We use the term “baptism by fire” in the fire service to measure that milestone that we achieve with our first big fire; our first true test as a firefighter. The “baptism” welcomes us into a world where ranks are closed very tightly and bonds are never to be broken. And when one dies, the aggrieved mourns the loss, but it is the fire department that captures all of the attention.
This blog is done with respect to and in honor of Fire Paramedic Apprentice (FPA) Rachel Wilson of the Baltimore City Fire Department, who died during a training exercise on February 9, 2007.
The intent of this blog is to examine pre-incident issues, post-incident issues, recommendations that were made post-incident and corrective measures taken to date. Comments are welcome, but they will be respectful, thoughtful and most of all, civil. I expect there to be differences of opinions, but again; they will be respectful replies.
Because of the many issues involved, I believe that it is important that a dissection of available information takes place and we intake them as lessons learned.
First of all, I know very little about the “inner” workings of one of our storied fire departments in this country; Balitmore City Fire Department. After all, they were the backdrop for the feature film “Ladder 49”.
However; though I may not know how BCFD fulfills their mission statement, I know how it should work at ANY fire department, because firefighters are NOT supposed to die during their training. They are supposed to be learning the skills that will keep them alive!
I will tell you that, based on the information circulated after the death of FPA Rachel Wilson and since, it appears that this tragic incident has become a political football and though inappropriate, it is the exclamation point to a series of decisions that may have been made for the wrong reasons that culminated in the death of a 29 year old mother of two small children.
After I read the NIOSH report for this LODD, I was reminded of a training death that occurred on September 25, 2001. Bradley Golden died during a training exercise in Lairdsville, NY.
I was reminded because, in my opinion in both cases, leadership failed. Those who were charged with protecting these new probationary firefighters, failed to do so. Make no mistake; that “protection” begins from the selection process through the rest of their tenure with the fire department.
They are similar incidents because, in both cases, national standards that could have protected them were either violated or ignored. They certainly were not followed. As an example; in both cases, more than ONE fire was set and materials containing petro-chemical components were used as fuel for the training fires.
The other, obvious similarity between the two was that; post-incident, no one was willing to accept responsibility for their actions/inactions. Baltimore Mayor Dixon wasn’t accepting responsibility for Rachel Wilson’s death, even though she pushed for diversity for city employees.
BCFD Chief Goodwin fired three officers because he wasn’t accepting responsibility for Wilson’s training death, even though it was his personal pick heading up the training academy.
In the Lairdsville, NY case, at least the person who refused to take responsibility for his actions was arrested, charged, tried and convicted of contributing to the death of Bradley Golden.
FPA Rachel Wilson was described in the NIOSH report as a 29 year old female, who stood 5’ 4” tall and weighed 192 pounds. According to the CDC Body Mass Index Calculator, Wilson’s BMI was 33; considered to be “obese”. A weight of 110 – 140 pounds for that height would produce a “normal” range BMI stat. This could have been a factor with Wilson’s inability to self-evacuate through a window with a 41” high sill.
Furthermore, there were accusations made early on in the investigation that diversity was a key consideration in Wilson’s hiring. In addition, at the time of FPA Wilson’s training death, the fire department did not have any physical fitness requirements. In other words, NO CPAT (Candidate Physical Ability Test)!
During the post-incident investigation, all fire department officers interviewed, stated that the “city had removed physical fitness requirements” some years before, in an “attempt to recruit a more diversified work force”. The fire department had a physical agility test that lacked national consensus and it relied on “self-elimination” of candidates. The environment at the fire academy was to pressure the less qualified recruits to drop out,” according to interviews.
So; if a candidate made a poor decision to apply, what are the chances that they will make the decision to “self-eliminate”? It is common during the agility portion of a CPAT certified course to FAIL. This tells that applicant: (a) better luck next time and (b) go get into better physical shape and come back. BUT; you don’t get hired until you can pass and damn the diversity initiatives, because being fit for the job has NOTHING to do with race, gender or religion.
Without knowing BCFD’s complete testing process, reports stated that FPA Wilson experienced “mask claustrophobia” during previous training evolutions. Additionally, Wilson had not met the minimum time of the physical agility test. It was reported that Wilson tested again just prior to the live burn and produced a slower time than her initial test time.
So; it is clear that FPA Rachel Wilson’s firefighter skill sets were being brought into question, but only after her death.
Reports were saying that certified fire instructors in Maryland were in short supply. Plus, it was costly to schedule and hire them for training, so, under the watchful eye of Chief Goodwin, the fire department was going to save money by hiring “adjunct” instructors and pay them with more time off, which simply means that he was going to use HIS people and instead of paying them overtime, they would be given more Kelly days. But, wouldn’t someone have to cover them in the rotation and wouldn’t they be paid overtime to do it?
It was reported that, on the day of Wilson’s death, none of the adjunct instructors participating had any training as a fire instructor. Also reported was that the adjunct instructor in FPA Wilson’s squad was doing so for the FIRST time.
