Internal Investigation into the Line of Duty Deaths (KCFD, MO 10/12/2015)

The Internal Investigation into the Line of Duty Deaths of Fire Apparatus Operator Larry Leggio and Firefighter John Mesh

Fellow Brothers and Sisters, Colleagues, and Professionals;

On October 12th, 2015 the Kansas City, Missouri Fire Department experienced a stunning loss. Two of our dedicated brothers and friends of mine perished while battling a blaze in Old Northeast. This is not the first tragedy our department has had to face in its long, lustrous history nor will it likely be our last.

With that being said our Fire Chief and Locals 42 and 3808 have teamed up to create a body to review the events of October 12th to come up with recommendations in the hope we can forestall any tragedy such as this from touching our lives again. This group of members and management has devoted countless hours of work to complete the task that was asked of them.

The stacks of reports and standards to review seemed insurmountable in themselves. Couple that with the firsthand accounts from the After Action Review and the information from the Bureau of Alcohol, Tobacco, and Firearms and you get an idea of the massive task load of the working group. In addition to that task load was the emotional weight this incident carries and the personal nature of which many on the group knew the fallen. I want to thank each member of the group for doing a job that was exhausting, heart breaking, and what I hope will be worth all of the sweat and tears that were shed in this endeavor.

The intent of this report is not to condemn any person who was on the scene the night of the fire but instead to learn from this tragedy and move forward as a group better than we were before. Larry and John can continue to contribute to the jobs they loved so much in this document and the memories of those who knew them.

My condolences go out to Stations 10 and 17, the members who were close to the brothers, but most importantly to the Mesh and Leggio families. There is not a day I donít think of you and the sacrifice you made. This document is dedicated to all of you in the hopes we never have any such disaster strike us again.

Clay Calvin
IAFF Local 3808

Read the Report

Following are the recommendations generated by the report:

Recommendation #1

The department should develop a Collapse Zone policy. Currently, the fire department does not have a specific policy addressing Collapse Zones. This policy should be developed utilizing NFPA, NIOSH, IFSTA and other industry recognized standards and recommendations as reference. This policy should include the visual identification of establishing Collapse Zones such as by lighted beacons or colored incident scene tape.

Recommendation #2

The department should update current communication policies as they apply to emergency incidents. Currently, the department does not employ a uniform applied to radio communications. The policies addressing critical information exchange should be updated. The investigative team also identified the need to establish departmental procedures regarding confirmation of critical emergency incident communications. Much in the same manner as we conduct PAR procedures, these confirmation steps should be employed for every major benchmark within an incident. The investigation team has concluded that GAG 3-4, Radio Communications, should contain updated information regarding radio call procedures.

Recommendation #3

The department should develop an inclusive training program that revolves around the merits of Situational Awareness. The Incident Commander is specifically responsible for managing risk at the incident, however, one person cannot be expected to apply these principles to an incident if the organization has not integrated a standard approach to risk management into its policies and its organizational culture. Firefighters and fire officers should be trained and a system should be implemented to outline clear rules of engagement and initial scene size-up. The risk versus reward methodology should be employed.. This recommendation coincides with Goal 5 of the departmentís strategic plan (2014): Provide comprehensive training and professional development to ensure personnel are fully prepared to effectively perform their duties and responsibilities.

Recommendation #4

The departmentís current Incident Management System Manual needs to be updated to include current practices and new standards. The following bullets identify the elements of this policy that should be included or updated.

The review and changes to the departments IMS manual should refer to: NFPA 1500, Standard on Fire Department Occupational Safety and Health Program; NFPA 1561, Standard on Emergency Services Incident Management System; and the National Incident Management System.

Recommendation #5

Train all department officers regarding Safety Officer duties and responsibilities. One critical characteristics of the Safety Officer function is t that this incident function is not task oriented. The responsibility of this IMS function is overall scene safety. This recommendation coincides with Objective 3K of the departmentís strategic plan (2014): Define the role and function of the Safety Officers.

Recommendation #6

Train all emergency personnel in building construction. Building construction has drastically changed of the last two decades. It is imperative that this organization recognize critical structural weaknesses and signs of collapse. The knowledge gained through this department training should be incorporated into all scene size-ups given by the first arriving officer. This recommendation coincides with Goal 5 of the departmentís strategic plan (2014): Provide comprehensive training and professional development to ensure personnel are fully prepared to effectively perform their duties and responsibilities.

