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CHERRY ROAD RECONSTRUCTION
May 30, 1999, District of Columbia Fire Fighters Anthony Phillips and Louis Matthews
sustained critical injures in the line of duty that resulted in their deaths. Three
additional fire fighters sustained injuries ranging from critical to minor. Fire Chief
Donald Edwards (now retired) appointed a Reconstruction Committee to investigate and
evaluate the emergency response activities at this fire. This report is the result of
extensive interviews, independent investigation, and evaluation of the reports of other
investigators. The Reconstruction Committee has found that the District of Columbia Fire
and EMS Department (Department) has several deficiencies, particularly in training,
staffing. equipment, and administration. The mere knowledge of these shortcomings and
recommended actions does nothing. Many of the recommendations contained in this report are
the same recommendations made in a report of the investigation of the death of Sergeant
John Carter in the Kennedy Street fire of October 24, 1997. Further inaction on these
recommendations cannot be tolerated.
The Cherry Road fire was initially
considered by most of the personnel to be a "routine" fire. The events that took
place demonstrate the serious consequences that result from failure to train, equip, and
staff appropriately. At 00:17:00 on May 30, 1999, the District of Columbia Fire and
Emergency Medical Services Communications Center (Communications) received a 9-1-1
telephone call reporting a fire at 3150 Cherry Road, NE. In response, Communications
dispatched Box Alarm 6178, consisting of engine companies E-26, E-17, E-10 and E-12, truck
companies T-15 and T-4, a battalion fire chief (BFC-1) and a rescue squad (RS1). A second
9-1-1 call at 00:18:40 provided a corrected address of 3146 Cherry Road, NE, and reported
that there was fire in the basement. Communications announced this new information, but
only one of the responding companies acknowledged the address change. The first units were
on the scene within approximately four minutes of dispatch.
Several initial actions were taken
within the next five to six minutes.
- The first due engine company, E-26,
arrived to find heavy smoke pouring from the front door of the structure and advanced a
200-foot 1-1/2 inch attack line into the first floor area.
- The first due truck company, T-15,
arrived one minute later and began placing and ventilating at the front of the structure.
- The second due truck company, T-4,
arrived and prematurely began forcible entry and ventilation of the rear basement sliding
glass door without an attack line in position for entry. The T-4 officer was informed by
the occupant of the building that no one remained inside the structure, but T-4's officer
failed to report this information to the incident Commander. Truck 4's officer also failed
to give a rear size-up report.
- Rescue Squad 1 arrived and, failing to
follow SOPS, reported to the rear with one team entering along with a member of T-4. The
RS-1 officer was informed by the occupant of the building that no one remained inside the
structure, but RS-1's officer failed to report this information to the Incident Commander.
- The second due engine company, E-10,
supplied a 350-foot 1-1/2 inch attack line to the rear and reported to the Incident
Commander, BFC-1 that they were in a position to extinguish the fire.
- The third due engine company, E-12,
supplied E-26 with water and advanced a 400-foot 1-1/2 inch line into the first floor to
back up E-26.
- The fourth due engine company, E-12,
supplied E-17 with water, then, failing to follow SOPS, advanced a 200-foot 1-1/2 inch
line into the front of the building.
- The Incident Commander, BFC-1,
requested additional resources while en route, based upon the initial report from E-26.
After observing the fire location and conditions in the rear, BFC-1 reported to the front
of the building. Battalion Fire Chief 1 failed to establish a fixed command post and
relied on a hand-held radio for communications, rather than the stronger radio mounted in
Conditions quickly deteriorated after
the first six minutes of operations. Companies operating in the front of the building were
unaware that fire was growing in the basement because of inadequate communications and
improper ventilation activities. A failure to sound a "Mayday" alarm resulted in
a failure to realize immediately that there were missing fire fighters and a delayed
- Fire Fighter Matthews (E-26) and F/F
Morgan (E-26) advanced their attack line into the structure's front door, followed by
their officer. Fire Fighter Phillips (E-10) and E-10's officer advanced their hose line to
back up E-26. During the initial entry,. personnel indicated that they felt only moderate
- Truck 4 forced entry and ventilated
the rear basement sliding glass door, and soon after, E-17's officer requested permission
to attack the fire from the rear. Battalion Fire Chief 1 was unsuccessful in an attempt to
contact E-26 and E-10 to determine their location, and denied E-17 permission to attack.
