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Looking Back at The Cherry Road Townhouse Fire, Double LODD; DCFD May 30, 1999
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By CCFCA
May 30, 2012

Train like your life depends on it, because it does!


On May 30, 1999, (DCFD) fire fighters responded to a box alarm involving a townhouse fire at 3146 Cherry Rd NE, Washington, DC 20018-1612.

DCFD FireFighter Anthony Phillips, Engine 10

DCFD FireFighter Louis Matthews, Engine 26

From the NIOSH Report: The initial report came in as a house fire, and it was later reported that the fire was in the basement (all fire fighters did not receive the follow-up report of fire in the basement). Engine 26 (Lieutenant and 3 fire fighters) was the first to arrive on the scene and reported smoke showing on the front (side 1) of a row of townhouses (see Diagram 1). A fire fighter (Victim #1) from Engine 26 advanced a 1½-inch attack line through the front door (1st floor). Soon after, the layout man from Engine 26 entered to back up Victim #1. Engine 17 (Lieutenant and 3 fire fighters) arrived shortly after and stretched a 350-foot 1½-inch hose line to the rear (side 3) (see Diagram 1).

Truck 15 (Captain and 3 fire Engine 26 and Engine 10 advanced their lines through the front door in a search for the fire and the basement door (at the top of the basement steps). As the two crews searched, Truck 4 made forcible entry through a sliding-glass door in the rear (basement entrance door at ground level). Engine 17 (at the basement door with a charged line) reported to the IC that they were on the first floor, in the rear, with a small fire showing (Engine 17 was actually at the basement level). Engine 17 radioed the IC for permission to open their line and knock down the fire.

Knowing that he had two engine crews on the first floor in the front, the IC denied Engine 17's request until he could locate the interior crews' positions. He radioed the officer from Engine 26 several times for their position, but received no response.Engine 17 asked a second time for permission to hit the fire, as it began to grow. The IC denied the request a second time and again tried unsuccessfully to radio the officer from Engine 26. Conditions in the interior rapidly deteriorated, forcing the fire fighters on the first floor to search for an exit. A fire fighter in the interior recalled seeing fire appear from a doorway on the first floor.

After seeing the fire, the fire fighter stated that everything went black and he felt an intense blast of heat. Victim #1 and Victim #2 were unable to escape, while the Lieutenant and a fire fighter from Engine 26 escaped with severe burns. All injured fire fighters were transported to a local hospital. The Lieutenant and fire fighter were admitted with burn injuries. Victim #1 was treated for severe burns and was pronounced dead the following day. Victim #2 was pronounced dead on arrival at the hospital.

EXECUTIVE SUMMARY CHERRY ROAD RECONSTRUCTION

On May 30, 1999, District of Columbia Fire Fighters Anthony Phillips and Louis Matthews sustained critical injures in the line of duty that resulted in their deaths. Three additional fire fighters sustained injuries ranging from critical to minor. Fire Chief Donald Edwards (now retired) appointed a Reconstruction Committee to investigate and evaluate the emergency response activities at this fire. This report is the result of extensive interviews, independent investigation, and evaluation of the reports of other investigators. The Reconstruction Committee has found that the District of Columbia Fire and EMS Department (Department) has several deficiencies, particularly in training, staffing, equipment, and administration. The mere knowledge of these shortcomings and recommended actions does nothing. Many of the recommendations contained in this report are the same recommendations made in a report of the investigation of the death of Sergeant John Carter in the Kennedy Street fire of October 24, 1997. Further inaction on these recommendations cannot be tolerated.

The Cherry Road fire was initially considered by most of the personnel to be a "routine" fire. The events that took place demonstrate the serious consequences that result from failure to train, equip, and staff appropriately. At 00:17:00 on May 30, 1999, the District of Columbia Fire and Emergency Medical Services Communications Center (Communications) received a 9-1-1 telephone call reporting a fire at 3150 Cherry Road, NE. In response, Communications dispatched Box Alarm 6178, consisting of engine companies E-26, E-17, E-10 and E-12, truck companies T-15 and T-4, a battalion fire chief (BFC-1) and a rescue squad (RS1). A second 9-1-1 call at 00:18:40 provided a corrected address of 3146 Cherry Road, NE, and reported that there was fire in the basement. Communications announced this new information, but only one of the responding companies acknowledged the address change. The first units were on the scene within approximately four minutes of dispatch.

