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Summary

On November 1st, 2008, an apprentice instructor incurred burn injuries as a North Carolina Community College conducted a live fire training exercise in an abandoned two-story motel structure. There were two North Carolina Fire & Rescue Commission (NCFRC) Qualified Live Fire Instructor employed by the Community College present during the incident, with one of these individuals designated as the instructor-in-charge. There were to be only a couple of interior attacks performed before the structure was to be burned down. The injury occurred during the first evolution of the day, while the apprentice instructor was waiting for the attack line to enter the structure to perform fire attack.

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Introduction On November 1st, 2008, an apprentice instructor received burn injuries while participating in training under live fire conditions while functioning as an instructor. The injured instructor sustained significant 1st and 2nd degree burns to his left arm and shoulder areas. The Office of State Fire Marshal was requested to investigate the incident by Deputy Director Steve Sloan in accordance with the North Carolina Fire and Rescue Commission (NCFRC). Interviews were conducted with both Live Fire Qualified Instructors as well as the injured apprentice instructor. Written statements were obtained from the qualified instructors, the injured apprentice instructor, the line coach in charge of the attack line, as well as two students operating on the attack line at the time the injury occurred.

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Injured Firefighter Relevant Training History The burned apprentice instructor has been in the fire service for approximately 13 years, six of those as an instructor. He is qualified in FF I & II, RT, and SCBA specialty. The instructor has participated in over ten live fire burns as an apprentice. Instructor-in-Charge The Instructor-in-Charge has 23 years in the fire service, 10 of those as a Live Fire Qualified Instructor. 2nd Qualified Live Fire Instructor The qualified instructor has 27 years in the fire service, 10 of those as a Live Fire Qualified Instructor. Line Coach The line coach has approximately 15 years of fire service experience. He is not a qualified instructor. Injured Firefighter Turn-out Gear The turnout gear of the injured firefighter consists of Coat and Pants built to the NFPA 1971 standard (2000). The gear contained a Comfort Zone Moisture Barrier with a Q9 Air Bed Mat Thermal Barrier. At the time of the injury, the burned firefighter was wearing a short-sleeve t-shirt beneath his turn-out gear. The major area of concern in this incident is the coat the injured firefighter was wearing at the time of the incident, specifically the area around the left arm and shoulder. These areas show significant and catastrophic damage due to direct thermal insult. The worst affected area being located directly above the left shoulder area. In this area, the outer layer of the coat has completely burned away, exposing the inner liner. Traveling distally from the sight of the most intense damage, the gear shows a great degree of char and onioning as thermal impact and direct flame impingement actually broke down the protective elements of the outer liner. It is evident that the degradation and delaminating of the turnout coat acted to actually release heat from the inner liner and prevent the injuries from being significantly worse. Investigation On November 1st, 2008, an apprentice instructor incurred burn injuries as a North Carolina Community College conducted a live fire training exercise in an abandoned two-story motel structure. There were two North Carolina Fire & Rescue Commission (NCFRC) Qualified Live Fire Instructors employed by the Community College present during the incident, with one of these individuals designated as the instructor-in-charge. There were to be only a couple of interior attacks performed before the structure was to be burned down. The injury occurred during the first evolution of the day, while the apprentice instructor was waiting for the attack line to enter the structure to perform fire attack. Upon interview, the instructor-in-charge provided a comprehensive pre-burn plan including numerous drawings of the fireground layout. The instructor-in-charge stated that he utilizes our office’s audit form every time that he conducts a training burn. Items that were missing from the pre-burn plan provided during the interview

