Progress reports from all operating locations are critical to the incident commanders' decision-making. At the Phoenix event, the incident commander's view of the roof was obscured partially by the height of the walls at the front of the store. He did not have a good line-of-sight view of smoke issuing from the roof that was carried horizontally across the roof by a breeze. Complicating the situation, the incident commander was able to see white smoke from the fire attack on the loading dock materials, which was drifting across the roof. He was not able to see the increasing dark smoke issuing off the roof behind the white smoke.

A post-incident review of video taken by the media shows rapidly worsening fire conditions. These conditions were not adequately communicated to the incident commander.

Firefighters need to be constantly aware of their SCBA air supply. In this incident, crews were sucker-punched by the initial clear conditions inside the store. When conditions suddenly changed, many were caught with inadequate air supply to safely exit the building. Every firefighter must repeatedly check his or her air supply and not get caught past the point of no return with inadequate air to retreat. Waiting for the low-air warning on the SCBA places the firefighter at great risk of not getting out in time.

For about a decade, Phoenix had been using a detailed accountability system. The system consisted of passports, which listed the individual names of crew members being assigned to the hazard zone. The passports are turned in at an accountability location near each point of entry. Because of this, the department quickly knew who was missing and what general area they were in. This permitted a fast, concentrated rescue effort. It also eliminated wasted efforts based on guessed firefighter locations.

Concealed spaces in large-square-footage buildings can hide a lot of fire and smoke that simply may not be visible by interior crews. This active fire can spread over a large area above the ceiling space before it erupts in visible fire. If firefighters are deep in a large building, they can be overtaken by the flashover before they can exit.

A rapid, 360° reconnaissance of conditions must take place. Progress reports need to be obtained from the roof and all sides of the building to allow for accurate risk assessment. Any dark smoke growing in volume observed from the exterior should signal a concern that there is a significant fire in concealed spaces. This information needs to be communicated to the incident commander and to interior crews.

If smoke conditions are deteriorating, the incident commander must seriously reconsider continuing interior operations versus withdrawing crews.

Deep penetration operations are low-frequency events that create very high risk to firefighters. The experience from the Phoenix fire indicated that firefighters often gauge risk and SCBA air consumption from their experience with the more routine house fires. However, in large buildings, there are no nearby exits or windows available when advancing hose lines deep into the building. If a firefighter gets drawn into waiting for the SCBA low-air warning to activate, he or she may not have a chance to get out in time.

All deep-penetration operations must be viewed as very high risk. The incident commander must understand that it will take longer to evacuate firefighters under deteriorating conditions than it took crews to get deep into the building. The incident commander must take a very cautious approach to these types of operations and closely monitor the conditions and control crews. Evacuation must occur early.

While it was shown that RITs save lives, the Phoenix fire also demonstrated the difficulties in rescuing unconscious firefighters. Finding a lost firefighter is one thing. Extracting him or her from the building is extremely challenging and requires several rescuers to get it done. It takes time.

Following the fire, Phoenix and the Seattle Fire Departments, conducted research in rescuing firefighters from large-square-footage buildings. Phoenix determined 12 firefighters are needed and the average time to search and extract was 21 minutes. Seattle determined 11 firefighters were needed and it took an average of 19 minutes for removal. That is a long time for a firefighter to be out of air — and will likely be lethal.

Firefighters must do all they can to not in trouble in the first place. They must closely, and constantly, monitor their air supply. They must be aware of their surroundings and changing conditions and not push the envelope of risk. They must evacuate before conditions prevent their exit.

When interior crews in Phoenix experienced rapid deterioration of conditions, they immediately chose to retreat rather than continuing to attack a growing fire. They recognized there simply was more fire than they could control with hand lines. They did not need, nor did they seek, permission to evacuate. The interior sector did, however, provide the incident commander a progress report of deteriorating conditions and their decision to self-evacuate. Trying to take a stand on this type of fire would have killed firefighters.

While meeting with chief officer staff in the first days following fire, then-Chief Alan Brunacini stated NIOSH would produce an 80-page report of what went wrong. The Phoenix Fire Department's objective must be to produce an 80-page plan on how to prevent this tragedy from ever occurring again. And Phoenix did just that.

Phoenix provided NIOSH access to more than 100 members to be interviewed — reportedly the largest number of interviews NIOSH had conducted for any pervious fatality investigation. Phoenix also put together a joint labor-management team to conduct an open internal investigation. They took the results of that investigation and the NIOSH findings and created a recovery plan that described changes needed in training, procedures, equipment and more. The investigation report and recovery plan were made available to the fire service and the public. Phoenix since has plotted through the plan and implemented multiple changes, improved training and purchased new or appropriate equipment.

Charleston also has created an investigation team to advise the city on needed changes. This external team is made up of nationally recognized fire offices who have the credentials to conduct a thorough investigation. This team has the talent to make the appropriate recommendations necessary, which if adopted, will prevent this tragedy from occurring again.

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Gary Morris is the fire chief for the Rural-Metro Fire Department, Maricopa and Pinal County Operations, near Phoenix. He previously was the fire chief for the Seattle Fire Department, and he retired as an assistant chief with the Phoenix Fire Department after a 30-year career. He holds a master's degree in organizational management from the University of Phoenix.