November 12, 2014
201311November 12, 20149 Volunteer Fire Fighters and 1 Off-Duty Career Fire CaptainKilled by an Ammonium Nitrate Explosion at a Fertilizer Plant Fire– TexasRevised on January 20, 2015 to address comments from the Institute of Makers of Explosives to remove potentiallyconfusing references to “incipient” fires and to add reference to IME’s ammonium nitrate best practice guidelines.Executive SummaryOn April 17, 2013, ten emergency first responders (ranging inage from 26 to 52 and all male) were killed when a burningfertilizer plant containing an estimated 40 to 60 tons ofammonium nitrate exploded just outside the city limits. Theexplosion occurred less than 20 minutes after the emergencyresponders arrived on-scene. The victims included 5 volunteerfire fighters with the city’s volunteer fire department, and 4volunteer fire fighters from 3 neighboring volunteer firedepartments who were attending an emergency medicalservices (EMS) class in the city. One off-duty career firecaptain and two civilians who responded to offer assistance tothe volunteer fire department were also killed by the explosion.The victims were among a number of first responders engagedin fire suppression and support activities and were in closeproximity to the burning structure when the explosionoccurred. Five other volunteer fire fighters with the city’s firedepartment were injured. The two civilians were providingnon-suppression support to the fire department whenBurning fertilizer plant prior to the explosion, asthey were killed by the blast. Three civilians livingseen from the South looking North.nearby also died as the result of the blast.(Cell phone photo courtesy of ATF)Contributing Factors Non-recognition of the hazards associated with ammonium nitrateLimited pre-incident planning of commercial facilityFire quickly spread to an un-controllable sizeApproximately 40-60 tons of solid ammonium nitrate unexpectedly detonatedResponders working within blast radius at time of explosionLarge non-sprinklered, wood construction, commercial structure.Key Recommendations Fire departments should conduct pre-incident planning inspections of buildings within theirjurisdiction to facilitate development of safe fireground strategies and tactics, especially forhigh hazard / high risk structures and occupanciesPage i
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – Texas Fire departments should have a written risk management plan, use risk management principlesat all structure fires and especially at incidents involving high risk hazardsFire departments should develop, implement and enforce a written Incident ManagementSystem to be followed at all emergency incident operationsFire departments should ensure that fire fighters wear a full array of turnout clothing andpersonal protective equipment appropriate for the assigned tasksFire departments should ensure that fire fighters are trained to standards that meet or exceedNFPA 1001 Standard for Fire Fighter Professional Qualifications.Additionally, governing agencies (federal, state, regional, and local municipalities) should: Consider requiring automatic sprinkler systems, performing regular fire inspections, and othertypes of active fire prevention methods in industrial facilities, especially those with high risk /high hazard inventory Consider following the most current safe handling procedures for ammonium nitrate fertilizerstorage and handling.Engine 2 post explosion. Note that it is believed the force of theexplosion moved the engine from its original location and orientationat the time of the blast.(NIOSH Photo)The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federalagency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1998, Congressappropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the NIOSH “Fire Fighter Fatality Investigation and Prevention Program”which examines line-of-duty-deaths or on duty deaths of fire fighters to assist fire departments, fire fighters, the fire service and others to prevent similar firefighter deaths in the future. The agency does not enforce compliance with State or Federal occupational safety and health standards and does not determinefault or assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH investigatorsinterview persons with knowledge of the incident who agree to be interviewed and review available records to develop a description of the conditions andcircumstances leading to the death(s). Interviewees are not asked to sign sworn statements and interviews are not recorded. The agency's reports do notname the victim, the fire department or those interviewed. The NIOSH report's summary of the conditions and circumstances surrounding the fatality isintended to provide context to the agency's recommendations and is not intended to be definitive for purposes of determining any claim or benefit.Page ii
