Plant 44 Audit Reports - Wright-Patterson Air Force Base

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FOR OFFICIAL USE ONLYDistribution authorized to DoD components and their contractors only; administrative/operational use;August 19,2005. Other requests for this document shall be referred to the Chief, AcquisitionEnvironmental Safety & Health Division, Engineering Directorate, ASC/ENV, Wright Patterson AirForce Base, OH 454333.1.4. Mutual Aid. The Fire Officers were counting on several fire ground duties, operations and supportto be performed by outside fire companies during the early stages ofthe incident. The IC adjustedwell without them during the initial attack with their limited staffing. Once the mutual aid supportshowed at the gates, the security escort and coordination with the fire department IC was wellexecuted.3.] .5. Radio communication and the switch to the emergency frequency were well demonstrated.However, communication inside the building was degraded which jeopardizes the safety ofthefirefighters.3.1.6. Hose Advancement: The appropriate fire hydrant was used to supply the first Engine. However,the crews delayed the pulling ofthe pre-connect hose lines. When the crews attempted to pull thehose down to the basement the hose tangled and there were not enough firefighters (FFs) availableto assist. There was also a delay in charging the line. Once in the basement, the crews haddifficulties advancing the line due to the line was charged and tangled outside the building. Aftera short advance toward the simulated fire and victim, one FF ran short on air and had to withdraw.This action required both FFs to exit the building. Instead of laying the nozzle down they delayedtheir exit by attempting to remove the hose back to the exit instead of following the hose out.However, they did exit as a team instead of separating. In tum, by not laying the hose downdelayed the replacement crews in fire fighting efforts and rescue attempt. The second crew wasnot briefed by the first crew as to the process already accomplished. The crews also failed to takeappropriate equipment with them on the initial attack i.e., the thermal imaging device which wouldhave enhanced their probability of finding the fire and victim. (Action required)3.1.7. Incident Management System: The IC set up in an ideal location and had complete vision oftheoperations. Although a checklist was not used, the IC demonstrated total knowledge of hisresponsibilities and duties. His command and control abilities were well performed. Thesupporting personnel, i.e., security, maintenance, etc reported to the IC and all were gathered in asafe area away from danger. The communications between the operation commander and handline personnel were weak. The first crews to arrive fai led to report their observation of the sceneimmediately to dispatch and the IC after an input card was provided. The OpslC was over tasktrying to perform duties ofthe OpslC and Safety Officer. FFs were entering the basement withoutaccountability and reporting to or being directed by the OpsIC. As a result, the fire suppressionand rescue operation was being performed in an unsafe manner and the objectives ofsaving a lifeand extinguishing the fire was not met. Once it was determined the fire could not be extinguishand the victim could not be rescued, the IC immediately placed his crew in a defense mode which,unfortunately, was the proper call. Recommendation: Provide more FFs on the fire groundslAW NFPA ]710. (Action required)3.1.8. Immediate Danger to Life and Health (IDLH): The IDLH was not declared. This made it unclearas to where to set up the Accountability person and where FFs were required to be 'on-air' andwhere the Rapid Intervention Team (RIT) and Rehab area were to be formed. Recommendation:Conduct more exercises. Ensure all fire operations are lAW local standards and procedures andmeet all the National Standards as required. Procedures shall be in place to identify the IDLH areaIAW NFPA ]500 for all exercises and emergency responses involving fire and/or Hazmatincidents plus broadcasting as required. Ref: OSHA 191 0.134(g), NFPA ]500, par. 5-3,6-4.(Action required)3.1.9. Rehab: The rehab vehicle and equipment was set up as directed by the IC in a safe area awayfrom immediate danger. However, with limited staffing, it was not always manned. When FFswere directed to go the rehab. the EMT/paramedic was not equipped with necessarytools/equipment i.e., a watch with a sweep hand to take vitals, etc. By not having the requirednumber of FFs on scene, FFs are performing prolong duties without proper rehab.Recommendation: Follow the Raytheon medical department's recommendation as to whatequipment is necessary for the safe being of FF on scene to ensure proper rehab and care.3.1.10. Safety Officer: Department is not properly staff to assign a Safety Officer at an emergencyincident. The Safety Officer was not readily identified by a vest or the like. He did not ensure thatATCH2
