Last week we posted the LODD reports from a fire in Baltimore County, MD in 2013. You can find Gene’s NIOSH report here and the Interdepartmental Investigation here. Take a look at both and let the facts presented soak in. A lot of very good discussion came up and I hope that people were driven to the reports to learn what we can. Unfortunately we will never know exactly what happened on the second floor of that house on that fateful night. There are many ideas or theories which are plausible, some more likely than others. At the end of the day we will each settle on our own opinion of the truth and that is ok. What I would like to focus on for the sake of argument is one possible reason FF Kirchner was overcome by smoke that night. Follow along until the end and see if it makes sense to you.
Scott AV 2000 with Exhalation valve on the left side respective to the mask. If you look close you can see the red valve seal.
FF Kirchner's face piece with missing exhalation valve. Picture from Baltimore County internal investigation.
Do you trust your SCBA Emergency Procedures? I ask you this because I am going to try and connect the dots which neither of these reports had the freedom to do. FF Kirchner was found in a second floor bedroom with the door closed, his face-piece, helmet gloves and hood all removed. His SCBA bottle had been turned off. It was found on the floor of the bedroom he was removed from. So what happened? What would drive a fairly seasoned FF to remove all of this equipment while performing a search for a reported victim, on an upper floor knowing all along that these pieces of equipment keep him alive? Take a look at his face-piece. He was wearing a county issued Scott AV-2000 series face mask with an exhalation valve located on the left side of the mask. When his equipment was recovered, the exhalation port was empty. As noted in the internal investigation, “During the inspection of the turnout gear and SCBA on June 3, it was discovered that the exhalation valve was missing from the face piece. Per police reports the exhalation valve was recovered the next day from the bedroom where Firefighter Kirchner was found.”
One theory is that this valve came out during the removal process. His mask however was not on him when the FF from E56 found him. I would argue that the valve actually came out during FF Kirchner’s search. More on this in a minute.
Another theory is that FF Kirchner never clipped his regulator into his face piece when he entered the building. Possible, but highly unlikely. There were fire and smoke conditions on the first and second floor. That would mean he would have had to hold his breath from entry until he made it upstairs. If you follow the timeline of radio traffic you will see that there is at least 3 minutes of time from when E56 and FF Kirchner entered the front door until the PASS alarm is heard. I know 3 minutes is not a long time but I ask anyone reading this to hold their breath for 3 minutes while conducting some physical activity. Not likely possible.
So what if it was something else? What if, in that particular mask set up, when the rubber in the valve warmed up from heat it became much easier for it to be dislodged? The reason I go down this path is I have personally had this same exhalation valve on the same series face mask partially dislodge during flashover simulator training. After the mask and myself had been in the simulator for a fairly short period of time it had accumulated heat soak, warming the rubber valve up. Because the valve extends away from the mask about an inch, it is easy to brush up against something, which is what happened to me and partially dislodged the valve. I noticed this happen and quickly exited the simulator loosing positive pressure air while I exited. When I brought this up to an instructor I was informed that this actually happens sometimes and if you run it under hot water to warm it back up will pop back in. Being younger, less informed and less thoughtful of how bad this actually was, I followed those instructions and that is where it ended. Amazingly enough this same mask passed yearly fit test evaluations for approximately 4 years after the incident. Makes you wonder…?
Now I ask you, what are your current SCBA Emergency Procedures for dealing with a regulator free flowing air? I can tell you what ours were when I went through FF1. If you experience free flowing air from the regulator follow these steps:
Following these steps, if controlling the purge valve does not control the leak you then move to control the leak by turning your cylinder off. It will take a few seconds to breathe down what is left in the system and then as it gets low you can crack your cylinder valve open and close it again quickly. These steps were originally developed to conserve air. It was assumed that the reason your regulator would be free flowing air is a malfunction of the regulator, not a hole in you mask. In a zero visibility environment with full PPE and fire gloves and a little bit of extra stress due to the malfunction it might not be that easy to diagnose the problem.
Now put yourself in FF Kirchner’s shoes. You are part of a search crew going above the fire to look for a reported victim. The occupancy is filled with debris and has the makings of a hording environment. During the search your notice you are free flowing air from your regulator. Following your procedures you check your purge, which does not solve the problem. So you move to the next step and close your bottle down. BOOM. Your next breath is filled with hot, sticky, smoky shit. You panic. You followed your training perfectly and now you are in a situation you were never told you would be in. Only a few breaths after panic and frustration have set in you have now inhaled enough CO to alter your decision making ability.
Not one of the recommendations or contributing factors in either of the two LODD reports above mention this. NIOSH writes “The initial evaluation by the contractor (SCBA Evaluator) revealed that the facepiece was missing the external exhalation valve on the left side. An external exhalation valve was recovered by the police investigators the next day in the bedroom. When the SCBA was tested by the external contractor with the external exhalation valve reinstalled the SCBA pass all tests except for the high pressure leakage. The positive pressure system worked properly.” They do not lend anymore details to the “high pressure leakage.”
Two things from this statement. Being that the positive pressure system worked properly, if the external exhalation valve had become dislodged while performing a search then FF Kirchner would have had free flowing air from his regulator giving him a reason to follow the above emergency procedures. Also, I could not find out any more info on what the “high pressure leakage” test is.
NIOSH does not hypothesize why the external exhalation valve dislodged and separated from the facepiece. However they do hypothesize why FF Kirchner removed his mask stating “In this incident, the victim apparently experience an SCBA emergency and went into a near-by room to try and fix the issue by removing his facepiece without the knowledge of his partner. It is assumed this is where they (FF Kirchner and his partner) became separated. The victim was overcome by the toxic conditions and his PASS device was heard by the engine crew at the top of the stairwell. The victim’s external exhalation valve was later recovered in the bedroom.” Why take us down one path if they were not ready to take us down all possible paths that lead to this tragedy? I don’t know and we probably never will.
What I ask of you is this, since you have taken the time to read this far, now take the time to review this incident with your crew. Talk about the recommendations and contributing factors because they are worth it. But take your discussion one step farther and talk about the things no one mentions! Talk about how nothing in the fire service is 100% for certain. SCBA emergency procedures are just that, for emergencies, and the fact that we are using an SCBA means we are already in a hairy environment. Take a look at your SCBA emergency procedures and ask yourself if they are right. Consider the idea that your procedures need to be amended.
I offer you this. We have since changed our emergency procedures and eliminated closing the cylinder. Basically if you have a SCBA malfunction, notify your partner, call a Mayday and get out of the IDLH. It is simple and it keeps our life sustaining air from being turned off. There is no one solution for this scenario. We can Monday morning this all day long. Each building and each fire will present different situations and decisions will have to be made. One key is to train to keep our brain engaged in the fight, keep making decisions based upon your reality.
As firefighters and emergency service personnel we are used to solving other people’s problems. We spend our days war gamming, pre-planning and coming up with solutions for different situations, always trying to be prepared. All of this is good but we have to remember we operate on the edge of control, somedays we have it and other days we have the illusion of it. We operate in the boundaries and as James Gleick has said in his book Chaos, “strange things happen near the boundaries.”
-Jim