May 15, 2004, was an overcast and misty day in the greater Cincinnati area. Wyoming Fire-EMS, a 74-member combination department, was using the nearby Colerain Township Fire Training Facility to hold live-fire training and practice several related multi-company evolutions.

The first two scenarios involved firefighting and hose movement. Both were Class A fires in the first-floor front burn area to simulate basement fires. The third scenario simulated a bedroom fire by placing the Class A burn on the second floor. Crews entered the first floor and made their way via the internal stairwells to the second floor. The four-person ladder crew was split into two teams for this evolution, with one team being the inside search and rescue and the second simulating vertical roof ventilation.

As the safety officer, I observed the inside crew search the floors, find the rescue dummy and exit the building. I returned to the second floor to watch the engine crew extinguish the fire. With the fire under control, I reversed my direction to exit the burn building through a set of doors opposite those used by the engine crew for hose placement. Within approximately five feet of the doors, I heard a dull thump and then low moan; nothing could have prepared me for what I was about to see as I walked outside.

The unimaginable

Through my facepiece, the sight seemed surreal. Less than 10 feet from me was a firefighter on the asphalt lying on his left side, conscious but moaning. Beyond him was a second firefighter, also on his left side. A 12-foot roof ladder lay perfectly parallel to the burn building on its beam, and a running chain saw lay just beyond the ladder. The medic and RAT crews that had been pre-positioned on this side of the burn building began to respond in what appeared to be slow motion. Sounds were muffled and nearly nonexistent. My first thought was, “No, no the ‘downed’ firefighter scenario was to be a part of the next evolution.” Then it struck me; this was not part of the drill.

I dropped to my knees at the side of Firefighter Bryant Davis, who had been assigned to the exterior ladder crew. The medic crew stopped at the second firefighter, Jon Glassman, the other member of the ventilation crew. Both had sustained compound fractures of the left arm and leg, with suspected internal injuries. Glassman regained consciousness while Davis was continually losing blood. The communications center was radioed to advise them of the incident and request a Colerain Township medic unit to assist. A paramedic engine and a transport unit were dispatched and arrived within three minutes of our request.

Sensing the severity of the injuries, Wyoming Lt. Ethan Pagliaro, who also is a paramedic, suggested that we check on the availability of a medevac helicopter. Calls to both the University of Cincinnati's Air Care and Dayton's Care Flight found the helicopters either already committed to other runs or grounded due to the deteriorating weather conditions. I requested escorts for both the Wyoming and Colerain ground transport units to University Hospital. Within seconds, two additional police units arrived and were briefed by Colerain Police Lt. Dan Meloy as to the escort duty.

With the firefighters packaged, IVs established and drugs administered, both medic units went to the hospital. Cincinnati Police units joined the Colerain Police escort, and together they leapfrogged from intersection to intersection, arriving at the emergency room of University Hospital in 14 minutes. Two trauma teams were waiting in the ER and immediately began their assessments of both firefighters.

Beginning the investigation

As the cleanup began, I spotted Colerain's chief and my good friend, Bruce Smith. He told me that he had several fire units coming to help us with the aftermath. Somewhat relieved, I asked Smith to have his training division take possession of our injured firefighters' gear, and to treat this incident with the potential of two line-of-duty deaths. The additional Colerain units arrived quickly and helped reload and repack the equipment.

What was initially apparent was that the 12-foot roof ladder had come undone from the cap of the burn building's metal roof. Both firefighters had ridden the ladder down the roof to the edge of the 2-story building, then fallen 30 feet to the asphalt pavement. Staff officers from Colerain's Training Division and investigators from the Colerain Police and Hamilton County Sheriff's Department Investigative/Reconstruction Unit began the long process to piece together the incident with both physical evidence and witness statements. This process included interviews with everyone present; examination of the roof, ladder and PPE; and the study of photos both prior and subsequent to the incident.

