Accident Review Factual Report Huntsman Incident

SACRAMENTO FIRE DEPARTMENT SACRAMENTO METROPOLITAN FIRE DISTRICT
Accident Review Factual Report
Structure Fire-Fall Injury February 26, 2011 3341 Huntsman Drive CA-XSA-11-24041
The Board of Review approved this report on July 26, 2011.
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ACCIDENT REVIEW REPORT HUNTSMAN DRIVE-XSA 11-24041
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Investigative Team
Kim Iannucci, Assistant Chief
Sacramento Fire Department
Team Members
David Baldwin, Captain
Rick Lee, Captain

Michael Teague, Captain

Sacramento Metropolitan Fire Protection District
Technical Specialists
Barbra Brenner, Safety Specialist

City of Sacramento- Risk Management Division
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Board of Review
Lloyd Ogan Sacramento Fire Department Deputy Chief Operations Brian Rice Sacramento Metropolitan Fire District Deputy Chief Operations John Michelini Cosumnes Fire Department Deputy Chief Operations Jody Gossner California Department of Forestry and Fire Protection Amador-El Dorado-Sacramento-Alpine Unit Deputy Chief
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Table of Contents
EXECUTIVE SUMMARY...................................................................................................... 7 INTRODUCTION .................................................................................................................. 9 Terminology .................................................................................................................... 10 Building Layout ............................................................................................................... 11 Report Organization:....................................................................................................... 12 DEPARTMENT DEMOGRAPHICS .................................................................................... 13 Sacramento Fire Department ......................................................................................... 13 Sacramento Metropolitan Fire District............................................................................. 13 Standard Operating Guidelines ...................................................................................... 14 STRUCTURAL SUMMARY ................................................................................................ 15 Building Construction Features: ...................................................................................... 15 Roof Assembly ............................................................................................................ 16 Wall Construction ........................................................................................................ 16 Floor Assembly ........................................................................................................... 16 Windows ..................................................................................................................... 16 Exposures: ...................................................................................................................... 16 Alpha Side ................................................................................................................... 17 Bravo Side .................................................................................................................. 17 Charlie Side ................................................................................................................ 17 Delta Side ................................................................................................................... 17 PRE-INCIDENT INFORMATION ........................................................................................ 19 Pre-Incident Company Status and Location ................................................................... 19 Weather Conditions ........................................................................................................ 21 INCIDENT NARRATIVE & TIMELINE ................................................................................ 23 PHOTOGRAPHS & ILLUSTRATIONS ............................................................................... 29 FINDINGS .......................................................................................................................... 33 Human Findings.............................................................................................................. 33 Management Findings .................................................................................................... 35 Building Findings ............................................................................................................ 36 Equipment Findings ........................................................................................................ 37 Communications Findings .............................................................................................. 38 Staffing/ Response Time Findings .................................................................................. 38 CAUSAL AND CONTRIBUTING FACTORS ...................................................................... 39 Causal Factors ............................................................................................................... 39 Contributing Factors ....................................................................................................... 39 LESSONS LEARNED ........................................................................................................ 41 RECOMMENDATIONS ...................................................................................................... 43 SIGNATURE PAGE ........................................................................................................... 45 APPENDIX A - INCIDENT COMMUNICATIONS ............................................................... 47 Radio System Overview ................................................................................................. 47 Incident Radio Traffic Transcript ..................................................................................... 49 Appendix B - Glossary and TERMS ................................................................................... 57 Appendix C - Standard Operating Guidelines .................................................................... 65
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 At 21:19 an Emergency Traffic was transmitted informing the Incident Commander that a Firefighter was down after falling from a ground ladder. While attempting to transition from a portable ground ladder to the roof of the structure, the Company Officer from SFD Engine 60 fell approximately 8 feet to the concrete driveway below, landing on the SCBA bottle that was attached to his back. The Company Officer received care from on scene medics and was transported to the UC Davis Medical Center with a serious low back injury. At approximately 21:15 SMFD Engine 54, the second arriving engine, assumed Incident Command, and assigned SFD Engine 60 to conduct vertical ventilation. At the time the order was given to Engine 60 to ventilate there was no truck company on scene.
EXECUTIVE SUMMARY
The Huntsman Drive fire was reported on February 26, 2011 at 21:09 hours Pacific Standard Time (PST) in the Rosemont neighborhood, located in the un-incorporated section of Sacramento County, California, and within the jurisdiction of the Sacramento Metropolitan Fire Department (SMFD). As part of the long standing boundary drop agreement between fire agencies in Sacramento County, a Sacramento Fire Department (SFD) Engine Company was assigned to the incident as part of the first alarm response.
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INTRODUCTION
This Accident Investigative Report is a comprehensive and factual review of the response to the February 26, 2011 fire incident on Huntsman Drive. Specifically, the Investigative Team was asked to:
Obtain all available incident facts/information and communicate a detailed, validated factual incident review report to the Sacramento Fire Department and the Sacramento Metropolitan Fire District. All information contained in the report will be factual documentation of the events leading up to the incident, the incident operation(s), and incident mitigation to include treatment and transport of the injured personnel. The results of the findings and recommendations will be used as lessons learned for Fire Service in Sacramento County.
Personnel from the Sacramento Fire Department, Sacramento Metropolitan Fire Department, and the City of Sacramento Risk Management Division worked cooperatively to investigate the events leading up to the injuries to the Fire Captain.
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Terminology
All of the times used in this document are expressed using the 24-hour clock. In December 2007, the Sacramento Operational Area adopted International Phonetic Alphabet, which assigns a word to each letter of the alphabet, as listed below:
A Alpha B Bravo C Charlie D Delta E Echo F Foxtrot G Golf
H Hotel I India J Juliet K Kilo L Lima M Mike N November
O Oscar P Papa Q Quebec R Romeo S Sierra T Tango U Uniform
V Victor W Whiskey X X-ray Y Yankee Z Zulu
These words are used whenever it is necessary to identify any letter of the alphabet over the 800 MHz radio system or refer to the sides and interior divisions of a building (Figure 1).
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Building Layout
Building layout, location, and exposures are commonly identified with a letter (alpha) and a number (numeric) to describe the location of the structure relative to the fire building. The term exposure refers to a structure that is attached or adjacent to the fire building.
B/C Corner
Charlie Side
C/D Corner
Bravo Side
Delta Side
A/B Corner
Alpha Side
A/D Corner
Figure 1: The Alpha/Numeric graphic representation of the building sides.
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Report Organization:
This Report is organized into twelve (12) sections and three(3) Appendices. Each Section is divided into various sub-sections, which include relevant background information, specific discussion pertaining to the incident on Huntsman Drive, and, where applicable, recommendations for future action. The Appendices include a comprehensive post incident analysis of equipment used by the injured personnel, and a glossary of common terms used by the Sacramento Fire Department and the Sacramento Metropolitan Fire District.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Metro Fire responds to 70,000+ requests for service each year from 37 fire stations arranged in 5 battalions. Metro Fire deploys 37 engines, 4 trucks, 1 heavy rescue, 1
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DEPARTMENT DEMOGRAPHICS
The Sacramento Fire Department is a full-time paid professional fire department and has been serving the citizens of the city of Sacramento since 1850. The Department provides fire suppression, advanced life support transportation, hazardous materials response, technical rescue operations, fire prevention, and public education to the citizens of Sacramento and to the contract areas of the unincorporated portions of Sacramento County. The Department is also the sponsoring agency for the Sacramento Urban Search & Rescue Team, California Task Force 7. .
Currently the department deploys 23 Engine Companies, 8 Truck Companies, 1 Rescue Company, 13 ALS Ambulances, 4 Battalion Chiefs, covering an area of 99 square miles in the incorporated portion of the city and provides services by contract to 45 square miles of unincorporated Sacramento County. The Department currently serves 530,000 residents and over 500,000 transient workers due to a large state and federal government workforce associated with being a State Capital. The total daily suppression strength is 150 members. All suppression companies are staffed with four (4) personnel consisting of: Company Officer (Captain), Engineer, and two (2) Firefighters. The department responds to over 70,000 calls for service annually.
Sacramento Metropolitan Fire District