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included a floor/room layout and weather report. During the interview, the instructor-in-charge also acknowledged that he failed to obtain permission letters from personnel participating from outside departments prior to beginning the exercise. The body of the pre-burn briefing occurred at the fire station at which time the instructors asked the group to confirm that everyone involved met the NFPA 1403 requirements. After the briefing two individuals approached the two qualified instructors and stated that they did not meet the 1403 requirements. The instructors told the two individuals that there would be plenty to do outside the structure, and that due to the number of firefighters present and the limited number of anticipated burns, they had plenty of personnel to complete all of their interior attacks. The structure had been razed by vagrants for copper and other commodities, resulting in the integrity of several walls being compromised. No efforts were made to mitigate these deficiencies prior to the exercise due to the anticipated brevity of the interior training. This mindset may have also contributed to the failure of all personnel to conduct a walk-through of the structure prior to beginning the training. There is a discrepancy regarding whether or not the staircase to the second floor of the structure was intact prior to the exercise, however this inconsistency has no bearing on the injury itself. The initial training fire was set in the rear of the ground floor apartment closest to the ‘D’ side of the structure. As is common in motel construction, the individual compartments consisted of a single large open area. The only separated areas being the bathroom and small closet in each unit. Also typical of this layout, all ventilation for the fire was provided by the open door and large window opening at the front of the room. The fire was set against the back wall of the room, between the bathroom and closet areas. There is a discrepancy regarding the full load used in this fire set. The instructors concur that a wooden chair and wood paneling from the wall were used in the fire set. It is also agreed that no straw was used for setting the fire. The instructor-in-charge states that two dressers were placed in the fire set, while the apprentice instructor does not recall any dressers being present. However, the apprentice instructor states that there was some scrap wood placed on the fire set, to which the instructor-in-charge refutes the use of such materials. Both instructors concur that a small, appropriate amount of combustible ‘B’ (diesel) fuel was applied to the fire set prior to ignition. While materials such as couches and mattresses were not present in the fire room, numerous examples of these items occur throughout the rest of the structure. While the use of a debris room is an acceptable practice, the multiple existing wall breaches void the intent of utilizing an off-limits debris room where such materials were located. Again this apparently did not impact directly on the injury.

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Shown above: Remnants of what appears to be a sleeper sofa found in the debris pile several weeks after the incident. The injury occurred during the first burn of the day. Both the instructor-in-charge and the apprentice instructor were in the fire room during ignition. After the fire was lit, the instructor-in-charge left the room to gather the attack crew while the apprentice instructor stayed in the room to monitor the fire conditions. There appears to have been some confusion and consequential delay in the collection of the attack crew outside the structure. It is at this point that numerous discrepancies present themselves in the various accounts of what actually occurred. It is agreed by all parties involved that the two individuals present that did not meet their 1403 requirements (hereinafter referred to as students) were positioned on a hoseline with the aforementioned line coach. One of the biggest points of contention centers around which hoseline the line coach and two students were actually assigned. It seems that the instructors all concur that this group was assigned to the backup line, yet this is the line that ended up being the attack line during the incident, despite no recognized event that would have delayed or hindered the designated attack line’s advance. However the issue of whether or not the students were on the attack or the backup line is a mute point, as both lines require interior firefighters to staff them. It is also noted in the line coach’s written statement that he recognized that the two student’s helmets indicated that they were non-interior firefighters. Both students’ helmets displayed green leather fronts with the word “NON-INTERIOR” depicted on them. Despite this, the line coach told the two students to play “rock/paper/scissors” to see which one would be on the nozzle.

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Shown above: The leather front from one of the student’s helmets. Note the thermal damage to the upper half of the shield. As the fire grew in intensity and began to develop toward the front of the compartment, the apprentice instructor retreated to the front door and knelt down between the door and window and waited for the attack line. *It is important to note that the apprentice instructor had never participated in a burn in this type of structure. His normal actions in a residential structure have been to confirm that the fire is developing, and then retreat to the doorway that the attack crew is entering. This affords the apprentice numerous building features such as headers and walls to block the products of the fire from encroaching on him. In this case, the large open room afforded no protection from the advancing fire. This is further exasperated by the large ventilation openings located behind the apprentice instructor, placing him between the fire and its path of travel. Furthermore, due to the insulating qualities of today’s PPE, it is likely that the apprentice instructor did not recognize the amount of thermal insult that he had incurred until well after he had suffered injury to both his equipment and his person.

