2011-10-11 PacketCITY OF ALAMEDA* CALIFORNIA
SPECIAL MEETING OF THE CITY COUNCIL
TUESDAY OCTOBER 11, 2011 7:00 P.M.
Location: City Council Chambers, City Hall, corner of Santa Clara Ave and Oak Street
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business introduced by Council members may speak for a maximum of 3 minutes per
agenda item when the subject is before the Council
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1. ROLL CALL City Council
2. ORAL COMMUNICATIONS, NON AGENDA (Public Comment)
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Council has jurisdiction or of which it may take cognizance that is not on the
agenda
3. AGENDA ITEM
3 -A. Review of Crown Beach Incident by FireChiefs.com, LLC
4. ADJOURNMENT City Council
f
Marie L. Gi I more, Mayor
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Review of Crown each
Incident (Alameda, CA)
Prepared for: City of Alameda
Prepared by: FireChiefs.com, LLC
September 2011
Crown Beach Incident May 30, 2011
City Council
Agenda Item #3-
Pe 1
10-11-11
Elimination of the fire department rescue boat in 2008 and the rescue swimmer program
in 2009 resulted in the city of Alameda fire department not having the necessary
equipment, certified training, or personal safety protective gear to enter the water safely
at crown Beach on May 30, 2011. They were unable to provide support to police
personnel to gain access to the suicidal subject in the water or to perform a water
rescue when it became necessary.
The elimination of the fire boat and rescue boat stemmed from very old equipment
requiring significant maintenance that was not funded. It was estimated by the fire chief
in a memo to the city manager that each vessel would require approximately $60,000 to
bring therm into operational condition. The fire chief recommended elimination of the
boat program in favor of seeking grant funding for personal water craft. Personal water
craft were never obtained by the fire department.
The rationale for the elimination of the rescue swimmer program is less clear. Records
indicate it was the intent of fire management to maintain that program. However, it
appears from fire department training records and from a memo dated March 16, 2009
that rescue swimmer training last occurred in 200 8. From department records, It
appears that insufficient overtire availability was the reason for the discontinuance of
training.
In an e-mail dated larch g, 2009, the fire chief informed the city manager that he
intended to use $10,000 in overtime from his existing budget to reinstate the training
necessary to re- certify the rescue swimmers. The chief received approval from the city
manager, provided he did not exceed his approved budget.
In a department bulletin dated March 16, 2009, the deputy chief placed the rescue
swimmer program on hold and set a policy that "previously qualified rescue swimmers
shall not enter the water" to conduct water rescues. He indicated that refresher training
and recertification would be scheduled in the net 30 to 45 days.
The refresher training and recertification did not occur. No documentation could be
found to determine why the training did not happen. The logical assumption is that the
fire chief did not believe he could accomplish the training within his approved budget.
However, no evidence was found to demonstrate that it was effectively communicated
to the department, to the city Council, and to the community that the program had
ended. The department budget continued to indicate "water rescues'y was part of the
fire department performance measures, even after the program was ended.
Crown Beach Incident May 30, 2011 Page 1
The result of the elimination of the rescue swimmer program is that on May 30, 2011
reliance on mutual aid became the primary method of providing a safe response.
The police department has a patrol boat and personal water craft. However, the boat is
too large to enter the shallow waters at crown Beach. The personal water craft were
unavailable due to an inadequate number of ors -duty trained personnel to operate them.
Unlike the fire water rescue program, the police boat program was not designed or
funded to provide constant staffing of the marina and waterways.
Terminology 14 Use of Jargon
The Standardized Emergency Management System (SEMS) was developed to improve
management, coordination, and communication of complex or large scale. emergency
operations between various disciplines. As part of that system, terminology is
standardized to reduce miscommunication between disciplines who each have their
own jargon, abbreviations, or language.
The Incident Command System (ICS) also encourages the use of "plain texts language
and the elimination of jargon and abbreviations.
A seemingly small use of jargon in this incident resulted in a significant
misunderstanding and created operational expectations that may have delayed the
requesting of the appropriate type of rescue equipment and capability required for
operational effectiveness.
Approximately ately 1 minutes into the incident, from the initial call for a response, and
before his arrival at the scene, the on -duty Alameda fire battalion chief contacted
Alameda County Regional Emergency Communications center. Alameda county
Regional Emergency Communications center serves as the dispatch center for the city
of Alameda Fire Department. He requested that Alameda County Regional Emergency
Communications center contact the U.S. Coast Guard to confirm that the U.S. Coast
Guard boat responding was a "RHIB," pronounced `crib," for Frigid lull Inflatable Boat,
which is capable of operating in shallow water.