The Sacramento Metropolitan Fire District was created December 1, 2000 when the American River Fire District and the Sacramento County Fire District merged creating the 7th largest fire department in the State of California. Metro Fire represents 16 predecessor agencies. Metro Fire provides fire suppression, fire prevention, advanced life support transportation, technical rescue, and hazardous materials response to 417 square miles of eastern Sacramento County including the incorporated city of Rancho Cordova and Citrus Heights.
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hazmat, 1 ARFF and 13 advanced life support ambulances with a daily staff of 168. These stations protect over 650,000 people. The area is composed of residential, industrial, wildland urban interface and rural grass lands. Staffing on Engines is one Captain, one Engineer and one Firefighter. All engine companies have at least one paramedic assigned. Staffing for trucks, hazmat and rescue is one Captain, one Engineer and two Firefighters. Ambulances are staffed with two firefighters, one of which is a paramedic.
Standard Operating Guidelines

In 2010, the Sacramento County Operating Area began developing a set of regional Standard Operating Guidelines (SOG). The first set of SOGs including the SOG for residential structure fires were implemented July 1, 2010.
The Regional SOGs required the development of standardized naming of the riding positions on all emergency apparatus. These riding positions are identified by rank and function, with each position having a name and set of basic responsibilities on any given emergency. All company members are identified by their riding position and the company they are assigned to.
On an Engine Company the pre-assigned riding positions are: Officer (Captain), Engineer, Nozzle Firefighter and Back-Up Firefighter. The riding positions identifiers on the Truck Company are: Officer (Captain), Engineer, Saw Firefighter and Tools Firefighter. If a department member is calling a particular company, then the Officer will answer the radio for that company. (e.g. Engine 1, Engine 2.) The Officer for Engine 2 would answer the radio). If a one member needs to talk to a particular company member, then that member is identified by their riding position and company identifier. (e.g.: Truck 1 Captain, Truck 1 Saw).
All references to members involved in this incident will be referred to by their riding positions
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 This was the second fire in this structure. The previous fire occurred on 02/14/2011with the fire involving room and contents located in C/D corner of the structure. After the fire was extinguished, the windows and the ventilation hole in the roof were covered with plywood by the restoration construction contractor.
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STRUCTURAL SUMMARY
The Huntsman Drive incident occurred in a neighborhood known as Rosemont, which is located in an unincorporated section of Sacramento County on the east side of the Sacramento city limits. The basic structural information is a follows:
One story single family dwelling built in 1974 3 bedroom, 2 bathroom 1368 square feet 45 wide by 55 deep Wood frame (Type V) Conventionally framed roof assembly with composition shingles Stucco exterior wall covering Windows were boarded up at the time of the fire
Building Construction Features:

In the fire service, the term building construction refers to the type of construction of the structure, as well as the combustibility and the fire resistance rating of a building's structural elements. To classify buildings consistently, the National Fire Protection Association (NFPA) has developed five Types of construction. The structure on Huntsman Drive was of Type V construction, which means that its structural members consisted entirely of wood and is probably more vulnerable to fire, both internally and externally, than any other building type.
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Roof Assembly
The roof was constructed from 2X6 rafters that were placed 16 inches on center. The roof was sheathed with inch plywood. There were 2 layers of compositions shingles attached to the roof. On the charlie side, a 4 foot by 4 foot ventilation hole was present from a previous fire. This hole was covered with a 4 by 8 piece of inch plywood secured by decking screws.
Wall Construction
All interior and exterior walls were constructed of 2 X 4 wall studs that were 16 inches on center. The interior walls were covered with inch sheet rock. The exterior walls were covered with paper and stucco. There were no shear panels present. The exterior wall void spaces were filled with roll-in fiberglass insulation.
Floor Assembly
The floor assembly was composed on 2 X 6 tongue-in-grove subfloor. Most of the floor was covered with carpet.
Windows
The windows were single pane aluminum construction. All the window openings were covered with inch plywood after the building sustained fire damage on February 14, 2011.
Exposures:
The exposures adjacent to 3341 Huntsman Drive were not a factor and did not play a role in the outcome this incident. (Map 1)
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Alpha Side
The Alpha exposure was a landscaped front yard and street. At the A/B corner there was six foot wood fence which slightly impeded the movement of the ground ladders down the Bravo side.
Bravo Side
The Bravo-1 Exposure, located approximately 20 feet away, was a two story single family dwelling of similar construction. The exposed surfaces of the structure consisted of stucco siding. No fire or heat damage was reported for this exposure.
Running along the property line between the two structures is a 6 foot high wood fence. This fence ran from the C/D corner of the Bravo-1 exposure and ran the entire length of the property line and ended in the backyard. There were several aluminum sheds along the
fence line. None of the sheds received damage from the fire.
Charlie Side
The Charlie Side contained a large concrete patio and a large RV parking pad. The parking pad was access for the delta side on Thilow Dr. There was also a small area of grass. Running along the rear property line was a 6 foot wood fence.
Delta Side
The Delta side of the structure was composed of a landscaped side yard that ran along Thilow Drive. The landscaping limited access for ground ladders on this side of the structure.
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Thilow Dr
3341 Huntsman Dr
Delta Side
Charlie Side
Alpha Side Bravo Side
Huntsman Dr
Map 1: Aerial view depicting the location of 3341 Huntsman Drive.
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IMPACT ON INCIDENT
The sheets of plywood on the windows and doors contributed to the delay in horizontal ventilation, which may have been a contributing factor in the buildup of heat conditions that delayed the advancement of the attack hoseline.
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PRE-INCIDENT INFORMATION
Pre-Incident Company Status and Location
At the time of the incident, all of the first alarm companies were available in quarters. 4 Distance to Incident [9] 5 1.1 mi 6 1.4 mi 7 2.6 mi 8 4.4 mi 9 7.0 mi 10 6.0 mi 11 6.0 mi 6.2 mi 12 4.4 mi 13
Company E 62 E 54 E 60 E 61 TR 65 TR 50 Batt 9 (Sta 50) Batt 14 (Sta 66) M 61

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 AIQ= Available in quarters AOR= Available on radio
Status* AIQ AIQ AIQ AIQ AIQ AIQ AIQ AIQ AIQ
Staffing 3 3 4 3 4 4 1 1 2
Unvail= Unavailable for dispatch
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3341 Huntsman 3341 Huntsman Drive
3341 Huntsman
Legend
Engine 60 District SMFD Response area
240047-CAD
Pick Zones
Map 2: Station locations in relation to incident location.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Temperature: Humidity: Wind Speed: Direction: Sky: 43.5F 62% 5 mph 326 degrees Clear
Weather Conditions
Weather conditions at 2109 hours taken at the Sacramento Regional Fire Emergency Communications Center weather station, located 2.45 air miles from Huntsman Drive, at the time of the incident:
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INCIDENT NARRATIVE & TIMELINE

