Lessons from Listowel
Pre-planning, size-up are keys to managing risk
Written by Laura King
When March 17 came and went with no charges laid by the Ontario Ministry of Labour (MOL) over two firefighter deaths in Listowel a year earlier, there was relief: lives would not be turned upside down in a lengthy legal process as they were in a trial after two firefighters were injured in Meaford, Ont.; the families and colleagues of firefighter Raymond Walter and Deputy District Chief Kenneth Rea would not experience the public airing of details of the fatal dollar-store fire; and, after months of speculation and cynicism about the MOL’s intentions, it was clear that the municipality and the North Perth Fire Service had met their obligations under the Occupational Health and Safety Act to protect their firefighters.
While the Ministry of Labour’s investigation into the dollar-store fire is not publicly available – a Freedom of Information request is required to obtain the report – the investigation by the Ontario Office of the Fire Marshal (OFM) sheds considerable light on what happened on St. Patrick’s Day 2011. The details, and the fatal consequences, have led to a renewed push by the OFM to emphasize incident command, size-up, the need for fire chiefs and officers to know the buildings in their communities and properly weigh the risks associated with those structures against the fire department’s response capabilities, and the importance of educating all firefighters about the perils of lightweight construction.
|The March 17, 2011, tragedy at a dollar store in Listowel, Ont., has led the Office of the Fire Marshal to consider changes to the fire code and fire-safety education for roofing operators. Photo by The Canadian Press
As OFM senior investigator Christopher Williams took care to point out in an interview in June, fire investigators enjoy the luxury and the horror of having more information about the circumstances of an incident than do the firefighters on the ground.
“What we know now is based on some of the evidence that we learned from our investigation,” Williams said of the Listowel fire. “And that is nowhere near what the fire service may have known at the time.”
North Perth Fire Chief Ed Smith couldn’t agree more.
• • •
Photos and video from the afternoon of March 17, 2011, shot by bystanders with iPhones and BlackBerrys, helped investigators determine that by the time the 911 call came in at 1509, the fire in the roof of the Listowel dollar store may have burned for as long as 40 minutes.
“This is not a sudden roof collapse as was first thought,” Williams said during a presentation to the Canadian Fire Safety Association in Toronto in April. Williams elaborated in the interview: “We have a hard timeline of an individual who is on the phone seeing roofers on the roof and applying a propane torch, and that’s at 2:29 in the afternoon.
“We know that the alarm time is 3:09, so we’re not saying that fire necessarily burned for 40 minutes but we do know that sometime in that 40-minute window, ignition occurred.”
The investigation determined that almost 10 minutes before the 911 call, roofers working on the building were told by customers entering the dollar store that they could see smoke.
“And the roofers, they’re up on the roof, throwing snow and water onto where they think the fire is, and it’s not successful,” Williams says. “The civilian goes back into the store . . . brings out a fire extinguisher, and that’s not successful.
“As they’re lifting up some of the aluminum siding on this parapet, they’re seeing more flames. So we know that at approximately 10 minutes before the 911 call is made there’s enough fire development that a member of the public sees smoke, and then for nine or 10 minutes they’re engaged in activities on the roof thinking they’re going to control a small fire.
The first-in pumper arrived at 1519.
“And then, based on video-taped evidence from a number of different sources, we have evidence of a critical change in smoke conditions at about 19 minutes after the arrival of the fire service,” Williams says.
The change happens 69 minutes into the fire, presuming the 1429 start time.
“And at 71 minutes – from the onset at 1429 – that’s when we have the roof collapsing.”
• • •
The first-arriving pumper had eight firefighters on board; there was “a little bit” of white smoke showing, Williams says, and two firefighters entered the dollar store to conduct a primary search.
According to Chief Smith, who arrived three minutes after the pumper, at 1522, the first-arriving crew had seen shoppers coming out of the store, there was no evidence of roofers in the area, the owners of the building were not on scene (the building was being rented) and firefighters had no idea the building’s roof was made of volatile, lightweight construction.
|Profile – North Perth Fire Service The North Perth Fire Service comprises stations in Listowel, Atwood and Monkton. Its 65 volunteer firefighters in the amalgamated municipality of North Perth protect an area of 487 square kilometres with a population of 11,622.
“They had gone in to start to look to see that all the shoppers were out,” Smith said in an interview. “And they had come back out, and before I took command I went into the building to take a look around too and to see what we did have; at no time was I aware of, or were my firefighters aware, that it was a lightweight-construction roof. We all were shocked; we thought it was web-joist steel roof.”
Firefighters returned to the building and saw glowing combustion – or evidence of fire – Williams says, and additional crews were sent to help.
