A case of complacency: Inside the USS Bonhomme Richard fire
The Navy warship fire highlights key themes for all fire agencies – inspections, training, command and communications
The Navy’s recent report on the 2020 fire aboard the USS Bonhomme Richard in the San Diego shipyards addresses several critical factors that led to the fire’s spread and, ultimately, the loss of a ship that once played a pivotal role in our defense initiatives in the Pacific.
At the time of the fire, the USS Bonhomme Richard was undergoing a $250 million upgrade and was therefore not being staffed at its full complement of personnel. Other factors contributing to the failed fire response: Some of the Damage Control Stations lacked firefighting equipment; many of the younger sailors on watch or on Damage Control were not trained on or were unsure how to activate the ship’s firefighting foam system; and there was a delay in reporting the fire – at least 10 minutes – due, in part, to several of the nearby fire alarm stations being rendered inoperable.
In the end, more than 30 officers and enlisted personnel were cited for failings that contributed to the severity of this fire.
Navy report conclusions
The following is an excerpt from the report:
Although the fire was started by an act of arson, the ship was lost due to an inability to extinguish the fire.
Throughout the maintenance period, the material condition of the ship was significantly degraded, to include heat detection capability, communications equipment, shipboard firefighting systems, miscellaneous gear clutter, and combustible material accumulation. To illustrate the extent of degradation, on the morning of the fire, 87% of the ship’s fire stations remained in inactive equipment maintenance status.
The training and readiness of Ship’s Force was marked by a pattern of failed drills, minimal crew participation, an absence of basic knowledge on firefighting in an industrial environment, and unfamiliarity on how to integrate supporting civilian firefighters. To illustrate this point, the crew had failed to meet the time standard for applying firefighting agent on the seat of the fire on 14 consecutive occasions leading up to 12 July 2020.
… Naval Base San Diego (NBSD) failed to ensure its civilian firefighters were familiar with Navy vessels on the installation, verify they were trained to respond to a shipboard fire, or effectively practice how to support Ship’s Force and simultaneously integrate responding mutual aid assets.
After reading a synopsis of the Navy’s report, one word comes to mind: complacency.
4 factors to minimize complacency
There are nearly 29,000 individual fire departments across the United States. How many of us are complacent in our work, and perhaps more importantly, how can we overcome such complacency? I believe there are four critical factors: inspections, training, command including leadership, and communications.
1. Fire service inspections
Some chiefs consider inspections to be one of the “lesser” duties or services provided by a fire department, perhaps even a necessary nuisance. No doubt, inspections are sometimes unpopular with businesses and the public. But while we seemingly embrace the community risk reduction (CRR) practices, we seldom fully realize the vital role that inspections play in our CRR efforts.
Fire inspectors protect both the public and our own firefighters by spotting new hazards and keeping occupancies within the guidelines of the fire and building code. While each state is free to promulgate its own set of codes, these are usually grounded nationally by those consensus groups such as the International Code Commission (ICC), the NFPA, and the National Electrical Code (NEC).
By pointing out new hazards within a community, fire inspections provide the local fire department with an advanced warning of a changing occupancy that, while within the realm of these codes, could prove to be disastrous unless preplanned and subsequently trained on for an adequate emergency response.
Some fire departments or fire chiefs feel they are too small or too busy to worry inspections. Yet some of our most rural areas may have some of the most dangerous hazards (e.g., grain mill silos, propane supply or fertilizer storage).
Large cities may also have unexpected issues. As state fire marshal, I once had a call in the middle of the night from a battalion chief in a major metropolitan area. After responding to an automatic fire alarm at one of our state university’s high-rise dormitories – a call that turned out to be overcooked popcorn in a microwave – the chief, who had several rookies on his responding companies, decided to show the new firefighters the inner workings of the high-rise sprinkler and standpipe systems.
Much to his surprise, the chief discovered that the building’s fire pump, which fed the sprinkler system for 12 occupied stories, was gone, rendering the system inoperable. There had been no notification to either the fire department or the fire marshal’s office. His question was simple: What can we do in the middle of the night for a high-rise dormitory without fire protection but with hundreds of students – students who are now awake, grumpy and impatiently waiting outside the structure because of the alarm?
First, I directed the dorm’s resident assistants to become part of a 24-hour fire watch – one RA for every two floors making rounds at least every 15 minutes. Later that morning, I called the university’s vice president, who agreed to continue the plan, now augmented by some of his facility employees. He also had a pointed talk with the maintenance crew foreman who had removed the pump without proper notifications or replacement. Finally, a new pump was found, installed and tested within days.