The development of an accurate account of the events as they transpired requires the use of multiple sources including: dispatch logs; radio transmissions; individual statements; interviews; and electronically recorded MDT transmissions. When a specific sequence of events occurred simultaneously, all attempts were made to place them in the best logical order. The names of the Department members involved in this accident have been
redacted from this report and they are referred to by their riding/assignment position. The sequences of events are described in the narrative below:
On the evening of February 26, 2011, at 21:09 PST, the Sacramento Regional Fire Emergency Communications Center (SRFECC) begins receiving multiple calls for a house fire located at 3314 Huntsman Drive. The first 9-1-1 caller reported visible flames from the back of the corner house that faces Huntsman Drive, and that the house appears boardedup.
Shortly after the initial call was processed, the SRFECC received five additional 9-1-1 calls reporting the same information as the original caller.
At 21:09:02 (+0:00) the SRFECC dispatched a residential house fire assignment to 3341 Huntsman Drive. The assignment included: 4 Engine Companies, 2 Truck Companies, 2 Battalion Chiefs and 1 Medic. As part of the assignment, the tactical radio channel of A6 was pre-assigned for on scene operations. The companies assigned were: SMFD Engine 62 (1st due Engine); SMFD Engine 54 (2nd due Engine); SFD Engine 60 (3rd due (1st due Truck); SMFD Engine); SMFD Engine 61 (4th due Engine), SMFD Truck 65 Truck 50 due Battalion Chief); SMFD Medic 61 (1st due Medic) The 1st due Battalion Chief, Battalion 9, conducted a roll-call on radio channel A6 to ensure all companies were enroute and on the correct radio channel and continued with the rollcall process until all companies assigned acknowledged.
(2nd due Truck); SMFD BC 9 (1st due Battalion Chief); SMFD BC 14 (2nd
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21:12:00 (+3:58) SMFD Engine 62 was the first arriving engine and transmitted the following report on conditions:
62s arrived. We got a attic fire at the same house we had the fire at about a week ago. Be advised we have an attic fire. Engine 62 is assuming fire attack.
The Officer and Nozzle Firefighter of Engine 62 stretched the initial attack line and began interior fire attack, while the Engineer assisted with other support functions on the exterior. The Officer reported progress into the structure was slowed due to the heat conditions and ventilation was needed.
21:13:48 (+4:46) SMFD Engine 54 was the second arriving engine and radioed the following:
Were at the hydrant at Huntsman and ahh, I cant remember what it is. I think its Rosemont. Were laying into the scene. Engine 54 will be assuming Huntsman Command here in just about 30 seconds. Well give you an update in a second.
21:14:08 (+5:06) Battalion 9, not yet on scene, acknowledged Engine 54s transmission:
Copy 54s got water and Command
21:14:20 (+5:18) Engine 54 replied back to Battalion 9:
Engine 62 is going to be Fire Attack, Engine 54 is getting water supply. Well provide 2 out at this point. And Ill get some other crews going when they get here.
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Engine 54, approaching from the south, laid in wet, approximately 300 feet of LDH to Engine 62. Engine 54 Nozzle remained at the hydrant during the lay-in. Engine 54
Engineer completed the lay and assisted Engine 62 Engineer with the completion of the supply line hook up. The Engine 54 Captain assumed Command. After the water supply was completed, the Engineer and Nozzle Firefighter of Engine 54 stretched the 2OUT line and assumed the 2OUT team.
21:14:39 (+5:37) SFD Engine 60, the third arriving engine, transmitted On scene from their MDC, and simultaneously announced on the tactical channel that they were on scene.
After Engine 60 arrived, the Back-Up Firefighter and Nozzle Firefighter retrieved their tools and removed the 14 roof ladder from Engine 60 and proceeded to the Alpha side of the building where they encountered the Engine 54 Captain, who had just completed a visual inspection of the Bravo and Charlie sides, and were instructed face-to face by the Engine 54 Captain (IC) to perform vertical ventilation and remove the plywood sheeting that was covering the previous ventilation holes. At the time the instruction was given, Engine 60 Captain was not present, because he was still obtaining this equipment from the engine. The Engine 60 Captain his first knowledge of the ventilation order is when he heard the IC transmit the assignment over the radio:
21:15:48 (+6:46)
All incoming units, we have Engine 60 taking vertical ventilation. Incoming Engine 60 has vertical ventilation. Firefighter 54 shut off the hydrant. Firefighter 54 shut off the hydrant. The Nozzle Firefighter and Back-Up Firefighter from Engine 60, spotted and raised the ladder to the eve-side of the roof of the garage located at the A/B corner of the structure. The ladder lay resting against a metal rain gutter of the structure. Neither firefighter noted the slope of the concrete driveway, where the ladder was footed. None of the three
members of Engine 60 remember exactly how many rungs of the ladder were extending over the roof line, but they estimate it was in the range of two-four rungs.
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After the ladder was raised, the Back-Up Firefighter was the first to climb the ladder, while the Nozzle Firefighter footed the ladder. The ladder was footed according to the
department standards taught in the recruit academy; the fire firefighter standing on the inside of the ladder, with his back to the building, grasping the beams of the ladder with each hand, and gently pulling the ladder toward his body. After the Back-Up Firefighter reached the top of the ladder he stepped onto the roof, and secured the ladder by holding the tip while the Nozzle Firefighter climbed. Both firefighters reported that the ladder did not move or slip during the climbing process. Once the second firefighter reached the roof, they proceeded to the ridge of the roof and began the ventilation process.
21:16:19 (+7:17)
Engine 54 (IC) updated companies assigned to the incident:
All incoming units, the majority of the fire is going to be on the C side of the building. We gonna have a bedroom fire that appears to have gotten up into the attic. The majority of the fire is coming from the back left window. We have boards over a lot of the windows so RIC company we going to need to pry off all the plywood. Engine 60 Engineer was the third person to reach the ladder. By the time he reached the ladder, the two Firefighters had already climbed and were on the roof performing ventilation operations. The Engineer proceeded to climb the ladder without it being footed, and noted that when he reached the roof there was a rung from the ladder in-line with the gutters edge. The Engineer also noted that when he began to transition from the ladder to the roof that the ladder had slipped a bit, but he was able to maintain his balance. The Engineer proceeded up the roof and assisted the two Firefighters.
21:16:46 (+7:44) Engine 54 (IC) assigned the fourth arriving engine, Engine 61 to RIC:
E61 youre going to be the RIC Company. I need you to go around the structure once again and pry of plywood and make sure that the interior crew can get out if they need to.
21:17:34 (+8:32) Battalion 14, the first arriving Battalion Chief, arrives on scene:
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Battalion 14s on scene. Command can we do a face to face
21:18:04 (+9:02) The Officer of Engine 54 transmits to all companies operating on scene:
All incoming units update from fire attack too hot inside theyre unable to interior attack until we get this ventilated. E60 is working on vertical ventilation at this point.
21:18:31 (+9:29) The Officer of Engine 54 assigned Medic 61 to Fire Attack. He mistakenly believed that is was Medic 64.
Fire Attack Engine 62 Im sending you Medic 64 crew. 64 crew is coming to you.
Engine 54 Captain walks to the Delta side of the structure to do a face-to-face transfer of command with Battalion 14. 21:18:46 (+9:44) Truck 50 marks on scene with the MDC and voices impending arrival on the Tac A6
Command, Truck 50 is about 30 seconds out.
Engine 60 Captain arrived at the ladder. No one was around to foot the ladder. He began climbing the ladder without anyone footing it. He stepped on to the roof with his right foot. The ladder began to slide out. Engine 60 Captain tried to step back onto the ladder but this just accelerated the motion of the ladder. Engine 60 Captain attempted to grab the roof with his right hand but was unable to hold on. Engine 60 Captain fell from the roof landing on his back and SCBA.
Although it was not announced on the Command or Tactical frequencies, Battalion 14 assumed Command.
21:19:47 (+10:45) Engine 54 Engineer and Engine 54 Nozzle witness the fall from their position as two out. Engine 54 Engineer transmitted the firefighter down information.
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Command, firefighter down A side of the building off a ladder approximately 10 feet. Ill repeat. Firefighter down out front (Covered).
21:19:57 (+10:54) Battalion 14 acknowledged the emergency traffic and changes the fire to a defensive mode.
Okay all units this is Command with emergency traffic. We are going defensive at this time. All units defensive. I got a firefighter down on the A side the building. I need a medic unit to that location. Medic 61 you will now A side of the building medical group. This is a defensive fire.
All units exit the structure. 21:20:23 (+11:20) Battalion 14 notified Fire Dispatch of the firefighter down and the switch to defensive mode.
Fire Dispatch Huntsman Command. Ive got a firefighter down on the A side of the building, requesting a code 3 medic. Going defensive.
Medic 61 began treating Engine 60 Captain. Engine 61 assisted with removing Engine 60 Captains PPE. Spinal precautions were applied.
Command requested two (2) additional engine companies and an SFD Battalion Chief from Fire Dispatch. Command began conducting a Personnel Accountability Report (PAR). All interior firefighters were accounted for.
Once all the crews were accounted for, Command began formulating a plan to re-engage the fire offensively.
21:30:21 (+20:58) Medic 61 transported Engine 60 Captain to UC Davis Medical Center code 2.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Captain Teague had several firefighters climb the ladder on March 1. Each time while the firefighter was stepping on to the roof, the ladder began slipping. As presented in the diagram, due to the slope of the driveway, the measured angle between the driveway and the ladder is 60. This means that more of the firefighters weight is transferred outward overcoming the frictional force that holds the ladder in place. The ladder was placed in approximately the same position it was in at the time of the accident. The climbing angle of the ladder was set by using the method outlined in IFSTA Essentials page 290. The angle of a properly set ladder should be approximate 75.
PHOTOGRAPHS & ILLUSTRATIONS

