Wednesday, June 11, 2014

December hangar fire resulted in dismissal of Butte fire officials

WASILLA -- A smoky airplane hangar fire in December in the Southcentral Alaska community of Butte left a young Palmer firefighter unconscious, overcome by fumes at the top of a ladder as his small team tried to evacuate.

Fallout in the aftermath of the fire also led to the departures of the longtime chief and assistant chief of the Butte Fire Department this year.

A combination of faulty breathing equipment and toxic gases sickened the firefighter as well as two other responders, according to Matanuska-Susitna Borough documents obtained in late May through a public records request.

All told, smoke inhalation sent seven Palmer and Butte firefighters and one medic to Mat-Su Regional Medical Center for screening after the Dec. 17 fire. Two needed about six hours of treatment to restore healthy blood-oxygen levels. The Palmer firefighter wasn't released until the next day. All are doing fine now, officials say.

But the incident revealed a more systemic and potentially troubling problem. Testing on the air tanks and masks worn by the more seriously injured firefighters revealed multiple failures, documents show.

Former Butte Fire Chief Charles Von Gunten said Friday he resigned in March rather than pick a battle with Central Mat-Su Emergency Services Director Dennis Brodigan over problems with the air packs. Issues surrounding the fire also led to the removal of Assistant Chief John Akers, Brodigan said in a separate interview. Akers said he wasn't at liberty to talk about anything related to the borough.

The borough's eight fire service areas are responsible for testing and maintaining the breathing apparatuses that firefighters rely on in potentially hazardous situations, Brodigan said.

"It's the responsibility of the fire service area chiefs to ensure that all of their equipment is inspected, maintained and kept up to standard," he said. "Normally our chiefs are very, very on top of the air packs. They're a vital piece of equipment."

Both Palmer and Butte fire departments are staffed by paid on-call volunteers who may have to leave jobs, family life or bed to respond to calls.

Man down

The story that emerged from the borough documents about the fire reveals a situation far more serious than initial reports indicated.

Just before 2 a.m. on a frigid mid-December night, the owner of an airplane hangar on Maud Road reported a fire with three aircraft but no people inside, dispatch records show. The hangar, owned by experimental aircraft aficionado Frank Knapp, lies toward the end of the two-lane road that backs up to the Chugach Mountains, becoming dirt before ending up at Jim Lake.

A lieutenant from Palmer's fire department arrived at the hangar first, followed by a Butte unit and more responders from Palmer and Butte. The lieutenant, Louis Larousse, established command.

It was 18 below. About a foot of snow surrounded the hangar.

Heavy, shiny black smoke initially surged from the eaves of the metal hangar, but no flames were showing, and the smoke got lighter except near a second-floor living area, the lieutenant wrote in his report.

Three firefighters and Palmer Fire Capt. John Prevost donned breathing apparatuses -- tanks like those worn by underwater divers, connected to face masks -- and entered the hangar. Finding no fire on the main floor, most of the group ascended a ladder to a second floor radiating heat to check for flames.

It was hot in the attic-like space. Prevost asked for a hole cut in a wall to vent the heat.

Then the trouble started. As the group upstairs moved back toward the ladder, at least one man started saying he didn't feel well. A 20-year-old Palmer firefighter lost consciousness at the top of the ladder. Prevost radioed down for medics to be ready. Responders outside heard the "man down" call, Akers wrote in his report.

A Butte firefighter emerged outside from the second floor, vomiting as he pulled off his air mask, Larousse wrote in his post-fire report. Dispatchers started checking on the availability of medevac helicopters.

Three people were still inside the hangar, including the motionless Palmer responder.

'No time to communicate a Mayday'

Palmer firefighter Rick Howe, stationed at the bottom of the ladder, described what happened after the first "firefighter down" report emerged from the hangar.

The unconscious man hung on the ladder about nine feet off the ground, Howe wrote in an email to the borough's safety officer. The Palmer captain managed to free the unconscious man from above. Howe, below, ended up wedged against the ladder holding the firefighter just off the ground.

Struggling to move down, Howe decided to tumble off the ladder with the unconscious man on top of him.

