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The smell of smoke was enough to spike firefighter Mike Estrada's bloodstream with adrenaline. He knew it was going to be a big fire, because there was no wind that morning and yet he could still smell the smoke from blocks away. By the time the fire engine he was riding in began winding its way through the maze of warehouses off Bayshore Boulevard in the Bayview, Estrada's senses were splinter-sharp. He could feel the heat. He could taste the soot. And when his rig turned a corner onto Revere Avenue, all he could see was fire: Backdropped by a dark mat of early morning sky, a blazing behemoth billowed from the roof of a warehouse.
But 13 years of firefighting experience had trained the human instinct of flight out of Estrada. He and his crew arrived ready to go to work. They were instructed to go defensive, which meant they began preparing to surround and drown the building from the outside rather than make an aggressive attack from the inside, as Estrada had done just hours earlier at a nearby residential fire.
Less than five minutes after their arrival, the fire was raised from a two- to a three-alarm. More rigs were on the way, but in the meantime, Estrada was instructed to man the front of a hose line with another firefighter at street level. They would shoot water into the building, while others took on the beast from above with a ladder hose. As two firefighters worked beside him to cut a hole in the warehouse's roll-up door with a rotary saw, Estrada focused on his assignment: Man the hose; put out the fire.
The last thing he remembers is thinking that he should get into position to shoot water through the hole in the door — he could feel the heat radiating behind it. Later, he would learn that the heat from inside was so intense that it had melted off the door's supports, causing it to sag outward and lean to one side. Some firefighters had been directed to stand back. But not Estrada. He had crept so close to the building that he could almost touch it.
So when a large chunk of flaming wall and concrete the size of a small car suddenly came crashing down, the firefighters standing nearby — those directly next to Estrada, and the few standing behind him — just barely missed getting hit. But Estrada wasn't so lucky. In less than a second, he went from fighting fire to being on fire — unconscious, buried under a pile of blazing debris, and fighting for his life.
Estrada somehow survived the collapse. But more than five months later, he's still unsure how he wound up under a fiery wall that nearly killed him. Part of the reason is that San Francisco Fire Department heads have yet to share the findings of their internal investigation. The result is that few firefighters know what happened at the Revere Avenue fire, how it happened, and exactly how they should train to prevent it from happening in the future.
The department's deputy chief of operations, Patrick Gardner, said he decided against conducting a full-blown safety report after the fire and sharing the results with the department because, he said, "it wasn't a mystery what happened. ... A safety zone was established, and it wasn't enforced."
When a fire is big enough to require a defensive approach, firefighters are trained to keep a buffer, or "safety zone," between themselves and the building (or "collapse zone") at least one and a half times the height of the structure. The logic behind this rule is that no building without people in it is worth a firefighter's life.
Gardner's explanation of events at the Revere Avenue fire points to the first and most obvious preventable mistake: Firefighters shouldn't have been working in the collapse zone. But incident reports and interviews with sources on the scene indicate that the story is more complicated and that not just one, but a series of mistakes occurred that, if prevented, could save the next San Francisco firefighter from ending up buried under burning debris.
In July, the city's firefighters' union called in federal investigators to conduct a thorough safety report that they say should have been made by the department months ago. Union officials hope this report will unveil mistakes made at the Revere Avenue fire, and lead to a series of recommendations for training based on those mistakes.
Meanwhile, Estrada is suffering the consequences of those errors. In addition to severe damage to his right leg, his right knee was shattered, and he broke bones in his right shoulder, left foot, left hand, collarbone, and neck. He also has second- and third-degree burns to his left hand and the left side of his face. The damage could have been worse if fellow firefighters hadn't been right there to pull him out of the rubble as quickly as they did.
During the six weeks he spent at St. Mary's Medical Center in San Francisco, where he underwent 10 surgeries, Estrada had time to pore over incident reports that included narratives of the fire from the perspective of every chief who was there. With the help of those reports and conversations with fellow firefighters, Estrada has been able to piece together the events of that morning that, combined with luck and the inherent dangers of the job, changed his life forever.
Estrada remembers little from his journey to the hospital after the collapse, except for the part where he woke up in the ambulance begging for morphine. He had what's called a multisystem trauma, so medics couldn't risk slowing his breathing to a standstill by administering narcotics. Estrada had been trained as a paramedic, so he understood this perfectly well. But he begged for it anyway. Then he passed out.