The following diagram was created by Denis Murray GIS specialist at SMFD. The measurements utilized in the construction of the diagram were taken by SMFD Captain Teague. Captain Teague compiled these measurements on March 1, 2011, at 3341 Huntsman Drive while utilizing a 14 foot straight ladder similar to the ladder utilized on the fire. The photographs utilized herein were taken the same day as the measurements.
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1 2
Diagram of the approximate ladder placement.
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Approximate location of the ladder
2 3
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FINDINGS
The following the conclusions of the Accident Review Team based on the chronology of events and factual data, weight of evidence, interviews, and professional judgment. Findings are grouped into the following categories: human, building construction, management, equipment, communications, staffing, response times.
Human Findings
H-1 All Sacramento Fire Department members assigned to the Huntsman Drive Incident on February 26, 2011 met or exceeded current agency qualifications and training requirements for fire positions held.
H-2 The personnel assigned to Engine 60 had a combined 58 years of experience. Company Officer- 25 Years; Engineer-16 years; Back-Up FF- 12 years; Nozzle FF-5 years.
H-3 Training records indicated that all Sacramento Fire Department members training met or exceeded those recommendations contained in the National Fire Protection Association (NFPA) 1932: STANDARD ON USE, MAINTENANCE, AND SERVICE TESTING OF INSERVICE FIRE DEPARTMENT GROUND LADDERS
H-4 Training records indicated that all Sacramento Fire Department members training met or exceeded those recommendations contained in the National Fire Protection Association (NFPA) 1001: STANDARD FOR FIRE FIGHTER PROFESSIONAL QUALIFICATIONS
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H-5 All Sacramento Metropolitan Fire District personnel assigned to the Huntsman Drive incident met or exceeded agency qualifications and training for the positions assigned.
H-6 Engine 60 crewmembers were not a sleep at the time of the incident.
H-7 The fire occurred during the 37th hour of a 48 hour shift.
H-8 After arrival, Engine 60 Captain was separated from his crew as he finished donning his PPE.
H-9 Engine 60 Firefighters received orders to ventilate from the Incident Commander (Engine 54 Captain) without their Engine 60 Captain being present.
H-10 Engine 60 Captain became aware of the order to ventilate by radio transmission.
H-11 Engine 60 Firefighters and Engineer climbed the ladder prior to Engine 60 Captains arrival at the ladder.
H-12 Engine 60 Captain ascended the ladder without it being secured.
H-13 During Engine 60 Captains transition from the ladder to the roof, the ladder slipped out from under him.
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H-14 The ladder was spotted on the concrete driveway by Engine 60 Firefighters.
H-15 The interior attack crew, Engine 62 was unable to access the seat of the fire due to excessive heat in the structure.
H-16 Engine 60 Captain received prompt medical care from the Medic 61s crew.
Management Findings
M-1 The Huntsman Drive fire was located in the jurisdiction of the Sacramento Metropolitan Fire Department.
M-2 Incident Command was established by Engine 54 and was announced over the tactical channel at 21:13:48.
M-3 Some directions were given to the IC by the responding Battalion Chief prior to their arrival on scene.
M-4 Incident Command was transferred to Battalion 14 on his arrival at 21:18:46.
M-5 The transfer of command was not announced on the Command or Tactical radio channels.
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M-6 Sacramento Fire Department engine companies are not typically assigned truck company operations, for example, vertical ventilation.
M-7 Metro Fire engine companies are, at times, called upon to perform ventilation.
M-8 The incident commander deviated from the Regional Standard Operating Guideline by assigning Engine 60 to ventilation.
Building Findings
B-1 The fire building was a single story residence built in 1974
B-2 The fire building was classified as Type V construction.
B-3 The involved building sustained fire damage due to a room and contents fire 12 days prior to this incident.
B-4 A ventilation hole was cut in the roof on the previous fire.
B-5 The windows and the ventilation hole were covered with plywood by a board up contractor after the previous fire.
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B-6 The driveway is made of concrete and sloped away from the structure at a 10 angle.
B-7 The building was unoccupied at the time of the fire. .
Equipment Findings
E-1 The Captain was wearing department approved PPE ensemble.
E-2: The ladder used was from Engine 60.
E-3: The ladder used was 14 foots solid beam roof aluminum ladder manufactured by the DuoSafety ladder company.
E-4 The ladder was placed in service with Engine 60 in December 2010.
E-5 This ladder, as well as all ladder used by the Sacramento Fire Department, meet the recommendations set forth in the National Fire Protection Association (NFPA) 1931 STANDARD FOR MANUFACTURER'S DESIGN OF FIRE DEPARTMENT GROUND LADDERS
E-4 Ladders are tested as required by NFPA 1932.
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Communications Findings
C-1
The SRFECC assigned tactical channel Alpha 6 (A6) for the Huntsman Drive incident.
C-2 There were no reports of communications problems, or radio failure during the incident.
C-3 The tactical frequency (A6) did not appear congested throughout the incident.
Staffing/ Response Time Findings

SR-1 All companies responding to this incident were running with their departments standard staffing levels; four person for SFD; thee on SMFD engines, and four of SMFD trucks.
SR-2 The closest truck company was located at Station 50, six (6) miles from the incident location.
SR-3 The initial engine arrived on scene in 4 minutes 12 seconds after dispatch within the time frame recommended by NFPA 1710.
SR-4 The first truck company did not arrive on scene until 9 minutes 44 seconds after dispatch which is 1 minutes 44 seconds longer than recommended by NFPA 1710.
SR-5 All first alarm units were on scene at 11 minutes 25 seconds after dispatch.
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CAUSAL AND CONTRIBUTING FACTORS

Causal Factors
Causal Factors are any behavior, omission, or deficiency that if corrected, eliminated, or avoided probably would have prevented the injuries.
Causal Factor 1:
Engine 60 Captain ascended the ladder without the ladder being secured. H11, H-12, H13, H-14
Contributing Factors
Contributing Factors are any behavior, omission, or deficiency that sets the stage for an accident, or increases the severity of injuries. Contributing Factor 1: The ladder was placed on a downward sloping concrete driveway. This placement allowed the ladder to be easily dislodged when transitioning to the roof. E-2, E-3, B-6
Contributing Factor 2: Engine 60s crew did not maintain crew continuity. H-9, H-11
Contributing Factor 3: The incident commanders order to firefighters instead of their supervisor interrupted the chain of command. H-9, H-10
Contributing Factor 4: The Sacramento Fire Department and the Sacramento Metropolitan Fire District have cultural differences as to the fireground duties and responsibilities of the engine company. M-6, M-7
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Contributing Factor 5: Deployment of truck companies by both agencies has created an area where extended response times are present. SR-2, SR-4, SR-5
Contributing Factor 6: The sheets of plywood covering the windows allowed the structure to retain the heat from the fire, thus making it impossible for the interior fire attack crew to access the seat of the fire prior to ventilation. B-5, H-17
Contributing Factor 7: The delay in the arrival of the truck company coupled with the inability to access the seat of the fire placed pressure on the incident commander to find another course of action. M-8, H-17, SR-2, SR-4, SR-5
Contributing Factor 8: Firefighters acted independently on the fireground without the knowledge of their company officer. H-9, H-11
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 There are cultural difference between the Sacramento Fire Department and the Sacramento Metropolitan Fire District. These differences were made apparent as it relates to the expected duties of engine companies and truck companies. Crews from both agencies must understand these differences to ensure a safe response. Maintaining crew continuity is a priority. If all four members of Engine 60 were together, it is unlikely that the accident would have occurred. Captains need to keep their crews together to ensure proper supervision. The surface a ladder is placed on directly affects its stability. Ladders placed on sloped surface will slip out more easily that on flat surfaces. Concrete surfaces do not provide adequate friction to keep the ladder in place. As a result of the After Action Incident Analysis, the Serious Accident Review Team has identified some key learning points that will help prevent a re-occurrence of an event of this nature.
LESSONS LEARNED
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RECOMMENDATIONS
As a result of the After Action Incident Analysis, the Accident Review Team has identified opportunities for improvement that will decrease the likelihood of a similar incident given similar circumstances could be avoided.
Recommendation 1 Provide training programs that re-emphasize basic firefighting skills including raising, lowering and climbing ladders. The refresher training program should emphasize the safety precautions that need to be taken during the implementation of these skills.
Recommendation 2 Formalize interagency training so that companies along jurisdictional borders understand each others capabilities.
Recommendation 3 Develop and implement leadership/followership training and crew resource management training in an effort to have crews maintain cohesiveness during emergency incidents.
Recommendation 4 Evaluate the location of truck companies county-wide to ensure a timely response to all incidents. Consider placing a truck company in the Rosemont area to reduce the response time for first alarm units.
Recommendation 5 When the assigned medic crew is given a fire suppression assignment consider requesting second medic crew to handle medical emergencies on scene.
Recommendation 6 Require incident commanders to maintain the chain of command when giving fireground assignments.
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Recommendation 7 Crewmembers should not accept orders on behalf of their company officer.
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SIGNATURE PAGE
Respectfully Submitted by Incident Review Team,

