A split second decision

‘Breakdown in communications’ cited in library fire report

Just more than a year after the Porterville Public Library fire, the City of Porterville and the Porterville Fire Department (PFD) received the complete Multi-agency Serious Accident Review Team (SART) Investigation Report which provided a comprehensive timeline of the incident, as well as more than 25 findings and recommendations from the incident PFD will use moving forward.

The report details a fateful two minute — 4:18 to 4:19 p.m. — in which Porterville Fire Captain Raymond Figueroa and Porterville Firefighter Patrick Jones who lost their lives — made the decision to enter to search for someone in the building even though it eventually turned out no one was in the library. The report also details a breakdown in communication.

THE TIMELINE

According to the SART report’s timeline of the incident, which was gathered through police and fire dispatch audio, CAD information, helmet camera footage, body-camera footage and interviews, at 4:16 p.m. on February 18, 2020, dispatchers received reports of a fire a the Porterville Public Library on Thurman Avenue. Within the same minute, Engines 71 and 72 and Battalion Chief 77 were dispatched to the incident. The first responding Porterville Police Department (PPD) Officer was on scene at 4:17 p.m. The PPD officer confirmed the first floor of the library was clear of occupants.

At 4:18 p.m. Engine 71 (E-71) was the first engine to arrive on scene. “Captain 71,” Porterville Fire Captain Ray

mond Figueroa, as the SART report states, radioed to incoming units there was heavy smoke coming from the entrance of the building. Figueroa received reports the fire was in the back of the building, and the crew from E-71 began using a hoseline at the front entrance. At the same time, Battalion Chief 70 (B-70) responded to the incident and reported heavy smoke and requested traffic control, notification to Socal Gas Utility and Southern California Edison, as well as the staging of two ambulances at the scene.

At 4:18 p.m. the first responding PPD officer reported the building was clear to B-70. B-70 then directed Figueroa to initiate an attack on the fire. In this same minute, a bystander reported a woman with a walker trapped on the second floor of the library to a second PPD officer.

After receiving the report of the potentially trapped woman, at 4:19 p.m. in a split-second decision, Figueroa and “Firefighter 71,” Porterville Firefighter Patrick Jones, made entry into the library through the entrance of the building, without a hoseline or tagline, to search for the victim. This decision to enter and search the building wasn’t communicated to B-70 or any of the other responding resources at the scene.

At 4:19 p.m., B-70 established Library Command and directed Fire Truck 73 to enter the scene from Hockett

Street and establish a water supply. A minute later, a third PPD officer confirmed they had searched the second floor and the reported woman with the walker had exited the building and immediately advised Engineer 71 of this.

At 4:21 p.m., Battalion Chief 77 (B-77) arrived at the scene and confirmed the heavy smoke and fire. B-77 requested all radio traffic to Channel 2. It’s PFDS policy for every unit working on an incident with two or more units to use Channel 2 for radio communications. B-77 directed Truck 73 to attack the fire through a window on Hockett Street and confirmed the plan with E-71. At this time, Engine 72 (E-72) arrived on scene.

B-77 took command from B-70 and initiated a “second alarm” which called back off-duty personnel to respond to the scene. B-77 requested additional mutual aid as well. B-77 met with Engineer 71 but it’s unknown what was discussed.

According to the SART report, at 4:23 p.m., B-77 attempted to contact Figueroa on Channel 2, but he didn’t respond. Engineer 71 confirmed Figueroa and Jones were inside the structure, prompting B-77 to ask Figueroa for a Conditions, Actons, Needs (CAN) report.

At 4:24 p.m., Figueroa contacted B-77 on Channel 1 and said they had cleared the library’s banquet room and were continuing their search. Figueroa relayed the report of a woman in a wheelchair and asked B-77 if he could confirm if she was still in the building. B-77 stated he believed she was out, but would confirm when he could. B-77 asked Figueroa to switch his radio communications to Channel 2 if possible.