While Flagler took charge of the Wyoming personnel who had accompanied the medic units to the hospital, I made notifications to the families and city manager. A conscious decision was made while still at the training facility to provide critical incident stress debriefing for everyone involved at both the hospital and the station. Two teams of CISD personnel were requested, and they arrived within 90 minutes of the incident. Wyoming Station 97 was taken out of service until after the initial debriefing, with Arlington Heights Station 11 placed on standby.

Additional Wyoming personnel along with firefighters from several neighboring departments also arrived at Station 97 and took over the responsibility of getting the fire and EMS apparatus ready for service. Among those was Cincinnati Fire Lt. Joe Arnold, president of IAFF Local 48, who offered whatever assistance was necessary for the firefighters, their families or our department. As the initial debriefing ended, my son Todd, a firefighter in Fishers, Ind., arrived at the station having been ordered by his shift commander, District Chief Steve White, to act as my aide for the remainder of the night. This proved to be invaluable as I had Todd work for me behind the scenes and pay attention to details I might have overlooked.

Long road to recovery

It was evening before my son and I arrived at University Hospital to visit the families and fire/EMS crews. Glassman already had been in surgery for more than an hour, and Davis was sedated in a private room. Their surgeries would last well into the next morning and were the first of three for Glassman and four for Davis. Glassman stayed at University Hospital for three weeks before going home for an extensive convalescence, while Davis spent a combined 100 days at University and Drake Hospitals before being discharged. Both men have shown incredible courage and determination with months of additional rehabilitation. Glassman, who had been within days of completing his paramedic classes at the time of the incident, sat for and passed both his Ohio and National Registry Certification tests during his recovery.

One of the most rewarding aspects of this ordeal was being able to watch the department pull together and channel its energy toward the support of the firefighters and their families. From the beginning, Wyoming firefighters were at the hospital for support and assisted the nursing staff. (We won't mention the bed race one weekend when both firefighters had to be taken to X-ray at the same time and hospital staffing was short.) For several weeks it was nearly a 24/7 operation, but even when Davis was hospitalized for a more extensive time, the “regulars” showed up during their time off with food, videos and conversation.

Serious injuries of this nature take time for worker's compensation to process. Several firefighters and members of the city's administrative staff took on the challenge of answering the initial worker's compensation questions, filling out forms, and gathering the financial records of both firefighters so that checks would continue to help out the families of the hospitalized firefighters.

Both Davis and Glassman received strong support from the department and the community in other ways to keep up their morale. With splints, casts and wheelchairs visible, both firefighters were allowed to ride in the annual Fourth of July parade. They received a very warm welcome home from the citizens of Wyoming, and two TV stations specifically covered the event to document their homecoming.

The turning point for both firefighters was their release to walk and drive themselves without assistance. Frequently one or both now drop by the station to visit. Their recovery is ongoing and has taken a great deal of personal diligence and perseverance with the nearly daily regimen of rehabilitation. We hope to have both of them back as firefighter/medics this month.

Investigation findings

The initial investigation began at the training facility and took several weeks to complete. It included the inspection of all the equipment involved, as well as the facility itself. Jon and Bryant were the outside crew on the aerial. Those positions required the aerial truck operator, in this case Davis, to ladder the building and prepare for ventilation along with his partner.

After setting the outriggers, the aerial had been raised to the peak of the metal roof on the burn building. Glassman climbed onto the roof straddling the cap and facing Davis. He passed the 12-foot roof ladder and a chain saw to Glassman before joining him on the roof cap. They had successfully set and secured the hooks of the roof ladder, placed themselves on the ladder and started the saw to simulate the ventilation exercise. Glassman was closest to the top of the ladder and Davis was closer to the bottom. With the completion of the simulated ventilation, both started to move back up the ladder. At that point the hooks began to ride up on the metal roof cap and then came completely loose of the ridgeline, starting the firefighters' slide down the slope of the metal roof.

Inspection of the roof ladder indicated that it was compliant with both NFPA 1931 and 1932. Despite the fall, it subsequently passed its annual non-destructive ladder test. The focus of the investigation then turned to the compatibility of the standard roof ladder and the typical metal roof construction typified by the burn building. Based on a review of the physical evidence, the following alert was posted on several fire service Web pages in June 2004.

