Audit Report Released In Controversial Greenwich Blaze

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REPORT OF THE INDEPENDENT FIRE REVIEW PANEL

Davis Street Fire Incident - December 5, 2003

February 23, 2004

Mr. James A. Lash

First Selectman  

Town of Greenwich  

101 Field Point Road  

Greenwich, Connecticut 06830

Dear Mr. Lash:

Transmitted herewith is our report and findings on the fire incident that took place at 314 Davis Street on December 5, 2003.

We reviewed all information made available to us, interviewed numerous fire fighters at the scene of the fire and also listened to the dispatch center tapes of the incident.

 

Our report describes the fire fighting activities that took place during the fire. Also included are reviews and comments on the decision to re-enter the structure by Chief Warzoha, and finally, concludes with recommendations we feel are necessary to elevate and enhance the fire fighting capabilities of the Greenwich Fire Department.

 

The Town of Greenwich is fortunate to have an extremely dedicated fire department. As such, we strongly urge that you consider implementation of our recommendations in a timely manner. We are of course, available to discuss our report and findings in more detail with you.

 

We wish to express our sincere thanks to town officials and Greenwich fire fighters, career and volunteer for their cooperation and participation during this process, without which, this report would not have been possible.

Very truly yours,

Independent Fire Review Panel

Three Career Firefighters were seriously injured making an emergency exit from a 4th floor window and falling to the ground, during a structure fire.  One Volunteer Firefighter and one Career Firefighter were also injured when struck by a falling firefighter.

INCIDENT FACTS

On December 5, 2003 at 22:18 hours three career firefighters were severely injured when they exited from a 4th floor window during a structure fire at 314 Davis Street Greenwich, CT. Firefighters Kennard Little, Eric Maziarz, and Deputy Chief William Puterbaugh were searching the 4th floor of a 4 story would frame residential structure when they were forced to exit via a window on the 4th floor because of rapidly deteriorating conditions. Volunteer Firefighter Steven Slusarz and Career FF Richard Magalnick were injured when Firefighter Eric Maziarz fell while attempting to reach a rescue ladder being raised to assist him, landing on the two firefighters.

 

During the course of approximately one hour prior to these injuries, a fire attack, and a primary and secondary search of the structure were performed. During the first hour of this fire the following summary of events occurred prior to the injury of the five firefighters: (this information assembled from audio tapes and interviews)

·        Approx 21:19 Hours - Police Officer Zuccerella and Police Officer Hendrie arrive on the scene before any fire apparatus and observe smoke billowing from every door and window at 312 Davis Ave. A male later identified as Pedro Ceiesdino approached them and informed Officer Zuccerella he is a resident of the building and that residents from each apartment have exited the building. The two Officers make an attempt to go to the door and shout to anyone inside, but are unable to get close to the building due to smoke. After the arrival of the fire department Officer Zuccerella is able to locate two other residents of the house from the first and second floor. There is a language barrier but the residents relate that the third floor family has already left the scene.

·         21:20 Hours - Tower 1 arrives on the scene. Firefighter Erik Maziarz was assigned to Tower 1 and observed light haze smoke condition. Police Officer reported to Tower 1 that everyone was out of the building. Tower 1 driver states he could not get the ladder up due to power lines.

·         Approx 21:20 Hours - Engine 2 arrives on scene (not captured on audio tape) with FF Little and FF Kear and they lay hose in the driveway on the "B" side.

·         21:22 C-1 Chief of Department responding

·       FF Little reported seeing flames on "B" side and thought they had an exterior fire. FF Little and FF Maziarz were told by FF Kear to bring the 1 3/4 line in the front door on the "A" side. Most of the fire was extinguished, but FF Little stated they could feel the effects of an exterior line. FF Krizan and Vol FF "Littman then

joined Little and Maziarz in advancing the line into the first floor. FF Kear stated that a 2 ½” line was taken to the "B" "C" side of the building at this time. FF Kear said he was still working off his water tank and trying to not run out of water when he saw a  2  1/2" line being directed into the "B" side from the exterior. He then notified C-4 about the exterior line being directed into the "B" side. FF Krizan also confirmed that an exterior line was being discharged on them while in the first floor.