At 4:26 p.m., B-77 attempted contact with Figueroa on Channel 2. Figueroa responded, but B-77 didn’t acknowledge his response. At 4:27 p.m. B-77 attempted to contact Figueroa on Channel 1, but Figueroa didn’t respond. B-77 attempted to contact him on Channel 2. Figueroa responded, and B-77 didn’t acknowledge his response. B-77 attempted contact with Figueroa a second time on Channel 2. Figueroa responded, and B-77 didn’t acknowledge his response.

At 4:28 p.m., B-77 attempted contact with Figueroa on Channel 2. Figueroa didn’t respond. At 4:31 p.m., B-77 directed a training captain to form a Rapid Intervention Crew (RIC) to locate Figueroa.

At 4:32 p.m., the same time Fire Chief Dave Lapere arrived on scene, Figueroa declared “mayday” over the radio.

“We came up the stairwell,” said Figueroa. “We thought we were in the banquet room, trying to locate the stairwell. We’re running low on air.”

B-77 told Figueroa a team of two would be entering the building to locate them, to which Figueroa repeated he and Jones were low on air. The low air alarm could be heard sounding in the background, and Figueroa informed B-77 they would be activating their Personal

Alert Safety System (PASS) devices. Radio traffic was switched to Channel 2 in order to take care of the mayday call on Channel 1.

Lapere assumed command of the incident while B-77 continued handling the mayday call. B-70 initiated an RIC crew of three to head into the building to check for Figueroa and Jones.

At 4:38 p.m., one of the three crew members reported they had made it to the second floor stairwell and could hear the PASS alarms and advised there was no fire but also no visibility.

The RIC team located Figueroa in the restroom at 4:40 p.m. and requested additional manpower. The team was able to partially extract Figueroa before running low on air and passing the task on to a second RIC team.

At 4:50 p.m., Figueroa was removed from the building and taken to Sierra View Medical Center where he was pronounced dead.

Efforts to locate Jones continued with several more RIC teams. Due to low visibility and building collapse, rescue efforts were suspended and the fire attack resumed.

JONES FOUND

In the early hours of February 19, in a coordinated effort between the Tulare and Kings County Fire Investigation Strike Team, just before midnight, Jones was located in the library. He was deceased. Jones’ body was removed from the building by members of the rescue team and members of PFD.

“There are basically three components of (the report),” said Mike Kraus, retired Fire Chief for Modesto Fire Department and the lead for the SART report. “Number one is the fact finding process. This includes interviews of the firefighters that were on the scene, body cam footage, helmet cam footage, radio traffic, that kind of thing. The goal in fact finding is for us as a team to reassemble the incident and get it as accurate as possible. From there we pair what we’ve found up against best practices and industry standards. When we do that usually gaps show up, so the third portion is issuing recommendations to fill those gaps.”

Among the dozens of findings in the SART report, the miscommunication between responding personnel is highlighted the most. Another major finding in the SART report for the department was there were needs in the areas of training and staffing.

“For me, all of the findings are major,” said Lapere. “There are some I would say that are driven by cost, some are driven by time and logistical requirements. It runs the gamut. It was a full comprehensive review of the department. I initiated a third party report, which not every department does. I thought it was important to do that because of the fact that this is not only a report for the Porterville Fire Department, but for the entire fire service. The commonalities in the findings are throughout the entire industry.”

Lapere says some of the staffing and training issues are already being bolstered, and the department is addressing the things it immediately can right away.

“With all of the findings and recommendations, I have the Council and City Manager’s full support,” siad Lapere. “There is going to be an annual report issued from the fire department each year with our activities and, moving forward, in that report will be a section of where we are at in achieving those recommendations. One of the findings that the National Institute for Occupational Safety and Health (NIOSH) has found is that a commonality in firefighter fatalities is the breakdown in communications. It really boils back down to a training issue. Moving forward with the recommendations, we are going to be looking in our training division to go after those findings right away and correct those.”

With many findings to rectify, Lapere said it will be a long time before all of the recommendations are complete.

“This will be a multigenerational endeavor,” said Lapere. “I’m sure to get all of the findings done will be past my tenure and on to the next chief. We will be doing our diligence to make sure we move forward on that always. I would like to thank the SART Team and the amount of hours they put out and the steadfast emotional support from the other chiefs in the area, the community, the Council and the City Manager.”