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					The Day The Impossible
      Happened



    The tragic death of Captain
   Bob Gallardy during training.
     PENNSYLVANIA
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           HE NNSYLVAN



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                                              Sunday 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 ARE




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                                              The Pennsylvania State Fire
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                                                      Academy
                                            • Located in Borough
                                              of Lewistown -
                                              Mifflin County, PA
                                            • Facility opened in
                                              1955                                     * PSFA
                                            • Only facility owned
                                              and operated by
                                              Commonwealth of
                                              PA

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                                                      Academy
                                            • Managed by the
                                              Office Of The State
                                              Fire Commissioner
                                              (OSFC)
                                            • Supported by the PA
                                              Emergency
                                              Management Agency
                                              (PEMA)


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                                                    Academy
                                                                 • Current class A burn
                                                                   buildings opened in
                                                                   May 1993
                                                                 • Buildings lined with
                                                                   “High Temperature
                                                                   Lining” (HTL) in
                                                                   2001



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                                                      Academy
                                            • Four (4) main              • Fourteen (14) full-
                                              program areas                time employees
                                              – Certification                – 2 are Resident
                                                Program                        Instructors
                                              – Resident (on campus)     • 140 Adjunct
                                                classes                    Instructors
                                              – Academy On The
                                                Road classes             • 1500+ Local-Level
                                              – Local-Level (field
                                                                           Instructors
                                                delivery) classes            – Suppression
                                                                             – Non-Suppression

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                                             The Suppression Instructor
                                            Development Program (ZFID)




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                                                        Requirements
                                            • 8 years experience in      • Must be certified
                                              fire service                 Firefighter II, Fire
                                            • 3 letters of                 Instructor I
                                              recommendations            • Attend NFA ISO
                                            • Attend 150 hours             class
                                              “structural track”
                                              training
                                            • Attend educational
                                              methodology class

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                                             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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                                            Development Program (ZFID)
                                            • 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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                                                    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 class
                                            • 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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                                                      ZFID class
                                            • 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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                                                       ZFID class
                                            • 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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                                                    ZFID class
                                                                 • 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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                                                      ZFID class
                                            • 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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                                                      ZFID class
                                            • 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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                                                       ZFID class
                                            • 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




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                                            Development Program (ZFID)
                                            • Sunday October 23, 2005 was the final
                                              day of the class
                                            • Last of the 16 normally scheduled
                                              evolutions




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                                                      ZFID class
                                            • 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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                                                      ZFID class
                                            • 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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                                                      ZFID class
                                            • 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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                                                     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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                                                     OCCURRED
                                            • 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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                                                     OCCURRED
                                            • 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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                                              OCCURRED
                                                            • 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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                                                     OCCURRED
                                            • 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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                                                      OCCURRED
                                            • 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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                                                     OCCURRED
                                            • 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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      FIRE ACADEMY




                                                  TRAGEDY STRIKES
                                            • Captain Gallardy           • NFFF, State EOC,
                                              spends 2 bad nights          participants from
                                                                           Sunday’s class are
                                              in burn unit
                                                                           notified
                                            • Family and friends         • Altoona Fire
                                              surround him at              Department and Fire
                                              Allentown                    Commissioner Mann
                                            • Bob passes away late         agree to allow Altoona to
                                                                           hold LODD Funeral in
                                              Tuesday morning              Altoona


October 2006                                               THE DAY THE IMPOSSIBLE HAPPENED             32
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                                                       NIOSH 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



October 2006                                              THE DAY THE IMPOSSIBLE HAPPENED     33
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                                                     NIOSH Investigation
                                            • Investigator Berardinelli
                                              takes 3 days to complete
                                              work at Lewistown             • Works closely with
                                               – interviews persons           PSFA staff and displays
                                               – reads statements             professionalism while
                                               – takes pictures               explaining as much as
                                               – closely examines burn        possible
                                                 building
                                               – fire training grounds
                                               – victim’s PPE and SCBA



October 2006                                                  THE DAY THE IMPOSSIBLE HAPPENED           34
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                                            WHERE WE ARE TODAY




October 2006                                     THE DAY THE IMPOSSIBLE HAPPENED   35
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                                                  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



October 2006                                             THE DAY THE IMPOSSIBLE HAPPENED   36
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                                              Live Burn Policy Changes since
                TH
                   ROUGH EDU

      FIRE ACADEMY




                                                      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

October 2006                                                 THE DAY THE IMPOSSIBLE HAPPENED         37
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                                              Live Burn Policy Changes since
                TH
                   ROUGH EDU

      FIRE ACADEMY




                                                      October 2005
                                            • 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

October 2006                                             THE DAY THE IMPOSSIBLE HAPPENED   38
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                                             Live Burn Policy Changes since
                TH
                   ROUGH EDU

      FIRE ACADEMY




                                                     October 2005
                                            • 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

October 2006                                                 THE DAY THE IMPOSSIBLE HAPPENED            39
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                                              Resident 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


October 2006                                                   THE DAY THE IMPOSSIBLE HAPPENED               40
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                                             Resident 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


October 2006                                              THE DAY THE IMPOSSIBLE HAPPENED   41
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                                                     Information 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

October 2006                                                THE DAY THE IMPOSSIBLE HAPPENED     42
Closing Comments and
      Questions
         Contact Information
PA State Fire Academy
1150 Riverside Dr.
Lewistown, PA 17044

717 248-1115
800 459-4096(In PA)
Tim Dunkle – Fire Academy Administrator
TDunkle@state.pa.us

				
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