“And in the minds and the eyes of the firefighters, not knowing how extensive the fire is, the firefighters are hitting small areas of visible flame thinking they’re suppressing a small fire,” Williams says,
There were two crews in the building – a crew of three on one side and a crew of five on the other side near the loading dock. They were moving ceiling tiles, hitting spot fires and checking for extension – “all the normal things you would do in a structural fire”, Williams says.
“The crews on the side where loading dock is, they see change in conditions and pull out, and the three on the other side – one firefighter is just leaving because his alarm has gone off and he’s tapping the other two and saying I’m stepping out; he gets to doorway and the T-bar ceiling comes down. That’s the instantaneous change in heat . . . and that’s where the change happens in the smoke and the heat.
“That causes the other guys try to get out of the building – firefighter Long, [whose alarm activated], who gets to the door – is knocked down by the T-bar collapse. They do what they’re trained to do; they deploy RIT and RIT gets to the door where firefighter Long is when the entire structural component of the roof collapses and the other two firefighters are trapped and killed in the fire.
“From that point on there’s nothing they can do. Nothing because of the cantilever nature of the collapse; the structural elements are on top of them, and the entire fuel load of the contents now becomes available to the heat, and it’s just a tragic conflagration after that.”
• • •
“Hindsight’s 20-20,” Chief Smith acknowledges, having reviewed the incident countless times with his crews. But more than 15 months after the fire and with the benefit of the OFM report and the MOL investigation, which found no wrongdoing, Smith is adamant that his firefighters were exceptionally well trained and followed protocol and procedures.
“We’ve discussed many times in operations here and in health and safety,” Smith says, “and we’ve sat and talked and talked about it and said, What could we have done differently?
“And every one of my people has come back and said, ‘What could we have done differently?’ We didn’t know what we had; we were trying to figure out what we had. We had no exposed fire, we could not see flames, at the time when it started we had very light smoke, and the guys were trying to search out where the fire was.”
Smith says he understands now that the flat roof was made of lightweight trusses with a layer of insulation above the suspended ceiling tiles. Firefighters were trying to pull down the tiles and the insulation to see what was happening above.
“We did not know that at the time, and we did not know the extent of the fire,” he says. “And, as the OFM has stated, the amount of time that the building was burning, that we did not know about; that probably would have made the difference, but a fire department, when you pull up, you may not be privileged to that information.
“Nobody did anything wrong. In my opinion, my officer who passed away in that fire had 30-plus years, and he knew what was going on and he was not a chance taker, and if he thought there was any danger he would be have been out the door with his crew. Nobody knew what we were dealing with.”
What, then is the legacy of Kenneth Rea and Raymond Walter?
• • •
In Listowel, where the North Perth Fire Department has always been known for its rigorous training – twice a month, consistently, for three or four hours a night – and where, like in most departments, there was a can’t-happen-to-us attitude, there’s a more somber and serious approach to mayday practice and firefighter survival.
“When they sound the [mayday] horns now you should see what we look like,” Smith says, “because we’ve lived through it. Now, when we practice, it it’s a whole different outlook by the firefighters and the officers.”
And on the department’s new pumper, there’s a horn button on the pump panel so the pump operator doesn’t waste valuable seconds climbing into the cab to sound it.
“Some departments have had that before but we never did,” Smith says. “Now, with this new truck, because it has hit home with us . . . That’s just a change we made but was that going to change the outcome of our call? No.”
For the OFM, the incident has led to a partnership with the roofers association to look at code changes including better fire-safety education for workers and a protocol for calling 911.
“Quite frankly, much of the code is designed around engineered solutions to building issues, and fire safety within buildings, and a lot of the code doesn’t regulate the human behavior associated with the use of a flame,” Williams says.
“What about the management of that heat source? Let’s put a requirement on there and impose a standard of care. There is education and training that could have made a difference.”
Williams says using the first two lines of defence – public fire-safety education and fire-safety standards and enforcement – rather than relying on suppression, is crucial to protect firefighters.
“One of the critical things here is the link back to the actual folks that were in control of the ignition source. We had an occupied building with workers on a roof – a combustible roof, using an open flame.”
Had those roofers and, perhaps, the shoppers who saw the smoke, been better educated about fire safety, “that would have been nine or 10 minutes shaved off that timeline,” Williams notes.
As for the OFM’s role outlined on its website – training firefighters, providing best practices and helping them provide the best fire prevention and fire-protecting services they can –Williams says the goal is to help fire chiefs and officers understand their changing roles as risk managers in an era of lightweight construction and highly combustible contents.
“There was an IC on the scene when they went in, and the IC did transition when Chief Smith arrived,” Williams says of the dollar-store incident.
“When you get into strategies and we start talking about safety officers and accountability, there’s nothing that’s going to help that team once that cataclysmic failure has taken place – it’s too late.
