Human Behavior. Five Years Later We Can’t Shake It

It is the greatest liability we must deal with

By Bill Carey

Originally published 18 June 2012. Links to related articles no longer exist due to website redesigns.

FireRescue Magazine/FirefighterNation took a look at Charleston five years after the Sofa Super Store fire. Below are articles from Battalion Chief Mark Davis, Deputy Chief of Operations, John Tippett, J. Gordon Routley and myself. Take in what Editor-in-Chief Tim Sendelbach says and take it back to your department,

“On June 18, 2007, the Charleston Fire Department (CFD) suffered the loss of nine firefighters while battling the Sofa Super Store Fire. This incident quickly became the focal point of fire service critics from around the world. A department long recognized for its rich history, strong organizational culture and traditional tactics was suddenly forced to endorse an unparalleled level of change. Five years later, under the leadership of Chief Thomas Carr, the CFD is rising from the ashes of tragedy to become a recognizable symbol of fire service excellence. As we look back at this incident and the events that took place that fateful day, every firefighter and fire officer should take a moment to consider the culture within their own organization, the safety and effectiveness of the tactics they’ve deployed over the course of their careers, and the resistance they’ve imposed on the leadership of their organization in support of their traditional beliefs. We hope these articles provide that opportunity. The Sofa Super Store Fire has provided countless lessons for us all, and there is no better way to remember the lives that were lost than to learn from this incident and to train others to do the same.” —Timothy Sendelbach, Editor-in-Chief, FireRescue Magazine/

An Officer’s Perspective

Tippet: Critics Wouldn’t Recognize the CFD

Investigation Team Leader Sees Significant Improvements at CFD

Here is my contribution.

On June 18, 2007 nine firefighters became disoriented and died inside a furniture store in Charleston, S.C. The deaths of the “Charleston Nine” and investigations became one of the most critiqued fireground tragedies in the 21st century. With exception to the loss of 343 firefighters on September 11, 2001, this has also become one of the most significant tragedies of the modern American fire service. Unfortunately, the lessons to learn from the Charleston fire were known years before the fateful day and, even more unfortunately, went unlearned years after.

Of the multiple lessons learned and recommendations to come from the Sofa Super Store fire investigation, the greatest focus on developing and following standard operating procedures; utilizing an incident command system; conducting proper size-up and risk analyses; and communicating conditions found inside. Although there are more many more recommendations from the various reports, these main four have been found to be significantly recognized in past and recent firefighter tragedies.

Highlighting these repeatedly overlooked tasks should cause us to heavily consider if the common lessons learned from active firefighting tragedies are being delivered, taught and understood in a manner worthy of honoring the fallen. Two such fires before the Charleston fire set the parameter.

Mary Pang Fire

In January 1995, four Seattle firefighters were killed in a floor collapse while fighting a warehouse fire known as the “Mary Pang Fire.” Arson and unusual construction details contributed to the collapse; however, the investigation noted the importance of a fluid risk assessment combined with accurate information of conditions coming from the interior.

During the fire—similar to Charleston—the initial interior fire reports led others to believe the fire was minor when compared to the reported conditions observed en route at each fire.(1) As the Mary Pang fireground progressed, the investigation noted that no 360-degree size-up was done. J. Gordon Routley notes that different interpretations in Seattle led to an incomplete picture for the incident commander and failed to paint the “big picture” or provide significant information.(2)

Move forward 12 years and among the first five recommendations from the Charleston investigation is the initial size-up and risk assessment before starting interior firefighting operations. Among NIOSH’s note is that no 360-degree size-up was conducted and if it had been, coupled with proper preplan information, the initial strategy should have switched from offensive to defensive.(3)

Southwest Supermarket Fire

In March 2001, the Phoenix Fire Department responded to a fire inside a supermarket. Much like the Mary Pang fire and the Sofa Super Store, Phoenix firefighters faced a minor fire with significant smoke during arrival and unknown conditions changing inside. Firefighter/Paramedic Bret Tarver became missing and what ensued was a lengthy operation involving location and removal.

From their investigation, the Phoenix Fire Department stressed the realization that rescuing a missing firefighter is much more complex and lengthy than originally believed to be. In large structures the rapid intervention mission had been tragically proven to need expanding, not only within the command structure but the company level as well.

Six years later, a fire in a mixed-construction commercial structure covering over 51,500 square feet reinforced those lessons.