·         At the same time the  Â¾â€ line is advancing into the structure Lt. Taubi is assuming Command in front of the building. There is reported to be confusion over who is actually in Command as there is also a Volunteer Chief Officer on scene. The end result is ultimately Lt. Taubi takes command of the scene.

·         21:32 C-1 assumes Command of scene orders Volunteer Chief Tom Andersen to get Ladder - 4 setup in the front of the building.

·         FF Little and FF Maziarz exited the building at this time and had their air bottles changed at this time then reported to C-5.

·         C-5 ordered FF Little and FF Maziarz to the third floor for search and overhaul. Upon arrival on the floor the conditions are such that FF Maziarz had his mask on but the regulator was unattached. They moved a refrigerator and saw no visible flames but could see embers and found charred lath. They split up and searched the third floor. After searching the interior "A" "D" side FF Maziarz could not find FF Little and exited the structure to find him. Maziarz found Little on the "C" side exterior when he went to change his bottle.

·         1 ¾” line being operated in rear of building on 2nd floor off porch. Line being operated into rear door of 2nd floor limited entry made into area with line.

·         21:39 C-1 reports that initial crew is reporting knockdown and primary search is negative, there is also extension through the 2nd and 3`d floor and they are opening up.

·           21:40 "302" reports heavy fire on the second floor "C" side it is not totally clear but it appears that a 2 ½” hose line is being directed onto the 2nd floor fire from the exterior.

·        Volunteer Chief Tom Andersen and Volunteer Captain Slusarz appear to be supervising the "C" side of the building.

·        Approx. 21:40 Utility 4 arrives on scene with FF Hoha and Volunteer Assistant Chief Medico. Hoha is told to get a K-12 and open up the "D" sidewall and coordinate with Chief Andersen. Assistant Chief Medico is told to get the L-4 crew to cut the ventilation hole higher in the roof. (Although the panel was not able to determine who cut the ventilation hole, its location was low on the "A" side of the building straddling a knee wall in the attic). Medico returned to L-4 and went to the roof. There was difficulty getting a saw operating for a second hole. The area where Medico states he ultimately cut a second hole is completely burned away so there is no way to gauge the size or position of that ventilation hole.

·         21:50 "C" side requesting rear small roof be opened C-1 reports that truck is currently opening the front roof

• 21:54 C-5 orders Little and Eric to go to 3rd floor and search, C-1 orders all units search and rescue operation report of somebody - 2 children in the building on the number two or three floors.

·          21:56 C-1 calls 201states another secondary search is ordered of the second and

third floor make sure making sure all personnel know.

·          21:58 Secondary search under way two crews in the building

·          21:58 C-1 reports crews back in on secondary search because of information from

civilians

·          22:00 C-1 reports additional searches have revealed nothing

·          22:00:30 rear of building reports heavy smoke getting darker

·          22:04 orders an evacuation of the building and tones are sounded.

·         22:09 PD communications that the child parents are looking for is in Stamford

and is OK

·         22:10 Dispatch notifies Command that two children are safe in Stamford, Dispatch advises to check with PD to confirm. C-1 sends Inspector Fronio to check with the PD. At this approximate time C-1 interacts with a woman that PD has brought over indicating there may still be a child in the house. FF Little reports to the C-1 that he and Maziarz had been up there but feels the third floor may not have been thoroughly searched. FF Jason James states over and over that he has searched. C-1 makes the decision to send in D/C Puterbaugh telling him to do a quick search if he can and get out. Puterbaugh takes FF Little and FF Maziarz and enters the building from the "D" proceeding up to the third floor via stairwell.

·         Three-person crew led by Puterbaugh passed a hose line at the "D" side doorway and proceeded up. The hose line was unmanned. FF Little is equipped with a thermal imaging camera.

·         22:13 302 reports that a gas line is going on the second floor (actually 3rd floor) later determined to be burning aerosol cans.

