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Report released: PGFD Safety Investigation Team looks at Riverdale Heights, MD fire that injured 7 firefighters.

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Maryland’s Prince George’s County Fire/EMS Department is holding a briefing for the press this afternoon on the release of its Safety Investigative Team Report into the February 24, 2012 fire in Riverdale Heights that injured seven firefighters. The executive summary is below and you can click here to read the entire 300 page report. News coverage of today’s event will be added when available.

Executive Summary 

On February 24, 2012, at 2111 hours, Prince George’s County Fire/Emergency Medical Services (EMS) Department personnel responded to a structure fire at 6404 57th Avenue in Riverdale Heights, Maryland. Upon arrival, Fire/EMS Department personnel observed flames extending out of a basement window, pressurized smoke on the first floor, and high winds impacting the rear of the structure.  

Shortly after arriving, firefighters forced the front door of the structure, which immediately changed the fire’s flow path and dynamics by adding a ventilation opening above the fire. This situation was intensified by weather conditions (high winds impacting the rear of the structure). Firefighters entered the structure through the front door, placing themselves above the basement fire and in its outflow path. This exposed them to high velocity and high temperature gases.  

Two (2) firefighters were trapped on the first floor without the protection of a hose line, when the front door shut behind them and changed the fire’s flow path. The hot smoke and gases that were coming up the interior stairwell and escaping out the front door were now contained to the first floor. This dropped the smoke layer to the floor and temporarily increased the temperatures from floor to ceiling in the front room where the firefighters were trapped. One (1) firefighter was able to self-rescue through a front window and the other firefighter was removed through the front door by other firefighters. The fire in the basement was burning unchecked, until an engine company entered the basement from the rear of the structure and began putting water on the fire.

Ultimately seven (7) firefighters were injured; the two (2) firefighters that were trapped on the first floor sustained the most significant injuries. There have been several documented incidents in the County, as well as nationally, with similar concerning tactics and operations, that have injured or killed firefighters, such as DCFD Cherry Road LODD[1], SFFD Diamond Heights LODD[2], and BCoFD Dowling Circle LODD[3].

This makes the recommendations of this report vitally important.   

The Safety Investigation Team (Team) visited the scene, reviewed statements, conducted interviews, and gathered data during the course of the investigation. The Team identified many factors that contributed to the outcome and injuries to the firefighters. While the report details all of these factors, the Team identified the following as most critical:  

  1. An effective size-up was not completed, including a 360-degree survey walk around the building, as well as evaluating environmental conditions.
  2. No incident action plan was communicated, and firefighters were dangerously positioned above and in the outflow path of the fire.
  3. A firefighter emergency occurred, but no MAYDAY was effectively communicated.
  4. Multiple existing policies and procedures were not followed.
  5. Training deficiencies were identified at all levels.
  6. Command, control, and accountability deficiencies were identified at all levels.  

While the Team analyzed the entire incident, the focus of this investigation was to determine what happened, what factors led to the injuries and, most importantly, what recommendations should be made so future incidents do not have similar or worse outcomes. During the course of the investigation, the Team prepared many recommendations intended to assist the Prince George’s County Fire/EMS Department in improving the operational safety of personnel, fireground operations, command and control of fire incidents, as well as training. These recommendations, which are listed throughout the report, are separated into categories termed: immediate (red – Life safety & firefighter survival), short term (yellow – Relatively easy to implement), and long term (green – May require significant planning including fiscal impacts). A complete list of all recommendations is provided in Appendix 1.

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Comments - Add Yours

  • Fire21

    It took a long time for fire depts to begin looking at why injuries and deaths occurred…it used to be just accepted as part of the job. Now many incidents are being investigated and conclusions drawn, with recommendations for improvement. A lot of depts don’t heed those suggestions, and we continue to have multiple-casualty incidents. Hopefully we all will learn very quickly to listen to those who had time to look at things and offer ways to improve our ops. I believe that most of us can still learn a lot about how to work safely.

  • Anonymous

    Nothing will change.

    • Fire21

      Not with that attitude, it won’t!

  • waheid

    Terrific report, for which the investigating team deserves high marks. Having said that — and this is not a criticism of the report — it must be noted that nothing in the report is new. Unfortunately, we’ve seen it all before and that is what makes these incidents so tragic.

  • 0 cool

    PGfd’s culture needs to change in order to accept the changes recommended. When you have those (on both sides) that can’t, or won’t take responsibility for their actions you are going to get the same results. Everyone needs to be held accountable for safety. The wild west attitude of ” what are they going to do? Fire me or take away my check?” or ” hey the union gots my back”, needs to go away. There is an overflowing horse shoe of luck in the county.

  • Dumb Volunteer

    Stretching attack lines from 3rd and 4th due engines at distances of 400′ and 650′ when there’s an engine sitting in front of the building with 4 out of 6 pre-connects available? I don’t get it, but then again I’m from Pennsyltucky.

  • Anonymous

    there is a house in New Orleans….

  • Anonymous

    3 Things jump out at me:

    1. Will any of the officers involved in this incident be demoted? Mistakes like this that result in serious injuries to multiple firefighters need to have consequences beyond just a report. If being an officer, even a volunteer officer, is to mean anything, there must be accountability.

    2. The stuff about the unauthorized PPE is incredible. Each station needs to implement a system of inspections by officers at the beginning of each shift. You lay our all of your gear, and if anything is unauthorized or missing, you go home. PPE is designed to protect you from serious injuries, not to look cool in your end of year banquet videos.