During the following week, while Estrada waited to find out whether doctors would have to amputate his leg, many of his fellow firefighters visited him in the hospital. One visit, he says, was particularly memorable. Battalion Chief Charles Crane had been supervising Estrada and his crew at the time of the collapse. At Estrada's hospital bedside, Crane took full responsibility for what had happened. Estrada says this confession was confusing at the time — it wasn't until later, when he was looking over the incident reports, that he began to understand.
Investigators believe that the warehouse caught fire when faulty electrical wiring went haywire. The wiring was connected to grow lights feeding an illegal marijuana farm of 80 to 100 plants. The department's Assistant Deputy Chief, Barbara Schultheis, mentioned Estrada's injuries in a recent press conference highlighting reasons that grow houses pose particularly dangerous fire hazards: "One San Francisco firefighter was seriously injured in an illegal warehouse operation fire this year when a part of the structure collapsed onto him," she said.
But it wasn't pot farming that almost killed Estrada in the early hours of May 21. It was the wall facade at the front of the warehouse, which had appeared unstable from the start. In their reports, officers identified the building as a single-story warehouse with a wood roof and concrete parapet wall — a continuation of an exterior wall beyond roof level. Just the presence of these walls should be considered a collapse warning sign, according to fire safety expert Vincent Dunn.
Fire had already engulfed three-quarters of the Revere Avenue warehouse by the time firefighters arrived. Most of them gathered at the incident command post, which acts as the fulcrum of a fire scene, where firefighters are required to check in with their superiors to get their assignments. The post was set up across the street from the front of the warehouse, just outside the periphery of the building's collapse zone.
Designated safety officer Bryan Rubenstein checked to make sure firefighters would be safe by conducting a 360-degree examination of the fire, looking for hazards like parapet walls before they claimed lives. He wrote in his incident report following the fire that he was in the midst of his examination when the wall collapsed. Before he made his rounds, he wrote that he advised crews to stay away from the sidewalk next to the building, but that he "did not pull crews back [one to one and a half] times the height of the building."
Gardner, who took over full command of the fire scene when he arrived 10 minutes before the collapse, said that he gave clear orders to establish a safety zone. He believes that firefighters awaiting their orders at incident command had begun creeping slowly toward the building without realizing it. Although Gardner's orders may have been given verbally, they were never dispatched over the radio to other officers at the scene, according to incident reports, radio transcripts, recordings of radio communications between officers and incident command, and sources in the fire department.
It wasn't until Estrada began reading incident reports that he learned Crane had received a verbal order from Gardner to clear the safety zone a few minutes before the collapse. Crane wrote in his narrative of events: "Gardner ordered me to pull back the crews from the front of the building and reaffirmed the fact that no one was to enter the building." Crane didn't indicate whether he relayed this command. Instead, he wrote, he instructed crews — including Estrada's — to continue working:
"We continued to fight the fire for several minutes and I kept monitoring the status of the building."
Crane's original report, dated May 21, doesn't mention that he had received orders to get the crews back. But in an addendum dated May 23, he gave a far more detailed account of events that included Gardner's order. Estrada says that when he read this part of Crane's report, the hospital bedside confession began to make more sense.
Although Crane preferred not to comment for this story, he wrote in his report that he turned briefly from the warehouse just before the collapse to order firefighters to stay away from a spot where he knew power lines attached to the roof were about to come down. Then he heard a large crash. When he turned back, he saw that the wall had fallen on Estrada.
Estrada wiggled his toes with pride. His right foot was puffy, like it had been overstuffed, and tissue on the front of his shin appeared to be bulging out from under a sheath of hard, scaly skin. Above that, darkened burn scars the shape of T-bones ran up the entirety of his right leg. But that day, propped on the exam table at St. Mary's waiting for his doctor, the fact that he could wiggle his toes was enough for Estrada to praise God.
Estrada is 6-foot-1 — he loses roughly a foot when hunched over crutches. Besides his mangled leg, a nickel-sized scar next to his left eye, and some discoloration on his left hand, few would guess from his appearance that he celebrated his 37th birthday in the hospital. His smiles are warm and frequent, he laughs easily, and he still proudly sports his long-sleeved Harley-Davidson T-shirt, despite the discouraging words of some doctors who have told him he will never ride again.
Charles Lee, whom Estrada was visiting that day, was not one of those doctors. Lee, the director of microsurgery at St. Mary's, is a body reconstruction expert. He and his team received media attention in January 2008 when they successfully harvested a man's big toe to replace a thumb he had lost in a woodworking accident.