·         22:14 Command calls C-3 advised about gas flames on 3rd floor and tells C-3 to get out as soon as complete. This is the first radio transmission indicating that a crew has reentered the building to search.

·         Crew is searching the third floor Maziarz states "why are we searching this area, I already did this floor". Maziarz saw small orange flame on counter "C" side reports this to Puterbaugh. Puterbaugh ordered crew to fourth floor to search. Little went first with camera, Puterbaugh, and then Maziarz.

·         22:14:49 Radio transmission from second floor entry to rear of building "we have tenants on the floor" C-1 acknowledges with "Roger" unknown source of radio transmission however Chief Andersen is on the "C" side (rear) and stated he was in a "defensive mode" unaware that there was a crew in the building.

·        Once on the third floor they begin a counter clockwise search.

·        22:15 Command orders C-3 to get out quick and then orders L-4 to set up ladder pipe operation - unknown radio transmission states "crew out yet?"

·          Crew begins to leave forth floor after one minute, as Puterbaugh goes down the stairs flames are coming up the stairs rolling. He tries to go under but cannot and returns to fourth floor.

• 22:17 C-3 calls Command and reports that he has flames coming up the stairwell and request a line up here. C-3 again calls to have a line up here.

·         22:17:38 C-3 calling on radio "Ladder on "B" side of building, Ladder on "B" side of building K" reports from FF's on the ground indicate Puterbaugh is hanging out the "D" side 4th floor window making this transmission.

·         Inside the 4th floor Puterbaugh had instructed Little and Mozlarz to get out (meaning the "B" side window that he had called for the ladder to be setup at) The crew reported heavy heat in the room. Little led the crew to the window and kicked out the window. Little hears Puterbaugh say go out the window now. Little went out the window hung momentarily and let go to make room for the others. Maziarz had a bailout line but no time to use it. Maziarz could see the ladder being raised straddled the window with one leg over the sill. He was almost out the window when Puterbaugh exited. Puterbaugh tried to hang on but could only for a few seconds and fell. Maziarz looked back in the attic and saw fire rolling on the ceiling. He is hanging on the window by his arm and felt the ladder pin him to the wall and thought they would lower it. He felt he could hold on no longer and reached for the ladder with his right hand. He missed the ladder but looked down and heard it hit the wall below him. He felt he could make it to the ladder but fell backwards tumbling down the ladder.

·         22:17:58 radio reports of Firefighter down this was Little falling from building

·         22:18:23 C-9 makes general broadcast to all companies on the scene report of

somebody on the 2nd floor needs some water in there now.

·         22:18:30 Dispatch advised C-1 of transmission of firefighter down C-1

acknowledges orders RIT into the building

·         22:19 reports by PD that multiple firefighters down.

 

All three firefighters are subsequently treated along with two firefighters that are injured when FF Moziarz falls on them.

RECOMMENDATIONS/DISCUSSION

This panel after careful review concludes that, to minimize the risk of similar occurrences, the Greenwich Fire Department should:

·         #1 - The Fire Department should adapt an Incident Command System capable of managing the dynamics of a combination fire department. Discussion: The current command practice creates confusion as to who is command especially during the initial stages of the operation. One person cannot effectively manage over 50 firefighters, as was the case at this incident. This resulted in the lack of a coordinated attack. At this incident, interviews indicated that supervisors were in the A-B-C and D "sides" of the building. At incidents such as 312 Davis Avenue there is little need to establish supervision on the exterior of the building when supervisors were not assigned to most critical areas of the incident, (1) the fire floor, (2) floor immediately above the fire, (3) uppermost floor and (4) ventilation resulting 4 supervisors reporting to an operations officer who is in contact with the IC. In addition, there were enough

Chief Officers available to be assigned to the Safety Officer position. After the assignment of a Rapid Intervention Team the remaining firefighters on the scene can be assigned to a staging area. The current ICS document 629.0 is inadequate. The ICS structure should breakdown firefighters into working crews with leaders that report to Division Commanders. The command system should be flexible enough to allow first arriving officers to be working supervisors, but at the same time ensure a fixed command post is established when an officer arrives on the scene whose personal involvement is not required in tactical operations. This Command Post concept will ensure that all supervisory personnel on the scene from all agencies will have a place to report to coordinate their efforts. It was apparent during the interview process that the concept of command is not understood.