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The next two photos show the apprentice instructor’s turnout coat. Note the evidence of delamination and onioning from the areas that incurred the most significant damage.

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The apprentice instructor’s helmet and face piece from the day of the incident.

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The apprentice instructor’s arm and shoulder approximately one month after the injury occurred.

As the fire began to show out of the window and door above the apprentice instructor, the instructor-in-charge ordered the attack line to advance and put the fire out. This was the line with the two students and line coach. After a hesitation, the crew advanced to the doorway, and the student functioning as the nozzleman opened the nozzle slightly with the stream pointed toward the floor. The student’s account states that he noticed that the apprentice instructor’s coat and pants were on fire, and that he was attempting to put water on the apprentice instructor in an attempt to put the fire out. The apprentice instructor exited the structure at this time and was extinguished by what everyone concurs is the backup line. The attack line extinguished the remaining fire. The student operating as the nozzleman incurred thermal damage to his coat, helmet, hood and gloves during this time.

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The (student) nozzleman’s coat, gloves and helmet flap are pictured on the following pages.

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Both the apprentice instructor and the student were checked by EMS. The student was released however the apprentice instructor was transported to the hospital for further treatment. He was released later that same day. All parties involved were asked to write a narrative concerning the incident. The instructor-in-charge notified the community college coordinator of the incident the same day, with notification and accompanying documentation received to our office in a timely manner.

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Recommendations In order to minimize the risk of the above incident happening again, the North Carolina Office of State Fire Marshal provides the following recommendations to facilities and instructors who provide live fire training. Recommendation #1: NFPA 1403, 3.3.5 defines an instructor as an individual qualified by the AHJ to deliver firefighting training, who has the training and experience to supervise students during live fire training evolutions. NFPA 1403, 6.5.4 states that the instructor-in-charge shall be responsible for full compliance with this standard. It is obvious that both the AHJ and the instructor-in-charge take a proactive approach to ensuring qualified and experienced personnel are available to conduct live fire training. However the use of a line coach who is not qualified or competent to function in this role jeopardizes the AHJ and the instructor-in-charge’s professional standing. While the AHJ decides who is an instructor, or instructor-in-charge, it is in the AHJ’s best interest to place the most qualified individuals in these positions to ensure safety and limit liability. Likewise, the instructor-in-charge is responsible for adherence to the standard by all instructors and personnel present. Furthermore, the utilization of an apprentice instructor provides a valid and important training opportunity. However it is imperative to remember that the instructor-in-charge is ultimately responsible for an apprentice’s actions and well-being. Though the apprentice instructor has numerous training burns to his credit, operating in an unfamiliar structural layout quite possibly contributed to his injury. Recommendation #2: NFPA 1403, 6.2.15.4 states that all features of the training area and structure shall be indicated on the pre-burn plan. NFPA 1403, 4.2.22 states that awareness of weather conditions, wind velocity, and wind direction shall be maintained, including a final check for possible changes in weather conditions immediately before actual ignition. NFPA 1403, 4.2.25.4 states that all participants shall be required to conduct a walk-through of the structure in order to have a knowledge of and familiarity with the layout of the acquired structure and to facilitate any necessary evacuation of the acquired structure. While a comprehensive pre-burn plan was available during the interview, the lack of a room/structural layout omits important elements including the location of the fire, exits, and any concerns of which the students should be made aware. A weather report was also absent from the pre-burn plan. Failure for everyone to conduct a walk-through of the structure further reduced personnel’s familiarity with the structure. Recommendation #3:

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NFPA 1403, 6.4.7.1 states that back-up lines shall be provided to ensure protection for personnel on training attack lines. NFPA 1403, 6.4.7.3 states that the instructor-in-charge shall assign the following personnel:

