The Day The Impossible Happened The tragic death of Captain Bob Gallardy during training

The Day The Impossible Happened

The Day The Impossible Happened

The tragic death of Captain Bob Gallardy during training.The tragic death of Captain

Bob Gallardy during training.

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October 2006 THE DAY THE IMPOSSIBLE HAPPENED 2

Sunday October 23, 2005Sunday October 23, 2005

On a mild October afternoon during the last training evolution of the day, a veteran state instructor was critically burned in the basement of the Pennsylvania State Fire Academy residential burn building. Two days later, Captain Bob Gallardy of the Altoona Fire Department died from those burns. Here is the story of that tragedy and the changes that have occurred since that day.

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WHO WE AREWHO WE ARE

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The Pennsylvania State Fire Academy


• Located in Borough of Lewistown -Mifflin County, PA

• Facility opened in 1955

• Only facility owned and operated by Commonwealth of PA

* PSFA

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• Managed by the Office Of The State Fire Commissioner (OSFC)

• Supported by the PA Emergency Management Agency (PEMA)

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• Current class A burn buildings opened in May 1993

• Buildings lined with “High Temperature Lining” (HTL) in 2001

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• Four (4) main program areas– Certification

Program– Resident (on campus)

classes– Academy On The

Road classes– Local-Level (field

delivery) classes

• Fourteen (14) full-time employees– 2 are Resident

Instructors

• 140 Adjunct Instructors

• 1500+ Local-Level Instructors– Suppression– Non-Suppression

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The Suppression Instructor Development Program (ZFID)

The Suppression Instructor Development Program (ZFID)

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ZFID Attendance Requirements

ZFID Attendance Requirements

• 8 years experience in fire service

• 3 letters of recommendations

• Attend 150 hours “structural track” training

• Attend educational methodology class

• Must be certified Firefighter II, Fire Instructor I

• Attend NFA ISO class

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Suppression Instructor Development Program (ZFID)


• Started in 2000 for the purpose of evaluating instructor candidates

• This 40-hour program contains:– specific PSFA policies including the intent of NFPA 1403– presentations by instructor candidates, – tour of PSFA facilities including walk-through of burn

building– wet-line drills– live fire evolutions

• Candidates act as Students, Ignition Officers, ISO, IC, and Instructors

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• Program is presented by 8 Adjunct Instructors– A lead and co-lead spend first 20 hours with

candidates– 6 additional Adjuncts assist during next 20

hours– Act as evaluators during live-fire exercises– Shadow instructor candidates during all

evolutions

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Live Fire Evolutions during ZFID class


• Instructor candidates are shown safest methods of stacking pallets, spreading Excelsior, and starting fire

• Fires occur in basement and Division 2 of residential structure

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• ZFID Candidates will act as the:– Incident Commander

– Incident Safety Officer

– Instructor Up

– Instructor Down

– Students

Each position is

shadowed and evaluated by an adjunct instructor

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• Fire Suppression– 2-person hose team assigned to the basement

– 2-person hose team assigned to Division 2

• RIT– 4-person team stands by on Side A with wet-line

• Radios– One assigned to every team

– Assigned to all Staff involved in the evolution

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• Resident Instructors:– Operate engine

– Provide other support as required

– Can perform duties of an adjunct instructor if necessary

• Field Supervisor:– Monitors drills

– Monitors candidates’ progress and counsels them as needed

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• 2-person EMS crew with BLS ambulance on scene (may have medic aboard)

• Ladder in place on Side D for secondary egress

• Engine has additional water supply

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• First 4 evolutions – Wet-lines only , no live fires

• Live-fires for 12 evolutions

• Each evolution is slow and methodical as the IC, ISO and Instructors verify with each other, each team and each level of building are ready to start the evolution

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• Fire sets are smaller and fires are less intense than those in Resident structural firefighting classes– Candidates have previously proven their

skills as interior firefighters

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• Simulated emergencies may be staged in later evolutions. They may include one of eight. Such as:– a burst hose line– a PASS device sounding somewhere (not on a person

but by itself)– a portable radio that quits working– a separated crew member

• These are scripted and staff are informed prior to evolution starting

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WHAT HAPPENED THAT DAY

WHAT HAPPENED THAT DAY

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• Sunday October 23, 2005 was the final day of the class

• Last of the 16 normally scheduled evolutions

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• Because of an issue with one candidate the Curriculum Specialist was monitoring evolution #16 basement fire

• This meant one additional staff member was evaluating the candidates going to the basement

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• Evolution #16 – Fire sets were built by adjunct staff which

were equivalent in size to a Resident Program

– Why?• Motivate candidates

• Create a condition that if seen in an acquired structure would be cause for concern (Go/No-Go)

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• Evolution #16 – Started and proceeded– Candidate Safety Officer recognized and reported a

smoke condition different from previous evolutions– Crews entered assigned areas after all radio checks

were verified– A radio transmission stated “firefighter down”– Confusion among outside staff

Is this a staged emergency?