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – TexasFor further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).IntroductionOn April 17, 2013, ten emergency first responders (ranging in age from 26 to 52) were killed when aburning fertilizer plant that contained an estimated 40 to 60 tons of ammonium nitrate exploded. Thevictims included 5 volunteer fire fighters with the city’s volunteer fire department, and 4 volunteer firefighters from 3 neighboring volunteer fire departments who were attending an EMS class in the city.One off-duty career fire captain who responded to offer assistance to the city’s volunteer firedepartment was also killed by the explosion. The 10 victims were among a number of first respondersengaged in fire suppression and support activities and were in close proximity to the burning structurewhen the explosion occurred. Five other volunteer fire fighters with the city’s fire department wereinjured. Two civilians who were providing non-suppression support to the fire department in their firesuppression efforts were also killed by the blast. Three civilians who lived nearby also died as a resultof the explosion. The explosion occurred less than 20 minutes after the emergency responders arrivedon-scene.The National Institute for Occupational Safety and Health (NIOSH) became aware of the incident thesame day through numerous media outlets. The U.S. Fire Administration reported the deaths of thefive city volunteer fire fighters on April 22, 2013 and continued to update the number of line-of-dutydeaths as additional information became available.On April 22, 2013, a safety engineer and an occupational safety and health specialist with the NIOSHFire Fighter Fatality Investigation and Prevention Program traveled to Texas to investigate thisincident. The NIOSH investigators met with representatives of the Texas State Fire Marshal’s Office(FMO) and the U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives(ATF) and were integrated into the incident management system as part of the line-of-duty deathinvestigation (LODD) team. The NIOSH investigators visited the site of the fire and explosion andworked with Texas FMO investigators to evaluate, catalog and photograph over 185 pieces of personalprotective clothing and personal protective equipment collected on-scene that was used by thedeceased fire fighters. The NIOSH investigators and FMO investigators also examined, photographed,and cataloged as evidence four fire apparatus damaged by the blast. NIOSH investigators and TexasFMO investigators met with representatives of the Texas Department of Public Safety, Texas HighwayPatrol in an attempt to download and recover vehicle event data recorder information from three fireapparatus and an ambulance. This effort was unsuccessful, since due to their ages, the four vehiclesdid not contain data logging equipment. As part of this investigation, the NIOSH investigators metwith representatives of the Texas FMO; ATF; Federal Emergency Management Agency (FEMA); theU.S. Chemical Safety Board (CSB); the U.S. Attorney’s Office, Western District of Texas; the city firedepartment; the city policy department and the county precinct court justice.On May 13, 2013, the NIOSH investigators returned to Texas and conducted interviews with firefighters and fire department officials with the city fire department, the city emergency medical servicesPage ii
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – Texas(EMS) personnel, and also the fire department that was dispatched to the initial fire for mutual aid.Note: Two members of this mutual aid fire department were attending an EMS class at the time the firewas reported and responded to the incident scene and became victims. A total of four victims killed bythe explosion were participating in the EMS class. Three of the victims responded to the scene inpersonally-owned vehicles that were damaged by the explosion. The fourth class participant rode tothe scene in an ambulance with two city EMS personnel. The NIOSH investigators reviewed themutual aid fire department’s standard operating procedures, training records, incident reports, 911dispatch recordings, photographs and cell-phone videos of the incident.Fire DepartmentThe city where this incident occurred is served by an all-volunteer fire department that had served thecommunity since 1894. The fire department operates from one station located near the center of town.At the time of the incident, the fire department had 30 active members. The fire department serves apopulation of approximately 2,690 in an area of approximately 54 square miles with 1500 residentsliving within the city limits. Potential members must be 21 years old in order to join the firedepartment. Potential members must submit an application which is voted on by the existing firedepartment membership. If the application is accepted by majority vote, the police departmentconducts a background check. No prior fire service training