"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: https://www.tdi.texas.gov/reports/fire/documents/fffsadeem.pdf