“On May 15, 2004, two Wyoming (OH) Firefighters were seriously injured following a 30-foot fall from a roof ladder while participating in a ventilation drill. The ladder's hooks slipped from the metal roof cap while being used on the metal roof of the Colerain Township Fire Training facility. The metal roof system of the training facility was very similar in design to roof systems being used in commercial and residential applications.

“All fire service agencies are cautioned to evaluate the use of roof ladders for their ability to remain affixed in place on metal roofs, especially, but not limited to, those designed for commercial use.”

Consideration was given to replicating the actual fall using the training facility with tethered firefighters and safety nets, but this was soon abandoned as impractical and too risky. Instead, I turned to a good friend and colleague in the Institution of Fire Engineers, Professor A.K. “Kirk” Rosenhan from Mississippi State University. He is not only an active fire chief, but is nationally recognized for his expertise in the engineering field relative to the fire service. With his knowledge of computer modeling, Rosenhan was able to quickly confirm a problem with the coefficient of friction between the standard NFPA-compliant roof ladder and certain metal roof buildings. His hypothesis also was confirmed using a test model he constructed in his laboratory. (See “A Matter of Physics, page 44.)

Recommendations

With the growing use of metal roofs, it is extremely possible that the design of the NFPA-compliant roof ladder has not kept pace with newer building construction. Based on this training incident, I recommend the following to every chief and company officer:

• Evaluate the metal roof buildings that exist within your jurisdiction and mutual aid areas for their design including the pitch of the roof.
• Preplan what equipment and tactics you would use to perform ventilation of that roof or effect rescues from it.
• Strongly consider only performing either evolution from an aerial ladder or platform for the safety of the firefighters involved.
• Request that the NFPA 1931 committee address the use of roof ladders on metal roofs with either a redesign to enhance the coefficient of friction or a recommendation that they not be used in such operations on metal roofs.

Any incident that results in injuries as critical as those suffered by Glassman and Davis deserves extensive investigation and review by the fire service. However, several searches of both recent fire service literature and NIOSH bulletins found no documentation of similar incidents.

With few exceptions, there's reluctance after firefighter injuries or deaths for chief officers to face the challenge of determining the true underlying cause of these catastrophic incidents. This reluctance may be based on potential litigation or the possible embarrassment to the officers or their department. It's extremely important, however, that we overcome such fears and instead begin to learn from these occurrences.

Our role as chief officers is to ensure these vital lessons are passed on to the fire service. Doing so may help avoid repetition of the same circumstances and avoid other firefighters facing similar injuries or death. It is my hope that this article will start a process that will eventually make operations on metal roofs safer for all firefighters not only in the United States, but also across the world

On behalf of the members of Wyoming Fire-EMS, I would like to acknowledge and thank Chief Bruce Smith and the staff of the Colerain Township Department of Fire-EMS for their unwavering dedication to our firefighters and this investigation. My thanks as well to Wyoming City Manager Robert Harrison, Colerain Administrator David Foglesong, and the members of the Wyoming City Council and Colerain Township Board of Trustees for their support of Rosenhan's incident reconstruction.

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Chief Robert R. Rielage, CFO, EFO, MIFireE, is the chief of Wyoming (Ohio) Fire-EMS, a 74-member full-service combination fire department bordering Cincinnati. He previously served as the fire marshal of the State of Ohio, was a member of the State of Ohio Security Task Force and a delegate to the National Governor's Association for Homeland Security. Prior to becoming fire marshal, Rielage served for 27 years as an assistant chief of the Colerain Township Fire Department. A graduate of the Kennedy School's Program for Senior Executives in State and Local Government at Harvard University, Rielage holds a master's degree in public administration from Norwich University. He is the immediate past-president of the Institution of Fire Engineers — USA Branch and a member of the Fire Chief editorial advisory board.