Several initial actions were taken within the next five to six minutes.

The first due engine company, E-26, arrived to find heavy smoke pouring from the front door of the structure and advanced a 200-foot 1-1/2 inch attack line into the first floor area.

The first due truck company, T-15, arrived one minute later and began placing and ventilating at the front of the structure.

The second due truck company, T-4, arrived and prematurely began forcible entry and ventilation of the rear basement sliding glass door without an attack line in position for entry. The T-4 officer was informed by the occupant of the building that no one remained inside the structure, but T-4?s officer failed to report this information to the incident Commander. Truck 4?s officer also failed to give a rear size-up report.

Rescue Squad 1 arrived and, failing to follow SOPS, reported to the rear with one team entering along with a member of T-4. The RS-1 officer was informed by the occupant of the building that no one remained inside the structure, but RS-1?s officer failed to report this information to the Incident Commander.

The second due engine company, E-10, supplied a 350-foot 1-1/2 inch attack line to the rear and reported to the Incident Commander, BFC-1 that they were in a position to extinguish the fire.

The third due engine company, E-12, supplied E-26 with water and advanced a 400-foot 1-1/2 inch line into the first floor to back up E-26.

The fourth due engine company, E-12, supplied E-17 with water, then, failing to follow SOPS, advanced a 200-foot 1-1/2 inch line into the front of the building.
The Incident Commander, BFC-1, requested additional resources while en route, based upon the initial report from E-26. After observing the fire location and conditions in the rear, BFC-1 reported to the front of the building. Battalion Fire Chief 1 failed to establish a fixed command post and relied on a hand-held radio for communications, rather than the stronger radio mounted in his vehicle.

Conditions quickly deteriorated after the first six minutes of operations. Companies operating in the front of the building were unaware that fire was growing in the basement because of inadequate communications and improper ventilation activities. A failure to sound a "Mayday" alarm resulted in a failure to realize immediately that there were missing fire fighters and a delayed rescue response.

Fire Fighter Matthews (E-26) and F/F Morgan (E-26) advanced their attack line into the structure's front door, followed by their officer. Fire Fighter Phillips (E-10) and E-10?s officer advanced their hose line to back up E-26. During the initial entry,. personnel indicated that they felt only moderate heat.

Truck 4 forced entry and ventilated the rear basement sliding glass door, and soon after, E-17?s officer requested permission to attack the fire from the rear. Battalion Fire Chief 1 was unsuccessful in an attempt to contact E-26 and E-10 to determine their location, and denied E-17 permission to attack.

Intense heat then traveled out of the basement and up the stairway to an inadequately ventilated first floor, severely burning the fire fighters. At this point, the fire fighters attempted to exit the building. Fire Fighters Phillips (E-10) and Matthews (E-26) were critically injured and unable to exit.

Engine 26?s officer informed BFC-1 that F/F Matthews did not exit the building. Engine 10?s officer noted that F/F Phillips did not exit the building but did not report this to BFC-1.
The seriousness of the situation was not fully realized until critically injured F/F Morgan (E-26) exited the building. BFC-1 then organized a rescue effort to search for F/F Matthews.

Rescue activities were also characterized by a lack of organization, effective communication, and personnel accountability. The rescue efforts also demonstrate the importance of each fire fighter wearing an automatically activated PASS (personal alarm safety system) integrated with the self-contained breathing apparatus.

When rescuers entered the building, they heard a PASS alarm. They found F/F Phillips face down on the first floor without his facepiece, apparently removed because it had started melting. It was difficult to extricate F/F Phillips from under a table; personnel noted that the first floor was extremely spongy and there were extreme heat conditions.
When F/F Phillips was brought outside, it was apparent that F/F Matthew: was still inside the structure and rescue efforts for F/F Matthews were resumed.