More Examples

As time passed, the fire service mourned other firefighting line of duty deaths. It has been said that the past is indicative of the future. By looking a tragedies since the Sofa Super Store, our future looks dim when we see the conditions that led to the major recommendations from Charleston repeated years later. Looking not at specifically comparable building and fire conditions, but at the recommendations identified in the Charleston report, here are tragedies since 2007 that should lead us to question what it is we are “remembering” when we say “remember fallen brothers.”

California, July 2007. Two Firefighters Killed While Conducting Primary Search: Transfer of command was never established and initial tasks were not coordinated; positioning of positive pressure placed search team between fire and exhaust opening.

Massachusetts, August 2007. Two Firefighters Killed During Initial Attack at Restaurant Fire; Several examples where IMS and ICS was not followed or properly operated; no 360-degree size-up conducted; no stationary command post; no report on interior conditions broadcast over radio; assigned RIT was not prepared.

Pennsylvania, February 2008. One Firefighter Killed, Another Injured in Duplex Fire. Victims left hoseline on first floor and were caught in rapidly changing conditions on floor above; ventilation ordered by the IC contributed to rapidly changing conditions; no SOP or written policy on managing the mayday; important information about the structure (duplex) was not relayed to companies; no radio communications between the IC and search crew.

North Carolina, March 2008. Two Firefighters Killed, Officer Burned During Fire in Millwork Facility. Operational modes (offensive/defensive) changed several times, sometimes within minutes of each other; RIT burned while searching without a hoseline.

Ohio, April 2008. Two Firefighters Killed in Residential Floor Collapse. Entry made prior to conducting and initial size-up; mayday unheard or not understood; uncharged hoseline advanced into structure, calls for water went unheard.

Alabama, October 2008. Firefighter Lost and Killed During Residential Fire. Department had no verbal or written SOPs and no outlined minimum staffing procedures; despite all residents accounted for, entry was made without an IC established and without sufficient resources; no IC established during duration of incident; no procedure for the awareness of a trapped firefighter; no RIT established; no horizontal and vertical ventilation.

New York, August 2009. Firefighter Killed in Collapse, Firefighter Killed in Rescue Attempt. Not all interior conditions reported to IC; increase in “freelancing” noted after mayday.

Illinois, March 2010. Firefighter Killed, Another Injured in Flashover in During Residential Fire. Incomplete 360-degree size-up; uncoordinated ventilation placed victims between fire and ventilation source; no accountability system in place; no PAR after mayday; victim’s radio found unusable in back pocket of station pants.

Illinois, December 2010. Two Firefighters Killed, 19 Injured in Collapse at Commercial Structure Fire. Number of firefighters inside exceeded the number needed for the small amount of fire, in light of the abandoned structure; interior conditions not reported to IC; accountability not maintained, fragmented crews.

California, June 2011. Two Firefighters Die in Residential Fire. Inadequate size-up; incomplete radio communications.

With brevity, it is easy to see certain factors repeated since the Charleston tragedy. The complication comes in not dismissing them by referring to NIOSH reports as generic findings, nor is it by trying to pick apart every detail in each incident. Rational thinking should prompt us that despite specifics, the majority of contributing factors in Charleston and tragic fires since involve human behavior. While we see advances in apparatus, PPE and the science of fire behavior, human behavior is the greatest liability we must deal with.

As we see them being repeated we must begin to ask if the problem lies not in the lesson but in how we are teaching the lesson. While we echo “remembering the fallen and their sacrifice,” we let them die in vain when we don’t challenge our own behavior to see if the same mistakes are lurking in the dark, waiting to be repeated in our fire.


1. Investigation reports from both the Mary Pang fire and the Sofa Super Store fire reported that initial arriving companies at each fire reported smoked showing from the structure before arrival. Once after arrival, the initial action reports stated that either the fire attack was progressing (Mary Pang) or the fire was minor in nature (trash outside, Sofa Super Store).

2. “Four Firefighters Die in Seattle Warehouse Fire 1995.” J. Gordon Routley, USFA Technical Report Series, pages 38, 39.

3. “Nine Career Fire Firefighters Die in Rapid Fire Progression at Commercial Furniture Showroom – South Carolina,” NIOSH Firefighter Fatality Investigation and Prevention Program, 2009.

Published by Data Not Drama

Data Not Drama is writings that provide a point of critical thought about firefighter fatality data and education, line of duty deaths, and risk. The main focus is to encourage less risk aversion and better knowledge on the subject of firefighter fatalities in firefighters, fire departments, and fire service organizations.

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