“So, the point would be to tactically do as much pre-fire planning as possible and as much size-up as possible, then make a decision; if there’s no immediate threat to individuals then we’re not going in, and that’s a very difficult decision for chiefs, because they’re wired to believe their job is to put the fire out and we’re now asking them to be risk managers.”
Williams says the key message for dealing with lightweight construction is to take the time to size-up the situation and make decisions based not only on what is visible, but what is known about the building from pre-plans.
“It’s not that lightweight’s going to fail immediately,” Williams says. “It’s that boy oh boy, you have to have some pre-fire planning and size-up and they become a huge factor in the decision-making process.
“In the absence of knowledge – and in this case, the knowledge that there’s lightweight construction – you may engage in some tactical operations that are very high risk.”
Where and how, then, in Listowel, could fire officers have learned more?
“Those opportunities all take time,” Williams says. “It would take time for the fire service to interview or question the workers and employees and civilians that were at this particular fire – but they might have been able to learn more about the activities that were on the roof, more insight into where the fire was burning, that it was a confined structural area and that it was wood frame and possibly lightweight – and gain more knowledge as to anyone inside the structure.
“So, armed with the knowledge you’re more likely to make incident-command decisions that are well informed and less risky.
“I think the key is that where there’s an incident commander, the biggest piece of protective equipment is knowledge.
“Our direction right now is that defensive operations are key if you’re involved in lightweight construction, especially if you don’t know the timelines; even when rescue is being deployed, and there are lightweight trusses involved, we’re saying firefighters should minimize being under the trusses for their own heath and safety.”
Admittedly, Williams says, the focus on size-up requires discipline.
“When we were interviewing firefighters we heard repeatedly that we thought we just had a little electrical fire.
Notwithstanding other issues, if they took the time to interview people who were at that building, and ask ‘What do you know?’, they might have been able to determine that hey, wait a minute, there’s a roofing exercise ongoing here and then we know they had primary rescue but at some point when the building is confirmed not to be occupied do you continue based on what you know, or do you stop and pull out and say now what are we going to do?”
Chief Smith wonders about the practicality of some of the OFM’s advice, particularly for volunteer departments.
“Its going to be very difficult,” Smith says of pre-planning. “Because, like most municipalities, under guidance from council, they only want us to do the bare minimum, so we’re meeting bare minimum under the Fire Prevention and Protection Act and doing inspections under request and complaint; we don’t get into a lot of these buildings to be able to have a good look at what’s going on in them and what they’re constructed of.”
Smith offers an alternative: placarding. He has been working with the Ontario Association of Fire Chiefs (OAFC) to have legislation proposed that calls for placarding – or signage – on commercial and industrial buildings that use lightweight construction. Some U.S. municipalities have adopted the practice and NFPA Canadian regional manager Sean Tracey has supported placarding in his column in Fire Fighting in Canada.
OAFC president Kevin Foster says placarding is a practical solution, along with more realistic training for officers.
“We have recognized that particularly on the senior officer side there are gaps in training and education opportunities,” Foster says.
“The emphasis on how to do pre-fire planning is something that’s part of several training programs and we’re encouraging people to know what’s in their communities but it’s also time consuming; there are still true volunteer fire chiefs who are left to prioritize all the issues that they have to deal with, and how many of them have the time after dealing with the day-to-day items, to do things like pre-fire planning?”
Foster also says there’s a need for more live or realistic training about lightweight construction through the OFM’s programs.
“When you’re sitting in a classroom trying to learn it and you’re trying to visualize it and somebody’s trying to explain to you what it looks like, you don’t have a good perception,” Foster says.
“You’re trying to learn from an environment of safety about an environment that’s unsafe.”
And that’s why pre-plans and size-up are crucial, says Williams.
“The challenges become insurmountable for an IC to be on top of,” he says. “Communications are extremely difficult on the fire ground and we’re seeing this regularly – not so much a communication failure, it’s the recognition of the risk.
And the tactical decision as to what’s going to be acceptable – what can you do within your means, and recognizing that if you’re operating within your means and operating safely, that’s all that can be fulfilled within that fire protection arrangement within your community.
“Knowing where that line is, is the challenge; if you go beyond your means and are making tactical decisions and something goes wrong and there’s no opportunity to recover, then you’ve gone too far.”
Knowledge, Williams says, is the most important piece of equipment for an incident commander.
“Knowledge takes time, and that requirement to take time flies in the face of the overwhelming desire for speed and minimizing the intervention time,” he says.
“Where does this knowledge come from? Does it come from arriving on scene as an IC? That knowledge dovetails with other key messages, that traditionally or historically there has been a huge focus on suppression as first step in fire-safety solutions. Our modern reality is that in some situations it doesn’t matter how many guys and trucks you have on the ground because there are some situations that are going to be out of your control.”