Sunday, May 3, 2009

One Year Anniversary of Fatal Rockville Apartment Fire and Significant Firefighter Injuries

Message From Montgomery County Fire Chief Richard Bowers

Subject: Twinbrook Parkway Significant Injury Report Update


It has been a year since the fire at 12819 Twinbrook Parkway. I am glad to report that as of last Monday, all personnel injured in that incident have returned to full duty.

The purpose of this correspondence is to provide an update on the Significant Injury Report. This fire incident was a complex incident that included a civilian death, severe firefighter injuries, and a catastrophic structural collapse.

Immediately following the fire incident, an investigation panel was assembled that included several representatives from neighboring jurisdictions. It is my intention to provide the final report in June, 2009. I wanted to provide some preliminary report information about the Twinbrook Parkway incident as it is finalized for distribution. In order for a report of this nature to be effective, it must be factual, complete, and accurate. The findings from such a report will be utilized not only as a road map for our department, but will be studied by the fire service as a whole.

Preliminary Report Information Summary

On May 3, 2008 Montgomery County Fire and Rescue Services (MCFRS) responded to an apartment fire located at 12819 Twinbrook Parkway in Rockville, Maryland. During the incident, a catastrophic floor collapse occurred that injured three firefighters. One firefighter experienced a combination of orthopedic injuries, internal trauma and burn injuries. Two other firefighters suffered multiple injuries including burns.

Following the incident, a Significant Injury Investigation Team was assembled to analyze the events leading to the injuries and associated Department policies and procedures. Specifically, the Team was to examine the following:
The actions of the units and command officers during the incident, up to the mitigation of the Mayday
The circumstances which contributed to the floor collapse
The firefighter injuries

A team approach was employed to examine the events that occurred at this incident and all the information contained in the report is factual and has been validated through a multidimensional approach. The report will outline the detailed analysis performed by the Significant Injury Investigation Team.

Incident Overview

On May 3, 2008 at 00:45 hours the resident of Apartment 203 at 12819 Twinbrook Parkway in Rockville, Maryland was awakened by glass breaking and flames bursting into the bedroom. Soon after his 9-1-1 call, units from Montgomery County Fire and Rescue Service were dispatched to the address for an apartment fire. Fire Station 23 units arrived first and found heavy fire involvement in an apartment on the second level as observed from Side C of a three story garden apartment building. Units began to advance hose lines, position ladders to balconies and windows and go about the difficult tasks associated with confining the violent fire. Engine 723’s Officer and crew discovered residents trapped on their balconies by heavy smoke issuing from their apartment windows. The crews began rescue operations. Engine 723’s Officer and crew entered the top floor apartment from side A. This placed the crew in the apartment above the point of origin. As Engine 723’s Officer and crew began to advance down the apartment hallway on the top floor apartment they were subject to increasing heat and an environment filled with dense black smoke. Engine 723’s Officer and crew felt the floor suddenly drop. They were caught in a sudden and complete collapse of the floor beneath them.

Engine 723’s Officer and crew suffered a range of injuries from minor to critical. After Engine 723’s Officer transmitted a Mayday, Engine723’s Officer and one of the two firefighters were able to make their way to the window of Apartment 103 and bail out of the burning apartment. Engine 723’s Officer suffered traumatic injuries and severe burns. The first firefighter received injuries from the fall and also suffered burns. The second firefighter was separated from the other two and was missing. Many tense minutes later, crews were able to locate the second firefighter. All three fire and rescue personnel were transported to Washington Hospital Center’s Med Star Burn Unit.

A careful review of the circumstances of the floor collapse and Mayday event identified areas needing improvement. It should be noted that there are positive outcomes associated with the Twinbrook Parkway incident. Just prior to the Mayday, a command team formed which helped to continue operations while the Mayday event was resolved. Firefighter personal protective equipment was donned fully and correctly and worked very well limiting injury to the firefighters. The firefighters received excellent treatment from EMS personnel for their injuries. Orthopedic surgeons who followed the traumatic injuries of one of the firefighters said that effective immobilization prevented a probable paralyzing injury. The fire was limited to two apartments with minor extension into a third apartment.


The Investigation Team identified several key factors that had a positive impact during the incident operations

Personal Protective Equipment
· Injured personnel properly donned their personal protective equipment correctly
· High quality of personal protective equipment limited the extent of thermal injuries

Incident Priorities
· Units rescued numerous civilians who were trapped by the rapidly advancing and intense fire
· Fire was confined to two apartments

Command Support
· A Command Support Team was formed just prior to the Mayday
· The presence of a Command Support Team facilitated the division of responsibilities at the Command Post resulting with an increased ability to effectively manage an active fire ground and firefighter mayday event

Emergency Medical Care
· Emergency medical services (EMS) personnel provided high quality patient care which was effective in preventing further debilitating injuries.


The Team also identified critical factors which adversely impacted incident operations:

· Compliance with established procedures
· Identified gaps in MCFRS procedures
· Incomplete size up and situational reports
· Failures and deficiencies in MCFRS Personnel Accountability System

The Twinbrook Parkway Significant Injury Report contains discussions, findings and recommendations about the incident for organizational improvements at all levels that are aimed at increasing firefighter safety.


Please read this correspondence with your shifts and use it as a learning tool. I look forward to providing the final report in June for the entire service. Please continue to "train, train, train"!


Thank you and take care!

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