(listed alphabetically by last name, room left for signatures)
David Baldwin, Captain Sacramento Fire Department
Kim Iannucci, Assistant Chief Sacramento Fire Department
Rick Lee, Captain Sacramento Fire Department
Michael Teague, Captain Sacramento Metropolitan Fire Department
Date
07/28/11
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 The Sacramento Regional Fire/EMS Communications Center (SRFECC) is the third largest fire dispatch center in the State of California dispatching over 150,000 incidents annually. They are organized as a Joint Powers Authority (JPA) and are supported by the fire agencies we serve. Together with these agencies, they provide fire protection and emergency medical service (EMS) dispatching for nearly all of Sacramento County and parts of Placer County covering over 1,000 square miles and serving over 1.3 million residents. The SRFECC provides dispatching services for eight (8) different fire agencies in Sacramento County. The county-wide trunked system has been operational since 1995.
APPENDIX A - INCIDENT COMMUNICATIONS
Radio System Overview

The Sacramento County Fire Service Agencies operate on a county-wide public safety and local government 800 MHz trunked radio system. The system consists of ten (10) different zones, with each zone assigned to a specific agency or liked agencies. Each zone contains 16 different radio channels. This system allows for county wide inter-agency communications by simply switching zones and selecting the proper channel. Each zone is formatted to fit the needs of that specific agency. However, all radios used by the various agencies operating on trunked system are programmed the same.
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The Sacramento Fire Department operates on the Bravo or B Zone of the 800 MHz trunked radio system and Sacramento Metropolitan Fire Department operates on the Alpha A zone. The jurisdiction that the incident occurs in will dictate what zone the incident will operate on. The radio programming for the Bravo zone is:
Sacramento Fire Department Radio Channel Template Channel 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 7 8 9 10 11 12 The Radio Channel template layout for Sacramento Metropolitan Fire Department is the same, with the exception that the letter A would be substituted for the letter B. For example FCOMA2 would be used to communicate between the dispatch center and field units. Display FDSPB FCOMB2 FCOMB3 FCOMB4 FCOMB5 FT B6 FT B7 FT B8 FT B9 FT B10 FT B11 FT B12 FT B13 FT B14 Dir 15 Dir 16 Description Dispatch Channel Operational Tactical Tactical Tactical Tach B6 Tach B7 Tach B8 Tach B9 Tach B10 Tach B11 Tach B12 Tach B13 Tach B14 Direct 15 Direct 16 Use Dispatching incidents only Dispatch to Field/Field to Dispatch Command Level Tach Channel Command Level Tach Channel Command Level Tach Channel Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Fire ground tactical operations Non-trunked direct channel Non-trunked direct channel
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 In an effort to help eliminate confusion regarding the radio transcriptions, the radio channels on the transcription table have been color coded. The assigned color code is as follows: 9-1-1 Call Taker Main Dispatcher CAD entries MDT transmissions Radio Channel A3 Radio Channel A6 (Tactical) The development of an accurate timeline requires a multiple of sources including: dispatch logs; radio transmission voiceprints; individual statements; and interviews; At the height of the incident, there were two (2) different radio channels being utilized for this incident. There are several occurrences of radio transmissions occurring simultaneously on different channels. All efforts were made to place those transmissions in the best logical order as possible. Some situations, time estimations were necessary because personal observations and radio transmissions were made without a time record/reference or source time references conflicted. When a specific time could not be determined, a best estimate of time was provided. Events that occurred sometime between established time references are indicated by asterisks (*). The time in pretences is the running time from time of dispatch
Incident Radio Traffic Transcript
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Channel Time 21:10:09 A3 21:11:02 A6 21:11:50 A6 21:11:54 A6 21:12:05 A6 21:12:07 A6 21:12:10 A6 21:12:15 A6 21:12:18 A6 21:12:21 A6 21:12:25 A6 21:12:29 A6 21:12:37 A6 21:13:00 A6 A3 A3 A3 A6 A3 A6 A6 A6 21:13:18 21:13:29 21:13:33 21:13:36
Unit Dis. BC14 BC9 E62 E54 E60 BC9 E61 M61 BC9 TR65 TR50 E62 BC9 BC9 Dis. BC9
21:13:48 E54 21:13:50 Dis. 21:13:14 21:14:08 BC9 21:14:20 E54 21:14:34 BC9 21:14:39
Transcription BC9, BC14, E62, E54, E60, E61, M61, TR65, TR50 Dispatched to S3 to Huntsman and Thilow Battalion 9, Fire Dispatch Battalion 14 on is Tac Copy B14, Battalion 9 roll call. Engine 62, Engine 54, Engine 60 Engine 62 Engine 54 Engine 60 Engine Medic 61 Engine 61 Medic 61 Truck 65 and 50 65 Truck 50 62s arrived. We got a attic fire at the same house we had the fire at about a week ago. Be advised we have an attic fire. Engine 62 is assuming fire attack. I copy 62 got a working fire in the attic from previous, previous fire. Fire Dispatch, Battalion 9 Fire Dispatch 62 on scene reporting a working attic fire. Could you please notify Arson 5 that this is the same residence we had last week. Were at the hydrant at Huntsman and ahh, I cant remember what it is. I think its Rosemont. Were laying in to the scene. Engine 54 will be assuming Huntsman Command here in just about 30 seconds. Well give you an update in a second. Copy Battalion 9 Engine 62 on scene with a working attic fire, advise Arson 5 same residence as last week. E62 marks on scene (4:12) Copy 54s got water and Command. (E54 did not mark on scene) Engine 62 is going to be Fire Attack, Engine 54 is getting water supply. Well provide 2 out at this point. And Ill get some other crews going when they get here. Sounds good thanks. E60 marks on scene (5:37)
Channel A6 A3 A3 A3 A3 A6 A3 A3 A3 A6 A6
Time 21:14:41 21:14:47 21:14:55 21:14:58 21:15:10 21:15:48
A6 A6 A6 A6 A3 A6 A3 A6 A3 A3 A3 A3
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Transcription Engine 60 on scene. AMR108 Fire Dispatch Fire Disptatch Engine 23 can you send a code 2 medic here Engine 23 requesting code 2 medic. AMR108 Fire Dispatch Medic its that building to your left. All incoming units, we have Engine 60 taking vertical ventilation. Incoming Engine 60 has vertical ventilation. Firefighter 54 shut off the hydrant. Firefighter 54 shut off the hydrant. 21:15:52 AMR28 Fire Dispatch AMR28 go ahead and give us the call please for Medic 21. Theyre unaware. 21:16:01 Dis. Copy AMR28 to handle in place of Medic 21. It will be code 2. 21:16:08 AMR28 Copy. 21:16:12 Unk Were shut down. 21:16:19 E54 All incoming units, the majority of the fire is going to be on the C side of the building. We gonna have a bedroom fire that appears to have gotten up into the attic. The majority of the fire is coming from the back left window. We have boards over a lot of the windows so RIC company we going to need to pry off all the plywood. 21:16:42 E61 E61 is arriving from the north. 21:16:46 E54 E61 youre going to be the RIC company. I need you to go around the structure once again and pry of plywood and make sure that the interior crew can get out if they need to. 21:16:57 M61 Medic 61 on scene. Assignment. 21:17:02 Unk Hydrant were ready for water. 21:17:05 M21 AMR28 Medic 21 Are you closer to the call with TR23? The one you just jumped? 21:17:06 E61 61 copies were assuming RIC. 21:17:11 M61 marks on scene (8:09) 21:17:11 AMR28 Yeah Probably. We are already at Greenback and Mariposa. We take that one. Fire Dispatch AMR23 go ahead and put on that call with Truck 23. 21:17:12 E54 61 copy you have RIC 60s doing the vertical ventilation at this point. 21:17:22 Disp. Copy AMR28 and M21 exchanging calls 21:17:27 AMR108 Fire Dispatch AMR108 we handle the call off of Ranger. Go ahead and cancel Engine 108. 21:17:30 Disp. Copy Engine 108 Fire Dispatch you copy Cancel. 21:17:31 BC14 marks on scene. (8:27) 21:17:27 E108 Were copy could you put us AIQ please.
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Unit E60 Dis E23 Dis. Unk E54
Channel A6 A6 A6 A6 A3 A6 A6 A6 A6 A6 A6 A6: A6 A6 A6 A6 A6 A6 A6 A3 A3 A3
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Time 21:17:34 21:17:37 21:17:42 21:17:48 21:17:50
Unit BC14 E54 BC14 E54FF Disp
21:17:53 Unk 21:18:04 E54 21:18:31 E54 21:18:46 21:18:46 TR50 21:18:53 BC14 21:18:59 21:19:02 21:19:05 21:19:09 21:19:17 12:19:17 21:19:20 21:19:27 21:19:47 TR50 E62 BC14 E62 BC14 Unk BC14 E54
21:19:57 BC14 21:20:07 TR23 21:20:12 AMR28 21:20:13 TR23
Transcription Battalion 14s on scene. Command can we do a face to face. Affirmative. Im meeting up with 62 year quick. Ill be over there in about a minute. Copy, Ill be located on the D delta side of the fire. Command Nozzle 54 you gonna want this hydrant charged. Truck 23 now responding with AMR28. Patients a 90 year old female with chest pain and rapid respirations is clammy code 3 both units. Go ahead and charge it. All incoming units update from fire attack too hot inside theyre unable to interior attack until we get this ventilated. E60 is working on vertical ventilation at this point. Fire attack Engine 62 Im sending you Medic 64 crew. 64 crew is coming to you. TR50 marks on scene (8:29) Command Truck 50 is about 30 seconds out. Truck 50 it looks like 60s might be working vertical vent. I would like for you to assume roof division. Truck 50 copies assuming roof division. Engine 62 Go ahead 62. Be advised its too hot to move in we get a ventilation hole. Okay. Go ahead and (Covered by other traffic) BC9 marks on scene (10:25) Unintelligible 54 Command Firefighter down A side of the building off a ladder approximately 10 feet. Ill repeat. Firefighter down out front (covered) Okay all units this is Command with emergency traffic. We are going defensive at this time. All units defensive. I got a firefighter down on the A side the building. I need a medic unit to that location. Medic 61 you will now A side of the building medical group. This is a defensive fire. AMR28 Truck 23. AMR28 Go ahead. Your best access to this place is actually going to be off of Luce. There is a little alley back there behind the house.
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Channel Time Unit A6 21:20:19 M61 A3 21:20:23 BC14 A6 A3 A6 A6 A6 A3 A3 A6 A6 A3 A3 A6 A3 A6 A3 A6 A3 A6 A3 A6 A6 A3

