The information contained in the reports brought forth a variety of primal urges in me that ranged from mad to sick to sad to disturbed and back to mad. Nine firefighters died and the lives of an untold number of people are changed forever for a few sofas and a cobbled-together old building. The fire didn't need to have the devastating outcomes we now morn and try to understand.

The facts and circumstances of this horrific situation, as so skillfully and carefully described in the reports on this incident, provide us all with lessons we would do well to learn in the aftermath of this tragedy. Learning lessons of this fire is one of the only positive things we can do to make sense out of so much loss and grief.

The building burned in a predictable manner based on the analysis of the actual design, condition and construction. It matters for our future that we understand that building and fire codes are developed and adopted as they are to prevent this sort of tragedy. In this case, they simply were not followed and in some cases knowingly circumvented. When a little code violation is allowed to slide here and there, as seems to have been done in this case, the cumulative effect was that they created the death trap that this building became as the fire progressed. I think the lesson is to enforce your building and fire code as if lives depend on it, because they do.

The progression of this fire occurred according to the design and construction of the building. Had proper building permits and the associated code provisions and requirements been met, the result of this fire would have been much different — as would have been the outcomes. A relatively small fire with some soggy sofas would have been the result with a few sprinkler heads properly operating had they been installed as required by their code. The report made that perfectly clear to me.

The firefighters used the tools and equipment in the manner that the organization intended for them to do. They acted as they were trained to act and they functioned in a manner that had reportedly been successful for them in the past. The lessons for us in the training, equipping and staffing of our own fire department are many. Firefighting is both a science and an art. Our personnel must be highly schooled in both. It is important, as Billy Goldfeder has suggested and Chief Routley agreed, that large sections of these reports can be taken as a sort of blue print for the rest of us. I would be shocked if any of us honestly can say that there are no structures in our jurisdictions that haven't somehow circumvented the established codes or slipped under our radar for effective pre-fire planning.

In the end it was a situation where the heat generated by the fire was much greater and was produced at a much faster rate than the heat absorbed by the operating fire streams. The fire simply could not be extinguished by the effectively operating hose streams inside and outside of the building. The firefighters died trying to save a building that was already lost. The report makes it clear that the actions of the firefighters fighting the fire were not to save the lone remaining occupant of the building but to do their best to conquer the fire that was destroying the building and its contents.

I read and re-read several portions of the report that explains that a number of the command officers on scene committed themselves to directly performing tactical operations, rather than supervision and coordination of resources and command and control of the incident. The lesson for me is the importance of the “dreaded” (by some) ICS-300, Intermediate ICS for Expanding Incidents, and ISC-400, Advanced ICS: Command and General Staff for Complex Incidents courses. Many fire officers have taken these courses and I wonder how many truly have incorporated the principles and practices of effective incident command in their day-to-day practices. Many departments have very seasoned and experienced command officers that handle large incidents regularly. If we continue to do what we have always done and gotten away with it (didn't have horrific outcomes), it is easy to assume that we are doing it right. The lesson is that we cannot get so complacent about the daily incidents being handled time and time again quite easily, that we forget that the “big one” of our career still may be in our future.

We lose too many firefighters each year. We will continue to lose firefighters who willingly give their lives in the service of their communities. We owe it to everyone, not to lose lives that could be saved through safe operations or by taking the necessary actions to ensure that incident is prevented. Understanding that it's the little things we skip here and there, the safety policies we circumvent or don't adhere to, and the complacency that, far too easily, slips into our fire departments that continue to lurk in the shadows of our operations that puts us at risk in our unknowable future as firefighters.
— Chief Mark Wallace
CFO, EFO, MIFireE, MPA
McKinney (Texas) Fire Department

John Catchings was my Boy Scout master and an American Airlines pilot. One of his closest friends was the writer Ernest K. Gann, author of such books as The Point of No Return, The High and the Mighty and Fate is the Hunter. Gann used to accompany us on Boy Scout camping events and we often found ourselves sitting around the campfire listening to Gann and Catchings talk about their adventures as pilots. As civilians, they ferried bombers to Europe and lost a lot of friends to “accidents.” One of the lessons I learned from these conversations was that when you are in a high-risk business you had better be paying attention to the lessons being taught by tragic events. You must remain a student for life. And you must constantly try to avoid being the example that other people talk about.

