Fire Report Cites Fatal Errors -- Misidentified Helmet Cost All- Too-Vital Time

CUTLINE: CRAIG FUJII / SEATTLE TIMES: INVESTIGATORS SEARCH THE SCENE OF THE BLACKSTOCK FIRE IN SEPTEMBER 1989.

For 15 to 25 minutes, firefighters had a chance to pull Lt. Matthew Johnson from the burning Blackstock Lumber Co. warehouse last fall, but missed the opportunity.

The search for Johnson could have begun at 10 p.m., when his incoherent partner, William Meredith, staggered out of the burning building with the help of another firefighter. But the commanding officer misread the helmet number of the other man and assumed the two were partners, according to a report by the National Fire Protection Association.

The officer, Battalion Chief Paul Hargrove, then listed Meredith and the man he thought was his partner as safely out of the building, the report says. Johnson, in fact, was still inside, lying near the end of the hose he and Meredith had dragged in.

At about 10:25 p.m., the report says, ``a huge ball of blue flames exploded out of the door'' from the area where Johnson later was found dead. After that, the building was unapproachable.

The scenario was laid out in the association's long-awaited report, released yesterday by Seattle Fire Chief Claude Harris. The department had requested the review by the association.

The 50-page report blamed Johnson's death on the department's methods of accounting for firefighters at large fires and specifically mentioned the misidentified helmet.

The report also, for the first time, said Johnson and his partner were partly responsible for the tragedy.

The report said Johnson and Meredith separated in the smoke-filled building, contrary to both department and national safety standards. The two firefighters also inadvertently used the wrong radio channel to call for help while lost in the vacant warehouse.

The NFPA report marks the second time in two weeks that the department has come under criticism for its failure to keep track of firefighters.

On March 1, the state Department of Labor and Industries announced that it was citing and fining the Seattle department $102,400 in connection with the Sept. 9 Blackstock fire.

The Fire Department was cited for two ``serious, willful'' violations, each of which drew a maximum penalty of $50,000, for failing to start a prompt search for Johnson and for not keeping proper track of individual crew members. A third fine, for $2,400, was for not training two firefighters on breathing equipment used at the fire.

Asked during a press conference yesterday whether he felt the state and national reports essentially came to the same conclusions, Chief Harris said: ``I don't feel they were similar. The state said we had no accountability system, and we have one.''

The system, he said, meets NFPA standards.

Asked how effective those standards were in view of the fact that Johnson was the second firefighter to have died at a blaze in two years, Harris said: ``It appears it has not worked here in the Seattle Fire Department.''

Pat Johnson, Matthew Johnson's mother, received a copy of the NFPA report late yesterday, after Harris' press conference, even though the association had suggested the department share it with the firefighter's family before any public release.

Johnson, who said she was only able to read a few pages of the report before breaking down in tears, said fire officials ``are making excuses for themselves. Obviously, it is not safe to be in the Fire Department.''

Johnson said her daughter-in-law, Esther, Matthew Johnson's widow, was following the advice of her attorney and would make no comment.

Meredith said he thinks the NFPA report unfairly criticizes Johnson, who is ``not here to respond.''

``I'm really disappointed, but I don't want to start throwing stones. I'm just disappointed in the criticism of Matt,'' he said. ``I think they kind of glossed over some things and dwelled heavily on some other things.''

Paul Harvey, president of Firefighters Union Local 17, and Battalion Chief Scott McEwen, president of the Seattle Fire Chiefs Association, representing 23 battalion and deputy chiefs, said they did not have a copy of the NFPA report and could not comment.

The report explains that numerous failures led to the breakdown of the department's system of accounting for firefighters.

The first failure was when Johnson left his nozzle without telling his partner where he was going.

The second was when the firefighter who found Meredith misidentified the crew to which he belonged and didn't question where the rest of the crew was.

The third mistake was when Battalion Chief Hargrove, commanding the front of the building, misread the helmet number.

Hargrove's misidentification becomes important because it occurred at a time when firefighters might still have been able to enter the building. The search for Johnson didn't begin until about 11:15 p.m. By that time, said the NFPA report, flames made it impossible to enter.

An interior search began about 11:50, shortly after the fire was considered under control. Johnson's body was not found until 1 a.m.

Shortly after the Blackstock blaze, the Fire Department was criticized for using conflicting strategies. Some firefighters were shooting water on the exterior while Johnson and Meredith, inside the building, moved toward the same area.

