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In addition, Smith, Hanley, and other department sources say that serious flaws in the most recent lieutenant's exam meant many of the more experienced firefighters did not end up high on the list for promotion. "Don't get me wrong," Hanley wrote in a recent union newsletter. "I'm not saying that these people with one or two years' experience are not qualified, but something happened with this recent lieutenant's test where experienced firefighters did not receive a promotion."
Smith agreed with this in a recent interview. "The result is that we have individuals in the department who are suffering, like the senior firefighters, who weren't as successful on this exam as they would have been on an exam that was a more accurate measure of what they're capable of doing," he said. "And possibly there are some people out there now who need more training."
Sources in the department wouldn't comment on whether the recent spike in firefighter injuries could be attributed to a new wave of recently promoted officers. Smith said that kind of accusation would be irresponsible. Gardner insisted that the officers at the Revere Avenue fire had nothing to do with problems at the scene, despite his confirmation that most of the lieutenants had indeed been recently promoted. Hanley simply wouldn't discuss it. No one in the department wants to say that the firefighters, or the public, for that matter, are at any increased risk. "We just want to put our best foot forward," Smith said.
Hanley believes the department can't do that without owning up to and learning from mistakes at fire scenes. Numerous incident reports from the Revere Avenue fire suggest that new officers at incident command — the official body in charge — could use more training. Audry Lee, the assistant chief in charge before Gardner arrived, recommends in his report "continuous training for new officers in Incident Command and management of personnel," among other things. "Practice increased communication of dangerous situations to all crew members," another lieutenant at the scene wrote.
The NIOSH report may reveal more about whether the recent changes in the department contributed to issues at the Revere Avenue fire. But more importantly, it will offer a series of recommendations for how the department can avoid making similar mistakes in the future.
Hanley says the department should have distributed such recommendations from the start: "Put it in a pamphlet," he said. Then "every officer goes over it with his men and women at 8:30 every morning for a week until everybody fully transcribes in their brain what mistakes were made and how to make it better."
Gardner says he's writing new safety policy for the department and updating its instruction manual to incorporate lessons learned from the Felton Street and Revere Avenue fires. The policy will lay out formal safety criteria to follow after a firefighter injury. Gardner is authoring those standards mostly based on recommendations from the union and nationally recognized safety protocols used in other departments around the country. He said that although those procedures may have been common practice for years, they hadn't previously been written down in any formal manner.
Boston fire department spokesman Steve MacDonald said that in his department, a life-threatening firefighter injury would probably be referred to a safety committee, but that there is no standard protocol following firefighter injuries unless they are fatal. Typically, he said, an informal team will go over unique incidents that can be used as teachable moments and then incorporate them into training. "You constantly train and train and train," he said. "That's just what it is — it's training."
When asked whether he thought the newly promoted higher ranks of San Francisco's fire department could use more training, Gardner echoed MacDonald's sentiments: "We all can use more training in incident command," he said. "The more we can learn, the better."
When the results of the NIOSH report are released next year, the department will have a clear direction. NIOSH recommendations following a similar situation in 1998 — in which a 35-year fire department veteran in Vermont was killed when a wall facade fell on him — recommended that a collapse zone be established in any defensive approach to a fire. The report on the Revere Avenue fire will probably say something similar, and suggest ways the department can improve training to target this issue. Estrada says he's eager to see the results of the report — especially if those results could save another firefighter from the five months of pain he has endured and the lifetime of physical therapy he faces.
Estrada may need one final surgery, a knee replacement, depending on how well it heals over the next few months. Only one doctor so far has told him the last words he ever wanted to hear: that he would never fight fires again. But Estrada plans to prove that doctor wrong. He says that ideally, he will wind up in the Division of Training, teaching new recruits the lessons he has learned from the fire.
Even after reading incident reports and noting that mistakes were made that could have prevented his injuries, Estrada still wouldn't comment on the performance of his colleagues at the fire, except to say that he thought his immediate superiors did an excellent job. If he is angry at anyone, it's the warehouse's pot-growing occupants; he recently learned they would be immune from liability, thanks to the state's "firefighter's rule" that prevents emergency service workers from suing when they sustain on-duty injuries.