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May16, 2003 
A followup to the Coos Bay Tragedy
Chief Billy Goldfeder
This is a followup to the Coos Bay fire in which Lt. Randall Carpenter, 46, and firefighters Jeffery Common, 30, and R. Chuck Hanners, 33, were killed Nov. 25, 2002 at the FarWest Auto and Truck Supply fire.
The City of Coos Bay has received 16 violations....but then "they" also say the issues and failures discussed in the violations were not responsible for the firefighters death. Hmmmm. I was not there and may not have all the facts....but I will tellya that we have reviewed some extremely in-depth videos and photos numerous times....and those comments make us a lil'nervous.

OK, fine. If the violations that included a breakdown in the command, control and communications at the fire, failure to have fully enough trained firefighters (read: STAFFING) outside the building to rescue firefighters inside, failure to properly maintain SCBA's (and applicable training)....what then, was the problem? 

WE NEED TO KNOW. Yeah-we know, the lawyers are watch'n like vultures. So what-WE still NEED TO KNOW. The message of what really went wrong at any FIRE is such a critical piece in reducing our deaths. For example, you may or may not like the Phoenix FD, and that's up to you-but I'll tellya this-when something goes wrong in Phoenix, they investigate it, they get the facts, they evaluate it and then they not only educate THEIR members-but we ALL get educated...and it doesn't take forever. And keep in mind that Phoenix has plenty of "vultures" float'n around as well. That doesn't matter-they still get the FACTS out to the rest of us. Why? We learn from it.

The reports on the Coos Bay firefighter deaths state that there was poor accountability, there was documented freelancing, no RIT teams and there were no training records for SCBA use. They found out that their SCBA's were not regularly inspected and that repairs and maintenance were not done according to the SCBA's manufacturer recommendations, amongst several other violations. Plenty to learn from? Absolutely. "New" information that is shocking you? Nope. You've heard it all before.

Fine. OK...sure, the report DOES have good information. But, then WHAT WAS the reason for the firefighters getting killed if the violations weren't? When do we get to read the OFFICIAL reasons so WE CAN LEARN. Or maybe, it's so obvious it's right in front of us. Maybe it's just a vulture issue. 

Think about the comments that are heard after almost every tragic run. It's the same issues over and over and over again....almost every NIOSH report identifies the same exact problems. As we wrote and have "blah blah blahed" about in the past.."THE BEAT GOES ON"....again....

What's missing? Once again-we may just have to actually go "out of our way" in order to fully prepare our fire department for what will eventually come...meaning, fires, such as described in this incident. Going "out of our way" means aggressive training, staffing, equipment setup, response plans, pre-plans, strict command and control, tracking, risk management and related safety procedures with attitudes that are focused and committed to preventing our deaths....and the funding that is required to make this happen. Sure-fighting fires takes courage-so does the ability for the leadership to stand up and make it clear to the politicians and community what we clearly CAN and CANNOT due based upon funding. It also takes COURAGE to MAKE the troops train and GET the FD well prepared.

When this fire first happened, we wrote that getting all the above stuff done can be a real pain in the ass when some priorities are to sleep, eat, talk on your cellphone, play on the computer, watch TV and generally waste time when at the firehouse. Next time you see this happening in your firehouse-maybe ya oughta stop it-lead your crew out for a real drill or do some building visits for preplanning purposes. Take'm and do something that will matter in saving their own lives. The result might be WHINING and MOANING in a lot of the cases....so what. Do it anyway. Who cares if they whine? It's the same whiney bastids that would complain anyway-about anything, all the time. Maybe their parents didn't like them or something. NOT your problem. Your problem is to get'm home safe, after the fire, so they can make it to their next therapy appointment or what whatever.

This stuff always reminds me of professional football. A pro-football team spends an incredible amount of time preparing for "The Big Game"...it takes a long time before a player can be used on the field-based upon training, skills and abilities....and ALL the coaches participate and get involved. There is a plan, a backup plan, strategy, tactics and enough STAFFING ON THE BENCH to take care of any problems that may occur. And NO ONE goes onto the field without their gear on. Coaches normally stay OFF the field but always know who is supposed to be doing what and they guide their players based upon specific angles, strategies, areas of expertise and THE BIG PICTURE. They communicate using radios that WORK and if the radio's didn't-they would get fixed REALLY fast. After all-this is pro-football. They have plenty of rehab for all the players, sports medicine experts on the scene (at practice too) and the ability to take care of their needs immediately. See any common links here?

