Charleston Phase II Report: Poor Training Led to Deaths

Posted: 05-15-2008
Updated: 05-16-2008 10:29:09 AM

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CHARLESTON, S.C. -- Water issues, inadequate training, no truck operations, building code violations, communications problems and no incident commander.

These were just a few issues cited in the Phase II report on the deadly Sofa Super Store fire released Thursday.

The panel also blamed the culture of the Charleston Fire Department for the events that led to the deaths of nine firefighters.

Gordon Routely, who headed the review panel, called the comprehensive analysis "a tremendous challenge but an enriching experience."

Routely, who presented the findings four times Thursday, twice to family members, to firefighters and finally, the city council and public, referred to the incident as an unparalled tragedy for the fire service and the city.

The report, one of the most definitive and complete post-incident fire reports ever completed, follows the release earlier of the Phase I document that caused the city to make dramatic changes to the fire department.

Since the Phase I report was released, the team has been working to analyze in depth the circumstances surrounding the incident. But according to the report introduction, "It will never be possible to determine every factor relating to this incident with absolute certainty. The deceased firefighters were the only witnesses who could have described or explained some of the events that occurred inside the Sofa Super Store."

The report does provide a minute by minute timeline and the actions of firefighters and locations of apparatus during those minutes. Detailed diagrams show apparatus locations and interior line operations. Radio transmissions, photographs and video were used in this recreation of the fire.

Many elements of the report tell the story of the tragedy waiting to happen.

The panel determined that the building had been remodeled without permits or inspections. There were flammable liquids stored improperly in several areas. Some of the exits were locked. "Had the firefighters gotten to them, they would not have been able to get out," Routely said.

Timed pictures of the fire's development -- taken from across the road -- showed heavy smoke and flames from the roof. Routely said the firefighters inside had no idea what was going on above them.

He noted that nearly every firefighter who arrived went into the building, including those on the ladder truck. "They were entering the building by ones and twos..."

One firefighter, who realized a supply line had not been established, turned the corner to find the hydrant missing. It had been removed because delivery trucks kept hitting it. Unaware where the next hydrant may be, he set out on foot to look.

He found one, but wound up 100 feet short of hose. He had to couple the lengths by hand. While that was underway, 16 firefighters were in the burning building with a booster line and an inch-and-a-half.

That water supply set-up took about nine minutes.

Routely said although they were hearing of deteroriating conditions, none of the chiefs made a decision to evacuate the store and move from an offensive to a defensive attack.

That decision didn't come until after several disoriented firefighters had been rescued.

Routely said it's imperative that officers know when it's time to change tactics and "get firefighters out of harm's way."

There was no accountability whatsoever.

According to the report, "The first person outside the building to become aware that firefighters were in trouble inside was an off-duty Battalion Chief (Car 303), who was enroute to the scene in his personal vehicle. He heard traffic on his portable radio that indicated a firefighter was lost and unable to find his way out of the building. The radio traffic was not heard by anyone at the fire scene."

"Car 303 attempted to contact the Fire Chief at 19:30:27 to advise him of the situation, but was unable to establish contact on the busy radio channel. He continued to the fire scene as quickly as possible, parked his vehicle, and located the Fire Chief on the west side of the fire building, near the loading dock. The face-to-face exchange with Battalion Chief 303 was the Fire Chief's first indication that firefighters were in distress."

Routely said no one had been assigned to listen. Fragmented messages of distress were not heard.

He also said the panel determined that the firefighters really didn't have a Mayday plan in place. Crews were not instructed when to call for one, and what to do to save themselves while awaiting rescue.

Basically, he said, if someone called in a Mayday, "we will figure out what to do."

The former fire chief added that firefighters need to know when to call for help. "We don't hire timid people..." Panel members also learned that the department didn't refill air bottles until the PSI dropped below 1,500. Tanks typically have 2,214 PSI. So, some firefighters may have gone into the store without a full tank.

Routely said there has been quite a bit of discussion on the breakage of the front display windows. "Was it the right or wrong thing to do? At that point, there were not a lot of options...They knew they had firefighters in trouble." The best option would have been a hole in the roof to allow the fire to vent, and clear. "But, you can do that in 30 seconds..." Examining pictures, the panel determined that there was "severe heat stratification" in the store. At first, outside air was drawn into the showroom. However, that soon reversed, according to the report. conditions suggested a flashover or backdraft was about to occurr.

And the report does not shy away from stating conclusions frankly. "The Charleston Fire Department was inadequately staffed, inadequately trained, insufficiently equipped, and organizationally unprepared to conduct an operation of this complexity in a large commercial occupancy."

"The final analysis of this incident does not suggest that any of the firefighters who lost their lives, or any of the surviving members of the Charleston Fire Department, failed to perform their duties as they had been trained or as expected by their organization. The analysis indicates that the Charleston Fire Department failed to adequately prepare its members for the situation they encountered at the Sofa Super Store Fire."

Read the Report