2007 Prince William, VA LODD: Read entire report into FF Kyle Wilson’s death. Listen to fireground audio. Staffing cited as a major factor.
Technician I Kyle Wilson in a Prince William County Department of Fire & Rescue photo
“I need water (inaudible) 512 bucket. I need water, I’m burning up in here, I need water fast!”
What are apparently the last words of Kyle Wilson. A radio transmission from the Prince William County, VA firefighter at approximately 6:19 AM on April 16, 2007. About four minutes earlier Technician Wilson had alerted his fellow firefighters that he was trapped, with these words: “Mayday, Mayday, Mayday, Tower 512 bucket, I’m trapped inside, I don’t know where I am, I’m somewhere in the stairwell, I need someone to come get me out.” By the time firefighters were able to get to Kyle Wilson it was too late.
View of burning home taken by neighbor prior to the arrival of the first fire units. Photo from the report.
A report released on Saturday by Prince William County Department of Fire and Rescue Chief Kevin McGee lists the major factors leading to Wilson’s death. They include two things that are beyond the department’s control: the morning’s high winds, with a peak gust of 48 mph reported at the time of Wilson’s second radio transmission, and the lightweight construction of the single-family home.
But the report also cites factors that require improved training and a commitment of resources. They include: the size of the initial suppression force, size up, rapid intervention, incident control and management.
Review team
Chief McGee calls this “the most comprehensive after action analysis” in the department’s history. This was also the first line-of-duty death in the department’s 41-year history. The team responsible for the report included five people from Prince William County: Battalion Chief Jennie Collins, Battalion Chief Jerry Shepherd, Captain Rob Clemons, Captain Brian Cooke and Lieutenant Ramon Perez. They were joined by Division Chief Richie Bowers of the Montgomery County, MD Fire and Rescue Service and Battalion Chief Danny Gray from the Fairfax County, VA Department of Fire and Rescue.
In his cover letter Chief McGee cited the efforts of those who tried to save Kyle Wilson:
I recognize the many heroic efforts of the firefighters that placed themselves directly in harms way under intense and extremely dangerous conditions in their repeated attempts to rescue Technician I Wilson. These firefighters were willing to sacrifice their own lives to save Technician I Wilson, and I will always be grateful to them. We were fortunate that additional firefighters did not suffer injuries during the extreme fire conditions experienced in this incident. As Chief, I could not have asked for, nor expected, our personnel to have tried any harder or done more in their personal and physical expenditure of effort, energy, and attempts to rescue Technician I Wilson.
McGee was an assistant chief at the time of what is known as the “Marsh Overlook incident”. He was appointed chief in September, 2007 after the retirement of Mary Beth Michos. Chief Michos retired last summer and now works for the IAFC.
Fireground issues and staffing
As with most after-action reports problems were identified in numerous areas, including the initial size-up due to no one performing a 360 of the structure, hose selection, RIT coordination and activities, and mayday procedures. It also makes very clear, at numerous points, the department has a significant staffing issue:
Current unit minimum qualified staffing levels provide an insufficient amount of personnel to perform all the necessary, concurrent critical tasks associated with firefighting activities.
In his cover Chief McGee said the department has already been addressing many of the issues.
Wilson followed mayday procedures
The report is inconclusive about exactly why Kyle Wilson was unable to self-rescue. It is something that will likely never be known. But in its discussion of mayday procedures the report points out, despite the conditions he faced, Kyle Wilson followed procedures:
Technician Wilson activated the EA button on his portable and broadcasted a clear, concise UCAN (Unit-Conditions-Actions-Needs) report. He identified his unit and riding position, advised he was trapped somewhere in the stairwell, and that he needed assistance. His actions initiating a mayday were consistent with procedures and firefighter survival training.
While rescue attempts were immediately initiated, radio transmissions indicate no one responded to or stayed in contact by radio with Technician Wilson:
There was no attempt by Command, OPSC, or any other fire ground personnel to establish direct radio communication with Technician Wilson to acknowledge his mayday transmission.
Here are the links to the 6 parts of the report. The LODD Death Report Video is a multi-media presentation that includes the radio transmissions mixed with still pictures, video and graphics of the fire modeling. It provides an audio-visual timeline of the conditions and some of the events during the initial stages of the fire. And a warning, it also includes Kyle Wilson’s last words.
