A fire engine took a wrong turn and got stuck trying to turn around on its way to a fatal house fire near Myersville, delaying the crew's response time by more than an hour, according to a report by the Frederick County Division of Fire and Rescue Services.
The post-incident analysis obtained by The Frederick News-Post identifies several deficiencies and mistakes with respect to directions and firefighter accountability during the Jan. 31 fire in the 3900 block of Highland Avenue.
Sisters Madigan Grace Lillard, 3, and Sophie Paige Lillard, 6, died of smoke inhalation in the blaze. Four other members of the Lillard family were hospitalized, including 8-year-old Morgan Lillard, who spent eight days in a burn unit at Children's National Medical Center in Washington before being released Feb. 8.
Division Director Tom Owens said in an interview this week that problems getting to the scene need to be dealt with, but officials do not believe the delays prevented rescue of the girls trapped inside the house. Firefighters entering the house through the garage roof found that the second floor had almost completely collapsed and they could go no farther.
"When you compare it with the pre-arrival photographs, how intense, how rapidly the fire had spread, even before 911 was called, and what the autopsy revealed about the cause of death, when you put all those things together, we do not believe that the outcome would have been any different," Owens said.
He said Engine 82 arriving on time "would have added a couple more working hands, and it would have added the tank of water that is on the pumper to the operation. But we never ran out of water, so was that critical to the operation? No."
The first two engines headed to the scene both went to the wrong place, followed by an ambulance crew that did not use its own directions, the report states.
Myersville Engine 82 turned from U.S. 40 onto Hollow Road after overshooting Harmony Road, which intersects Highland Avenue.
The engine became stuck trying to turn around and a heavy-duty tow truck was called to remove it. The engine arrived at 12:25 a.m., 65 minutes after it was dispatched.
Ambulance 89 followed Engine 82 until the crew realized they were heading in the wrong direction and followed Middletown Engine 72 to the scene. Engine 72 briefly went to the wrong location at 11:28 p.m. when it turned on Highland Court. The crew had laid out their supply line before realizing they were on the wrong street. Engine 72's error caused a delay of several minutes getting in position to fight the fire, the report states.
"There is no excuse for responding to an incorrect location when the CAD (computer-aided dispatch) printer is working properly and they can get a copy of the printed location prior to response," the report states. "The county is looking into printing more than one copy of the CAD information when stations are alerted for multiple unit response so all units can have a copy, not just one."
Owens said that some printers are being moved to more convenient locations so firefighters can quickly grab the printout on the way to their engines rather than having to detour into an office.
The report also mentions the possibility of a mobile terminal in each vehicle where information could be sent to crews, something that could be done during a planned reconfiguration of the CAD system.
Fire and Rescue Services spokesman Mike Dmuchowski said officials are still trying to determine what led Engine 82 crew members to go the wrong way and whether any disciplinary action is necessary. He said such mistakes are uncommon.
"They have maps on the apparatus," Dmuchowski said.
Dmuchowski said it is not department policy to make internal personnel decisions public.
Communication tapes obtained by The News-Post through a Public Information Act request reveal a sense of urgency at 11:28 p.m., nine minutes after the initial 911 call and eight minutes after the first units were dispatched. Lt. Steve Nalborczyk, of the Wolfsville Volunteer Fire Co., was first on the scene and established command at 11:27 p.m. before directing Engine 72 to the proper location.
"Come all the way up on Highland Avenue and lay up by the (inaudible) at the bottom," Nalborczyk ordered. "Get on up here."
The next two units arrived at 11:30 p.m. and 11:32 p.m., according to the report.
At 11:30 p.m., an Engine 72 crew member warned other units not to make the same mistake. "72 to all incoming units. It's not this street, it's the next street up on the right."
"That's correct," Nalborczyk said. "Highland Avenue is all the way at the top. Come on up here."
Engine 72 crew saw Engine 82 heading the wrong way, according to the report, but failed to tell the crew instead of confirming the correct location with a dispatcher.
The report made no excuses for Engine 82's crew heading to the wrong location, but it stated that Engine 72's mistake was understandable because of the similarity of the street names as well as high stress because people were trapped inside the burning house and the fire was visible and appeared accessible from Highland Court. The report attributed the mistake to "tunnel vision" by the crew upon seeing Highland on the street sign. But the unit officer should have looked at the map to make sure he and the driver knew the area, it stated.
"This is especially true since Engine 72 knew after seeing Engine 82 going in the incorrect direction they would now be the first due," the report stated. "Engine 72 also did not announce they were taking the first due assignment at any time."
The report found the ambulance crew at fault for "blindly" following Engine 82, then Engine 72, to incorrect locations rather than using its own copy of the directions. The same ambulance also got blocked in and could not transport a patient until several pieces of equipment were moved.
The report also stated that Myersvillle units did not take the most direct route to the scene and could have saved 11Ú2 minutes by taking another route. The station's maps are now being updated to reflect the fastest route across U.S. 40 and onto Bittle Road, which meets Harmony Road near Highland Avenue.
Each point of concern in the report is being examined by a working team within the division, Owens said.
"There's a lot of lessons ... related to communications that we're actively working on," Owens said.
Firefighter accountability is also discussed in the report, including a failure to properly use a passport system designed to let command staff keep track of who is at a scene. The safety officer abandoned the task of checking passports after finding empty passports on several first alarm units, the report stated, and the system was essentially not used during the fire.
Additionally, not enough PAR checks -- a type of roll call -- were performed during the fire, according to the report.
The fire service needs to look at improving either the accountability system or training in its use, Owens said.
"Because of the hazardous environment that they're working in, we want to know everybody operating on that incident is there and what their assignments are, and the fact that they are OK," he said. "Our accountability system did not work well that night."
U.S. Fire Association spokesman Tom Olshanski wouldn't speculate on why firefighters went to the wrong location, but he said GPS systems are becoming more common among fire companies across the country. Finding fires in residential areas can be especially challenging, he said.
"Every little bit helps when you are racing to get to victims," Olshanski said.
Olshanski, who has spent 40 years in the fire and rescue field, said that challenge is increased by the rate at which house fires tend to spread, which he attributes to the presence of more plastic materials in modern houses.
"The rate at which fires ignite and spread now is unbelievably fast," he said.