 

Because there is not a strong incident command system in place many of the personnel on the scene are forced to make decisions based on what they think is the right thing to do. This results in an uncoordinated effort and during this fire there were several occasions where exterior hose streams were unknowingly aimed at interior crews.

 

The department's written SOP on ICS should be revised to incorporate the above recommendations and all career/volunteer personnel should receive training. This will result in safer and more effective operations. It will also improve the utilization of personnel, for example: two of the injured firefighters were on their 4th air bottle despite having over 50 firefighters on scene. Commands management of the span of control needs to be practiced at a large incident. Functions of the Incident Command System, Incident Command, Operations, Planning, Logistics, Safety and Public Information should be delegated as incidents expand. This allows information and orders to be processed without overburdening one person.

 

·        #2 - Fire Department should develop, train and implement Standard Operating Procedures department wide.

Discussion: Department should have written procedures on how to direct personnel in basic firefighting operations that occur at most fires. They will address first due engine operations, second due engine operations, truck operations, and other common task that are performed. It was apparent from the interviews that there are many different opinions on what the department's procedures are and in some cases basic principles are not applied. Safety issues should take immediate precedence. There were instances of serious issues found during the interviews including; personnel protective equipment not worn, crews working above the fire floor without a hose line, concurrent offensive and defensive tactics, and freelancing. In a combination department this will establish performance objectives were each member of the department must be able to demonstrate competency. NOTE: A CD of an SOP manual of a similar type department has been included to assist the department in determining the types of SOPs that are needed.

• #3 - Rapid Intervention Teams need to be available by with equipment, ready to provide assistance or rescue.

Discussion: This team needs to be in position to execute a rescue will little notice. They should be well trained in this task and be able to function as a team. In this incident when the firefighters became trapped there was an uncoordinated attempt to rescue. Too many people tried to raise a ladder at one time causing an ineffective rescue. If the department implements an effective Incident Command System the commanders on the scene will be able to direct an effective rescue operation. Those serving on the Rapid Intervention teams need training in removing downed firefighters and rapid deployments of ladders. An effective RIT will deploy ladders to upper story windows whenever members are working on the upper stories on the interior of the building even before there is an emergency.

 

·           #4 Polarizations between Career and Volunteer members has resulted in dangerous conditions occurring on emergency scenes and every member of the department must commit to doing what is right for the department and its firefighters.

Discussion:

·        Career and Volunteer Officers should have regular officer

meetings to discuss department operational issues.

·        Decisions were made on this incident at every level where the lack

of trust between department members both career and volunteer,

officers, and Chief Officers affected the outcome of the incident.

·       There is an environment of blame rather than problem solving in

the department.

 

·          #5 Reorganize some components of the department to ensure functionality Discussion:

·       Chain of Command should be restructured to place the lieutenant in C-5 as the Shift Commander. Shift Commander should have overall rank above all career and volunteer personnel and be in charge of commanding the entire department in the absence of a senior career officer. This department has become a combination department and no longer can function as a volunteer department with paid drivers. Placing the career officer as a Shift Commander puts the accountability for command on his shoulders and eliminates any question of who is in command. Volunteer Officers should command the Volunteer members of their respective companies but orders issued by the Career Officers take preference.

·     Each apparatus should have a supervisor assigned to it to lead the crew.

·         Consider consolidating career crews onto fewer apparatus making functional crews of three or four person units and/or increase staffing levels on existing units ensuring a crew of at least three

persons. This may result in some companies reverting to all volunteer initially. Consider restructuring so at least.one 4-person engine and one 4-person truck can respond to all structure fires.