Excerpts from Fact Sheet
(These are highlighted recommendations for improvements)
• Staffing related:
o Increase the minimum staffing on all engine companies from three to four qualified firefighters.
o Increase the minimum staffing on all specialty pieces from four to five or six qualified firefighters and/or addressing the deployment of specialty unit crews on an incident scene.
o Increase the amount of resources that are dispatched and adopt a standard structure fire dispatch complement for all types of structures and address modifications to those resources during extreme environmental conditions.
o Perform a specialty unit resource allocation study.
• Training related:
o Address training needs related to:
− Operat
ions in extreme environmental conditions and the adjustment of strategy and tactics in extreme environmental situations.
− Building construction methods, materials, and designs.
− Strategy and tactics, decision making, and institute structured officer development training.
o Ensure the Training Division has resources to develop, coordinate, and provide the needed training curriculums.
• Procedure related:
o Comprehensive review and revisions of all procedures.
o Address operational procedural changes for:
− Operations in environmental extremes.
− Rapid intervention practices.
− Different types of building construction methods, materials, and designs.
o Standardization of apparatus, equipment, and procedures.
• Communications related:
o Development of a standard method for communicating important weather related information to all personnel.
o Radio technology improvements.
Complete Executive Summary
This Line of Duty Death (LODD) Investigative Report is dedicated to Technician I Kyle Wilson, his parents Bob and Sue Wilson, his sister Kelli, his brother Chris, his fiancée Kristi, and his extended family and many friends. Kyle will never be forgotten and to honor his supreme sacrifice, the Prince William County Department of Fire and Rescue commits to sharing our lessons learned in all aspects of this report within our department, system, region, and industry so that no other family or department suffer a similar tragic loss.
This report was developed with a multi-dimensional team approach. The objectives of the LODD Investigation Team were to examine the events that occurred at the Marsh Overlook fire incident and identify the factors involved with the line of duty death of Technician I Kyle Wilson. The Investigation Team has reviewed all available information at the time of publication and documented the factual findings, discussions, and recommendations in an effort to prevent another tragic outcome from occurring again.
Virginia Occupational Safety and Health (VOSH) and the National Institute for Occupational Safety and Health (NIOSH) performed independent investigations of the Marsh Overlook fire incident. The Prince William County Department of Fire and Rescue’s LODD Investigation Team’s report took a dissecting approach from every aspect which reaches beyond the scope of the VOSH or NIOSH reports. To prevent another tragic event, a critical self assessment of the organization was necessary. This report represents thousands of hours of effort to analyze fire and rescue operations and recommend needed improvements. These organizational improvements range in complexity and many will have budgetary impacts that will be impossible to achieve in a single fiscal year. However, the report provides a framework for improvements that when enacted will improve responder safety and elevate service delivery to the citizens and visitors of Prince William County.
The LODD Investigation Team had the advantage of examining this incident over a period of months. The team would spend days dissecting a single snapshot of time and considering what actions were taken and what the resulting impacts were. However, this is starkly contrasted by the actual incident the responding personnel faced on that fateful day. The Marsh Overlook incident was an immense fire fueled by extremely flammable building material products and a vicious wind. It was an environment where information gathering and decision making had to be performed in a time measurement of seconds. During the chain of events that occurred and under severe circumstances, fire and rescue personnel performed at exceptional levels. In an attempt to rescue Technician I Kyle Wilson, personnel displayed heroic efforts and jeopardized their own safety to try and reach their missing comrade.
The major factors in Technician Wilson’s line of duty death were determined to
be:
• Initial arriving fire suppression force
• Size up of fire development and spread
• High wind impact on fire development and spread
• Structure size, lightweight building construction and materials
• Rapid intervention and firefighter rescue efforts
• Incident control and management
The fire conditions that were present in the structure, the large size and lightweight building construction of the structure, the behavior of the fire impacted by the high wind environment, and the organizational preparation for and response to the incident were contributing factors in this tragic event. The weather conditions and construction features resulted in the rapid and catastrophic progression of fire conditions and the loss of integrity to the building. The conditions of the fire cannot be changed but this incident investigation shows organizational response to similar incidents can and should be improved. Resulting from this tragic incident and the dissecting analysis that followed, the Department will be improving numerous aspects of their operations centered on staffing, training, procedures, and communications.
We will never forget Kyle and by sharing our loss and knowledge unfortunately gained from our pain, we will ensure that he is not forgotten nor will his sacrifice have been in vain.
To Technician I Kyle Wilson, may you rest in peace. May your family, both immediate and fire and rescue, also find peace.
