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Following the incident, a five-member team interviewed all of the companies that
had been at the fire, including the chief officers from the mutual aid departments that had
responded to assist San Jose. A formal post-incident evaluation was also conducted on
October 17, 2002 and the department published a formal report on the incident, which
was presented to the City Council on December 17, 2002. The report included eight
priority findings. Those findings were:
- There is a pressing need for County-wide Radio/Data interoperability
- The Department needs to acquire additional radio frequencies
- A review of the best construction practices should be undertaken
- The mutual aid plan needs to be reviewed
- The computer aided dispatch system needs to be reviewed and evaluated
- Additional staffing and fire stations are needed
- Additional handheld radios are needed
- Update training for the EOC is needed
Many of the findings had been identified prior to the fire and were reinforced by
the problems encountered during the event, particularly the adequacy of the Department’s
communications system. Interviews conducted with senior fire department officials
revealed a number of key lessons learned from the incident:
- Identify an extraordinary event early into the incident.
The resources to adequately suppress and manage simultaneous incidents of the
magnitude as those presented by this event, while maintaining the ability to respond
to the routine fire and medical calls normally handled on a daily basis are beyond
the capabilities of all but the largest of agencies. Senior command officials believe
that they should have realized much sooner that this was an extraordinary event and
that a unified command structure should have been put into place to manage the
event, rather than trying to simultaneous manage the individual incidents. An early
activation of the EOC would have facilitated this process much better.
The local commander is often overwhelmed by the incident at hand and does not
have the luxury of a global perspective afforded by unified command. For example,
a unified command would have instituted ember patrols that potentially might have
lessened the impact of the fires downwind from Santana Row. A Unified Command
might have recalled the off-duty command officers who had gone home from the
staff meeting and who were awaiting recall. Only one safety officer was formally
appointed at each incident. Incidents of this magnitude require more than one safety
officer, a role easily played by off-duty command officers. Finally, off-duty personnel
might have been recalled to staff the fire watch thus relieving weary companies
to return to their stations and regroup for the balance of their shift.
Finally, the City was used to giving mutual aid and had little experience with receiving
mutual aid because of the size of its fire department. Unified command would
have helped manage the process more smoothly and would have facilitated the
deployment of mutual aid resources.
- A formal system of staging is crucial for proper resource management.
Attempts were made to stage apparatus in accordance with the established ICS guidelines
at both Santana Row and Huff/Moorpark. However, both incidents developed so
quickly that staging efforts deteriorated quickly. Companies put themselves to work
and off-duty personnel self dispatched to staff some of the reserve apparatus. When
staging falls apart, overall accountability is compromised. Fortunately, no one was
killed or seriously injured perhaps because most of the suppression efforts were
defensive in nature. Confusion was present as the communications system broke
down and numerous structural collapses occurred. Such factors place emergency
responders in harms way and require a through accountability effort.
Formalized staging also assists in maintain an adequate presence of RIT teams.
While small, routine events normally only require a single team, large events
necessitate the presence of multiple teams that are strategically placed for the
greatest effectiveness. A rapid depletion of staging companies can result in RIT
teams being diverted to suppression efforts without a timely replacement.
- Large scale incidents require the use of a formalized rehabilitation system.
Rehab was informal at both incidents. Normally, firefighters are sent to rehab for an
extended period of time after the use of two air bottles or about forty-five to sixty
minutes. Many firefighters worked up to three hours without a break during this
event and were quickly put back to work. Additional alarms may need to be called
in order to properly rehab personnel, which may overtax already depleted resources.
If mutual aid companies have to be called in for this purpose, those resources need
to be ordered early in an event to sure their timely arrival. Adequate re-hydration
and medical supervision are essential, particularly during extreme weather conditions
or unusually taxing events.
- Utilization of Equipment.
Many of the master stream appliances were equipped with fog nozzles. Due to the
intense radiant heat and the potential for structural collapse, many of the appliances
were positioned beyond the effective reach of a fog stream. Straight tips or smooth
bore nozzles provide a longer effective reach under such conditions. During defensive
operations, personnel must be trained to change over to straight tips to ensure
the effectiveness of their efforts. Likewise, pre-piped deck guns are also quicker to
place into service and have a higher vertical reach than portable master stream
devices that are normally positioned on the ground.
- Communications systems are quickly overloaded.
The call volume quickly overloaded the fire department’s communications system
even though the police department did not transfer all of the fire calls and helped
answer the 911 calls. In addition, the mutual aid dispatch process is not automated,
which complicated matters as well and delayed the arrival of resources
beyond the third alarm at the Huff/Moorpark fire. The amount of radio traffic
also exceeded the capabilities of the department’s radio system and there were
insufficient numbers of handheld radios available to suppression forces. Sufficient radio frequencies are necessary to divide the load among the several
divisions and sectors frequently established at large incidents and sector or
divisional commanders need to be in contact with both their subordinates as
well as command.
- Community relationships are important following a large incident.
There was an early admission that the fire department did not meet everyone’s
expectations following the fire even though a meeting was held shortly after the
fire to gather the community’s input. Fire department leaders must be sensitive to
the perceptions of the community with respect to their actions and the attention
paid to their needs. Partnerships with such agencies as the City’s housing department,
the Red Cross, and Salvation Army proved invaluable in this situation, but
many residents felt that more could have been done to assist them.
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