Report finds Texas firefighter’s death was ‘preventable’
The report said firefighters hadn’t followed nationally recognized best practices or even the department’s own policies in the death of Scott Deem
By John Tedesco
San Antonio Express-News
SAN ANTONIO — After firefighter Scott Deem died last year in a horrific blaze at the Spartan Gym, Fire Chief Charles Hood spoke at an emotional news conference and staunchly defended the department.
Hood said firefighters followed nationally recognized safety standards May 18 when they fought a rapidly spreading fire at the Ingram Square Shopping Center on the Northwest Side.
Hood also insisted he would have made the same decision to go “offensive” and send Deem and another rescuer into the smoke-filled gym to search for any trapped civilians.
“There is no blame,” Hood said a day after Deem’s death.
But the findings of a state investigation published last week flatly disagreed with some of Hood’s assertions.
The report issued by the State Fire Marshal’s Office concluded that San Antonio firefighters hadn’t followed nationally recognized best practices or even the department’s own policies.
The firefighters had attacked the growing inferno as if they were in a small residential structure — not a large commercial building — and the search-and-rescue team entered the gym without safety lines or hoses to find their way out of the gym’s pitch-black interior, the investigation found.
And contrary to Hood’s belief that a search-and-rescue effort was warranted when firefighters arrived at the gym at 9:17 p.m. and saw cars in the parking lot, the state’s investigation concluded that conditions were far too dangerous to try to locate any trapped victims.
The gym doors were locked and the lights were out, suggesting no civilians were inside, the report noted. And the smoke was so thick inside the gym by the time firefighters arrived, the chances of anyone surviving were slim.
“The decision to initiate a search is a complex one,” the report noted. “The incident commander must ultimately decide if the conditions are in favor of a victim’s survivability. This is an example of a ‘no go’ situation.”
Hood was out of town Friday and didn’t respond to emailed questions from the San Antonio Express-News. In an interview Hood gave Thursday before the report was released, the chief stood by the decision to search the Spartan Gym for victims, given the information firefighters had.
But Hood also stressed the department needs to learn from the report’s findings.
“We've had ample opportunity to work with the Fire Marshal's office on this,” Hood said. “There may be some verbiage that maybe we don't particularly like the way it sounds. But we wholeheartedly agree with the recommendations.”
Asked if he believed the department had mishandled its response to the fire or made any mistakes, he replied: “I don't necessarily like the word ‘mishandled,’ but yeah, there were mistakes made.
“Any time you get a fireman injured, there was a mistake,” Hood said. “Any time you get a firefighter killed, there were mistakes. And so we have to be able to look at that and say, yeah, this was a mistake or this is something that we need to correct.”
No civilians were inside the Spartan Gym that night. Months later, authorities arrested the gym’s owner, Emond Javor Johnson, 39, and accused him of deliberately setting the fire to get out of a newly signed lease.
Deem, 31, had two children. His wife, Jennifer, gave birth to their third child after her husband died. An autopsy concluded the cause of death was from “conflagration injuries,” according to the state’s report. The manner of death was homicide.
After the Fire Marshal’s report was made public Friday, City Council members said they strongly support Hood and have full confidence in his leadership.
“It opens a wound for the city and for the department and families from a very terrible night in May,” Mayor Ron Nirenberg said. “But in looking at the report and hearing from the Fire Department leadership, the institution didn’t fail. Of course, in any incident like that, there are things that we could do better.”
“I'm not upset with Hood,” City Councilman Rey Saldaña said. “It would be a mistake to attribute blame to anyone but the person who set fire to the building. A fire under those conditions doesn’t give license to anyone but fire professionals to have an opinion. The report is an important document to learn from, not permission to point fingers.”
Hood's boss, City Manager Sheryl Sculley, said Hood is an excellent fire chief who brought the Fire Department “light years” ahead of where it was before she appointed him in 2007.
“Only the firefighters on the scene of the Ingram fire know the complexity and difficulty of the decisions that had to be made in split seconds that night,” she said.
Firefighters outside San Antonio wrote and reviewed the state’s report.
The Fire Marshal’s Office investigates all cases of Texas firefighters who die in the line of duty. In the case of Deem’s death, the report’s authors and the experts who reviewed their findings included two members of the Houston Fire Department — District Chief Kelly Baudat and Capt. Robert Logan — and former members of the Phoenix Fire Department where Hood used to work: Alan Brunacini and Don Abbott.
Representatives from the Texas Commission on Fire Protection, the Texas Association of Firefighters, the Texas A&M Forest Service, the State Firefighters’ and Fire Marshals’ Association, Texas A&M Engineering and Extension Service, the Texas Fire Marshals’ Association and the Texas Chapter of the International Association of Arson Investigators also reviewed the report’s findings.
Their primary conclusion: Deem’s death and the injuries suffered by his fellow firefighters could have been prevented.
“The actions leading to the findings in this report collectively led to the tragedy at this incident,” the report concluded.
“The goal of this report is to challenge the San Antonio Fire Department to meet national fire service best practices identified in the recommendations to minimize risk exposure to the men and women of the SAFD,” the report added. “That path will honor the memory of (firefighter) Deem and take a good fire department to an even higher level of performance.”
The Fire Marshal’s report faulted the department for using tactics that might have been used on a residential fire, such as using small-diameter hoses to attack the blaze.
Firefighters used “improper or ineffective” ventilation techniques to air out the building and violated the department’s dangerous structure policy by venturing inside without a hose or safety rope — tools that help lost firefighters find their way to safety.
“The search crew saw what they believed to be fire in the attic and took actions outside of their assignment and changed from search to attack and began pulling ceiling without a hose-line readily available and unknown to Command,” the report stated. “These actions are commonly referred to as ‘freelancing.’”
When the ceiling tiles were torn down, conditions suddenly changed — there was no visibility and the heat “rapidly increased,” the report said.
A distressed firefighter called “Mayday” over the radio, but the report said several units continued to operate on the same channel, taking up air time that could have been devoted to finding the trapped firefighter.
“The accountability system used was ineffective.” the report stated. It was unclear what system the Fire Department used to keep track of its crews, creating confusion.
“While San Antonio Fire Department has many good policies and procedures in place, pockets of members remain who are resistant to change,” the report said. “The SAFD would benefit from a culture of continuous improvement.”
The report recommended a “cultural change” at the department.
“Too many lives are lost in situations where the risks were not justified,” the report said. “The fire service understands risks, yet the same accidents, injuries and fatalities keep happening. Incidents must be managed with a constant awareness and balance between risks and desired outcomes. High risk is only acceptable when there is a real possibility of saving a life.”
Hood said reading the report was like ripping open a scab.
“There’s a tremendous amount of sorrow and guilt” in the Fire Department, he said. The department needs to forgive itself for losing one of its own and take the report’s conclusions to heart.
Hood said he’s already taking action. He’s assigned a chief to be in charge of following the report’s recommendations, and a department-owned warehouse on the East Side will be converted into a firefighter safety and survivability center named in honor of Deem.
“We will build props in there that will challenge our firefighters to escape from entrapments, entanglements, zero visibility conditions,” Hood said. “So we are dedicating resources, we are dedicating personnel. We're very serious with this.”
Hood said the Fire Department is an excellent department. It’s important for people to remember that — and to remember who’s ultimately responsible for Deem’s death.
“The villains are not in the Fire Department,” Hood said. “The demons are not a part of the Fire Department. The villain and the demon is the person that caused fire.”
Copyright 2018 San Antonio Express-News
- Fatal Fires