or experience is required to join thedepartment. There were also no physical fitness or ability requirements.The fire department holds two meetings per month. The first meeting of the month is a businessmeeting while the second meeting is devoted to some type of training. Meeting attendance ismandatory unless excused by the chief. New members must be voted in by the existing membershipand successfully pass a background check before participating in fire department training. At the timeof the investigation, the fire department did not have any minimum training requirements but membersmissing more than two training sessions per year were required to present a valid excuse. The firedepartment did not have any standard operating procedures and guidelines. The fire department didnot have a formal pre-incident planning program.During 2011, the fire department responded to a total of 118 emergency calls including 55 fire calls.The 55 fire calls involved 3 structure fire calls, 2 vehicle fire calls and 50 “other fire” calls includingbrush fires, grass fires, miscellaneous fires and false alarms. During 2012, the fire departmentresponded to a total of 104 emergency calls including 73 fire calls. The 73 fire calls involved 18structure fires, 12 vehicle fires and 43 “other fire” calls involving grass fires, miscellaneous fires andfalse alarms. During the first 3 months of 2013, the fire department responded to 2 structure fires, 1auto fire, and 5 miscellaneous fire calls.Page 2
Report # F2013-11A summary of a NIOSH fire fighter fatality investigation9 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – TexasThe fire department had recently received an upgraded rating from the Insurance Services Organization(ISO), moving from a rating of 7 to a rating of 5. In the ISO rating system, Class 1 representsexemplary fire protection, and Class 10 indicates that the area's fire-suppression program does notmeet ISO's minimum criteria. aAdditional information about the fire department can be found on the department’s website e-dept.Training and ExperienceVictim Numbers and ExperienceNote: Throughout this report, the 10 victims are identified by the order in which they werelocated at the scene, removed from the scene and transported. The following table providesinformation on each victim.Table OneVictim(Order located)12345678910aRankAgeYears experienceFire Fighter4815 years with city VFDCareer Fire CaptainOff dutyFire FighterFire FighterVolunteer CaptainEMT/ FFFire FighterFire FighterVolunteer CaptainFire Fighter5231 years with career FD26372933415050292 years at mutual aid VFD3 years at mutual aid VFD10 years at mutual aid VFD1 year at mutual aid VFD2 years with city VFD13 years with city VFD18 years with city VFD3 years with city VFDISO is an independent commercial enterprise which helps customers identify and mitigate risk. ISOcan provide communities with information on fire protection, water systems, other criticalinfrastructure, building codes, and natural and man-made catastrophes. ISO’s Public ProtectionCriteria program evaluates communities according to a uniform set of criteria known as the FireSuppression Rating Schedule (FSRS). More information about ISO and their Fire Suppression RatingSchedule can be found at the website http://www.isogov.com/about/ .Page 3
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – TexasVictim 1 had been a fire fighter with the city’s volunteer fire department for 15 years. Trainingrecords included training certificates for: landing zone safety, propane emergency response, fire &ems emergency response, Introduction to Incident Command, Hazardous materials awareness, ladderpractices, hose handling, live burns, basic SCBA, ICS-100, ICS-200, IS-700, IS-800.b.Victim 2 was an off-duty career fire captain who had responded via personally-owned vehicle to offeradvice and assistance to the city fire department. He had over 31 years of experience as a career firefighter.Victim 3 had been a volunteer fire fighter for 2 years with the fire department dispatched for mutualaid to the fertilizer plant fire. He was attending an EMT class in the city at the time the fire wasdispatched. Training records included certificates for ICS-100, ICS-200, ICS-300, ICS-400, IS-700.a,IS-701.a, IS-702.a, and IS-703.a.Victim 4 had been a volunteer fire fighter at two nearby volunteer fire departments. He was attendingthe EMT class in the city at the time the fire was dispatched and responded to the scene in his POV.Training records included certificates for emergency vehicle operations, compressed air foamoperations, basic auto extrication, basic fire fighter, ICS-100, ICS-200, IS-700.a, and IS-800.b.Victim 5 had been a volunteer with the fire department dispatched for mutual aid to the fertilizer plantfire for over 10 years and held the rank of captain. He was attending the EMT class in the city at thetime the fire was dispatched and responded to the