NIOSH releases report on Charleston Sofa Super Store fire
By Jamie Thompson
The 107-page report released Thursday outlined a host of failures in the way the department tackled the fire in June 2007. Investigators outlined a series of recommendations departments should implement to try to prevent future such tragedies.
The report identified several examples during the fire in which recognized guidelines for an Incident Management System were not followed. Specific examples include:
- Multiple chief officers serving in command roles in an uncoordinated manner
- The lack of an established accountability system to track firefighters on scene
- A RIC not being established
- An ISO not being assigned
- Fire and police department not working effectively together to control traffic and protect hose lines delivering water to the scene
NIOSH investigators said formal incident command was never formally announced or transferred as ranking officers arrived on scene. Fire attack operations at the loading dock (D-side) and the main showroom (A-side) of the store were directed by different chief officers and were not coordinated, according to the report.
Stationary command post
It went on to highlight the importance of ensuring that the incident commander establishes a stationary command post in order to maintain the role of director of fireground operations and not to become involved in fire-fighting efforts.
"The involvement of the initial IC in firefighting also hampers the collection and communication of essential information as command is transferred to later arriving officers," the report said.
"In this incident, a stationary command post was never established and separate and uncoordinated activities were taking place in multiple locations. This contributed to a failure to size-up the overall incident scene, to properly evaluate risk versus gain, and to maintain accountability on the fireground."
Investigators also found departmental SOPs (standard operating procedures) mainly contained administrative guidelines and not detailed fireground operation procedures that would enhance firefighter safety and health, such as a risk management plan, a fire department occupational safety and health policy, and other components of a fire department occupational safety and health program.
The report outlined the importance of understanding the difference between a policy and a procedure.
"A department policy is a guide to decision-making that originates with or is approved by top management in a fire department," the report said. "Policies define the boundaries within which the administration expects department personnel to act in specified situations. A procedure is a written communication closely related to a policy. A procedure describes in writing the steps to be followed in carrying out organizational policies."
I don't believe there are any excuses for departments not applying the lessons that have been learned from this.
— Jay Lowry,
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The report also analyzed the offensive attack ordered during the fire, recommending that the IC should continuously evaluate the risk versus gain when determining whether the fire suppression operation will be offensive or defensive.
"In this incident, the store manager was present to inform the chief officers on the status of employees and patrons who had been inside the business," the report said.
"The fire department utilized offensive strategies focused on fire suppression. Truck company operations (search and rescue, ventilation, etc.) were not utilized until the fire department received word that an employee was trapped at the rear of the structure.
"As conditions inside deteriorated, offensive strategies were continued even as problems with establishing water supply mounted and the civilian was rescued."
FireRescue1 columnist Jay Lowry, of Firefighterhourly.com and a former Charleston firefighter and fire marshal, said he hoped the recommendations would be taken on board by everyone.
"I hope that every fire department will take this report and lay it side by side with their operation manuals and take a look at what they are doing or not doing to promote safety on the fireground," he said.
"I don't believe there are any excuses for departments not applying the lessons that have been learned from this."
Lowry said the extensive list of mistakes made during the incident and the string of recommendations that follow in the report is "unbelievable" for a modern fire department.
"It's what some of us expected, but it's still an emotional thing to see it especially when you knew the men who died," he said.