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.