Fresno firefighters who responded to a house blaze where Capt. Pete Dern fell through a roof and was severely burned failed to properly access the fire’s dangers, reflecting a Fire Department in which personnel are “picking and choosing” which procedures to follow, an investigative report released Tuesday says.
The 274-page investigative report on the March 29, 2015 fire in central Fresno makes sweeping recommendations for Fresno Fire Department.
Dern was engulfed in flames for more than 90 seconds. He suffered second- and third-degree burns on around 70 percent of his body. The incident and his long rehabilitation received national attention. Dern spent 164 days in the burn unit at Community Regional Medical Center.
In April, Fire Chief Kerri Donis assembled a Serious Accident Review Team team and authorized them to investigate the circumstances of the fire and Dern’s injuries.
The recommendations issued by the team cover everything from adhering to rules on personal protective gear to altering the fire department’s culture of safety.
The eight-member SART team was made up of current and retired fire officials from the Kern County Fire Department, the Modesto Fire Department, the Los Angeles Fire Department, and other agencies.
The report said causal factors in the house fire included fire department culture, risk management identification, ventilation training and water application techniques.
Firefighters’ approach to the blaze showed an The team an absence of a standard risk management process developed by the fire department to address hazards in firefighting operations, the report said. It recommended the department develop a vigorous training program with exercises on assessing risk.
“When dealing with department policies and procedures, it is apparent the membership at all levels is picking and choosing which ones they are willing to follow,” SART team members wrote. The report recommended an “imperative for safety” be established within the department.
A firefighting technique called vertical ventilation, which involves cutting holes over a roof to allow heat and smoke to escape, was a causal factor, the report said.
During the March fire, Dern was attempting to perform vertical ventilation when the garage roof collapsed and Dern fell inside. The report recommended a policy be implemented to ensure firefighters are not knowingly attempting vertical ventilation over unprotected spaces.
Nozzles and water application techniques were another causal factor the report identified. It noted that, in contrast to national standards, Fresno Fire Department had a policy of using 95 gallons per minute. Building materials and furnishings have shifted to plastics and synthetics, which burn hotter and quicker than traditional cellulose-based materials, the report said.
It recommended the fire department adopt the National Fire Protection Association standard of 300 gallons per minute be shared between the first and second hoselines at a home fire.
There is no fire department policy on residential garage fires, the report said. It noted that in 2010, Fresno Fire Department participated in a accident review process for a Modesto Fire Department roof operation similar to the circumstances in the March fire. However, there was little or change in Fresno Fire Department roof operations, the report said.
The report also found that during the March fire and other incidents, personnel sometimes acted independently, without the knowledge or consent of the incident commander. The report suggested a process for fire department vehicles to respond and receive assignments at emergencies.
Fire personnel should consistently conduct a more thorough process of sizing up a fire, the report said. At the March fire, no complete walk-around was done. “Executive staff shall provide and enforce clear expectations to ensure a 360-degree walk-around assessment has been completed or attempted,” the report said.
Fresno Fire Department has numerous policies about personal protective equipment (PPE), but the report found department personnel had lax attitudes toward following them.
“During the rescue attempt of the fire captain, several personnel were not wearing the appropriate PPE, potentially delaying rescue efforts,” the report said.
Fire Chief Kerri Donis said the report will help the fire department implement new safety polices. “We, as a department, from top to bottom, will courageously take a critical look at our organization, utilize this report as our playbook to implement changes necessary to improve fire ground safety,” Donis said.
“Our goal is to ensure that everyone goes home safe at the end of each shift, and each member has a healthy quality of life at the end of their careers.”