A hangar door flew open with a crash, Larousse wrote. Howe was on the ground inside the building, holding the unconscious firefighter, who was face down.

"Everything happened quickly, within the entry/exit door, with no time to communicate a mayday," the lieutenant wrote. "The scene was small enough communication-wise that everyone knew what was happening at this point."

He helped Howe up and turned the unconscious firefighter onto his side. The man wasn't moving. His breathing was slow and shallow. He responded only to painful stimuli.

Medics started treatment.

Everybody was out of the hangar.


The three firefighters who went up the ladder -- the captain, the Palmer firefighter and the Butte firefighter -- ended up needing treatment at the hospital. The captain and the Butte firefighter stayed for about six hours, officials say. The Palmer firefighter wasn't discharged until noon the next day.

The four air packs used during the fire failed subsequent tests in multiple areas ranging from visual inspection of the face piece to cylinders overdue for testing and stuck parts on an inhalation valve, according to documents provided by the borough.

The equipment failures triggered numerous changes.

The borough "stood down" Butte's fire department for a week -- they couldn't respond to any fires -- as soon as it became clear the breathing equipment wasn't working properly, Brodigan said.

Von Gunten left the department by March, as did Akers. Von Gunten had recently retired from his job with the U.S. Army Corps of Engineers, Brodigan said. "It was agreed that it was time to retire."

Von Gunten said he chose to retire rather than fight with Brodigan over the fact that Butte's air packs were out of certification because they hadn't been tested regularly. The firefighters he assigned that job to didn't follow through, Von Gunten said. "I've got people that are supposed to make sure that's done. That didn't get done," he said. "When you're chief, captain, the leader, it all falls back on you."

He's hoping to get approval to rejoin the Butte force and advise the acting chief, Eric Van Dusen.

Akers' departure was also "a personnel matter related to this fire," Brodigan said. Akers had responded with Butte for nearly 27 years.


The borough made changes to its respirator upkeep program that already included requirements such as annual mask fit tests and monthly tank inspections. New policies include a specific written maintenance schedule and a record-keeping system to track performance tests and any repairs, officials say.

Palmer Fire Chief John McNutt said Palmer tests its air packs every year, and the one worn by the unconscious firefighter had passed. McNutt said it's possible the responder's fall damaged his pack, and instead the pressure of built-up gas inside the hangar forced toxic chemicals into his face mask. All three responders who needed medical treatment were in that same area, he noted.

Nonetheless, Palmer made some policy changes after the fire. Each firefighter gets his or her own face mask for breathing apparatuses. And firefighters can't have facial hair more than a day's growth in the places where their mask seals, McNutt said. He said the Palmer firefighter who lost consciousness "had some scruff" that night.

Von Gunten added another theory about why the firefighters got sick: The toxic gases from burning urethane insulation entered their systems through any exposed skin.

The documents released by the borough don't offer an official cause of the smoke inhalation injuries.

Damage done

Investigators with the State Fire Marshal's Office determined the fire originated in a boiler room, said Megan Peters, state public safety spokeswoman.

A gas control valve on the boiler failed, causing gas to vent, hangar owner Knapp said in an email. The open pilot ignited the gas, which started releasing at full flow after the aluminum valve melted. The resulting "very rich burn" created a gas ball and heat by the ceiling that exploded, blowing open a 50-foot aircraft door, Knapp said. Heat and flames burned off the insulation inside the hangar. Knapp shut off the power and gas before firefighters arrived, he said.

Knapp also said he approached the Palmer lieutenant at the start of the incident and told him not to bother attacking the fire, a statement supported by the borough documents. By then there were no flames showing and the damage was done, he reasoned.

"This was MUCH over-responded (to) and there was NO REASON to subject anyone to the smoke and danger of climbing a ladder 13 feet to a mezzanine," Knapp wrote.

Several responders, without knowing about Knapp's remarks, said commanders and crews on scene did just what they were supposed to do.

"Where there's no visible flame, you have to go find it. Otherwise you're just wasting a bunch of water," McNutt said. "They just happened to go upstairs."


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