Factors Identified in Loudoun County, VA, Blast that Killed Firefighter

Communications challenges, risk assessment, command structure and resource allocation were some of the contributing factors at a Loudoun County house explosion last year that claimed the life of a Sterling firefighter.

Those were among the findings of a team of fire serivce leaders who conducted an investigation of the blast that killed Sterling Firefighter Trevor Brown and injured 13, some critically.

Factors, observations and recommendations are included in the Significant Incident Report released Tuesday.

Loudoun County Fire Chief Keith Johnson explained in a letter: "My direction to the team was to develop a Significant Incident Report which will identify findings, conclusions, and provide recommendations on how our System can improve our policies, plans, and procedures, to ensure first responder safety, and how we can best serve the residents of, visitors to, and businesses in Loudoun County. This report is not intended to place blame or identify any single action performed on the scene. The goal is to identify, learn, and improve our daily operations."

Contributing factors identified include

• Risk Assessment: Key indicators were not fully understood during the initial and on-going size-ups, which compromised the safety of on-scene personnel. 
• Event Escalation: The incident escalated from a routine outside gas leak call to a catastrophic explosion, catching responders off guard. 
• Communication Challenges: There were delays in relaying critical information and confusion regarding mayday calls, which impacted the effectiveness of response efforts.
• Resource Allocation: There were issues with resource allocation and coordination, particularly ensuring an adequate water supply and managing the rescue operation of trapped personnel. 
• Command Structure: The Command structure faced challenges in managing the complex and rapidly evolving situation, leading to difficulties in coordinating rescue efforts, patient treatment/transport, and ensuring scene accountability.

The team, lead by Frederick County, MD Fire Chief Tom Coe, also recognized procedures that were in place:

• Training: LC-CFRS requires firefighter mayday training as part of the Firefighter I and II curriculum that contributed to positive outcomes for the first responders trapped in the explosion. Prior to the incident, telecommunicators from the Loudoun County Fire and Rescue Emergency Communications Center (LCFR-ECC) participated in mayday training that helped prepare them for the intricacies of firefighter rescue operations. 
• LCFR-ECC Management and Coordination: The LCFR-ECC staff worked diligently to manage and track radio communications throughout the incident and ensured the Incident Commander was provided with the information in a timely manner.  
• Technical Rescue Expertise: Two technical rescue units, one from Loudoun County’s Kincora Station and the other from Fairfax County’s North Point Station, arrived quickly and used their extensive training to rapidly develop a victim removal plan and executed that plan in a coordinated effort.
• Behavioral Health Response: The emotional and mental well-being of LC-CFRS members was a high priority during and after the Silver Ridge Drive Incident. As responders were released from the scene, they were directed to a central location where peer support team members, clinicians, and canines were available for support. The LC-CFRS Behavioral Health Team remains engaged and ready to assist our personnel. 

The team outlined specific observations and recommendations in a matrix.

A communication failure was among the findings. During the incident, 136 radio transmissions failed. 

Analysis: During and after the incident, Communications staff generated reports on system 
capacity, talkgroup affiliations, and radio rejects (failures). Of the one hundred and thirty
six (136) radio rejects, one hundred and five (105) radio rejects between the time of the first 
transmitted Mayday until the time the trapped personnel were removed: an elapsed time of 
thirty-nine (39) minutes. The responders who were directly involved in the explosion 
accounted for thirty (30) of the rejects while the two (2) trapped individuals experienced 
twenty (20) rejects. These radio rejects were classified by the system as audio interrupt or 
stealth reject. An audio interrupt occurs when a radio attempts to transmit to a talkgroup 
while another radio is transmitting. A stealth reject occurs if two (2) radios try to send a 
push-to-talk request at close to the same time, resulting in only one (1) radio being granted 
the transmission. The radio that does not transmit gets charged with the reject. 

Incident command and other issues were outlined. 

Analysis: The Incident Commander (IC) faced significant challenges in establishing and 
maintaining accountability at the scene due to several factors. Engine 618 Officer-in-Charge 
(E618 OIC) established Command early in the incident. At the time of the explosion, 
Command was unaware that Truck 611 Officer-in-Charge (T611 OIC) and Engine 618 
Bucket 1 (E618 B1) had entered the home to search for an occupant. From the time Battalion 
Chief 601 (BC601) arrived and assumed Command, there was a clear struggle to establish 
and maintain accountability of on scene personnel. 
Upon assuming Command, BC601 was placed in the challenging position of obtaining an 
accountability report and situational update from the two (2) initial officers. T611 OIC was 
trapped in the basement under debris, and Command (E618 OIC) was affected by the blast 
and unable to assist. Establishing accountability, as well as attempting to coordinate rescue 
efforts for the trapped members, was the focus of Command’s efforts throughout the 
incident. Due to their focus on the status and location of the first two (2) units, accountability 
checks, either formal or informal, were never attempted for any units responding to this 
incident. The gravity of this fact is amplified by the post incident discovery that two (2) 
separate members were at one point partially submerged in the inground pool located in the 
backyard. The failure to establish accountability and document the location of the members 
operating on this scene, was compounded by a lack of an organized Command structure, 
and failure of units on the second and later alarms to establish and report to staging upon 
arrival.  Additionally, the computer-aided dispatch (CAD) system is not utilized to display the names of personnel assigned to apparatus, and separate web-based staffing platforms (both career and volunteer) may not be kept current to allow the IC to quickly and accurately reference staffing at the Incident Command Post (ICP) in real-time.