·          Many combination departments have found that stations staffed by only volunteers provide for better staffing levels and response times than mixed companies. In addition, Volunteers would have their responsibilities enhanced since the stations would become Volunteer Response Stations. It should be noted that research and experience has shown that the ability to successfully sustain an initial fire attack requires 12 to 16 personnel. Attention should be given that by redistributing personnel, assigning from dispatch duty to line and possible hiring of additional firefighters the above 12 to 16 initial response can be accomplished.

·          Volunteer personnel should be formed into teams and supervised by a volunteer officer to ensure team continuity. This will prevent the obvious "free-lancing" that was evident at this fire.

·          Incident Commander should utilize a command staff including assistance in operations. These command staff personnel can be volunteer officers and/or career officers.

·          Negotiations should be undertaken that the officers in the training division be given Command responsibilities for the fire ground. The Incident Commander can utilize the experienced officer and provide better command and control.

 

·          #6 Training should focused on the high risk low frequency activities of firefighting and include regular hands on experience for all department levels.

Discussion: department's training program should be focused on basic skills with a minimum hour's standard that are regularly practiced. Career and volunteer company officers should be required to submit written records when they have completed training requirements. The department should aggressively pursue joint career volunteer training to ensure members can work with one another on emergency scenes. Basic skills that should be stressed are ladder work, ventilation, and strategy and tactics.

 

·         #7 Fire department should ensure that the Incident Commander conducts a complete ongoing size-up of the incident and evaluates the risk versus gain during operations at the incident.

Discussion: During this incident a decision was made to re-enter the structure 51 minutes after arrival on the scene to conduct a search. The building had previously been evacuated of all firefighting personnel. The incident commander was bombarded with conflicting information regarding people in the building and the integrity of the search(s) that were done in the building. The system broke down and as a result the Incident Commander did not have a means to process this information into a risk vs. benefit decision. Unless this department adopts a true Incident Command System that includes standard operating procedures

ensuring certain functions are completed, this scenario has a large chance of occurring again. It should be noted that Deputy Chief Puterbaugh heard the same information the Chief did. The Deputy Chief concurred with the Chief's decision to re-enter the building. In hindsight, had the crew been backed up with a charged hose line to secure the stairway they would have been able to escape without incident. The department would also benefit by having a pre-plan program so firefighters have a chance to review and document hazardous buildings within the community.

 

 

·          #8 The department should adopt a zero tolerance drug and alcohol policy Discussion: There were accusations the incident commander was impaired at this incident. The Chief states he was not impaired and ranking officers who were in close contact with the Chief stated they do not believe the Chief was impaired. Because the department does not have a zero tolerance policy there is a shadow of doubt over the incident in this area. Decisions made seemed to have been impacted by many of the other factors described in this review, however alcohol cannot be a factor in an emergency scene in any way.

 

·         #9 Consider moving the career firefighter in Dispatch onto a truck and having civilians dispatch.

Discussion: In listening to the tapes of this incident there was a tremendous amount of outside non-emergency phone calls made to the dispatcher. These calls far out numbered tactical communications and demonstrated a very unprofessional demeanor on the part of the callers. Thought should be given to exploring the training and assigning of civilian dispatchers to the dispatch center. This would free up valuable uniformed personnel for much needed fire suppression duties. The civilians should report to the Fire Department Deputy Chief. At a very minimum current procedure in the dispatch room should be expanded to prevent the type of communication interactions this panel heard while reviewing this incident.

 

·           #10 Improve current personnel accountability system Discussion: Fire ground personnel accountability on a good day is a challenge. Until some form of affordable automatic GPS style electronic tracking system that tells us who and where, the best system available today (tags, key-rings, cards, etc.) is really only fair at best. The best current practice for accountability is a good company officer that knows where their firefighters are at all times with workable radios so everyone on the scene can talk to each other in emergencies. It also includes an ICS system that allows the IC and accountability officer to know where their crews are through competent and trained company officers. We tend to loose track of individual firefighters verses entire companies of firefighters. The officer of every company needs to make it "career ending clear" that no one breaks away from the crew, team or company. Career and Volunteer. The present system in this department should be reinforced and officers, career and volunteer, held accountable. The present system tells "who" but is weak on the "where".

