DC Fire and Medical Services Department
Report from the Reconstruction Committee
Fire at 3146 Cherry Road, NE, Washington, DC
May 30, 1999

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EXECUTIVE SUMMARY
CHERRY ROAD RECONSTRUCTION

On 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 his vehicle.

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 rescue response.

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 heat.
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 building.

Fire Fighter Phillips died at 0l :08. Fire Fighter Matthews died the following day. Fire Fighter Morgan is still recovering from his burns.

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 incidents.

DC Fire and Medical Services Department Report from the Reconstruction Committee Fire at 3146 Cherry Road, NE, Washington, DC May 30, 1999

DC Fire and Medical Services Department
Report from the Reconstruction Committee
Fire at 3146 Cherry Road, NE, Washington, DC
May 30, 1999