February 19, 2014

Chuck Duffy, State Fire Marshal Washington State Patrol PO Box 42600 Olympia, WA 98504-2600

State Fire Marshal Duffy: This document is my summary of the after action investigation into the incident that occurred on October 25th, 2013 at the Fire Training Academy aircraft rescue and firefighting (AARF) prop. I appreciate the opportunity to assist your office in this investigation. In my role as a Battalion Chief for my department, and over my twenty nine year career, I have been involved with after action reviews in various roles. During my time as Training Chief for my department I was responsible for researching and conducting after action reviews. The scope of this investigation centered primarily on the actions of the crews while engaged in AARF training on October 25th. Introduction: In 1997 a consortium of aircraft firefighting agencies entered into an agreement with the state of Washington for the development, management, and use of an aircraft rescue and firefighting (ARFF) training facility located adjacent to the Washington State Fire Training Academy (WSFTA) at North Bend. The facility has been used on an annual basis since that time. The inter-local agreement signed by all parties identifies the State, through the lead agency of the Washington State Patrol (WSP) as responsible for maintenance, scheduling, and instructor development among other responsibilities.

As part of this agreement training props were installed and an engineered water and fuel recovery system was put into place to recycle the water while removing the fuel from the waste water. It is important to note that this system is independent of the water/fuel recovery system co-located at the fire training academy. Maintaining the ARFF prop has been the responsibility of the staff of the WSFTA. Since the props became operational there has been a total change over in maintenance personnel. From 1997 until 2010 the maintenance supervisor was Tracy Caldwell. The new maintenance supervisor is Mika Elo assisted by Levi Scartozzi. Elo was hired after Caldwell left and Elo has limited experience with maintenance of the ARFF prop. Per Scartozzis interview he was primarily responsible for minor repairs while Caldwell was employed but took over a larger role in the maintenance of the prop after Caldwells departure and before Elos hiring. Scartozzi was instructed by Caldwell on procedures for operating the water/fuel recovery system. The scope of this investigation did not include what role this change in personnel may have had in the events that occurred in October of 2013 but there appears to be a loss of institutional knowledge after Caldwell left as well as a change in procedures. Background: The training that occurred on October 25th was part of ongoing annual training being primarily conducted by the Port of Seattle Fire Department (POSFD) in 2013. During prior training dates there were issues of non-standard events identified by the POSFD personnel in their statements. These issues are listed associated on the dates below. October 14th After an initial routine morning of training the ARFF prop experienced an ignition failure. The maintenance staff was notified and after attempts were made to fix the issue, which was unsuccessful, training was completed using an alternative ignition method. As part of the attempt to test the ability of the prop to self-ignite a quantity of fuel was flowed that was not ignited.

October 21st After several training evolutions were held it was observed that there was a black sludge coming out of the hydrants being used by the crews to re-fill the crash trucks. According to the statement of Todd Starkey, a Captain with the POSFD and longtime state certified prop operator who was present, this occurrence had not been seen in the past and after a brief discussion with academy maintenance staff it was decided to halt training for the day and the water/sludge that was in the crash trucks was ordered to be processed back into the prop for recycling. Since the POSFD was going to conduct additional training in four days (October 25th) Starkey stressed to Levi Scartozzi of the academy maintenance staff that the hydrant system needed to be flushed prior to the training on the 10/25. Captain Starkey talked to Scartozzi and was assured that system would be flushed prior to that training. Prior to the 10/25 training a phone call to ARFF Training Director Rich Galtieri was made to ensure that the hydrant system was flushed and everything was operational for the training on October 25th. Galtieri confirmed that the hydrant system was flushed. With that information it was decided to hold the training on 10/25. It is unknown who Galtieri checked with to determine if the hydrants had been flushed.

October 25th At approximately 0730 Shane Hughes, William Catlow, and Starkey entered the pump house building to turn on pumps. Hughes is part of the full time staff at the academy and Catlow was the state ARFF instructor for the day. They found what they described as a large amount of fuel rich water on the floor of the building as well as a strong fuel smell inside the building. The water/fuel separator was still in operation. Hughes phoned Mika Elo, the maintenance supervisor for the academy, and Elo advised Hughes how to shut down the separator.

Elo made a phone call to Levi Scartozzi to discuss the situation. Although Elo is the maintenance supervisor he has been at the academy a limited amount of time and Scartozzi has more experience with the prop. After the call Elo advised the POSFD that the situation had happened before and training could continue. (Tracy Caldwell, long time academy maintenance supervisor confirmed that similar situations of fuel splashing on the ground had occurred in the past) The decision was made by Starkey and POSFD Training Chief Rick Kruckenberg that training would take place. Around this time Starkey was informed by POSFD crews that the hydrant water still had the same issues with discoloration and sludge that had shut down training on 10/21. Starkey discovered that the system had not been flushed and per his statement he gave the order to have the hydrant water flushed back into the prop for recycling. Instead of this being carried out the hydrants were flushed onto the drill ground which resulted in an environmental issue. Since the water available for the props and hydrants is a closed system this also reduced the water supply by several thousand gallons. As videos of the days events show the first evolutions of the day were routine although POSFD firefighters stated that the fuel smell in the hydrant water was stronger than normal for the system. There was concern stated by some of the POSFD personnel that the concentration of fuel in the water system would contaminate their bunker gear and one firefighter stated that he did not wear his structural firefighting gloves when filling the crash truck from the hydrant for fear of contaminating the gloves. The hand line evolution portion of the training started out routine with all personnel in appropriate positions. Starkey and Kruckenberg were in the control tower with Starkey at the controls and Kruckenberg, acting as the site safety officer, nearby in the tower. According to the statements of both Starkey and Kruckenberg it was apparent that the problem evolution was non-standard from the beginning. Their statements point out that the body of fire and the location of the fire was changed from previous hand line operations. The same non-standard condition was also observed on the videos provided.