FOR OFFICIAL USE ONLYDistribution authorized to DoD components and their contractors only; administrative/operational use;August 19,2005. Other requests for this document shall be referred to the Chief, AcquisitionEnvironmental Safety & Health Division, Engineering Directorate, ASC/ENV, Wright Patterson AirForce Base, OH 45433the fire department's personnel accountability system was being utilized. A FF entered the firearea (IDLH zone) unaccompanied to deliver the thermal imaging device to the hand-line crew.Although there is a lack of FFs on the fire grounds the OpslC, Safety Officer, and theAccountability person should have disallowed the separations of fire crews. Also he did notensure that established safety zones, collapse zones, hot zone, and other designated hazard areasare communicated to all members present on scene and advise the incident commander of hazards,collapse potential, and any fire extension in such building(s). Also, the inside of the building wasnot checked for fire extension. The exercise was terminated before the fire was under control andbefore a primary and secondary search could be accomplished. Recommendation: The firedepartment shall have a Safety Office that meets the requirement ofNFPA 1521, Standard/orFire Department Safety Officer. Separate training subjects are required for the fire departmentSafety Offices. Also include procedures to perform 360-degree checks for fire extension. (Actionrequired)3.UI. Accountability: The accountability program did not work as planned. The accountability personis normally the last-chance person to check FFs for proper use of PPE. One FF entered thebuilding with a loose mask which ended in delay of fighting fire and rescuing victims. In addition,a Personnel Accountable Report (PAR) was not conducted routinely and after a firefighter comeout of the fire area due to the lack ofair. (Action required)3.1.12. Personnel Protective Equipment (PPE): The use of PPE including self-contained breathingapparatus (SCBA) and the enthusiasm expressed by the firefighters are commendable. However,not knowing where the IDLH area is located caused most of the firefighters to go on airprematurely. Also a buddy check could not be performed at the IDLH area to ensure a 'Iastchance' check ofPPE. Recommendation: A 'buddy system' should be used by the firefightersto ensure PPE and other equipment is properly in placed and ready to use as designed prior tostarting assigned duties inside the IDLH area. This is normally done by the Accountability person.(Action required)3.1.13. The Rapid Intervention Team (RIT): Although the fire department followed the standards for theinitial response to have '2-in and 2-out', the department failed to established a dedicated RIT lAWNFPA 1500. The second engine company to arrive failed to lay a backup line for the RlT. SeeNFPA 1500, para 8.4. (Action required)3.1.14. Rescue Operations: The lack of adequate number ofFFs on the fire ground, a rescue team was notformed. As a result, the objective of performing a rapid and safe rescue was not met. (Actionrequired)3.2 Recommendations: Develop checklist for expected incidents to be used during emergencies andchecklist for post incident briefings. Increase the training frequency without mutual aid support untildesired proficiency and knowledge are demonstrated. The training program shall be designed to improveindividual knowledge, confidence and performance reliability. The proficiency-training program shallenhance a firefighter's ability to work as team members. Operational procedures shall be established toidentifY and transmit the IDLH area for every structural emergency/exercises keeping in mind that the areacan be shorten as conditions change. The purchase ofa smoke machine and light kits will enhance thetraining program and make it more realistic for identifYing the IDLH zone and fire area. In addition, werecommend the IC's vehicle carry equipment that would provide wind speed and direction at the scene.With the close proximity offacilities at Raytheon the condition of wind current could change withoutnotice or knowledge of the dispatcher. Also increase the number of firefighters assigned to fire groundoperations beyond the defensive mode as demonstrated above.3.3 Summary: The fire department failed to meet objectives. The exercise utilized the assistance of the8-hour staff yet was unsuccessful. Having less FF during other shifts, weekends, and holiday force thedepartment to respond in a defensive mode until other recourses arrive. This was demonstrated in theabove exercise when the initial attempt failed and the IC was forced to place his department in thedefensive mode for the safety of his firefighters. This method is unacceptable for the protection ofATCH2
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RECORD REPRODUCTION COVER SHEETThe
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TRIP REPORT1. PERSONS MAKING THIS T
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ATTACHMENTS:I. Normal Maintenance R
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d. Building 811 A walk-through of t
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ii. Exterior wall is damaged and bi
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Photo 3Building 833 Damaged WallPho
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4. FACILITY REVIEW OBSERVATIONSThe
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4.4.2. Building 80 I, room G 1315.
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Air Force Plant 44 Facilities Revie
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3.17 Finding 04-17. Bldg 830. Cinci
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The audit followed an audit protoco
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AFP 44 ANNUAL FACILITIES REVIEW8 -
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local standards and procedures and
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FOR OFFICIAL USE ONLYDistribution a
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Plant 44 Audit Reports - Wright-Patterson Air Force Base

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