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21:20:27 21:20:30 TR65 21:20:32 Disp. 21:20:34 BC14 21:20:43 21:20:50 21:20:55 21:21:01 21:21:03 21:21:13 21:21:17 21:21:23 21:21:24 21:21:29 21:21:30 TR65 BC14 AMR28 Disp. BC14 E54 E53 Disp. TR50 E53 BC14
21:21:26 Disp. 21:21:41 E54 21:21:46 Unk 21:21:51 BC14 21:21:54 21:22:09 21:22:12 21:22:13 Unk. TR50 BC14 Arson 5
Transcription Medic 61s with the patient. Fire Dispatch. Huntsman Command. Ive got a firefighter down on the alpha side of the building. Start an additional code 3 medic and we are going defensive. TR65 marks on scene (11:25) Command Truck 65 on scene. Copy Huntsman Command. You have a firefighter down on the A side of the building requesting a code 3 medic going defensive. Truck 65 I would like you to come to the C side of the building and assume division Charlie and lets start looking at defensive operations. Copy Division Charlie. Defensive. Engine 61 youre going to be medical group and the medic will be working for. Truck 23 AMR28 we copy thank you Huntsman Command Fire Dispatch Engine 54 Command youre designator will be Division Alpha and Engine 62 is assigned to you. 54 copy Division Alpha 62 is assigned to me and we are defensive posture at this point. Fire Dispatch Engine 53 AOR Engine 53 AOR Command Roof Division Fire Dispatch Engine 53 is there a call in our first in we can handle Okay all units I need a quick PAR. A quick PAR. Division Alpha do you have Engine 62 and Engine 54 out of the building. Engine 53 negative. That is affirmative. The downed firefighter is from E60 the captain. He was not inside the structure. The ladder kicked out and he fell. Medic 109 pull up to the covered entrance in front of the fire lane. Okay. Copy that. Advise if you still think we can do a combination attack at this time. Im going defensive flames are through the roof and the C side is well involved. The far covered entrance. Command Truck 50 Go ahead 50 Fire Dispatch Arson 5 add me to B9s call please
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Channel A6 A3 A3 A6 A6 A6 A6 A6 A6 A6 A3 A3 A3 A3 A3 A3 A3 A6 A6 A6 A3 A6 A3 A6 A3 A3 A6
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Time 21:22:16 21:22:17 21:22:26 21:22:18 21:22:27 21:22:32 21:22:46
Unit TR50 Disp. Disp. Bc14 TR50 E54 BC14
21:23:02 E54 21:23:12 21:23:19 21:23:27 21:23:31 21:23:43 21:23:51 21:23:59 21:24:03 21:24:06 21:24:07 21:24:11 21:24:12 21:24:12 21:24:16 21:24:24 21:24:25 BC14 E54 BC14 Disp. BC14 Disp. E65 Disp. E65 TR50 BC14 TR50 Disp. BC14 Disp. BC14
21:24:28 E65 21:24:34 Unk. 21:24:48
Transcription You dont want us on the roof any more do you? Copy Arson 5 Operations A6. Other unit with traffic go ahead. Other unit with traffic go ahead. Thats negative. Go ahead and hook up with Division Alpha (covered) on this for the time being 10-4 If youre still okay with that we will do interior firefighting from the A side of the structure Okay. All units this is Command have coordinated with Battalion 9. Battalion 9 is going to assume Division Alpha. Front door and go in after the fire. This is Engine 54 who was Division Alpha just confirming that you understand that we have crews going interior. Thats affirmative. Assigning Battalion 9 to Division Alpha. Hell be working for you. Awesome Fire Dispatch, Huntsman Command, give me two additional code 3 engines. Copy Huntsman Command requesting 2 additional code 3 engines. Your code 3 medic is Medic 65. Could you also send a Sac City battalion chief to my location. I got a captain off Engine 60 that got injured. Copy requesting a Sac City BC Fire Dispatch Engine 65 Fire Dispatch Would be we on the pick for an additional engine for that fire. Command Truck 50 50 Utilities are secured. Standby Repeat your last. Engine 65 Negative. Okay Truck 50 Im going to assign you ventilation group and Ill have Truck 65 hook up with you now as ventilation. Both units will be ventilation. Truck 50 in charge. Copy thank you. E23 do you need a backboard in there. Command this is RIC
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Channel A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6
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Time 21:24:48 21:24:59 21:25:02 21:25:05 21:25:12 21:25:17 21:25:22 21:25:31 21:25:35 21:25:43 21:25:52 21:25:59 21:26:20 21:26:58 21:27:12 21:27:30 21:27:43 21:27:49 21:27:58 21:28:04
Unit BC14 BC14 BC14 TR65 BC14 TR50 BC14 TR50 TR65 TR50 TR65 BC14 BC14 BC14 E105 BC14 E105 E54
21:28:17 BC14 21:28:33 21:28:37 21:28:40 21:28:44 BC14 E54 BC14 E54
21:29:03 BC14
Transcription youre assigned to ventilation group which is now Truck 50. Command this is RIC Go ahead RIC The building has been softened the utilities have been secured. Copy that. Command Division Charlie Truck 65 are we being reassigned? Thats affirmative. Im going to make Truck 50 ventilation group. I would like you to work for him. Truck 50 do you copy. Were you talking to me? Truck 50 you are now, your designator is ventilation group and 65 truck is working for you. Truck 50 copies ventilation group. Truck 65 working for me. Ventilation Group Truck 65 what do you need? Nothing at this time. Just meet me at the front of the building. Copy Division Alpha Command Division Alpha Command Battalion 9 Command Engine (covered) Firefighter Command, are you on the tac? Command Engine 105s on A6. Yeah on your arrival I would like for you to take 2 out. Coordinate with Division Alpha. Copy. Command Engine 54. Engine 54 was assigned by Division Alpha to be 2 out. We have the full 54 crew is 2 out alpha side of the building at this point. Okay. Copy that. 105 I would just like you to stage out on the street at this time. Battalion 9 Division Alpha Command. Engine 54 Command Command 54 go ahead. Yeah, I like to account for the remainder of Engine 60s crew. Can we do that? Affirmative. The captain Engine 60, Engineer Engine 60 are on their way towards the ambulance. The engineer just as an escort. Two crew members for Engine 60 are interior with Engine 54 pardon me, Engine 62 and BC9 Division A. Okay copy. If you can I dont need to talk to Battalion 9 but can you confirm that we get him up on
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Channel Time A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 A6 1 2
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Unit E54 M65 BC14 BC9 BC14 BC9 BC14 BC9 BC14 E105 E105 BC14 E105 E54 E54 BC14 E54 BC14 E105 E54 BC14 BC14 E54 BC14
21:29:12 21:29:24 21:29:28 21:29:54 21:29:59 21:30:05 21:30:11 21:30:17 21:30:21 21:30:23 21:30:30 21:30:35 21:30:40 21:30:52 21:30:56 21:31:04 21:31:20 21:31:27 21:31:32 21:31:42 21:31:54 21:32:03 21:32:12 21:32:15 21:32:23
Transcription the tac channel so I can get a hold of him. Will do shortly. Hes interior right now. Command Medic 65 on scene. Medic 65 You would just for like you to stage out on the street with Engine 105. Command, Interior. Is this Division Alpha or Interior go ahead. Division Alpha We need a second line with a fresh crew in here. Extremely hard to hear. Did you say you need a second line? Second line. Fresh crew. M61 marks T2 to UCD. Okay a fresh crew. I go ahead and assign that to Division Alpha. Engine 105 Command did you copy? 105 Engine 105 copies. Were still about 1 to 2 out. Ive got 54 engine doing two out. Id like for you to hook up as the relief crew for one of the interior ones. Youre gonna assigned to Division Alpha which is Battalion 9. Copy that. Command, this is Engine 54 at the direction of Division A. (covered) Because Engine 62 exited the building (covered) another crew (covered) Okay 54 Just confirming that you are replacing Engine 62 thats coming out of the building, Correct? Thats affirmative at the direction of Division A. Okay I copy that. Engine 105 I need you now to assume 2 out outside the door. 105 copies. Command 54. Just updated from 62. Were going to need an air rig here if you dont have one coming already. Start that one more time. An air rig? Last unit with traffic repeat. Command that was 54. Engine 62 told us they need bottles topped off. We may need an air rig here. Copy. Ill get you rolling, one rolling. I think the trucks got some extra bottles at this time.
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Appendix B - Glossary and TERMS

