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LODD report: Read Baltimore County investigation into death of Lutherville VFC Firefighter Mark Falkenhan.

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Excerpt from the Executive Summary:

In fairness to those units involved in this incident, the investigating team had the advantage of examining this incident over the period of several months. Furthermore, given the size and nature of the event, and the fact that arriving crews were met with serious fire conditions and several residents trapped and in immediate danger, all personnel should be commended for their efforts for performing several rescues which prevented an even greater tragedy. The team did not identify a particular primary reason for FF Falkenhan’s death. What were identified were many secondary issues involving but not limited to crew integrity, incident command, strategy and tactics, and communications. These issues are identified and discussed, and recommendations are made in appropriate sections of the report, as well as in a consolidated format in the Appendix.

Some of the issues identified in this report may require some type of change to current practices, policies, procedures or equipment. Most, however, do not. Specifically, the analysis and recommendations regarding Incident Command and Strategy and Tactics show that if current policies and procedures are adhered to, the opportunity for catastrophic problems may be reduced.

Mark Falkenhan was a well-respected and experienced firefighter. He died performing his duties during a very complex incident with severe fire conditions and unique fire behavior coupled with the immediate need to perform multiple rescues of victims in imminent danger. It would be easy if one particular failure of the system could be identified as the cause of this tragedy. We could fix it and move on. Unfortunately it is not that simple. No incident is “routine”. Mark’s death and this report reinforce that fact.

Image from report showing conditions on arrival.


Comments - Add Yours

  • BCFDHoseHumper

    any idea when a NIOSH report will be published??

  • Uncle Buck Carpenter Jones

    April 31st 2012 is the planned release date….

  • mdff

    Mark was a great instructor and just a good guy, this was very painful to read.

  • Mack Seagrave

    “The initial attack line selected on side Alpha was 200’ 1 ¾ inch constant flow nozzle set at 95 GPM. The backup line was a 200’ 1 ¾ inch constant flow nozzle set at 95 GPM. The backup line was directed into a window to the right of the entrance door.” 95 GPM attack lines are not compatable with interior structural firefighting. If this is SOP in the department concerned, the person who made the decision to allow it should at the very least be forced to retire. Sadly, improper attack line size, improper nozzle selection, inadequate nozzle pressure and low GPM’s play a part in many fire deaths both LODD as well as civilian. Condolences to FF Falkenhan’s family. May he rest in peace.

  • Cynical in Seattle

    Painful to read for two reasons- It was a terrible operation and given the same fire next week- nothing changes…It was terrible because as the Chief said in his opening remarks there is nothing that he can point to and say, “that was why!” Even after all this time to think, study, and reflect, the truth is just as plain as it has always been: we keep doing what we always do because it always works, except when it doesn’t work and then we cry, and we promise, and we strive to honor the dead, we promise to never forget, and we engage in other similar ritualistic behavior. There was nothing to point to because it was no different than the one just before it or the one just after it. It is never the big mistake that kills. The death is almost always the death of a three thousand paper cuts. Here we come to a point where our official report argues that we don’t need to change how we think about fires, we don’t need to change how we frame these problems, we need only to follow the rules that we already have. What they are telling you and me and the family and themselves is something insidious and that is that sometimes we loose someone, you have to accept that. It was not his training that failed, nor was it the rules, it was this thing called bad luck that one in a million time when what we usually do got someone killed. It won’t happen again even it we don’t change because we don’t need to “change” we need to follow the rules that we already have. It is no one’s fault. How can we hold someone at fault when they don’t follow the rules? We can’t place blame because someone is dead and to place blame, any blame will take away from the tragedy and impede learning. You cannot, must not, write a report that places blame because it shuts people down and that is what is important-not shutting people down- even if someone dies and especially if someone dies. This report rhetoric is just that, rhetoric, a tool organizations use to dictate narratives. This narrative serves two main purposes: 1- to protect the organization – because ” if they had just followed the rules we gave them none of this ever would have happened.” 2. The guys who lived don’t have to die a thousand deaths knowing that if they had only followed the rules that guy might not be dead. Your mistake was a little one and no one can blame you for his being dead. Just follow them rules next time. very sad-very hard to read

