Final report on Southwest Inn fire finds eight contributing factors

HOUSTON – A final report, detailing the events that led to the death of four Houston firefighters in May 2013 has been released by the National Institute for Occupational Safety and Health, a division of the Centers for Disease Control and Prevention.

After a line-of-duty death, NIOSH conducts its own independent investigation to check for contributing factors to the incident and to make recommendations to prevent future deaths.

The 108-page NIOSH report found eight contributing factors to the deaths of firefighters Robert Bebee, Matthew Renaud, Robert Garner and Anne Sullivan, including:

•Fire burning unreported for three hours
•Delayed notification to the fire department
•Building construction
•Wind impacted fire
•Scene size-up
•Personnel accountability
•Fireground communications
•Lack of fire sprinkler system

Three-hour head start

As Channel 2 Investigates has previously reported, investigators believe the fire actually started around 9:00am the morning of May 31. Employees say they smelled smoke throughout the morning, but the first call to 911 came after noon, when black smoke started showing through vents and flames first became visible. The NIOSH report found the hours of smoldering allowed the fire to spread to an area above the first floor, unnoticed.

Wind-driven fire
Adding to the danger that morning, strong winds gusting to 20 miles per hour that made visibility on the scene difficult and affected firefighting tactics. A high rise building next to the fire scene also created a wind break, sending high winds channeling on both sides of the Southwest Inn. Intense heat and smoke continued to grow as crews arrived and hampered their efforts.

15 minutes, 29 seconds

The NIOSH report found that 15 minutes, 29 seconds elapsed from the time of dispatch to the roof collapse that killed 4 firefighters. In the 20 minutes following the collapse, command staff and rescue teams sent into the building frantically tried to locate the missing firefighters. The report states: "At this point in the incident, radio communications were severely hampered due to significant radio traffic which overloaded the radio system." Trouble with radio communication made rescue attempts even more difficult. The report found crews were attempting to account for every firefighter on the scene, but "Due to issues with the radio system, it took the Accountability Officer 44 minutes to complete the PAR (personal accountability report)."

Roof design

The report goes into significant detail about the roof design of the Southwest Inn and how the initial design and subsequent remodeling played a role in the roof's collapse within 16 minutes of the first crews arriving on the scene. The collapse trapped the four firefighters under layers of roof debris, making it difficult for rescue teams to find them inside the building. A secondary wall collapse trapped another team of firefighter,s who were later rescued.

The investigation revealed that the roof of the Southwest Inn had three layers of roofing material, with layers having been added during remodeling projects. The report states:

"When re-roofing occurred, instead of removing the existing roof materials, the new roof was placed on top of the existing roof materials. The roofing material consisted of asphalt shingles installed on ½-inch thick plywood roof decking which was nailed to the top chords of the trusses. Clay (cement) tiles were added to the roof on Side Alpha for decorative purposes."

When rescue teams rushed in following the collapse, they had to cut through the roofing material with chain saws and crawl through windows to reach trapped firefighters.

Actions taken by HFD since May 2013

Immediately after the Southwest Inn fire, Chief Terry Garrison initiated a recovery committee from all ranks within the department to review the incident and make recommendations to prevent another loss of life.

Garrison reported a summary of changes within the department to NIOSH.

A Communications and Technology work group met with Motorola to review radio problems discovered during the fire. Changes were made in the radio system and radio procedures were updated to improve emergency communications during major incidents. The department worked to update overall performance of the new digital radio system across the city. Equipment was added to improve communication within buildings. The city hired more people in the Office of Emergency Communication to improve incident communications.

A new city ordinance was drafted to address buildings with poor communication. It outlines new requirements that property owners and management companies will need to address to meet the standards set for firefighter safety.

New technology was added to help the incident commander track assignments at a fire scene.

HFD redesigned and updated equipment used by rescue teams sent in to save trapped firefighters. And standard operating guidelines for these teams were updated.

HFD is considering the use of "helmet cams" to perform on scene video recording, and the department has secured grant funding to upgrade mobile data terminals (MDT's) in each emergency response vehicle. HFD also introduced a program that gives chiefs in the field electronic building assessments and real-time information on structures as they respond.

The department also began new training in February 2015, which includes a compilation of fire behavior research conducted by Underwriters Laboratories (UL), Fire Safety Research Institute (FSRI), and the National Institute of Standards and Technology (NIST).

Recommendations from NIOSH report

Many of the actions taken by HFD address the 15 recommendations for fire departments nationwide made by the NIOSH report. The recommendations are detailed in the full report, which you can read here.

The Houston Professional Fire Fighters Associated released a statement Monday that read: "Houston fire fighters appreciate the resources committed by NIOSH to the investigation of the May 31, 2013 fire at the Southwest Inn in Houston. This 106-page report comprehensively addresses the factors  at the fire that contributed to the deaths of four Houston fire fighters and the injuries of  16 others.  
"Houston fire fighters  remain  concerned  about the  HFD  equipment, policies  and training, and staffing issues raised in the NIOSH report. We note that while the report cites numerous revisions of HFD procedures made since the 2013 fire, the department has not actually implemented several of the cited revisions. The truth is, we  still  face  staffing shortages, systemic radio failures  and other technology problems, an aging fleet and facilities, and inconsistent provision of training.  
"HFD is a world-class department in many respects, but seven fire fighters have died in the line of duty in four catastrophic incidents during the Parker Administration. Because of the current  environment  at City Hall, HFD is too politically timid and reactive to major incidents. More must be done to better and proactively ensure fire fighter and public safety. Our obligations to our lost – Robert Bebee, Robert Garner,  Matthew  Renaud,  and  Anne  Sullivan  –  and  the  16  injured  fire  fighters  demand  that  lessons  be learned from their sacrifices. For that reason, we urge HFD to immediately  adopt the 15 recommendations in the NIOSH report  and the recommendations  of  the 2014  HFD Recovery Committee report on  the incident."

Garrison issued the following statement in response to the NIOSH report:

"Last week the Houston Fire Department (HFD) gathered and shared this report with the families of the fallen and injured members. We did so to fulfill our commitment "to never forget" and to keep the families as informed as possible. The report is designed to educate not just the Houston Fire Department, but the entire American Fire Service. The NIOSH Report is alignment with the HFD Recovery Report & State Fire Marshal Report. I am grateful to NIOSH, State Fire Marshal's Office and all of those who internally worked to implement change within our organization to make it safer for our members."