When the Alameda county Regional Emergency communications center dispatcher
contacted the U.S. coast Guard, she asked "Are you sending a `crib'?" The U.S. coast
Guard Search Rescue dispatcher confirmed that they were. The Alameda county
Regional Emergency Communications center dispatcher then confirmed to the
Alameda battalion chief that U.S. coast Guard was responding with a "rib." The
Crown Beach Incident -Allay 30, 2011 Page 1
dispatcher then notified Alameda engine I on the radio that the U.S. Coast Guard was
responding with a "rib."
The U.S. Coast Guard was responding with a 2 Fescue Boat, which in U.S. coast
Guard terminology is referred to as a BS" or fescue Boat Small, also pronounced
"rib." A Coast Guard Fescue Boat small is not capable of safely entering waters more
shallow than sic fleet in depth.
This miscommunication resulted in command personnel on the scene expecting -the
responding U .S. coast Guard vessel to have different operational capabilities than it
had.
Policy
It is the policy of the Alameda Fire Department not to allow personnel who are not
currently certified as lifeguards or rescue swimmers to eater the water to perform water
rescues.
This policy is consistent with the policies of all the water rescue programs throughout
the state of Californian that were reviewed. Personnel who are unable to pass
recertification tests are disqualified or discharged from the programs. Attachment 13
Every water rescue program reviewed have standards of training and testing for
personnel certified and assigned as lifeguards, rescue swimmers, and boat operators
(Attachment 14). Typically, there is an initial training period, an annual training
requirement for continuing education, and an annual or biannual required swim test of
Soo yards in 10 minutes.
While the training standards, hours, and swim test may vary slightly from jurisdiction to
jurisdiction, it was consistent that personnel in the programs who failed to meet the
standards -or maintain their skills were disqualified from performing water rescues until
they passed department standards and are re- certified.
Safety and Trainin
Considering conditions present on May 30, 2011 command personnel on the scene
considered it unsafe to eater the water to perform a crisis negotiation and water rescue.
The factors leading them to that decision included; distance to the subject in the water,
temperature of the water, potential violent nature of the subject, lack of certified rescue
Crown Beach Incident May 30, 2011 Page 1
swimmers, lack of personal protective gear, lack of a shallow water rescue boat, and a
belief that the subject was within the survivability window for the responding mutual aid.
Police and fire work is often dangerous. A basic principal in an emergency response is
always to ensure the safety of your personnel. while police officers and firefighters are
expected to engage in activities that often place their personal safety at some risk, it
must be done in a manner in which those risks are reasonable and mitigated through
training, equipment, and operational policies and procedures. Emergency responders
must operate within the knowledge and scope of their training.
California Occupational Health and safety Standards (Cal OSHA) requires employers to
have a Disk Management and Prevention Plan RIVIP' As part of that plan, employers
must identify hazards in the workplace and put measures in place to eliminate or
minimize those workplace risks and hazards. If any employer, supervisor, or manager
knew or "should have known" of a workplace risk or hazard and does not take steps to
mitigate that hazard they may be subject to civil and criminal liability.
In law enforcement and fire those risks and hazards are often mitigated through training,
equipment, and policies and procedures. For example, police officers are often seat
into a building to subdue a violent criminal with the proper personal protective
equipment and training in special weapons and tactics. Firefighters are seat into
buildings containing hazardous materials that pose dangerous exposure to the public
when trained and certified in hazardous materials response and equipped with
appropriate protective clothing and self contained breathing apparatus.
Similarly, water rescues are extremely dangerous situations requiring properly equipped
and trained personnel. Fire personnel on the scene lacked the equipment and
certification to safely perform a water rescue. Police personnel on scene had nearer
received any water rescue training.
Dealing with suicidal persons are also extremely dangerous situations requiring properly
equipped and trained personnel. While competent to deal with potentially violent
persons, police personnel were not equipped or trained to do so in underwater
conditions. Fire personnel were neither trained in crisis communications, nor dealing
with potentially violent persons.
Rescue swimmers and lifeguards are trained to deal with drowning victims who want to
be rescued. Additionally, they are trained to deal with drowning victims who panic and
Crown Beach Incident May 0, 2011 Page
attempt to grab onto them. They do so by dropping under grater and kicking and
swimming ing away from the victim until the victim tires or becomes non threatening to the
rescuer. once given a rescue floatation device, most drowning victims will become
cooperative with the rescuer.
Sending either police or fire personnel 150 -200 yards into 54 degree water at a 5 foot
depth to deal with a suicidal and potentially violent subject posed safety, equipment, and
training issues for incident commanders.
Mutual Aid
Utilization of mutual aid occurs frequently in California. Alameda county Fire serves as
the operational Area coordinator for California Emergency Management Agency (cal
E MA Legion 11. They maintain a "Gaily situation Resource status Report" that lists
ghat resources are available for mutual aid requests. The report is updated regularly
and lists chief officers, strife teams,' air support, grater rescue, heavy rescue, and other
mutual aid resources.