All expertise aside, Lee admits there were times he thought they would have to amputate Estrada's leg: "It was a pretty big wound," he said. "This is about as big as it gets." Because Estrada had lost so much muscle, the injury required a similar kind of tissue transplant as the toe-to-thumb surgery. When he first arrived at San Francisco General, his bones were sticking out of his uniform pants. Lee says he transplanted muscle from Estrada's abdomen to replace what he had lost on his leg; Estrada sports a long, dark centipede scar running down his belly to prove it.
Thanks to Lee and his crew, Estrada may have the opportunity to get back to work as a firefighter, which he says he wants to do — no matter how hard it is for him to watch the YouTube video of the fire, captured on a cellphone by a passerby. The video shows the entire incident from the moment Estrada approaches the warehouse with the hose to the moment he's loaded into the ambulance.
It's a dramatic video to watch — so much so that the videographer was able to sell the clip to Most Daring, a TV show on truTV that aired most recently on Sept. 9. It's so dramatic that many of the comments on the thread following the YouTube video assume the firefighter had been killed. "That guy is for sure dead," commenter humzilla707 wrote. "Blow it up full screen you will see."
Estrada is less bothered by the video itself (or that it was sold for profit) than he is hurt by some of the comment squabbles on that thread. Many posters noted that more than one firefighter was standing in the collapse zone. Some questioned what the department leadership was doing at the time. Still others accused anyone making suggestions based solely on the video of "armchair quarterbacking" without complete information.
When executives from San Francisco's firefighters' union learned that the fire department wouldn't be issuing a full safety report, they asked the National Institute for Occupational Safety and Health (NIOSH) to conduct an independent investigation. Union officials hope it will provide the department with training recommendations based on lessons learned from the Revere Avenue fire. NIOSH officials started their investigation in August, and expect to have recommendations early next year. Gardner said department heads voluntarily complied with and welcomed the safety audit, even if they didn't initiate it.
But union president John Hanley says a department that cares about its members would have initiated its own full-blown safety investigation — especially since two firefighters were critically injured after a roof caved in during an arson fire on Felton Street just three months before. The department hadn't seen so many serious firefighter injuries in such a short period of time since the mid-1990s.
"There's no doubt that our injuries have increased," Hanley said. He says that the union is very concerned, and hopes that the federal report will shed some light on the causes: "What we want to know is whether this is a temporary spike, or if this is just going to be the way business is done nowadays."
In the last three years, the landscape of the department has changed dramatically because it started offering promotional exams again after nearly a decade without. But few are willing to discuss the possibility that this turbulent history had the unintended consequence of making the risky job of a San Francisco firefighter even riskier.
Following a host of discrimination lawsuits starting in the 1970s, the San Francisco Fire Department promoted firefighters from 1988 to 1998 based on a federal court order that required the city to hire at least 38 percent minority and 9 percent female firefighters. After the expiration of that order, several years of litigation kept promotional exams on hold until 2006, when the department finally offered its first captain's exam in more than 10 years.
According to Hanley and Kevin Smith, president of the San Francisco Black Firefighters Association, the department had decimated its upper ranks by that time — which meant that, starting in 2006, there was a massive influx of new blood to higher ranks. The most recent lieutenant's exam, administered about a year ago, was the first the department had offered in 11 years.
It's impossible to ignore such a glaring piece of context: When the department held off on offering promotional exams for so many years, it backed itself into a corner. Now it's paying the price, experiencewise. Of 200 lieutenants currently in the San Francisco Fire Department, 183 — 92 percent — were newly appointed to their positions, while 62 percent of those promoted had 15 years or fewer of experience. Many veterans had retired before the exams to avoid the possibility of demotion, so the newly appointed had few experienced lieutenants around to guide them.
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.
Mostly, Estrada is just grateful to be alive. When asked whether he knew he was in the collapse zone when the wall fell and crushed him, he answered yes at first, and then after some thought, changed his answer to no. The truth, he says, is that when you're staring into the maw of a burning building in the dark of morning after being yanked out of bed, when you're already exhausted from fighting a fire not four hours before, all you can do is hope that your training and your instincts will kick in fast — and if something goes amiss, that your peers and superiors will be there to get you in the right spot. Or, if you end up under a pile of burning debris, they'll pull you out and help put you back together again.