2201 2203 2208 2210 2216 2240 2241 2242 2280 2290 2292 2293 2408 2417 4680 4681 4682 9901 9903 Chief of the Department radio identifier. Deputy Chief-Operations radio identifier. Assistant Chief-Fire Marshall radio identifier. Assistant Chief-Operations radio identifier. Captain-Public Information Officer radio identifirer. Assistant Chief-Training/Department Safety Officer radio identifirer. Captain-Training Division radio identifirer. Captain-Training Divison radion identifier. Battalion Chief-Reserve coordinator radio identifier. Assitant Chief-Special Operations. Firefighter-Special Operations Haz-Mat Divsion Captain-Special Operations-Haz-Mat Division Assistant Chief Metro Fire Captain-Sac Metro Safety Officer. Fire Chapalin radio identifier. Fire Chaplain radio identifier. Fire Chaplain radio identifier. Communincatons Center Manager. Communications Center Operatoins Manager.
Acting Captain:
A firefighter who has taken the Captains promotional exam, but who has not been promoted to Captain and is filling in for a full time Captain on a short or long term basis. The Acting Captain has the same duties and
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responsibilities as a promoted Captain. Or the senior Firefighter who has not taken the exam but is filling in for the regular Captain for a short term (less than 4 hours) while the Captain is temporally out of the station or unavailable. Often referred to as Sitting in the Seat. Agency Administrator:
Managing officer of an agency, division thereof, or jurisdiction having statutory responsibility for incident mitigation and management. Example: Fire Chief. An acronym meaning Available in Quarters. When a fire company is in quarters and available for dispatch. See SCBA. A pre-designated set of fire companies and command staff that is assigned to certain or particular situations or calls for service. As an incident escalates additional alarms can be requested. Geographical designation that refers to the sides of a building, clockwise from the front. The Alpha side is the front or address side of a structure. An acronym meaning Available on Radio. When a fire company is out of the station in their 1st due district and available for calls via the radio. A member of an Engine Company, whos primarily responsibility is to assist the Nozzle FF with the stretch of the attack line, help with the movement of the hose, and assist with forcible entry. A secondary hose line that remains outside and is used to protect crews operating on the inside, and meets the intent of two in/two out.
A.I.Q.:
Air-Pak: Alarm:
Alpha side:
A.O.R:
Back-Up FF:
Back-Up Line:
BARB:
An acronym standing for Box Area Response Builder. BARB is a computer program that is part of the CAD system that determines the district boundaries for engine companies based on such factors as: driving distance, surface street speed limits, access problems and stations locations. Although a station may be physically closer to an area, it may be slower getting to that location because of traffic patterns, speed limits, etc, so BARB will pick the next closest engine because it can get there faster. A geographical response area. A command level supervisor who oversees a geographical area in which there are engine and truck companies assigned to it.
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Battalion: Battalion Chief:
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Bravo Side:
Geographical designation that refers to the sides of a building, clockwise from the front. The Bravo side is the left side (clockwise rotation) of the house if one is standing and facing the Alpha Side of the house. A situation where personnel or equipment is caught in an advancing flame front. An acronym for Computer Aided Dispatch: A combination of hardware and software that provides data entry, makes resource recommendations, notifies and tracks those resources before, during, and after alarms, preserving records of those alarms and status changes for later analysis An acronym meaning Conditions, Actions, Needs report. An update or progress report requested from the IC to companies operating on the scene of an emergency to the Incident Commander identifying the current conditions, what actions they are taking and if there is a need for further help. See Company Officer Any behavior, omission, or deficiency that if corrected, eliminated, or avoided probably would have prevented the injuries. Geographical designation that refers to the sides of a building, clockwise from the front. The Charlie side is the back side or the side opposite of the Alpha side of a structure. Position within the Incident Command System that is responsible for the overall management of the incident. Synonymous with the term Incident Commander.
Burnover:
CAD:
C.A.N.
Captain: Causal Factors:
Charlie Side:
Command:
Company Officer: The immediate supervisor of an engine or truck company members and is usually a Captain or Acting Captain. The Officer is responsible for selecting the initial strategies and tactics at a working fire. Contributing Factors:
Any behavior, omission, or deficiency that sets the stage for an accident, or increases the severity of injuries. Geographical designation that refers to the sides of a building, clockwise from the front. The Delta side is the right side of a structure, or to the right of the Alpha Side.
Delta Side:
Engine Company: A fire suppression apparatus with a staffing of four (4) personnel and carries 500 gallons of water, fire hose and a fire pump whos primary mission is to, extend hose to the seat of the fire for extinguishment. The
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Engine Company is staffed with four (4) personnel and includes: Company Officer, Engineer, Nozzle Firefighter and Back-Up Firefighter Engineer: A member of an Engine or Truck Company whose primary responsibility is to safely drive the apparatus and operate the apparatus at the scene of an emergency. Their duties including operating the fire pump or operating the aerial ladder. A situation where personnel are unexpectedly caught in a fire behavior related, life-threatening position where planned escape routes or safety zones are absent, inadequate, or compromised. These situations may or may not result in injury. They include "near misses." A preplanned and understood route firefighters take to move to a safety zone or other low-risk area.
Entrapment:
Escape Route:
Extreme Fire Behavior:
"Extreme" implies a level of fire behavior characteristics that ordinarily precludes methods of direct control action. One or more of the following is usually involved: high rate of spread, prolific crowning and/or spotting, presence of fire whirls, strong convection column. Predictability is difficult because such fires often exercise some degree of influence on their environment and behave erratically, sometimes dangerously. Refers to a structure in the vicinity of the fire building. Exposures are commonly identified with a letter and a number to describe the location of the structure relative to the fire building (e.g., Bravo-3 Exposure, Charlie-1 Exposure). Rapid oxidation, usually with the evolution of heat and light; heat fuel, oxygen and interaction of the three. The manner in which a fire reacts to the influences of the environment. The simultaneous ignition of all of the combustible contents in a space with an average temperature range of 900F to 1,200F. Any combustible material, especially petroleum-based products. An acronym for Gallons Per Minute: A unit of measurement that describes the rate of fluid flow. Typically used to refer to the amount of water flowed through a hoseline or the capacity of a pump. A forcible entry tool used for prying open doors and windows. The Halligan bar has three operating features: Fork, Adz, and pike or point.
Exposure:
Fire:
Fire Behavior: Flash Over:
Fuel: GPM:
Halligan Bar:
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HUD