Changing any FD's thinking and culture isn't easy at all. Like you, I have taken more than just a few tummy pills when trying to change stuff...but ya can't give up. As we have said before, don't EVER give up on this stuff. Do whatever you have to in order to NOT let this stuff happen. Read the violations...go to the NIOSH site and read ALL the violations and see the common continuing problems. http://www.cdc.gov/niosh/firehome.html

Without question, you gotta FORCE FEED this kinda stuff and MAKE THOSE INVOLVED LISTEN...no matter what...no matter what rank....no matter how much of a pain in the ass it is, or you are. Afterall, what are you at the FD for anyway? WHY DID you join? Afraid to make enemies? Screw'm...do what's right. Need friends or are you afraid "they" won't like you? Who cares...do the right thing. They probably don't like you anyway. Fine, if being "friends" is a big issue to you-ok, I'LL BE YOUR FRIEND. I promise. "I'll always be here for you my friend"....trust me. Still not comfortable with confronting those who need to be changed and woken up? Afraid you'll feel LONELY in the firehouse? OK, go to http://pbskids.org/rogers/ and you'll feel better....you now have a "happy little place" you can call your own.

The point is: If we spent a little less time worrying about all the social "I sure hope they like me" or "I don't wanna piss'm off" crap in the firehouse and spent a little bit more time on the real "why we are here" stuff, we might be able to reduce the amount of NIOSH reports, articles and stuff like this. We do have time to prepare our troops. We just "gotta wanna" do it. And accept that they may not like ya. Remember though: I always will !

Anyway-here is more on the tragic fire in Coos Bay. We continue to feel heartfelt sorrow for the CBFD...especially towards the 11 "daddy-less" children of Chuck Hanners, Randy Carpenter and Jeff Common....and hope that this information as well as "the rest of the story" will contribute to reducing the continuing, repetitive deaths of our Brothers and Sisters. 

May 16, 2003
Fatal Fire Fines
Coos Bay, OR
Courtesy of KVAL.Com
State investigators cited the city on Friday for 16 safety violations carrying fines of more than $50,000 connected to a fire that killed three firefighters, but said the alleged violations were not responsible for the men's deaths.

Citations included a breakdown in the command structure and communications on the fire, failing to station fully equipped firefighters outside the burning building to rescue firefighters inside and failure to properly maintain breathing gear and show firefighters could use it properly.

Oregon Occupational Safety and Health Division Administrator Peter DeLuca said he hoped the investigation would lead to safer working conditions for firefighters across the state and country.

"If we do not learn, the tragic significance is that much greater," DeLuca said.
Pat West, president of the Oregon chapter of the International Association of Firefighters, disagreed. West said the breakdown in command structure and failure to follow standard procedures were a factor in the firefighters' deaths.

"From the start, it has been clear to us that the management of the fire department and a clear lack of command at the fire aided in the deaths of three firefighters on that fateful afternoon," said West. "These feelings have certainly been substantiated by the full investigation conducted by Oregon OSHA."

Coos Bay Fire Department Lt. Randall Carpenter, 46, and volunteer firefighters Jeffery Common, 30, and R. Chuck Hanners, 33, were killed Nov. 25 while fighting a fire at FarWest Auto and Truck Supply.

The fire burned unseen for hours, weakening the roof, which collapsed on the firefighters soon after they entered the building.

The State Fire Marshal's Office traced the cause of the fire to heat from the chimney of an oven used to burn grease from parts in a machine shop within the building. Two men are awaiting trial on charges of negligent homicide connected to installation of the oven.
Carpenter's girlfriend, Christine Farmer, wearing Carpenter's old fire department jacket, said she agreed with West's criticisms, saying she felt proper safety procedures could have saved Carpenter's life.

"If they followed two-in, two-out, he would be alive," she said, referring to a procedure in which two firefighters are stationed outside whenever colleagues go into a burning building.

The citations carry fines totaling $50,450. Thirteen of the 16 were classified as serious.
Mayor Joe Bennetti said the city was committed to giving firefighters safe working conditions, and has already begun correcting some problems. He added that he hoped to significantly reduce the fines in negotiations with the division, particularly on technical citations concerning breathing equipment.

Bennetti added that Fire Chief Stan Gibson continued to have the full confidence of the city administration.

"These allegations in no way reflect on our firefighters' ability or dedication," Bennetti said.
Fire Department Lt. Randy Miles, president of the local firefighters' union, agreed with the state's conclusion that the safety violations were not responsible for the deaths.
"Even if none of these violations ever happened, those guys would still be gone," he said. "They're going to correct it. I have 100 percent confidence in that."

The division cited the city for failing to follow incident management standards set by the National Fire Protection Association. Those included a breakdown in communications between fire commanders and firefighters, failure to set up a team to rescue firefighters inside the building, and a delay in naming a safety officer. That citation carries a fine of $7,000.

A citation for failing to station two fully equipped rescuers outside the building and another for having no standard system for keeping track of personnel on the fire each carry a fine of $5,000.

There were no records that firefighters could demonstrate they knew how to use breathing equipment. Firefighters were not tested annually on operating their respirators or to be sure they had tight-fitting face masks. One firefighter went onto the burning roof without a respirator.

Breathing equipment was not inspected daily, and repairs and maintenance were not done according to manufacturer recommendations, the investigation found.