That, some firefighters said, was tantamount to the firefighters on the outside pushing the fire onto Johnson and Meredith.

An internal report by Deputy Chief S.E. Rose shortly after the fire said: ``The operation of exterior (fire hose) lines at the south and west side of the building could have . . . pushed the fire into uninvolved portions of the building.''

Deputy Chief Rod Bower was the first commander on the scene and, from a front corner of the building, initiated the strategies. His assessment was based on his belief that the fire was confined to a large shed he could see on a rear corner.

It's clear from the NFPA report that there was a lack of communication from commanders at the rear, who could see large parts of the building in flames.

At yesterday's press conference, Harris said, ``The communication between the firefighters and officers at the scene of the Blackstock fire was not as effective as it could have been and contributed to a breakdown in the transfer of information. This resulted in conflicting attack strategies.''

Although the NFPA report released yesterday touched on the use of conflicting strategies, it does not say they contributed to Johnson's death.

After Blackstock, firefighters also criticized commanders for sending crews into a vacant building.

The NFPA report said the Blackstock fire was similar to a 1987 abandoned building fire in Detroit. Said the report:

In both incidents, the report says, officers sizing up the fires misjudged their severity and sent crews inside. The report reasons that it is imprudent to send firefighters inside vacant buildings, since they usually aren't worth much and there's little risk that someone is inside.

Two years ago, firefighter Robert Earhart died fighting a blaze in a vacant apartment house. Labor and Industries fined the Fire Department, saying it had failed to protect its firefighters.

The department appealed the 1987 findings to King County Superior Court. Wednesday, it appealed the latest citations to Labor and Industries, saying its findings were based largely on investigators' misunderstanding of firefighting policies and procedures.

Fire Department goals

Seattle Fire Chief Claude Harris outlined four major goals for addressing the problems cited in a National Fire Protection Association report on the Blackstock Lumber Co. fire:

-- Improve communications at fire scenes by creating a special communications team and placing a communications van at all major emergencies. The van will be staffed by three people who will monitor radio and other firefighting communications. (The van was bought in the early 1970s for use as a command vehicle equipped with radios, but it has seen little use. Between the time the van was put into service Dec. 17, 1971, and the time of the Blackstock fire, the van had been taken to fewer than 15 fires. The van was not taken to the Blackstock fire.)

-- Upgrade the crew-accountability system so commanders have a better idea where individual firefighters are. To do that, Harris said, he hopes to set up a system that uses Velcro ID patches that can be taken from firefighters' gear and attached to an identification board.

-- Enhance training to emphasize the team-and-partner approach to fighting fires.

-- Improve the condition of vacant buildings. Harris wants to work with the city to broaden existing codes to ensure that vacant buildings are maintained in safe condition. The code does not now cover safety factors in vacant buildings.

EVENTS AT THE SEPT. 9, 1989, BLACKSTOCK FIRE

HOW IT ALL HAPPENED

9:21 p.m. First report of fire.

9:23 Deputy Chief Rod Bower arrives, directs aggressive attack from outside and inside the building.

9:25 Engine 20 with Lt. Matthew Johnson and Firefighter Bill Meredith arrives.

9:26 Battalion Chief Paul Hargrove, commanding front of building, not told of Bower's strategy, assumes attack will be on interior. Johnson and Meredith enter the building.

9:44 Bower sees fire intensifying, heat and smoke fill Section B where Johnson and Meredith are.

9:47 Flames are 100 feet at corners of building as Johnson, Meredith radio for help. There is no response to radio calls. Johnson, low on air, gives Meredith radio, lies on floor. Meredith leaves to find help, is disoriented.

10:00 Flames in Sect. A, C, D, E, F and G. Meredith staggers from building, incoherent. Hargrove misidentifies helmet number on firefighter helping Meredith, thinks they are partners and jots down that they are out of the building safely. Hargrove has Meredith taken to medics, then hospital.

10:25 Large ball of blue flame blows out front of Section B, singeing firefighter on ladder fleeing roof.

10:40 Johnson's radio, from Meredith, is returned to fire scene.

11:12 Deputy Chief Richard Colombi, in staging area, told something is wrong, given Johnson's radio, says Johnson will show up.

11:15 Safety officer, asked about Johnson, concludes he might be missing. Exterior search of building begins. Flames prevent interior search.

11:48 Fire under control, interior search started.

1 a.m. _ Johnson's body found.

SOURCES: National Fire Protection Association