scene in his POV.Victim 6 was a volunteer fire fighter at a nearby volunteer fire department. He was attending the EMTclass in the city at the time the fire was dispatched and rode in a city ambulance to the scene with twocity EMTs.Victim 7 had been a fire fighter with the city’s volunteer fire department for 2 years. Training recordsincluded training certificates for: basic auto extrication, emergency driving, landing zone safety, ICS100, ICS-700.a. He responded to the fire station and rode to the incident scene on Engine 1 (F-8)Victim 8 had been a fire fighter with the city’s volunteer fire department for 13 years. Trainingrecords included training certificates for: propane emergency response, landing zone safety, groundcover (basic and intermediate), fire and ems emergency vehicle response, vehicle extrication,hazardous materials awareness, introduction to incident command, fire emergency vehicle response,ladder practices, hose handling, live burns, rescue operations, basic SCBA, ICS-100, ICS-200, IS-700,IS-700.a, IS-800.b. He responded to the fire station and drove brush truck (F-6) to the incident scene.Page 4
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fire – TexasVictim 9 had been a fire fighter with the city’s volunteer fire department for 18 years. Trainingrecords included training certificates for: basic fire fighter, fire emergency vehicle response, propaneemergency response, ICS-100, IS-700.a. He responded to the incident scene in his POV.Victim 10 had been a fire fighter with the city’s volunteer fire department for 3 years. Trainingrecords included training certificates for: firefighting phase 1, emergency driving, basic autoextrication, landing zone safety, SCBA and smokehouse training, ICS-100, ICS-200.b, ICS-300, ICS400, IS-700.a, IS-701.a, IS-702.a, IS-703.a, IS-704, IS-706, IS-800.b. He responded to the fire stationand drove Engine 1 (F-8) to the incident scene.Equipment and PersonnelThe fire department responded with four fire department apparatus. Engine 1 (also referred to as F-8)was a 1997 model engine that carried a 750 gallon water tank and responded with two fire fighters onboard (Victim 10 driving with Victim 7 onboard).Engine 2 (also referred to as F-9) was a 2004 model engine with a 1000 gallon water tank. Engine 2responded with a captain driving and one fire fighter (injured) onboard.A brush truck (referred to as F-6) was a 1991 model equipped with a 750 gallon water tank and apowered hose reel with 100 feet of 1-inch booster hose. F-6 was driven by Victim 8.F-7 was a 1997 model water tender equipped with a 2000 gallon water tank. F-7 was driven to thescene by the Fire Chief (injured).Two fire department members who responded in their personally-owned vehicles (POV) were killed(Victim 1 and Victim 9). A total of five fire department members were injured in the explosion.An aerial ladder truck was dispatched from a nearby mutual aid volunteer fire department. The laddertruck was approaching the incident scene from the north at the time of the explosion and was slightlydamaged by the blast.Victim 2, Victim 3, Victim 4, and Victim 5 also arrived on-scene in their personally owned vehicles(POV). Victim 6 rode in a city ambulance from the EMT class to the incident scene with two cityEMS personnel.TimelineAn approximate timeline summarizing the sentinel events in the April 17, 2013 explosion at a fertilizerprocessing plant in Texas, up to the time of the explosion, is listed below. The times are approximateand were obtained by studying the available dispatch channel records, witness statements, run sheets,fire department records and NIOSH interview information. The timeline is not intended, nor should itbe used, as a formal record of events. Only those dispatch channel communications directly related toPage 5
A summary of a NIOSH fire fighter fatality investigationReport # F2013-119 Volunteer Fire Fighters and 1 Off-Duty Career Captain Killed by anAmmonium Nitrate Explosion at a Fertilizer Plant Fir
protective clothing and personal protective equipment collected on-scene that was used by the deceased fire fighters. The NIOSH investigators and FMO investigators also examined, photographed, and cataloged as evidence four fire appa
26 Extended essay results November 2010 39 27 Theory of knowledge results November 2010 40 28 Distribution of additional points November 2006–November 2010 41 29 Mean points score worldwide November 2006–November 2010 42 30 Mean grade worldwide November 2006–November 2010 42 31 Pass rate worldwide November 2006–November 2010 43
September: 2013 33,391.18 9/24/2013 October: 2013 33,391.18 10/24/2013 December: 2013 65,031.50 12/20/2013 January: 2014 33,099.37 1/23/2014 February: 2014 33,099.37 2/24/2014 March: 2014 33,099.37 3/24/2014 April: 2014 31,662.23 4/25/2014 May: 2014 31,662.23 5/22/2014 June: 2014 31,662.24 6/26/2014 392,881.03
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