Federal report released on Capt. Bowen’s death in 2011 fire

The Center for Disease Control’s National Institute for Occupational Safety and Health has released its findings in the 2011 arson-related death of Capt. Jeff Bowen of the Asheville Fire Department.

“No big suprises here, [in the NIOSH report]” said Asheville Fire Chief Scott Burnette “Their findings line up really close with our own internal investigations, [and] we are going to continue to concentrate on doing our jobs better.”

AFD’s final, internal review on the events of that day are due this month. The NIOSH release is the final of three studies that will conclude the investigation of the line-of-duty death that occurred July 28, 2011, during a fire at 445 Biltmore Ave.  They are: AFD’s 17-part internal report, the OSHA letter and the NIOSH report. Theses reports will be presented to the Asheville City Council’s Public Safety Committee on Monday, Aug. 27.

From the report

Contributing Factors

Lack of an automatic fire suppression system
Multistory/high-rise standard operating procedures not followed
Air management doctrine not followed
Reverse stack effect in stairwell
Inadequate strategy and tactics
Task saturation of the incident commander

Key Recommendations

Ensure that the existing standard operating procedures for high-rise fire-fighting operations are reviewed, implemented, and enforced.

Ensure that a deployment strategy for low-frequency/high-risk incidents is developed and implemented.

Ensure that the incident commander develops an incident action plan, which is communicated to all fire fighters on scene, and includes effective strategy and tactics for high-rise operations, a timely coordinated fire attack, and a coordinated search plan.

Ensure that the incident commander utilizes division/group supervisors for effective tactical-level management.

Ensure that fire fighters are properly trained in air management.

Ensure that fire fighters are properly trained in out-of-air SCBA emergencies and SCBA repetitive skills training (e.g., buddy breathing and clearing a facepiece)

Ensure that the incident commander is provided a chief’s aide to assist in incident management, including communications and personnel accountability.

Ensure that the incident commander establishes a stationary command post for effective incident management, which includes the use of a tactical worksheet, enhanced fireground communications, and a personnel accountability system.

Ensure that fire fighters are properly trained in Mayday standard operating procedures and survival techniques.

This follows up on the understanding the AFD had from informal and preliminary investigations, which has led to increased training for all Asheville firefighters in air management and rescue procedures, deployment strategies for the department and increased command presence at major fires. None of the recommendations found fault with AFD or its actions that day, only as general reminders to all fire departments of the hazards which high-rise fires pose.

About the NIOSH
The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program” which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar fire fighter deaths in the future.




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