On February 27, 1997, heavy smoke was showing as San Antonio firefighters arrived on the scene of a structure fire at 18:45 hours. Although this structure fire appeared to be like so many others that firefighters responded to throughout the country that day, this fire held special dangers, dangers that were unknown at the time. One critical structural detail that was to influence the outcome of this incident was that the building had limited egress and ingress - an enclosed design, determined to be extremely dangerous and characterized by having very few windows and doors in relation to the size of the structure. Other types of enclosed space include basements and the hallways and stairwells of high rise buildings.
The Structure
The 50- year-old unprotected structure measured 100'x150'x30' and contained a thrift store. Originally, a movie theater with a mezzanine, the single story building was built on a concrete slab foundation and was of non combustible construction having cinder block walls and an unprotected steel truss roof assembly. The roofing was of gravel over composite shingles and tar over four inches of insulating foam.
The means for ventilation and egress were limited. The structure had two plate glass windows, one on each side of double swinging glass doors on the A side. The B side of the building had a solid wall except for a single swinging door at the B /C corner. In addition, the building had three rectangular shaped windows on the D side, but they were covered on the interior by sheetrock and by wooden boards and steel burglar bars on the exterior of the building.
The Action
The firefighters who responded to this incident initially perceived nothing significantly hazardous about the building. As the first arriving officer conducted an initial size up, the thrift store manager informed the officer that everyone was out of the building. Using long established standard operating procedures and the Incident Command System, three engine companies made an offensive attack, aggressively advancing handlines into the thick blinding smoke pouring out of the double doors on the A side.
As the companies attempted to locate the seat of the fire, floodlights and several positive pressure ventilators were placed into operation. However, venting the structure was difficult due to the height of the ceiling, the roof construction, the limited openings, and the high burning fuel load. The floodlights were also ineffective in helping to locate the fire, succeeding only in illuminating the dense smoke that filled the structure.
After cutting utilities, truck companies were ordered to conduct vertical ventilation. A second alarm was called for. As the engine companies searched for the fire through shopping carts and the aisles of clothing racks in zero visibility, one acting officer located and began attacking the fire near the A/D corner only 30-40 feet to the right of the main entrance. At the same time the incident commander ordered an evacuation due to deteriorating conditions. As soon as the acting officer and his crew exited the structure, the acting officer, a 24 year veteran, advised the incident commander that they had located and were attacking the fire at the time the evacuation was ordered. After a brief discussion, an action plan was quickly developed to attack the fire a second time.
After retracing the handline through the loops that had formed in the hose, the acting officer managed to relocate the nozzle and to resume the attack on the fire, but company integrity was lost in the process. As excessive heat continued to build in the structure, a district chief, assigned as the interior sector officer, called for an evacuation and the evacuation tone was activated. Firefighters attempting to exit in zero visibility became disoriented when they ran into a pile of tangled handlines that had formed 15 feet inside the building. These firefighters and the interior sector officer barely managed to escape the structure as they ran out of air.
The acting officer who was attacking the fire at the A/D corner did not exit. The nozzle he was holding was inadvertently jerked out of his hands and out of the building. Alone, in zero visibility and with conditions rapidly deteriorating in the enclosed structure, the acting officer began to crawl in circles sweeping the cluttered floor with his hands searching for the nozzle. However, due to the thick smoke, he was unable to see that the handline had been pulled out of the building and through the front doors located only 30 feet away. With the fire rolling overhead and low on air, he quickly crawled in a direction he thought would lead to the main entrance. In reality, he crawled in the opposite direction, deeper into the structure. When the interior of the structure flashed over, the disoriented acting officer found a window that had been forced open and dove through the fire and out the window on the D side of the building, immediately, paramedics and firefighters, began caring for him and he was airlifted to a local burn unit for emergency treatment.
The Outcome
In his effort to evacuate the structure, the acting officer depleted his air supply inhaling superheated gases causing serious injury to his airway. He also sustained second and third degree burns to his hands, arms, and upper body. After numerous surgeries over a one year period, Fire Apparatus Operator Robert Jacinto returned to full duty at Engine Company #10 located on the busy West Side of San Antonio.
The San Antonio Fire Department instituted many changes as a result of this third alarm fire, including, the acquisition of thermal imaging cameras, safety directional arrows for all handlines, portable radios for all firefighters, an accountability system, formation of rapid intervention teams, training in the "Saving San Antonio's Own" Program, mayday training and adoption of an Enclosed Structure Standard Operating Guideline.
This author conducted a firefighter disorientation study which included, in addition to this incident, an analysis of 17 fires in enclosed structures from around the country where firefighters faced extreme safety risks and became disoriented. This research identified 9 major structural and operational similarities among the incidents. These similarities included:
- 100% occurred in an enclosed structure
- 94% had nothing, light, moderate or heavy smoke showing on arrival
- 100% utilized an aggressive interior attack
- 100% developed prolonged zero visibility conditions
- 100% experienced hand line separation
- 100% experienced loss of company integrity
- 100% experienced disorientation
- 88% lacked a functioning sprinkler system
- 100% involved a disorientation sequence
There was a sequence of events that occurred in each case and that led to firefighter disorientation: the loss of direction due to the lack of vision in a structure fire, common in incidents involving large, medium and even small enclosed structures. The events in the disorientation sequence are:
- Fire in an Enclosed Structure with light, moderate or heavy smoke showing
- An aggressive interior attack
- Deteriorating conditions
- Handline separation or tangled handlines encountered
- Disorientation
It is important to note that the loss of visibility in this incident was primarily caused by thick blinding smoke however study has shown that the loss of visibility can also be caused by fire, a combination of fire and smoke, or conversion steam as a result of flashover, back draft or fire stream application, respectively.
To help prevent firefighter disorientation which often leads to serious injuries, fatalities and narrow escapes, consider the study findings and reconsider the way you attack enclosed structure fires. The full study is available at:
U.S. Firefighter Disorienation Study or through a link at: USFA Firefighter Fatality Website.
or Firefighter Close Calls (for safety & survival downloads).
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