On the day of the incident, neither police nor fire personnel on the scene demonstrated
a good understanding of ghat mutual aid resources were available, what the capabilities
were of each mutual aid asset, and what resources had the closest proximity and best
estimated response times. Without a local capacity to provide water rescue capability
by the city of Alameda. reliance on mutual aid became mandatory for grater rescue
responses.
This need was identified to fire department personnel in Informational Bulletin #1733 on
April 17, 2008 when the fire department Rigid Hull Inflatable Boat I HIB was placed
into liMited service. Direction was given to consider Oakland Fire for rapid deployment
of Inflatable Fescue Boats IIB's on trailers..
This need was again identified to fire department personnel in Informational Bulletin
#1734 entitled "Update on Status of the Fescue Boat IHIB on May 1, 2008 when the
fire department RHIB was taken out of service.
The bulletin specifically stated the deputy chief had, "contacted Oakland Fire to advise
them of the situation and let them know we gill be contacting thorn for ilutual Aid for
any grater rescue incident. Incident corianders should also initiate Mutual Aid calls to
our other maritime partners at the beginning of any water rescue incident. our other
maritime resources include: U.S. coast Guard, ALCO sheriff, and Alameda Police."
Crown Beach Incident May 30, 2011 Page 21
The closest available mutual aid water rescue resource with shallow water rescue
capability on May 30, 2011 was Oakland Fire, located approximately 2-1/2 riles away
at Oakland Fire station #12 located at 822 Alice Street. This mutual resource was not
requested until the U.S. coast Guard senior chief arrived at the incident at
approximately 12:1 pm.
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United states coast Guard
fescue Boat small
Available Estimated Time
(BS not shallow
of Arrival 40 miry
water capable
East Bay Regional Park Police
Patrol Boat
Not available
and Fire
Zodiak Boat
Available Estimated Time
of Arrival 30 rain to 1 hour
Oakland Police
Patrol Boat
Not available
Oakland Fire
shallow water capable
Available Estimated Time
of Arrival 15 min.
Alameda county Fire
shallow water capable
Available Estimated Time
of Arrival 30 rain
Alameda County sheriff
Patrol Beat
Not available
Water and weather
The conditions of the water and weather at Crown Beach on May 30, 2011 between
11;30arn and 12:30pm played a significant role in determining what actions were taken
by incident command. The conditions were factors in considering the safety of
emergency response personal, timeliness of mutual aid response, and survivability.
The water temperature near Crown Beach was approximately 54 degrees Fahrenheit at
the time of the incident. The tide was 4.75 to 5 feet with swells of
approximately 1 to 3 feet high. The wind speed was approximately 6 MPH from a west
to northwest direction. The air temperature was 61 degrees Fahrenheit.
Time
Time was a critical factor in the response to the crown Beach Incident, Without the
local capability equipment and training) for police negotiation or water rescue by the
Crown Beach Incident May 30 2011 Page 2
City of Alameda, reliance on mutual aid became the primary emergency response
resource. An initial estimated time of arrival of 40 minutes had been received by police
dispatch from the United States coast Guard before the arrival of the first police unit on
the scene.
One of the police personnel on the scene was a former marine with some shipboard
training on survival. He estimated survivability of approximately 1-2 hours for water
temperatures in the raid 50's. Twenty-five minutes into the incident, police received
information from a kite surfer who had. contacted the subject in the water. He reported
that the subject did not appear to be in distress and was saying he was "OK." Police
personnel believed the U.S. Coast Guard was only a few minutes from arriving.
Time was a factor in the decision making ing of the police incident commander (IC). With
information that the large male subject had attempted suicide on two prior occasions,
the IC considered calling police negotiators. It was decided it would fake too long for
them to arrive based on existing conditions, and neither- police nor fire had any safe
method to get a negotiator out t the subject in the water. The police IC also considered
commandeering local civilian beat resources, but decided time was inadequate to get
one to the scene based on the location of the incident and the location of the marinas.
From the time of the arrival of the first officer 11 :34:58 am until the subject was_
reported .being seen face down in the water (12:06:00 pm was 31 minutes, 2 seconds,
It was reported that the subject was in the water for only a short time before the first call
was made to the Alameda Police Dispatch center (11:30:08 am). However, the first
arriving officer estimated the subject to already be approximately 150 -yards out into the
water when he arrived.
According to the United States Search Fescue Task Force, immersion in cold water
can quickly numb the extremities to the point of uselessness. Within minutes, severe
pain clouds rational thought. And, finally, hypothermia (exposure) sets in. However, this
will vary in each case due to the specific circumstances and physical condition of the
person involved.
Crown Beach Incident May 30, 2011 Page