In the control tower Starkey hit the emergency shutdown button. This action had no effect on halting fire growth which is to be expected since one of the features of the emergency shutdown system is to apply water to the props using small nozzles located on the props. Since this water system is the same as the hydrant system it would be expected that instead of water, fuel was being applied to the props. The crews that were fighting the fires initially tried to use standard methods to extinguish the fires but quickly realized that the intensity of the fires as well as the placement of the fires, which were flanking the crews made it necessary to withdraw from the area. The crews proximity to the large fire led to minor injuries and the damage to equipment that has been well documented. After the crews removed themselves from the prop area the three crash trucks attempted to extinguish the burn prop which was engulfed with flames. There is no evidence, either in the videos or with the statements of the individuals that the water coming from any crash truck contributed to the fire growth at this time. After the trucks were refilled with water from the hydrant system it was evident that the mixture in the tanks of the crash trucks was a high concentration of fuel. One of the videos depicted the apparent change over from water to fuel when the master stream opened up on the prop. In a video there is a change in both the color of the liquid being discharged as well as the effect that the stream had on the fire which was immediate and spectacular. This change took approximately four seconds to occur and it is probable that the water at the start of the application was residual leftover from the piping inside the crash truck. Once crews reacted to the non-standard condition of fuel coming out of the crash trucks actions were taken to shut down the trucks. After some initial confusion Starkey took command of the event over the radio. Calls were made to academy maintenance personnel and after some discussion it was decided to flow the fuel that was in the crash trucks back into the props. There were efforts to attempt to put out the prop fire using foam but lack of a water supply hampered that attempt.

After the fire was out all personnel filled out statements and photos were taken to document the injuries and damage. Fuel/Water Separator Initial investigation was conducted into possible reasons as to how the fuel got into the water system. As part of this investigation Tracy Caldwell and Levi Scartozzi were interviewed to gain an idea of the continuity of maintenance practices of operating the fuel/water separator between when the ARFF prop opened and present day. Given that Caldwell was involved with the initial development as well as the ongoing issues of maintaining the ARFF prop he understandably achieved a high level of organizational knowledge regarding operating the prop. Caldwell stated that one of the issues had to do with the training schedule which was, in his view too compacted. Caldwell stated that when the separator was working well fifteen gallons a minute of dirty water could be processed. It is unknown how many gallons were being processed between the 10/21 training date and the 10/25 training date. Caldwell also described his routine of maintaining the fuel/water separator by checking the level in the two cisterns and taking a water sample from the clean water cistern. Caldwell stated he would do a visual inspection of the water sample and based on this sample he would make minor changes to the separator by adjusting the water supply or powder supply. Caldwell stated that he would do this every two hours that the separator was running. When asked if he had ever run the system all night he stated he had on occasion run the system all night and when he did he followed the same routine of checking every two hours. Caldwell stated that this fact could be checked because he submitted time cards showing the night visits. Caldwell also stated he kept a safety level of water available between the pump outlet and the top of the water in the clean water cistern thereby reducing the chance of fuel getting drawn into the hydrant system. Caldwell also described his maintenance schedule for the ARFF prop as follows Solenoid valves Rebuilt every 6 months Cleaning rings - Serviced monthly Prop Nozzles Cleaned every 6 months

Levi Scartozzi stated in the interview that he would turn on the system and check on it periodically throughout the day. Scartozzi stated that he did not think it was important to check regularly since the academy no longer charged consortium partners for water usage which was previous practice. The reason for a tight control on the processing of the waste water is a safety issue and not a money issue. Scartozzi stated that he sometimes ran the system through the night did no checks on the system throughout the night. When asked about the maintenance schedule of the ARFF prop Scartozzi was uncertain on when the equipment was serviced. My investigation was stopped prior to further interviews. Further interviews with Elo and others on the academy staff would have to be held to determine if there are any more thorough maintenance procedures done on the props that are in line with what was done by Caldwell. Conclusions On October 25th the crews were faced with a non-standard condition at the AARF prop with a large amount of fire during hand line evolutions. The crews on the hand lines initially tried to react to the large fire in a routine way but quickly withdrew from the immediate fire area. The fire was mitigated with the priorities of life safety, incident stabilization, and property conservation in mind. Although only preliminary investigation has been made into the probable causes of how the fuel got into the clean water supply part of the cause is likely the change in maintenance routine after Caldwell left employment. Further investigation is ongoing by other parties that should help determine how the incident on October 25th occurred.

Respectfully Submitted,

Kevin Garling Battalion Chief, Kent Regional Fire Authority 24611 116th Ave Se, Kent WA. 98030 Phone 253-856-4300