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Fireground Operations & Tactics » Technical Reports

Santana Row Development Fire (San Jose, California - August 2002) » Lessons Learned

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:

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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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