I was reminded of that experience when I read the “Firefighter Fatality Investigative Report, Sofa Super Store Fire.” The write-up reflects Gann's contention that fate will not shun an inevitable consequence. He applied it to the airline industry, which has become one of the safest risky adventures that there is.

There will be a lot of people who read the Charleston report and choose sides on who was right and who was wrong. What was done before, during and after the fire are sets of factual circumstances that I can see clearly in retrospect.

I will let the attorneys figure out who is at fault and where liability lies. As a fire officer, I look at this situation as: There but by the grace of God goes every fire chief in this country.

In the executive summary alone are lessons crying to be accepted. I read 17 statements under the issues element and nine operational observations and findings. If you were to list all of those in a column and were requested to fill in the right-hand column with a course of action that could have been taken to prevent these from happening, I will bet any two-year community college fire graduate could have filled out the matrix.

Here's one example. “The Sofa Super Store was a large property that incorporated a very significant potential for a major fire to occur.” What goes in the right-hand column? Pre-fire planning. You don't have to read the entire report. Read the executive summary and ask yourself exactly what your fire department is doing regarding every one of those items.

This sort of tragedy can happen to any fire chief at any time because situations can deteriorate so rapidly under emergency conditions that there are no safe havens. Airline pilots use checklists when they take off and checklists when they land. They have the lives of all of their passengers in the palms of their hands. It is not beneath their dignity to check and double check what they are doing.

Reading the radio transmissions that were part of this study is enough to bring tears to your eyes, and like all other tragedies, we make remarks like, “Our thoughts and prayers go out to the families.” Personally, I would rather be buying those guys a beer at the next conference instead of analyzing this tragedy.

Here are some very valuable lessons that leap off the page at me:

How many fire departments are doing an effective job at pre-fire planning, or have we sacrificed that to other kinds of program activity that have nothing to do with firefighter safety?

How many departments have an effective fire-prevention program?

Do we have an effective and self-correcting incident command system or are people merely adopting a concept because it sounds good? If we don't practice it on day-to-day events and wait for the “barn burner” we often lack the edge needed to protect firefighters.

Do we have an adequate number of policies and procedures in place? Are they constantly being revised based upon changing structural conditions in our community, or are we still using legacy concepts largely unchanged for 25 years?

Has the fire service overcome its “Great Waldo Pepper mentality” that prevailed decades ago in which aggressive behavior overcomes the value of all the precautions that were put in place to be competent on the fireground?

Are our training programs focused on real world scenarios or are we wasting hours of our firefighters' time sitting in a seat listening to programs that may be mandated but are borderline irrelevant?

Does every fire officer in the chain of command including the first-in captain, the first-in battalion chief and everybody else who joins that command structure realize their level of accountability for the people under their commands?

We have an expectation in our society that when planes take off they don't crash. The airline industry has had to constantly raise the bar on every component of the delivery system. In the final analysis, we have to be better prepared to withstand the scrutiny of an intensive investigative process when we have tragedies in our business. If we are going to eliminate catastrophic tragedies such as the sofa store fire, firefighter safety has to be more than a slogan. It has to be supported by a systematic approach from top to bottom and side to side.
— Chief Ronny J. Coleman (Ret.)
Sr. V.P., Emergency Services Consulting

After I read both the NIOSH draft report and the city of Charleston Post Incident Assessment and Review Team Phase II Report, I stopped and shook my head in disbelief like most of us in the fire service. I had highlighted and indexed over a dozen problem areas covered by the reports, and my first reaction was, “How could all of this have happened in today's fire service where we emphasize safety, accountability and risk management?”