The battalion chief who had inadvertently found this major hazard could have chosen to ignore it until morning, but instead took immediate actions that mitigated the problem, averting what could have easily become a major campus tragedy had there been a fire emergency.
2. Training time
Training includes a cognitive component and a muscle memory component. I’m sure there are departments that always pull the same set of fire hoses, use the same tactics with the same point of entry, and expect the same result on every fire. This may be a department that feels it is too busy with real runs to bother training. But what happens when that same hoseline doesn’t work for the real emergency at hand, or worse, it plays a role in a firefighter’s injury or death?
In many cases, training starts with an inspection program. Here’s the flow: The inspection leads to a report, the report to a preplan, the preplan to a site visit by the fire companies, the visit into review of potential strategy and tactics, and the tactics into training scenarios.
3. Command leadership
While the command function of any incident starts with the first-arriving officer, it is a continuous process that includes the changing of command officers. Following the Incident Command System (ICS) model, there is only one command officer at a time, and this person is in a stationary position, away from the direct action, so they can concentrate on the overall complexities of the incident.
This has not always been true. When I was a very young firefighter, some emergency scenes had multiple chiefs, each of whom thought they were in command. Many would not take a stationary position, but instead would move around the perimeter barking orders at each group of firefighters. What resulted was chaos, and at times resulted in a building smoldering on the ground.
I distinctly remember one such incident at a large defensive fire. I was sitting on a 2½-inch “Keenan Loop” flowing water on the fire when a chief ordered me to direct the water into a window ahead of the fire where there was no smoke or fire showing. His rationale was to cut off the fire and not allow it to spread into another part of the building. He then walked away.
A few minutes later, another chief came by and ask why I wasn’t hitting the fire? When I explained the rationale of the first chief, he told me not to be ridiculous, and to move the fire stream back to the window with heavy smoke and fire to hit the seat of the fire where I had the best chance to knock it down. He then moved on. Now imagine the colorful conversation I had when the first chief, doing a second lap around the building, saw that I was again directly hitting the room on fire.
Clearly, we need a single incident commander calling the shot – one IC with one strategy, and subsequent officers supporting that strategy with appropriate actions and tactics.
As well as the single command system works on the incident scene, it is equally important that command includes a strong and supportive leadership component. That leadership begins before the fire, and part of it is deciding how your automatic- and mutual-aid fire departments will integrate into your system, recognizing that subsequent chiefs and departments will follow the strategy in place.
One of the most surprising discussions raised by the Navy’s report centered on communications and an apparent lack of a compatible radio channels between the San Diego Fire Department (SDFD) and the Federal Fire Department (FedFire) from the shipyard.
With all that FEMA and the USFA have done since 9/11 to promote ICS, compatible radio systems and P25-compliant radios, this lack of direct communications hampered the initial firefighting efforts at the warship blaze. The Navy’s report indicated that at one point during fire operations, members of the SDFD and FedFire assigned a firefighter with a radio from the other department to crews to help coordinate the fire operations.
Despite several attempts by onboard Navy firefighters and FedFire to locate the exact location of the fire and start fire operations, the SDFD reportedly had first water on the fire. During these initial interior operations, there were three groups of firefighters attempting to reach the seat of the fire, the onboard seamen trained in firefighting, FedFire and the SDFD backed up by other regional fire department assets. In addition to the lack of compatible radios, there was a lack of schematics detailing each deck that when combined became a labyrinth of confusing corridors.
Over time, the smoke and heat conditions deteriorated, and both the SDFD and FedFire decided to evacuate their separate firefighting positions. Within 90 seconds of that withdraw, an explosion occurred that rocked the pier and forced the Incident Command Center to be moved to an adjacent pier.
FedFire attempted to reenter the ship but soon decided that all operations should be switched to pier-side master streams, and ultimately to additional master streams from tugs and Harbor Police boats.
Communications and subsequently the ability to have an integrated single strategy is a critical factor to achieve the best outcome in any emergency. Taking advantage of the expertise of supporting officers using their best judgment on the options available, especially on complex incidents such as this one, should be a help and not a hindrance to the incident commander.
So, what are the takeaways for the fire service from the Navy’s report? First, as a chief, you can’t bury your head in the sand and hope that whatever might be the “unthinkable” incident in your jurisdiction will never happen. The odds will eventually turn against you. Second, being the chief is not just being the caretaker of your department. We all need to constantly improve our department’s preparation and ability to respond in part through inspections, training, command /leadership, and communications within our department and with all of our fire service partners. None of us can afford to be complacent in our duties.