Recommendation #7

Ensure that all personnel properly wear all assigned Personal Protective Equipment when required by policy. The organizational culture that allows for varying interpretations regarding when and where PPE should be donned must be terminated. This recommendation coincides with Objective 3G of the departmentís strategic plan (2014): Develop an organizational strategy to promote consistent use of personal protective equipment (PPE) to reduce potential for injury.

Recommendation #8

Develop, train and employ an Incident Accountability System for use in all emergency incidents. The department currently has a general operating guidline establishing a departmental accountability system (GOG 11-9). The details of this policy deal with the administration of an accountability system at emergency and non-emergency scenes. Impractical, outdated, and inefficient for emergency scene use, the policy has lacked consistent utilization from its first implementation. This recommendation coincides with Goal 7 of the departmentís strategic plan (2014): Develop an updated KCFD incident management accountability system

Recommendation #9

The fire department should consider preparing, training, and implementing new policies and procedures in a different format. Currently the department has over 200 policies, directives, GAGs and GOGs. In order to update and reorganize our current system, we must identify operational polices that should not be deviated from. Calling our operational procedures ďGeneral Operating GuidelinesĒ (GOGs) versus Standard Operating Procedures (SOPs) may imply that there is flexibility in complying with any given policy. There is no legal difference between GOG vs SOP. All policies and procedures must comply with state and federal regulations such as OSHA, NFPA, and the Code of Federal Regulations and should be cross- referenced to these standards. A procedure for an annual review of all policies and procedures should be implemented.

Recommendation #10

The department should develop a policy that addresses the formation of an investigation team concept to be employed in any serious injury incidents. The following resources are recommended for utilization and construction of this policy: LODD or Injury Investigation guides published by IAFF/IAFC; NFPA 1500, Standard on Fire Department Occupational Safety and Health Program and NFPA 1521, Standard on Safety Officer Professional Qualifications. By preparing in advance, the department will ensure that we are able to handle at least some of the myriad items that must be dealt with after a serious incident such as the Independence Avenue fire. Other organizations have developed Health and Safety Units that hold the responsibilities mentioned in this recommendation.

Recommendation #11

The Department should develop and implement a behavioral health training, referral and educational program that also addresses peer counseling, suicide prevention and intervention. Not all firefighters will need this service or take advantage of it. The construction of this team is crucial to ensuring the emotional health and recuperation of department members. Although not a contributing factor to the collapse, the department experienced many challenges that were a direct result from this incident. The construction of this program is crucial to ensuring thebehavioral and emotional health and recuperation of the members of the Kansas City, Missouri Fire Department. Recommended resources include the IAFF/IAFC Wellness Fitness Initiative, and NFPA 1500, Standard on Fire Department Occupational Safety and Health Program.

Recommendation #12

The Department should review the current May-Day GOG and update to include new communication considerations. The investigation team identified a possible element of confusion within the application of procedures outlined in the policy. After many years of successful implementation, this policy has provided a foundation for signaling of firefighters in distress. The review of this policy is recommended that also includes a regional perspective.

Recommendation #13

The Department should further develop leadership and foster management capabilities as part of an Officer Development program. This should include elements of supervision at both emergency incidents and non-emergency situations. Achieving this recommendation will position the department to be better prepared in the area of succession planning. The following resources are recommended for building the framework for this program: the IAFC Officer Development Handbook; NFPA 1021, Standard for Fire Officer Professional Qualifications, and NFPA 1026, Incident Management Personnel Professional Qualifications; and the Kansas City, Missouri Human Resources Academy coursework.

Recommendation #14

The Department should enhance its current building data collection methods utilized by emergency operations and integrate high hazard risk identification with Fire Prevention records. Pre-fire tactical preplanning should be considered in all areas of the city. Inspection records should be interchangeable between divisions within the department. Identification and visiting target hazards that have multiple violations will give primary response companies knowledge that may impact interior firefighting tactics and strategy. This policy should be developed utilizing the standards presented in NFPA 1620, Standard on Pre-Incident Planning, as a reference.

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