NIOSH investigators cited a number of issues occurred that led to the injury of a San Francisco firefighter last year.
Although senior officers discussed among themselves that a defensive operation should be undertaken, no one told firefighters who were already inside the structure, NIOSH officials noted in a report released Monday.
Firefighter/Paramedic Mike Estrada, 36, suffered compound fracture to his right leg, broken bones in his left foot, burns and a fractured clavicle.
He was hurt at a fire on May 21, 2009, when the overhang of a bowstring truss roof system collapsed, the report stated.
Among the contributing factors in the incident included scene management and risk analysis and firefighters operating in a potential collapse area. The federal investigators quoted two veteran fire instructors during their discussion of the issues.
"Retired Chief Alan Brunacini recommends that the arriving IC drive partially or completely around the structure whenever possible to get a complete view of the structure. While this may delay the ICs arrival by a few seconds, this drive-by may provide significant details not visible from the command post."
They continued that Brunacini recommends the size-up should include an evaluation of factors such as the fire size and location, length of time the fire has been burning, conditions on arrival, occupancy, fuel load and presence of combustible or hazardous materials, exposures, time of day, and weather conditions.
The NIOSH investigators said the size-up and risk assessment should continue throughout the incident.
They added that fires in commercial structures are typically more dangerous than residential building fires.
"Retired Assistant Chief Vince Dunn states that defensive operations should be used more often at special occupancy and commercial buildings. Chief Dunn cites statistics that 4 fire fighters die for every 100,000 residential fires compared to 9 fire fighter deaths for every 100,000 commercial structure fires"
NIOSH officials added: "Heavy fire showing from the roof upon arrival, inability to obtain entry to hit the seat of the fire, bowstring truss construction, and no known occupants/entrapments, were all indicators that could have prompted consideration of initially deploying defensive tactics."