Personal Protective Equipment (PPE) is a very important component to personal safety and especially to a firefighter. Turnout gear is literally their barrier to extreme heat and death. According to reports, turnout gear was replaced on the “front lines” and the throwaways were taken to the fire academy, where cadets would select their “gear” for training. On February 9, 2007, FPA Wilson was wearing a coat that was 5 years old and was dirty, but within compliance. Her pants, on the other hand, were 10 years old and well past their useful life and beyond repair. The crotch area shows extreme wear and tear and it was reported that the moisture barrier was no longer effective.
Radios, flashlights and SCBAs were provided on an “as needed” basis. Through interviews, it was noted that some of the participants did not have Personal Alert Safety System (PASS) devices and some instructors did not have radios.
One could suppose that poor communication caused NINE (9) fires to be set, with seven (7) of those fires set underneath the “fire floor”; in this case, the third floor, where Wilson’s crew was to extinguish a training fire (s).
For the training fires, according to NIOSH, a mixture of excelsior, wooden pallets, tree branches, an automotive tire, bed mattresses and foam rubber from a chair were used. Anyone with even a tacit knowledge of NFPA 1403 knows that you only use material with “known burn characteristics”.
The fires were arranged in “teepee” and “lean-to” fashion, both acceptable; however, stuffing excelsior into voids and vent areas are not.
Reports (NIOSH) state that FPA Wilson had difficulty controlling the hose line. As the fire that stood in their way on the second floor grew, her instructor took the hose, knocked down the fire on the second floor and then they advanced to the top floor, where conditions soon deteriorated.
Their exit was a window that led to a second story roof top. The window was approximately 28” wide and the window sill was 41” from the floor (see report). FPA Wilson could not self-evacuate through the window with the rest of her crew. It took a valiant effort for crews to push through the second floor and up to the third floor in order to assist with the rescue of FPA Wilson. She was in serious condition, quickly transported to the hospital, where she was pronounced dead from her injuries.
Mayor Dixon expressed outrage in a press release. Chief Goodwin stated that, if policies were violated, people would be held responsible. His recommendations were sent to the mayor for her press release.
An interesting termination occurred with the officer who was in charge of RIT. According to reports, the RIT officer was on “light duty” and could not actively participate. Had NFPA 1403 been followed, the likelihood of activating the team would have been highly unlikely.
On the day of the incident and during the press conference afterwards, Chief Goodwin praised everyone involved for their “valiant efforts” to rescue FPA Rachel Wilson. So; why would the officer in charge of RIT be one of the three terminated from the department? How was this reward for a “valiant effort”?
Why would anyone on “light duty” be involved beyond the planning stage of a live burn exercise? Who made the decision to place a person on light duty at the scene of a live burn and be put in charge of RIT?
Who made the decision to use this three story, dilapidated piece of crap as a live burn training exercise?
Who made the decision to set more than one training fire at a time during the training evolution?
Who allowed materials with known petro-chemical properties to be used as fuel for the training exercise?
And at the very beginning that led to a very sad ending: who made the decision to hire FPA Rachel Wilson?
Was the decision to hire Rachel Wilson made by city hall to achieve diversity? If so, then the mayor should be held accountable.
If Chief Goodwin allowed the culture that ultimately led to the death of Rachel Wilson, then he needed to be held accountable.
Who was accountable for Rachel Wilson on the day she was hired and on the day that she died?
How can the fire service be the face of compassion, if we show little, if any for our own? It becomes increasingly harder to save lives if we kill the ones hired to do that.
And at the end, there is a hypocrisy that allows for a middle aged, out of shape, paperweight to decree CPAT for everyone…else!
That same hypocrisy allows us to spin our information. I applaud BCFD for implementing the corrective actions to the ten (10) NIOSH recommendations. Note that I didn’t say “changes” as Chief Clack did. “Change” is what will occur within the department AFTER the recommendations are implemented.
And if anyone is looking for “justice” out of all of this?
Let’s just say that there must be a “sliding” scale, because in New York, you can go to jail if you don’t protect your people’s safety, but in Maryland? You just move on to bigger and better things.
Here are the links that I promised:
http://www.emsnetwork.org/artman/publish/article_25310.shtml
http://www.baltimoresun2.com/talk/showthread.php?t=112618
http://www.cdc.gov/niosh/fire/reports/face200709.html
http://wjz.com/topstories/firefighter.injured.west.2.425362.html
http://www.baltimorecity.gov/news/press/02-22-07StatementonWilsonInvestigation.pdf
http://www.ci.baltimore.md.us/government/fire/downloads/1208/121908%20NIOSH%20Report%202008.pdf
http://www.citypaper.com/news/story.asp?id=13835
http://www.cdc.gov/niosh/fire/reports/face200138.html
http://www.cwhms.com/news.php?id=1
http://www.firefighterclosecalls.com/pdf/BaltimoreTrainingLODDFinalReport82307.pdf
TCSS.
This article is protected by federal copyright under The Adventures of Jake and Vinnie© umbrella. It cannot be re-produced in any form without the expressed permission of the original author.
Also on Chief Reason …
- Be Honest; Call It Bureaucratic Bulls**t! – November 18, 2009
- Can We Put Risk Out of Business? – February 16, 2009
- Will Tragic History Be Repeated? You Decide! – December 7, 2009
- Ever-Changing is Always Confusing! – April 18, 2010
As someone who was there at the time, I can only say you are only scratching the surface.