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EMERGENCY HAS OCCURRED


• Discussions among outside staff in an attempt to clarify radio message

• This resulted in delaying assistance

• EMS crew is advised of “possible firefighter down”

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• RIT team sent to basement after several minutes

• Basement crew exited via exterior stairwell with victim

• Emergency evacuation/PAR conducted• Patient care started immediately by the

ambulance crew along with EMTs and Paramedics who were students or staff

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• Full-time staff members begin emergency notification process and site security measures

• Victim is transported to Lewistown ER after helicopter is put on stand-by

• All persons directed to write statement of incident immediately

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• Contacts made:– State Fire Commissioner

– State EOC

– PSFA Administrator

– Altoona FD Chief

• CISM team is requested

• All students and staff held at facility (guests)

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• Captain Gallardy is transferred from Lewistown ER via helicopter to Lehigh Valley Burn Center at Allentown with burns over 50% of his body

• The Gallardy family notified by the Altoona Fire Department

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• CISM Team meets with entire group then splits into staff, student and guest groups for defusing

• After defusing all persons stay for light meal and well-being check before traveling home

• A graduation and informal critique of the ZFID program was conducted in an attempt to conclude the day on a positive note

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• State Fire Commissioner Mann calls NIOSH twice and leaves message requesting an investigation

• All persons depart PSFA promising to check on one another and stay in close contact

• Billy Goldfeder is notified for national distribution of incident

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TRAGEDY STRIKESTRAGEDY STRIKES

• Captain Gallardy spends 2 bad nights in burn unit

• Family and friends surround him at Allentown

• Bob passes away late Tuesday morning

• NFFF, State EOC, participants from Sunday’s class are notified

• Altoona Fire Department and Fire Commissioner Mann agree to allow Altoona to hold LODD Funeral in Altoona

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NIOSH ArrivesNIOSH Arrives

• Tuesday October 25, 2005– NIOSH Investigator Steve Berardinelli

arrives to begin investigation– Full cooperation is promised by Fire

Commissioner Mann– Fire Commissioner Mann pledges to “tell the

world” when the NIOSH report is released

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NIOSH InvestigationNIOSH Investigation

• Investigator Berardinelli takes 3 days to complete work at Lewistown– interviews persons

– reads statements

– takes pictures

– closely examines burn building

– fire training grounds

– victim’s PPE and SCBA

• Works closely with PSFA staff and displays professionalism while explaining as much as possible

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WHERE WE ARE TODAYWHERE WE ARE TODAY

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What is the solution?What is the solution?

• State Fire Commissioner, PSFA management and staff discuss possible causes, changes, and remedies

• March 2006 test burns are conducted by NIST with staff and NIOSH investigator present

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Live Burn Policy Changes since October 2005


• Operating alone anywhere in the building is strictly prohibited

• Two instructors are now required for ignition and stoking of fires – One person must remain outside of burn room in

visual contact when the other person is in burn room

– Fires on multiple floors require multiple ignition teams

• Additional charged safety lines are added to live burn training sessions

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• Stand-by ambulance MUST be BLS during live burns in acquired structures; ALS is highly recommended

• Use of any combustible liquid is prohibited

• All live fire evolutions are conducted in accordance with NFPA 1403

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• Rapid Intervention Team– Must be six people

• plus a RIT Officer who is a suppression instructor

• two of those must be ready for immediate deployment

• could be a RIT not associated with the class

– A suggested list of tools– Charged hoseline

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Resident Course Specific ChangesResident Course Specific Changes

• Increased number of adjunct instructors– Two ignition officers plus safety officer

• Additional charged hoselines• A formal gear inspection required for all resident

programs • Baseline vitals taken prior to live fire activities

– Vitals required for staff and students after exiting live fire during rehab

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Resident Course Specific ChangesResident Course Specific Changes

• ALS Ambulance on-site during live fires

• Simulated emergencies during the ZFID program removed because they were not producing the intended result

• A redundant accountability system

• Maximum fuel load is more clearly defined

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Information SharingInformation Sharing

• NIOSH investigation findings have yet to be released

• NIST is currently compiling data from the test burns.– Upon completion two presentations are

scheduled• Fire Academy Staff and Adjunct Instructors

• Local-level instructors

Closing Comments and Questions

Closing Comments and Questions

Contact InformationContact Information

PA State Fire Academy

1150 Riverside Dr.

Lewistown, PA 17044

717 248-1115

800 459-4096(In PA)

Tim Dunkle – Fire Academy Administrator

[email protected]

Documents

The Day The Impossible Happened The tragic death of Captain Bob Gallardy during training