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San Francisco Fire Department releases report into deaths of Lt. Vincent Perez and FF/PM Anthony Valerio. Flashover caused when glass in sliding door shattered.

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Previous coverage of this story here, herehere & here


An internal safety investigation on the June 2, 2011, fire at 133 Berkeley Way indicates that firefighters Lt. Vincent A. Perez and Firefighter Paramedic Anthony M. Valerio were killed by extremely high temperatures of up to 700 degrees caused by a sudden flare up, known as a flashover.

The intense fire event, which lasted several minutes, was caused when a window shattered in the room where the fire started, sending a rush of oxygen to the flames, according to the report. The heat was drawn up a stairwell from a below ground-level floor, where the fire began, to the ground-level floor where Valerio and Perez were standing.

"They were caught in a chimney," said Assistant Chief David Franklin, who worked on the team that prepared the report.

From KGO-TV:

"We were well on our way to developing some of the new policies that, in some ways, could have made a difference," Chief Joanne Hayes-White said. "But basically, you'll find that the key factor was something that was a variable that we really had no control over. It was the failure of the window on the back end of the floor where Tony and Vince were." 

KGO-TV image.


 The report describes a number of errors and communication problems at the scene and makes recommendations for how the handling of future incidents can be improved. But fire officials said the flashover was not something that could have easily been prevented or predicted.

"What Vincent and Tony did is exactly what all of us would have done," said Fire Chief Joanne Hayes-White, noting that it is standard practice in the department to make an aggressive attack and try to get water on a fire as quickly as possible. "The key factor was something that we really had no control over."

Hayes-White said the department is developing a risk assessment policy to help determine how to approach fires, particularly in difficult situations such as that presented by the multi-level home.

Official release from the San Francisco Fire Department:

(San Francisco, CA – February 10, 2012) The San Francisco Fire Department held a press briefing today, reviewing the results of their Internal Safety Investigation related to the Line of Duty Deaths of Lt. Vincent Perez and Firefighter/Paramedic Anthony Valerio at a fire at 133 Berkeley Way on June 2, 2011.

Fire Investigators determined that the fire was accidental. The ignition source was “a nonspecific electrical sequence”, likely caused by either a failure in a ground outlet or in the appliance connected to the outlet.

The results of the Safety Investigation determined that the two Firefighters, who died as a result of internal and external thermal injuries, were conducting fire operations in a stairwell of the home above the fire room. The stairwell acted as a chimney when a large window failed in an oxygen deprived room that was below them, “causing them exposure to a rapid high heat event at temperatures that no Firefighter would have been able to survive”, said Assistant Deputy Chief Jose Velo, a member of the Safety Investigation Team.

Inspection of the Firefighters’ Personal Protective Clothing indicated that they performed according to their specifications. “We do have some concerns related to the handheld radios that all of our Firefighters carry”, said Chief Velo. “Both radio microphones appear to have failed from exposure to extreme heat conditions.”

Upon receiving the findings related to the radios, Fire Chief Joanne Hayes-White requested that the National Fire Protection Association (NFPA) research and develop a standard for Firefighter handheld radios.

The Safety Investigation Team identified three factors that contributed to the tragic outcome of this event. These factors include an excessive live fuel load which contributed to the growth of the fire, the layout of the building with the origin of the fire being in a room below grade and, extreme heat conditions accelerated by the failure of a window on the fire floor.

Chief Hayes-White indicated that this Safety Investigation was internal and initiated immediately following the rescue of the two Firefighters. Additionally, she stated that an independent Safety Investigation had also been conducted by the National Institute of Occupational Safety & Health (NIOSH). The NIOSH Report is pending.

“Twenty-five recommendations have been made as a result of information gathered from the Safety Investigation”, said Chief Hayes-White. “We take to heart all of the findings and recommendations in this report and will vow to do everything within our power to ensure a similar tragedy does not occur again in our Department.” The Department is in the process of implementing all recommendations and has initiated research and development where required.

President of San Francisco Fire Fighters Local 798, Tom O’Connor said, “While there is nothing that we can do to change the outcome of that fateful day, we can learn lessons from this tragedy and make every effort to ensure that this does not happen again.”

“The two brave firefighters who died tragically in the line of duty in June last year – Lieutenant Vincent Perez and Firefighter/Paramedic Anthony Valerio are heroes,” said Mayor Ed Lee. “As a city, we will follow up on every recommendation and finding from the report issued today by the San Francisco Fire Department to ensure our first responders are as safe as possible as they serve the residents of San Francisco.”

The Fire Department has forwarded their report to the National Institute of Occupational Safety and Health, the National Institute of Standards and Technology (NIST), the International Association of Fire Chiefs (IAFC), the International Association of Firefighters (IAFF), the National Fire Protection Association (NFPA), Cal-OSHA, the State Fire Marshal, and the CA Professional Firefighters Association for their review. 


Comments - Add Yours

  • Fire21

    It's nice to know that no major mistakes led to these terrible deaths.  Firefighters do their best to ensure that things go correctly, and these men obviously did.  May they RIP.

  • Former Chief

    Fire21, I hope you're right.  But I'm curious to see the other factors cited.  Something in my gut is just not sitting right.  I couldn't find the SFFD report.  The NIOSH report should shed some more light.  I do agree this was a tragedy and I hope they're serious about implementing corrective action.  RIP Brothers.

    • Tony’s Sister

      @Former Chief —  I received the report on Monday from the Chief and am in the process of reviewing.

      • Former Chief

        I'm assuming you are Firefighter Valerio's sister?  I am so sorry for your loss.  Anytime we lose a Brother or Sister, it takes a piece out of all of us. 

  • Shack

    Dave and Former Chief,
    Is the report actually available for review? I would love to actually read it, one of the news stories I saw, the reporter had it in his hands. Dave, any way you can get a hold of this and post? From a learning/training aspect, I would love to see their report before the NIOSH report comes out. Seems like a "normal call" that went wrong.
    Btw, I enjoy the site and all the comments, a lot learned and taken into consideration on this site! Thank you to everyone on your comments.

    • dave statter

      I have looked and so far, I have not found the report on the Internet.


  • Play4keeps

    Sounds similar to DCFD Firefighters' Matthews and Phillips death in 1999

  • Captain Daddy

    Play4keeps you may be on to something.  NIST is a part of this investigation as they were in DC in 1999.  I believe we will se some similarities.  Obviously descending stairs to access fire is one of the most dangerous things we do. 

  • Sharppointy1

    Dave, I'd like to second the motion to see the full report when/if it becomes available.  Thanks, Barb