    3. Maryland remains obsessed with medevac helicopters despite what the evidence shows about their value. From Riverdale to Washington Hospital Center by ground ambulance will almost always be quicker than calling for a helicopter, waiting for it to arrive, packaging the patient, and then the flight. Yet in this case USPP’s chopper was still dispatched to the scene, landed, and then took off without a patient. That’s a big waste of a very valuable resource that, even if used, would likely have had little to no impact on overall patient care. A better triage system and on-scence EMS command would have actually made a difference in this case, but that isn’t as “cool” as having a chopper fly in.

    • Fire Guy

      You’re right on all 3 points. Lets see is the County Commmand Staff has the cajones to do anything about these obvious failures in command and tactics during this incident.

    • 0 Cool

      There is no accountability when it comes to the volunteers of pg. they do what they want. Demoting a vol officer, yeah right. I have a better chance selling you a bridge than that ever happening.

  • Anonymous

    what if they had to go to baltimore? Shock trauma or the hyperbaric chamber?

    why not request a medevac?

    • Anonymous

      Why would victims from a fire in Riverdale be transported to Baltimore? The DC area has more than enough trauma center and hospital capacity to handle a mass casualty incident like this.

      Someone needs to break Maryland out of this Shock Trauma-Medevac cycle it has gotten itself into. Nearly every trauma case in the state goes to Shock Trauma, thus, Shock Trauma handles more cases than nearly any other trauma center in the country, which leads fire and EMS officials to feel like they have to send every case to Shock Trauma.

      The result is that all too often you have thousands of dollars spent flying patients to Baltimore only to have them walk themselves out of the hospital a few hours later. That is not proper triage and case management.

      The State Police Medevac system is a great asset for the state to have, especially for the rural areas. Shock Trauma is a world class hospital that is also an asset for the state. But that doesn’t mean that they have a role in every case. Save them for when they are truly needed.

  • Anonymous

    O Cool, they don’t demote or discipline incompetent career officers, either.

    And there are and have been many of them deserving of it.

    • 0 Cool

      To true, to true, Nope they get hidden away and hope nothing goes wrong. You are absolutly correct.

  • Anonymous

    The entire box assignment was completely volunteers, including the volunteer battalion chief.
    The only career people on this call were the additional additional EMS units, investigators, and upper command staff that were called when the volunteers f-ed up. The report clearly states that general orders were not followed, unapproved PPE was worn, …ect.
    **Changes are already in the process of being implemented. The union and upper management WILL use this opportunity to finally push for more control over the volunteers. A new chain of command will be established. If volunteers want to participate, they will have to test through a series of competency evaluations to become county certified officers similar to a process that career and volunteer medics go through to become county certified medics.
    The career officers are already one step ahead of the volunteers, they are already going through the process. Read the 300 page report, it was one of the recommendations. Also, the safety officers are checking gear on fire scenes and documenting the number of volunteers not wearing approved gear, this is all the amunition they need to prove to county goverment officials that the volunteers are out of control and are going to get someone injured/killed just like the 57th ave incident. They will use the SAFETY word to push the volunteers into compliance or out of existance.

  • OldSchool

    More control of the volunteers will solve it all?? NO, each individual reading this report and wanting to better themselves, instead of bashing volunteers will be more beneficial. The major problem, using this as “political power” which im sure those white shirts in upper marlboro are doing. Its too much to ask to legitimately try to better the combination fire department, its always a “get rid of the vollies” mindset. You must be referring to the career paramedics who make LT, then get thrown into the front seat of an Engine Company having never given layout instructions. Is that how your molding your excellent, street smart LT’s on the career side?? Yes, that happens. And would you believe that it actually gets worse when you promote them to a chief!!! That is the curse of the fire service in general…especially in every fire/ems combo department across the country. So for this specific incident, just because it was all volunteer companies does not automatically give you the right to blindly ignore the days, months and years in the past where incidents have narrowly escaped tragic events. Incidents involving both career and volunteer firemen. Come on, this isn’t a career vs volunteer debate. Fingers can be pointed all day long. If you told me that “career” companies follow the SOG’s and complete ALL their assigned duties on every working fire in this county, I’d laugh hysterically because those who witness the truth, know the truth. We can all be better, so we should all always try to better ourselves. if thats not the attitude you have, then quit the job, paid or volunteer, quit. I’m sick and tired of this union vs volunteer nonsense. Both sides have competent firemen. Both sides have cowards. If you don’t know that by now from being a PG fireman, then you must be one of the cowards who is just “fitting in” with your side of the field. So to all you paycheck collectors, and keyboard cowards, just remember that it might be you next time making split second decisions. It may be you following 3 out of 5 SOG’s in a matter of 60 seconds and things still go wrong. 100% safety will never, ever, ever happen in this job. It’s ok to aim for it, and make it your goal. When leaders start demanding 100% safety on working fires…the job of a true fireman vanishes.

  • John

    DUMB VOLUNTEER…. Why dont you worry about your multi-colored handlines and curb squirting. IF you stop being so ignorant and understood PGs general orders your wouldnt ask a stupid questions about why the 3rd due pulled their own attack line.

  • Fed up

    First, I wish the two young men a speedy recovery. The article the Washington Post published about this fire, as well written as it was; glorified the actions of the firefighters on scene. This report should be used for a training aid in what NOT to do at a fire. I can’t decide what actions on the foreground were the most flagrant. Was it the search in advance of the hose line ? How about the PPE? ( gotta have that cool looking ol leather, no matter how old and non compliant. It just screams salty Jake) The winner (or loser) has to be the flagrant freelancing and lack of accountability. That part alone needs to be the first training class in that house. These guys tout themselves as being all that with their run numbers and volunteer pride. How about being a company officer that is proud that all your guys make it home.