Thought should be given to an accountability board located in the command post where firefighters place their I.D tags on a labeled board as to where they are assigned (i.e. fire floor, floor above, roof, etc.).

SUMMARY/DISCUSSION

 

One of this panel's primary responsibilities was to evaluate the decision by the Incident Commander to send crews back into the structure which ultimately resulted in three firefighters jumping from a 4t'' floor window. The panel believes the 10 items identified above would have significantly improved the overall operation therefore resulting in the conditions of firefighter entrapment less likely. Given the situation that existed that night at the Davis Avenue fire, the panel considered the following in evaluating the Incident Commanders decision:

 

Discussion of the pros of the decision.

 

·         A report directly to the Incident Commander that two children may still be on the third floor, combined with an unconfirmed report that the children were in Stamford.

 

·         That the company (Little and Maziarz) reported directly to the Incident Commander, that the secondary search of the third floor might not have been completed.

 

·        That much of the secondary search was done without SCBA mask connected to air source, leading to the belief that any building occupant still on the third floor could still be alive.

 

·           That of the company (D.C. Puterbaugh, FF Little, and FF Maziarz) picked to conduct this search of the third floor, D.C. Puterbaugh was a veteran fire officer who had just arrived on the scene and FF Little and FF Maziarz had conducted the secondary search and were familiar with the layout of the third floor.

 

·           The company conducting the search had available a Thermal Imaging Camera as part of their equipment and used it effectively during the search.

Discussion of the cons of the decision

·           This occurred over an hour into the incident and confirmation that these children were not in the building could have been obtained prior to the report they still may have been inside.

·         Of the crew assembled to conduct this search D.C. Puterbaugh had just arrived on the scene, thus not giving him an overall picture of the fire travel through the

building and Firefighter Little and Firefighter Maziarz were on their third bottle with no rehabilitation.

·         Basic firefighting principles were not followed by protecting the interior staircases (to the third and forth floor).

·        Through overhaul techniques it was determine that fire was in the walls of this balloon frame construction but what was overlooked was how fast this would move from floor to floor.

·         Ladders were not pre-set at windows of the third and forth floors.

·            The crews assigned were not equipped or trained to perform bailout techniques.

 

Based on these facts, the decision to send a crew back into this fire building, that an evacuation had already been ordered, was based on good fire fighting practices and principles combined with years of experience. This conclusion is also supported by several interviews with other fire officers in the command post at the time the decision was made.

 

The Greenwich Fire Department currently has insufficient command personnel in place to support an effective Incident Command System.

 

As a conclusion, one needs to keep in mind that as serious and rare as this incident is; it has a striking resemblance to two other incidents that occurred in Connecticut during the writing of this report.

 

These incidents happened in New Haven on January 14, 2004 and East Hartford on February 12, 2004. In both cases firefighters were forced to bail out a second and third floor respectively. These cases did not have the same consequences as the Greenwich incident because firefighters fell only a short distance to shed roofs.

 

These incidents are mentioned in this report not to illustrate an acceptable risk, but to demonstrate the inherent danger in firefighting.

 

Only items like sufficient manpower, reliable equipment, uninterrupted water supply, progressive training, on-going pre-fire planning, and a strong incident command system can reduce this risk.

 

Based on the recommendation throughout this report, the Greenwich Fire Department needs to continue current plans to up-grade command staff, continue to strengthen the training program and finish updates to the Standard Operating Procedures.

 

During the interview with Chief Warzoha a full account of this incident was documented and backed up by an audiotape and over fifteen interviews. Chief Warzoha also discussed the working of the Fire Department including several recent up-grades that should lead to

an improved Insurance Service Office, I.S.O. schedule. Chief Warzoha also noted other current projects including, restructuring of department command staff, revising Standard Operating Procedures, back country water supply, and improving the training program that he and his staff have been working on.

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