The recent release of the NIOSH Investigation Report #F2007-28 detailing the deaths of a Captain Matt Burton and Engineer Scott Desmond of the Contra Costa County (CA) Fire Protection District is unquestionably a wake-up call for us all. The loss of two experienced firefighters in a structure encompassing less than 1000 square feet is proof that no incident, regardless of size, cannot be taken lightly.

In honor of Captain Burton and Engineer Desmond, I’d ask that we all take a moment to review this incident and compare the critical facts that relate to the jobs we perform each and everyday. Scott and Matt have provided us with some very powerful lessons, it’s our duty to respect their sacrifice and to ensure we never repeat the lessons they have given each of us.

Have you given any thought to your morning apparatus check and how such a small oversight could put you or your crew at risk?

“The E73 crew was using an apparatus marked “E74” because E73 was out of service.”

Passing command in many departments is considered taboo, but in this case it presented an opportunity for a minimally staffed crew to act in a life saving manner. Regardless of your position on passing command, the critical lesson is “closed loop communications” – when giving an order, the receiver MUST repeat the order before taking action.

“The IC was observed looking at “E74” at the time he passed command. The officer on E73 did not hear the radio transmission and was unaware that Victim #2 had passed command.”

Ventilation, regardless of the type or method, all forms of ventilation provide two things – removal of hot gases/particulates and the introduction of oxygen. Ventilation MUST be a coordinated action initiated upon approval of the attack team.

Ventilation induced flashover - It is not recommended to initiate positive pressure ventilation after firefighters enter the building. If used post fire control, fire fighters should be withdrawn to a safe (uninvolved) area or out of the building while it is pressurized. If used in positive pressure attack, the building should be pressurized and the effectiveness of ventilation verified by observation prior to entry.

All structures must be searched is a conversation that is currently being debated from coast to coast. The one caveat to this conversation is – TENABLE spaces for VIABLE victims. If you can feel the heat through your turnouts and are working in zero visibility, is this a tenable space for a viable victim?

“The conditions were hot and visibility was near zero.”

A 360-degree size-up has long been known as a “critical action step” for an effective size-up, but do we give proper consideration to what we see? Do we evaluate the roof and consider what forms of ventilation are appropriate? Are there outward signs contraindicating vertical ventilation (i.e., rain roof)? Do we take the time to relay our findings to incoming crews?

“Initially there wasn’t any smoke or fire coming from the 6-foot by 6-foot ventilation hole.”

To their credit, NFPA is currently working to revise the thermal requirements of the modern PASS alarm, but do we as firefighters take the necessary precautions to effectively prepare for a “safety system” failure? Have you ever taken the time to ask, “What if…?”

“The crew did not hear any PASS devices.”

Air management is another topic of many kitchen table discussions, but what role does it play in a 956 square foot house fire? The reality – the same as a 30,000 square foot warehouse. No one should be operating inside an IDLH environment with their low air alarm sounding. Our performance should always be a reflection of due caution.

“…exited while their low-air alarms sounded.”

The use of Flashover Simulators has become incredibly popular throughout the fire service, but what are we teaching our firefighters about fire behavior? Is it a badge of honor or are we walking away with a full-fledged understanding the dynamics of fire and the role ventilation plays in feeding the fire (good or bad)?

“Currently these qualifications do not include the need for a sound understanding of the physical, chemical, and thermal behavior of fire and do not make a connection between fire dynamics and the influence of tactical operations (positive pressure ventilation) and external factors (wind).”

Never forget the lessons they’ve shared with us…Thanks Guys!!!

Timothy E. Sendelbach is a 23 – year student and educator of the fire & emergency services currently serving as Editor-in-Chief for FireRescue Magazine and President of TES² Training & Education Services. Tim is also the immediate past president of the International Society of Fire Services Instructors. (ISFSI)