a REAL FIRE!

You can't hit the STOP button when things go wrong.

-REAL HEAT,

-REAL SMOKE,

-REAL FIRE,

-REAL DANGERS!

REAL INJURY and sadly REAL DEATH!

I hope we can ALL learn from her death.

My heart goes out to her family.

JEMS.COM

Fratricide

The recent death of a Baltimore fire cadet during training has hit the fire and EMS community hard. Racheal Wilson was a 29-year-old mother of two, who had been in the training academy since November when she fought the fire that would be one of her first, but also her last. The day before, two cadets were injured during training. Once again, those of us who are charged with taking care of others failed to take care of our own.

The cadets were sent into a staged rowhouse fire. The abandoned rowhouses had been designated for training fires. But something went wrong — very wrong. Wilson took the nozzle and led her crew into the burning building in full turnout gear. She was initially burned on the stairs between the second and third floors, with fire raging on the second floor. On the third floor, she attempted to climb out of a window that was 3 and half feet above the floor, and somehow her boot became trapped. Wilson ended up halfway in and halfway out of the window; her air supply dislodged and her helmet askew. Before her fellow cadets could save her, she was dead.

The preliminary report from the Baltimore Fire Marshal's Office showed multiple violations of NFPA standards and federal regulations. The cadets had no radios, and there were no instructors inside the structure. Instead of the permissible one fire, there had been seven fires set. And it defies logic, even if you are not a firefighter, to send a crew to the third floor when fire is raging on the second floor.

The chief of the training academy was suspended and subsequently fired. Two other officers were placed on suspension. But for Wilson, there will be no appeals of employment actions, and no second chances.

The IAFC has called training deaths "fratricide" — killing one's brother — or in this case, one's sister. It's inexcusable that we place trainees in a position of danger in the interest of trying to create a realistic scenario. Our jobs are dangerous, without question. Much of the danger, however, can be mitigated by the use of caution, the following of established standards and the use of good old common sense.

Each year, we see a growing number of EMS vehicle accidents. Despite intensive training in emergency vehicle operations, we continue to see the morbidity and mortality statistics climb. Perhaps we simply need a change in our culture: perhaps we need to teach our new recruits that we come first, not our patients, or a raging fire. If we don't arrive at the emergency, or if we are injured or killed trying to extinguish a fire, we haven't achieved our goals at all. Our own safety, and the safety of our partners and crews, should be paramount. Nothing should come before our own safety.

Wilson's death is not the first during training. We can only hope that it will be the last.

God Bless

BE SAFE!

[Guest alsfirefighter]

You can't hit the STOP button when things go wrong.

You can at Westchester DES burn building. While it has numerous disadvantages propane fed live fire training buildings are gaining popularity because of their low risk and liability. Then again this type of incident would be further limited by OFPC's policy of no acquired structures for live fire for courses.

While its great to see a few that get it...we are the minority however. NFPA 1403 is simple and will protect you to the max. We don't hear of incidents when it is followed properly. Do injuries still occur, absolutely it is a fire. Does everyone wear seatbelts...after this month that is easy to see...no.

[firecapt32 282]

The Fire Service and the Military are the only sectors that killl their people during training. somthing has to be done NFPA 1403 it a great start---- if its followed correctly.

For all you new Chiefs READ IT and be aware of the concequences when something goes wrong.