    • M. R. Rehfeld

      Dear Cynical in Seattle,

      First let me introduce myself, Mike Rehfeld, retired Ladder 13 Baltimore County FD. First and foremost Mark & Gladys are good friends of mine. That said, you my friend without knowing much about my former employer have nailed the truth. I was one of several in our department, that for the last 10 years of my career not only predicted this event, but worked very hard to prevent it from happening. Little did I know it would happen to a friend! Mark was a solid firefighter and instructor, basic skills came easy to him. The department on the other hand has the mindset that “thinks just happen”! As Gordon Graham has preached if it’s predictable, it’s preventable! Marks loss was the result of many failures, first, the old adage that we do what we do, because we always have! Second, my department has failed to adjust tactical changes to the very bread and butter of our structure fires (Garden Apartments). Third, a failure to not only follow written policies regarding RIT but to this very day it is at best a tertiary thought and practice. GPM fire flow is inadequate for the fuels and space involved in these events. Self escape equipment and training is not provided!!!! I could go on, feel free to email me, I plan to write about this incident in the near future, but am waiting to see what NIOSH provides.

      In Brotherhood
      Michael R. Rehfeld
      Realist Training Solutions

  • BCFDHoseHumper

    Failure to notify command of fire conditions in the rear upon arrival of E1, and truck crew not closing off doorways after searches. Those two factors cannot be overlooked as contributing causes.

  • BH

    It was no different than most other internal department death investigations I have read. It’s always 30 pages of blaming everything except individual actions or lack of action, because nobody wants to tell a guy that his actions contributed to the death. At some point we became more concerned with feelings than preventing the need for such investigations in the first damn place.

    So instead, nobody learns anything. Move along, nothing to see here. Wash, rinse, repeat.

  • Carl Burney

    I was captivated by this report because there is a ton of these type if apartments buildings in my area. I believe there is much to glean here that hopefully will keep this from happening again. I intend to share this with my department because one of these days it is going to be us. In fact, it was us one morning when a 2nd story resident in a 3-story building caught a mattress on fire and tried to drag it out of the apartment. As he reached the stairwell with it the flaming mattress started burning his hand and he dropped it there where it blocked the only door egress for those on the upper floors. There wasn’t that much fire but a lot of smoke…enough that several panicked residents jumped from 3rd story windows as we arrived on scene and were injured.
    In the fire where FF Falkenhan perished I would have to say that the defining moment of this incident was the actions of the T2 Residents. Had they exited leaving their doors closed instead of open I believe the sheetrock would have done it’s job containing the fire to that unit if not all but smothering it from lack of oxygen by the time the first units arrived. Their unfortunate decision to open the sliding door and then exit through the front leaving that door open set the stage for disaster, blocking escape routes and fueling the flames with plenty of fresh air enabling it to turn into the deadly inferno it became. I feel that public education for these folks who live in apartment buildings like this is imperative. We need to make them understand that their actions can be highly detrimental to their neighbors should they not follow set rules for exiting the building and leaving a way for others to do the same.

  • Anonymous

    Mack Seagrave,
    Don’t mark my words Sir, but I do believe some Departments are still putting fires out with 95 GPM with akron nozzles

  • Styles

    From reading the report and looking at the Fire Dynamic recreation it seems pretty clear that the exposures (2nd. floor) were left to no one to cover. This is how the fire traveled to the 3rd. floor and entered the apartment that F/F Falkenhan was in. Had a line been placed on the 2nd. floor we may have had a different result. It’s a shame the committee missed this as a recommendation and that the Fire Chief put out a blanket statement that nothing could have really prevented this.