Marshal's Report: Circumstances Leading to Deem Death 'Were Preventable"

"The  circumstances  surrounding  the  death  of Firefighter  Deem,  severe  injury  of  Firefighter  Phipps,  and injury of  Firefighter Vasquez were preventable."

With that sentence, a one hundred plus page report on the May 2017 Ingram Square fire that cost the life of San Antonio Firefighter Scott Deem recommends several key changes in SAFD management, training, and fire scene procedures to prevent a similar tragedy in the future, News Radio 1200 WOAI reports.

"The actions leading to the findings in this report collectively led to  the tragedy at this incident.  The goal of  this report is  to  challenge  the San Antonio Fire Department to meet national fire service best practices identified in the recommendations to minimize risk exposure to the men and women of  the SAFD. That path  will  honor  the  memory  of   FF  Deem  and  take  a  good  fire  department  to  an  even higher level of  performance," the report says.

The Fire Marshal conducts an after action report whenever a firefighter is killed fighting a fire, and the marshal stresses that his report is not meant to criticize, but to provide instruction to honor the service and memory of Firefighter Deem by instituting changes to prevent another firefighter from dying.

Among the recommendations:

*Prohibit the practice of firefighters 'freelancing' at fire scenes.  The report cited a 'go get it' attitude in the SAFD which prompts firefighters to take action they feel is critical in fighting a fire, without the support of other firefighters.  "It  is  critical  that  any  SAFD  members  who  are  known  to  promote  the  independent and “Go Get It” attitude that might result in a disregard for command structure, firefighter  safety  or  fire  suppression  best  practices,  be  dealt  with  directly  by supervisors  and  managers.  This  should  be  addressed  through  remedial  training, disciplinary action, or if  necessary, relayed to the SAFD senior staff  for action," the report concluded.

*Come up with new procedures on when to call for a 'Mayday,' and organize the radio channels that are needed for a 'Mayday' situation.

*A key recommendation is to require more frequent and more thorough fire inspections, and denials of certificates of occupancy for buildings which don't meet fire codes.  They also recommend that 'pre-fire plans' be on file for commercial buildings, which would give firefighters information on floor plans, the type of building materials used, and other key items of information.  "At  the  time  of   the  fire,  none  of   the  involved  occupancies  had  a  fire  sprinkler  system installed. This allowed the initial fire to grow in size and severity. Fire sprinkler systems have an  excellent  record  of   saving  lives  and  property.  Some  portable  fire  extinguishers were present in various occupancies. Several penetrations in the walls between units were not sealed correctly to prevent fire spread. An inspection of  the property would have  likely  identified unsealed penetrations in the fire  wall separating the gym from the storage area."

*The report also recommends a 'a culture of continuous improvement' within the SAFD.  "While  San  Antonio  Fire  Department  has  many  good  policies  and  procedures  in  place, pockets of  members remain who are resistant to change. The SAFD would benefit from a culture of  continuous improvement.    Despite  improvements  in personal  protective  equipment  (PPE),  apparatus  safety  devices,  more  availability  of  training,  greater  emphasis  on firefighter health and wellness, and decreases in the number of  fires  and dollar loss  due to fires,  the rate of  on-duty firefighter death  and injury has remained relatively un-changed in the past four decades."

The report also recommends specific improvements in training, organizational accountability, and risk control.

Chief Charles Hood has pledged to implement the recommendations, 'to honor the memory of Firefighter Deem.'

READ: the full report:

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