Multiple factors led to firefighters' death

Several factors led to the deaths of two Kilgore fire fighters killed in a training accident earlier this year, according to a report by a federal government investigation unit.

Ronnie Moore, city public safety director, said in a press conference Friday morning that Kilgore Fire Department and the fire truck manufacturer's personnel have since worked together to try to ensure the same type of accident that killed Kyle Perkins, 45, and Cory Galloway, 28, never happens to another department.

Moore released a copy of the report prepared by the National Institute for Occupational Safety and Health (NIOSH), which investigated the fatal accident that occurred Jan. 25 at the eight-story Stark Dorm on the Kilgore College campus.

According to the report, which Moore said was in keeping with an in-house investigation performed by KPD, the key factors leading to the accident were:

— Firefighters being unfamiliar with the controls on the newly purchased aerial platform truck, or ladder truck, known as "Ladder One" or "L-1";

— Training in a "high risk" scenario before becoming familiar with the new equipment;

— Failure to use fall restraints (safety belts);

— The design of the platform (or "bucket") railing and integrated doors; and

— The location of the lifting eyes underneath the platform where four firefighters were standing, which contributed to the platform snagging on the dormitory building's parapet wall.

The lifting eyes, which are metal "hooks" that protruded horizontally from the bottom of the platform, are needed to lift a Stokes basket, used by rescue personnel to transport victims in emergency situations, such as from the top of a building to the ground. A Stokes basket was not in use at the time of this accident.

Those lifting eyes have since been removed from the bottom rail of the platform and relocated to the top of the bottom platform rail.

KFD had ordered safety belts for the ladder truck but had not received them when the training accident occurred, so none of the firefighters involved were wearing them.

According to the NIOSH investigation, four firemen were in the aerial platform hoisted up to the top of the dorm when the lifting eyes caught the edge of the concrete parapet.

"During (the operator's) attempts to free the platform, the top edge of the parapet wall gave way and the aerial ladder sprung back from the top of the building, then began to whip violently back and forth.

"Two of the four fire fighters standing in the platform were ejected from the platform by the motion. They fell approximately 83 feet to the ground and died from their injuries," the report said.

Both were thrown through the platform's integrated doors, one from the left side and one from the right. The two other firemen managed to stay inside, though one landed on the platform floor "with his head and shoulders hanging outward through the open doorway."

Also according to the report, the two survivors "observed that the platform doors were sprung outward (the doors are designed to only swing inward into the platform)."

The firemen were in the city's new 2008 custom-made 95-foot ladder truck, which was received by KFD on Nov. 19, 2008. According to the report, the men were trained for eight hours by a representative of E-One, the manufacturer. That training included both classroom and practical exercises, held over the course of three days, Dec. 13-15, for KFD's three work shifts.

The report states that after completing the factory training, each shift practiced and drilled on the new truck in front of the fire station and at "the local football field, elevating the platform and flowing water on at least one occasion."

One of the requirements dealing with the apparatus, or truck, that NIOSH investigators said should have been in place was four ladder belts.

According to the report, "The NFPA (National Fire Prevention Association) Standard that governs the construction of the aerial apparatus in 2008 was NFPA 1901 Standard for Automotive Fire Apparatus, 2003 Edition." However, at the time of the accident in Kilgore, NFPA 1901 had not been adopted by the Texas Commission on Standards and Education for firemen.

The report further states the investigators reviewed a PowerPoint presentation of the eight-hour training provided by E-One and it "did not mention the need for personnel to use fall protection while working in an elevated platform." However, E-One's 302- page operator's manual for the truck mentioned in several places "the need for personnel to use protective safety belts," including one "'Warning' box located in the Aerial Safety section which stated 'Do not allow personnel on the end of a moving aerial unless they are secured to the aerial with a personal protective safety belt.'"

NIOSH recommends that fire departments should:

— Ensure firefighters are fully familiar with new equipment before training under "high risk scenarios."

— Ensure fall protection (safety belts) is always used whenever firefighters and other personnel are working in elevated aerial platforms.

— Follow standing operating procedures (SOPs) for training, including the designation of a safety officer; and

— Ensure SOPs covering the operation and use of fire apparatus (including aerial platform apparatus) are developed and followed during training exercises as well as in fire suppression activities.

NIOSH concludes fire apparatus manufacturers should:

— Provide safety belts with all aerial ladder and platform apparatus and ensure fall protection is used during manufacturer-provided training.

— Ensure that aerial platforms and other aerial devices are deigned to reduce or eliminate the potential for snagging on buildings or other elevated surfaces; and

— Ensure aerial platform doors or gates are designed to prevent opening in the outward direction.

A third KFD fireman fractured his left heel as he jumped from the ladder truck's cab to the ground when he saw Perkins and Galloway were falling.

Stark dorm is the tallest building in the city and the primary reason the city purchased the ladder truck, which cost almost $250,000.