- Intense heat then traveled out of the
basement and up the stairway to an inadequately ventilated first floor, severely burning
the fire fighters. At this point, the fire fighters attempted to exit the building. Fire
Fighters Phillips (E-10) and Matthews (E-26) were critically injured and unable to exit.
- Engine 26's officer informed BFC-1
that F/F Matthews did not exit the building. Engine 10's officer noted that F/F Phillips
did not exit the building but did not report this to BFC-1.
- The seriousness of the situation was
not fully realized until critically injured F/F Morgan (E-26) exited the building. BFC-1
then organized a rescue effort to search for F/F Matthews.
Rescue activities were also
characterized by a lack of organization, effective communication, and personnel
accountability. The rescue efforts also demonstrate the importance of each fire fighter
wearing an automatically activated PASS (personal alarm safety system) integrated with the
self-contained breathing apparatus.
- When rescuers entered the building,
they heard a PASS alarm. They found F/F Phillips face down on the first floor without his
facepiece, apparently removed because it had started melting. It was difficult to
extricate F/F Phillips from under a table; personnel noted that the first floor was
extremely spongy and there were extreme heat conditions.
- When F/F Phillips was brought outside,
it was apparent that F/F Matthew: was still inside the structure and rescue efforts for
F/F Matthews were resumed.
- After a short search. F/F Matthews was
located and evacuated. A total of approximately 21 minutes had elapsed from the time that
the fire fighters were burned until all the fire fighters were evacuated from the
Fire Fighter Phillips died at 0l :08.
Fire Fighter Matthews died the following day. Fire Fighter Morgan is still recovering from
Evidence has shown that the fire
started in an electrical junction box in the space between the basement ceiling and the
first floor, initially smoldered and consumed most of the air in the basement. The fire
grew rapidly when the basement sliding glass door was broken, producing large amounts of
super-heated fire gases. The fire gases traveled extremely quickly up the basement
stairway to the first floor. The injured fire fighters were in the path of the superheated
gases and were burned almost instantly.
The Reconstruction Committee
determined that the deficiencies in operations and equipment resulting in these deaths
fall into the following categories.
- Fire fighter accountability (e.g.,
company officers failed to keep personnel together and operate as a team; personnel did
not use the "Mayday" alert when fire fighters were discovered missing)
- Fireground command (e.g., the Incident
Commander failed to establish a fixed command post; did not have an aide and was thus
unable to coordinate front and rear teams; failed to sector the incident)
- Communications (e.g., no size-up
report of the rear was provided; interior companies did not make radio transmissions of
their initial attack and progress; it was impossible for injured fire fighters to
communicate information because they did not have radios)
- Company/unit operations (e.g., actions
of companies were not coordinated, so the actions of some companies threatened the safety
of others; some officers and fire fighters worked alone or with other companies instead of
staying with their own companies; truck companies were inadequately staffed)
- Safety (e.g., PASS devices that help
locate fire fighters who are immobile were not in use by each fire fighter; the
Department's Safety Office lacks the staffing and authority to conduct appropriate
investigations and follow-up on safety recommendations)
- Administration (e.g., nearly identical
recommendations, made following the Kennedy Street fire were not acted upon, resulting in
many of the same problems at this incident; personnel do not receive adequate training in
live fires because the Department's fire training building is unusable)
Each of the identified problems has a
solution, described in detail in this report. Some solutions are relatively easy,
involving equipment and its use. Some are more complicated, and involve changing behaviors
in individuals and attitudes throughout the Department. Proper training and staffing are
key to solving many of the problems. It is clear, however, that none of these solutions
are possible with the neglect, insufficient funding, and mismanagement that has
characterized the Department. The Department's budget must adequately support staffing,
equipment and training. Additionally, the Department must no longer tolerate the notion
that SOPs and proper fireground behaviors are only important for "major" fires
and not as important for "routine" fires. The Department must vigorously enforce
SOPS and demand professionalism at all levels of the fire department and at all emergency