(1) One instructor to each functional crew, which shall not exceed five students (2) One instructor to each backup line (3) Additional personnel to backup lines to provide mobility (4) One additional instructor for each additional functional assignment

The utilization of a line coach to accompany the attack crew, while sometimes necessary, does not provide an adequate substitute for the presence of a qualified instructor. Although back-up lines were deployed and manned, it is apparent that either the attack or the backup line was manned by non-interior firefighters. It is imperative that capable firefighters man these lines at all times during evolutions. The potential loss of the attack line during fire attack makes the presence and vigilance of the back-up line vital. Recommendation #4: NFPA 1403, 4.1.1 states that prior to being permitted to participate in LF training evolutions, the student shall have received training to meet the performance objectives for FFI for the following sections of NFPA 1001, Standard for Firefighter Professional Qualifications: Safety, Fire Behavior, Portable Extinguishers, PPE, Ladders, Fire Hose, Appliances and Streams, Overhaul, Water Supply, Ventilation and Forcible Entry. The AHJ should have documentation that all participants have achieved the minimum level of knowledge in the NFPA 1001 performance objectives as stated in NFPA 1403. NFPA 1403, 4.1.2 states that students participating in a live fire training evolution who have received the required minimum training specified in 4.1.1 from other than the authority having jurisdiction shall present written evidence of having successfully completed the prescribed training prior to being permitted to participate in any live fire training evolution. The AHJ should use a standard form for written evidence to ensure students have received the minimum basic training when that training is from other than the AHJ. NFPA 1403, 6.5.6 states instructors shall take a head count when entering and exiting the building during an actual attack evolution conducted in accordance with this standard. NFPA 1403 6.5.7 states that instructors shall monitor and supervise all assigned students closely during the live fire training evolution. It is obvious that between the qualified instructors and the line coach, the two students were known to be non-interior status. Regardless of the student’s intentions during the burn, the instructors are in charge of the exercise and therefore have the ultimate say as to who is allowed to do what. This is further exasperated by the fact that the students had different colored and marked helmet fronts, as well as different SCBAs than any other participants. Proactive and accurate accountability is essential at all live fire exercises.

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While the students both had letters giving them permission from their Chief to participate in the exercise only from the exterior of the structure, this letter was not requested nor received by the instructor-in-charge until after the incident had occurred. Recommendation #5: NFPA 1403, 4.2.10 states all hazardous structural conditions shall be removed or repaired so as not to present a safety problem during use of the structure for live fire training evolutions. NFPA 1403, 4.2.10.1 states floor openings shall be covered. NFPA 1403, 4.2.10.2 states missing stair treads and rails shall be repaired or replaced. NFPA 1403, 4.2.10.4 states holes in walls and ceilings shall be patched. Due to the limited number of anticipated burns, little was done to mitigate the structure prior to conducting interior training. Recommendation #6: NFPA 1403, 4.4.11 states emergency medical services shall be available on site to handle injuries. NFPA 1403, 3.3.3 defines Emergency Medical Services as the provision of treatment, such as first aid, cardiopulmonary resuscitation, basic life support, advanced life support, and other pre-hospital procedures including ambulance transportation, to patients. No EMS transport was available on site, although a valid effort appears to have been made by the instructor-in-charge to obtain this resource.

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References 1. NFPA 1403, Standard on Live Fire Training Evolutions. 2001 edition, Quincy, MA:

National Fire Protection Association. 2. NFPA 1403, Standard on Live Fire Training Evolutions. 1997 edition, Quincy, MA:

National Fire Protection Association. 3. NFPA 1142, Standard on Water Supplies For Suburban and Rural Fire Fighting.

2002 edition, Quincy, MA: National Fire Protection Association. 4. North Carolina Live Fire Instructor Qualification Course, North Carolina Office of

State Fire Marshal. Investigator Information This incident was investigated by Jonathan Sowers and Kevin McArthur, both Training Specialists with the North Carolina Office of State Fire Marshal.