I deliberately put these reports aside for a week just to let my thoughts settle. During that time, wherever two or more chiefs came together, it seemed these reports were the topic of discussion. Unfortunately, most of my colleagues had read only the executive summary or a synopsis of the report from one of the many e-mail postings. Most seemed to assail Charleston's tactics and incident command, but by that time I was trying to find something with more significance.

I have long felt that a line-of-duty death required a domino effect. That, is several things have to go wrong sequentially for a death to occur. Not all of those effects had to be omissions or oversights; sometimes it is just the hidden factors we've never experienced that start us down a path that leads to a firefighter death. In most cases, one or more of the positive things we've learned and put in place, such as accountability, crosses this path and that interrupts the domino effect and we call it a close call. But in Charleston's case, there were several simultaneous paths ongoing, any one of which could have lead to a LODD.

After the week had passed, I again reviewed my highlighted problem areas and realized that many of these problem areas or paths individually still were being practiced by departments that I knew — not just small or medium departments, but some fairly large departments covering metropolitan areas. This led me to believe that collectively the problem areas experienced in the Charleston fire may be somewhat unique, but nearly every department is probably guilty of practicing one or more of these individual problem areas everyday, and we needed to learn and then act to safeguard our own departments using the detailed discussions in the Routley report as a template.

For example, large warehouses with extremely high fire loads are within or close by nearly every jurisdiction. Most new buildings over 10,000 square feet are sprinklered, but how many have been inspected beyond the cursory look to find the hidden hazards, such as flammable liquids storage or new drop ceilings with corresponding concealed spaces, and then have this data turned into effective preplans? When has a sprinklered location changed occupancies without the corresponding upgrades to the suppression systems? This could be a building retrofitted with rack storage or having a greatly increased fire load while the sprinkler system remains engineered to the initial retail hazard.

Operationally, do you consistently staff four firefighters on every crew, or sometimes do you settle for three or even less? Do your initial engine companies bring water with them, layoff their own supply line, or do you rely on the second- or third-due engine? What happens when they arrive out of sequence? Do all your engine companies carry enough supply line to make the longest layoff in your community? Does each firefighter on an arriving ladder or engine know the pre-assigned duties of his or her position if not instructed otherwise by the company officer or incident commander? Do they know what size of fire line to pull based on the severity of the fire or default to a single choice by habit? Do you have an arriving company (either engine or ladder) immediately assume truck company tasks like vent, enter and search? Are dedicated RIT companies performing pre-mayday tasks to open more access/escape routes for firefighters working on the interior?

Do you practice air management? If so, does the officer keep in direct contact with each crew member and report the lowest air pressure in the SCBA of the crew each time a PAR is called? Is air management tracked as part of the accountability sector?

Does the IC stay in a stationary location, preferably inside a staff car or crew cab, to cut down on noise and concentrate on radio traffic and strategy? Are there radio terms practiced that, when spoken on the radio, mean that everyone else needs to shut-up like “mayday,” “emergency traffic” or “urgent?” Does the department employ a safety officer at each working fire? Do you regularly train with those who are on your automatic aid, mutual aid or extra alarms? Do you choose the closest and best departments for aid or do you prefer to call for help from just your good-old-boys network so there will never be criticism of your tactics?

Failure to follow each and every step of these items has lead to one or more LODD in the past five years. For the past year, Dr. Burton Clark of the National Fire Academy has challenged us to be 100%, a hundred percent of the time. I know how difficult that is for a department my size, and how diligent a chief has to be so that the unthinkable won't happen. But let's not fool ourselves with the Charleston reports by saying this type of catastrophe could never happen to any of us. Let's learn from Charleston by having every fire chief force themselves to read every word of the report, from the obvious mistakes to the painstaking radio traffic and 16 distress messages. Only then can we begin to learn the lessons of Charleston so painfully given us by nine of our brothers and then correct our own deficiencies.
— Chief Robert R. Rielage, CFO, EFO
MIFireE, Wyoming (Ohio) Fire-EMS