An acronym for Heads Up Display. A HUD is a series of LED lights located in the SCBA mask indicating the air remaining in the SCBA bottle. 2 Green lights=Full; 1 Green light=3/4; Yellow light= ; Red light = . An acronym for Immediately Dangerous to Life or Health: An atmosphere that poses an immediate threat to life, would cause irreversible adverse health effects, or would impair an individuals ability to escape from a dangerous atmosphere. This ICS position is responsible for overall management of the incident and reports to the Agency Administrator for the agency having incident jurisdiction. A planned response to a wildfire given the fire's potential fire behavior. The objective of initial attack is to stop the spread of the fire and put it out at least cost. An aggressive suppression action consistent with firefighter and public safety and values to be protected. A set of tools used for forcible entry, usually consisting on a Halligan Bar and Flat head axe. The range or sphere of authority. Public agencies have jurisdiction at an incident related to their legal responsibilities and authority for incident mitigation. Jurisdictional authority at an incident can be political/geographical (e.g., city, county, state or federal boundary lines), or functional (e.g., police department, health department, etc.). An acronym for Large Diameter Hose. LDH is 4 or larger in diameter and is used to transport water from a supply (hydrant) to an engine. A radio transmission to report firefighters who are trapped, lost, disoriented, or in a life threatening situation and are in need of immediate assistance. An acronym for Mobile Data Computer. A MDC is the latest onboard computer system used to transmit the status (AOR, enroute, AIQ, etc) of the company, or to send messages to another company or dispatch. Additionally, MDCs have mapping programs available for use. An acronym for Mobile Data Terminal. A MDT is an onboard computer system used to transmit the status (AOR, enroute, AIQ, etc) of the company, or to send messages to another company or dispatch. MDTs are an older technologically, and have limited capabilities. An EMS transport unit that provides Advance Life Support (ALS) care to patients. Or a Firefighter/Paramedic assigned to a Medic unit.
IDLH:
Incident Commander:
Initial attack:
Irons:
Jurisdiction:
LDH:
MAY-DAY:
M.D.C.:
M.D.T.:
Medic:
Mode of
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Operation:
A strategic plan for the initiation of operations based on size up of incident conditions. The three modes of operation are: Investigation, Fire Attack or Command. Trade name for a fire resistant synthetic material used in the manufacturing of flight suits and pants and shirts used by firefighters. Aramid is the generic name. An acronym meaning the National Fire Protection Association. The NFPA is a national organization comprised of firefighters, private sector manufactures representatives, safety organizations, and other interested parties, that establishes guidelines the equipment used, the manufacturing specifications or equipment and testing procedures for evaluating the equipment used by the fire service. The NFPA publishes bulletins containing the information and requirement for the various equipment. For example, NFPA 1951 is the bulletin that contains the specifications for production, use and testing of fire service ground ladders. A member of an Engine Company whos primarily responsibility is to extend the initial attack and operate the nozzle at the direction of the Officer. An acronym meaning Personnel Accountability Report. A PAR is initiated by the IC when a May-Day or other emergency exists on the fire ground to account for all company members, their location, and their status. During PAR checks, company officers report the total number and accountability of members assigned to their company, the area they are operating in, and indicate the number of people operating outside of the hazard zone and the status of their SCBA air supply.
Nomex :
N.F.P.A.:
Nozzle FF:
P.A.R.:
PASS:
Acronym for a Personal Alert Safety System. A device that senses movement and is designed to automatically activate an alarm signal indicating the wearer is in need of assistance. The device can also be manually activated to trigger the alarm signal. PASS devices may be integrated into the SCBA or a standalone device.
Personnel Accountability System:
A system that readily identifies both the location and function of members operating on an incident scene. A set of tools carried in the turnout pocket of firefighters. These tools may include: Crescent Wrench; Screw Driver set; Allen wrenches; Vice-Grips, Etc.
Pocket Tools:
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P.P.E.:
An acronym meaning Personal Protective Equipment: That equipment and clothing required mitigating the risk of injury from or exposure to hazardous conditions encountered during the performance of duty. PPE includes but is not limited to: fire resistant clothing, helmets, goggles, gloves, respirators, foot wear. A Primary Search is a rapid search of the structure for trapped or missing civilians or occupants.
Primary:
Riding Positions: A pre-designated assignment and responsibilities on a fire company based on equipment type and seat assignments. On an Engine company the riding positions are: Officer, Engineer, Nozzle Firefighter, and BackUp Firefighter. No a Truck Company the riding positions are: Officer, Operator, Tools Firefighter and Saw Firefighter. Roll Call: A procedure that occurs on the radio tactical channel and is conducted by the Battalion Chief to ensure that all companies are enroute. During this procedure, all Company Officers are to voice if they are responding with reduced staffing levels. Refers to a mode by which personnel can monitor multiple radio channels simultaneously. An acronym meaning Self-Contained Breathing Apparatus Portable air (not oxygen) tanks with regulators which allow firefighters to breathe while in toxic smoke conditions. Usually rated for 30 minutes of service. Used primarily on fires involving structures or hazardous materials. An acronym for the Sacramento Regional Fire Emergency Communications Center also referred to as: Comm Center of Fire Dispatch.
Scan: S.C.B.A.:
S.R.F.E.C.C.
Situational Awareness: SOG:
The knowledge of being aware of a situation as it actually exists. An acronym for Standard Operating Guidelines. Standard Operating Guidelines outline general practices used on emergency incidents and special situations and outline of basic roles for Engine Company members, Truck Company members, Medics, Battalion Chiefs, and Staff Officers during fire operations. All the work of extinguishing or confining a fire beginning with its discovery. A pre-connected fire hose line with a nozzle attached, usually located in the cross-lay bed. A typical SFD engine company has two tanklines: 1150 1 and 1-200 1 . A majority of the time, the tankline is the preferred choice by the Officer for initial fire attack.
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Suppression: Tank Line:
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Technical Specialists:
Personnel with special skills that can be used anywhere within the ICS organization. These personnel may perform the same duties during an incident that they perform in their everyday job. An acronym for Thermal Imaging Camera. A TIC is an electronic hand held device that uses the infrared spectrum of light to detect heat or temperature changes in an area, and displays the readings on and LCD screen. An additional tactical channel that is used by 2nd alarm companies to conduct roll call. This channel will eventually become the staging channel. This channel keeps all unnecessary radio traffic off the primary tactical channel. A fire suppression apparatus with a crew of four (4), and an aerial ladder. The primary mission of the truck company is to support the engine company during suppression operations and to search and rescue trapped or missing civilians. Truck Companies carry all of the tools and equipment for their mission including: Chain Saws, Ventilation fans, forcible entry tools, and specialized rescue equipment. The Truck Company staffing includes: Officer, Engineer, Saw Firefighter, and Tools Firefighter.
T.I.C.:
Travel Channel:
Truck Company:
Type V Construction:
As defined by the National Fire Protection Association, a form of construction where structural members consist entirely of wood. An agreement between management and the local bargaining unit allowing department members, who are union officers, out of the fire station to attend to union related business or issues. The act of walking around an emergency incident to conduct a scene size up.
Union Time:
Walk Around:
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Appendix C - Standard Operating Guidelines
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Accident Review Factual Report Huntsman Incident

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Accident Review Factual Report Huntsman Incident

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SACRAMENTO FIRE DEPARTMENT SACRAMENTO METROPOLITAN FIRE DISTRICT