After a short search. F/F Matthews was located and evacuated. A total of approximately 21 minutes had elapsed from the time that the fire fighters were burned until all the fire fighters were evacuated from the building.
Fire Fighter Phillips died at 0l :08. Fire Fighter Matthews died the following day. Fire Fighter Morgan is still recovering from his burns.

Evidence has shown that the fire started in an electrical junction box in the space between the basement ceiling and the first floor, initially smoldered and consumed most of the air in the basement. The fire grew rapidly when the basement sliding glass door was broken, producing large amounts of super-heated fire gases. The fire gases traveled extremely quickly up the basement stairway to the first floor. The injured fire fighters were in the path of the superheated gases and were burned almost instantly.

The Reconstruction Committee determined that the deficiencies in operations and equipment resulting in these deaths fall into the following categories.

Fire fighter accountability (e.g., company officers failed to keep personnel together and operate as a team; personnel did not use the "Mayday" alert when fire fighters were discovered missing)

Fireground command (e.g., the Incident Commander failed to establish a fixed command post; did not have an aide and was thus unable to coordinate front and rear teams; failed to sector the incident)

Communications (e.g., no size-up report of the rear was provided; interior companies did not make radio transmissions of their initial attack and progress; it was impossible for injured fire fighters to communicate information because they did not have radios)

Company/unit operations (e.g., actions of companies were not coordinated, so the actions of some companies threatened the safety of others; some officers and fire fighters worked alone or with other companies instead of staying with their own companies; truck companies were inadequately staffed)

Safety (e.g., PASS devices that help locate fire fighters who are immobile were not in use by each fire fighter; the Department's Safety Office lacks the staffing and authority to conduct appropriate investigations and follow-up on safety recommendations)

Administration (e.g., nearly identical recommendations, made following the Kennedy Street fire were not acted upon, resulting in many of the same problems at this incident; personnel do not receive adequate training in live fires because the Department's fire training building is unusable)

Each of the identified problems has a solution, described in detail in this report. Some solutions are relatively easy, involving equipment and its use. Some are more complicated, and involve changing behaviors in individuals and attitudes throughout the Department. Proper training and staffing are key to solving many of the problems. It is clear, however, that none of these solutions are possible with the neglect, insufficient funding, and mismanagement that has characterized the Department. The Department's budget must adequately support staffing, equipment and training. Additionally, the Department must no longer tolerate the notion that SOPs and proper fireground behaviors are only important for "major" fires and not as important for "routine" fires. The Department must vigorously enforce SOPS and demand professionalism at all levels of the fire department and at all emergency incidents.

NIOSH investigators concluded in their 1999 report that, to minimize the risk of similar incidents, fire departments should:

ensure that the department's Standard Operating Procedures (SOPs) are followed and refresher training is provided

provide the Incident Commander with a Command Aide
ensure that fire fighters from the ventilation crew and the attack crew coordinate their efforts

ensure that when a piece of equipment is taken out of service, appropriate back up equipment is identified and readily available

ensure that personnel equipped with a radio position the radio to receive and respond to radio transmissions

consider using a radio communication system that is equipped with an emergency signal button, is reliable, and does not produce interference

ensure that all companies responding are aware of any follow-up reports from dispatch

ensure that a Rapid Intervention Team is established and in position immediately upon arrival
ensure that any hose line taken into the structure remains inside until all crews have exited

consider providing all fire fighters with a Personal Alert Safety System (PASS) integrated into their Self-Contained Breathing Apparatus (SCBA)

develop and implement a preventive maintenance program to ensure that all SCBAs are adequately maintained.

Full article HERE: http://commandsafety.com/2011/05/the-cherry-road-townhouse-fire-double-lodd-dcfd-1999/

Full DCFD Investigative Report HERE: http://commandsafety.com/files/2011/05/Cherry-Road-Investigation.pdf


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