2011-10-11 3-A Power PointCrown Beach Review
FireChiefs-com, LLC
1[:R eview Process
Incident review and chronology
Recommendations for best practices
Not internal or administrative
investigation
Reviewed all documents and records
1[:R eview Process
Reviewed all audio recordings
Interview of all employees
Reviewed Department policies and
d irectives
Reviewed training and safety standards
1[:R eview Process
No limitations to access of City records
Consultation with other professionals
Water rescue, incident management,
organizational le,,aderillship
Observations and conclusions were
also drawn from my own experience,
knowledge, and training.
Crown Beach Review
Nature of the call
Suicide vs water rescue
Conventional response
Negotiations w /suicidal persons
Crown Beach Review
Anthony Hare, Psy.D.
Executive Director, Center for
Catastrophic Risk Management
UC Berkeley, C hool of B usiness
Oakland P olice D 111111111111
epartment, Re tired
Actions Taken
Response time to call was good
Early request for US Coast Guard
Checked for other local rescue boats
Consideration of issues (conditions,
safety, survivability, Intel, negotiator,
private boats)
Medical response and standby
Location and triangulation of person in
water
Actions Taken
Incident Commanders believed:
Appropriate rescue boat was
responding
Subject was within survivability
window
Subject was potentially dangerous
It was unsafe to enter the cold water
without training and personal
protective equipment
Obstacles
Command and Control
Availability of local water rescue
capability
Terminology and use of jargon
Policy
Obstacles
Safety and training
Mutual aid
Water and weather
T ime
Recommendations
Provide equipment, training, and
certifications to police and fire
departments to provide the ability to
rapidly respond to water emergencies
surrounding the City of Alameda.
Recommendations
Provide redundancies in the equipment
to accommodate out -of- service time for
maintenance. The number of trained
and certified personnel should allow for
absences and turnover due to
personnel injuries, leaves, and
retirements.
Recommendations
Provide incident management training
to all supervisors and managers
in the
police and fire departments.
Recommendations
Provide crisis communication training to
all field police personnel and fire
department rescue swimmers.
Recommendations
Develop clear policies on
responsibilities of police and fire in
water rescue emergencies and conduct
regular training to satisfy those
responsibilities.
Recommendations
Schedule and conduct regular cross
training and familiarization between
Alameda Police and Fire. The training
should include Incident Command
System (ICS), Standardized Emergency
Management System (BEMs),
multidisciplinary responses, joint
responses to complex emergencies,
and mutual aid.
Recommendations
Conduct joint regional training and
familiarization with mutual aid resources
(City of Oakland, Alameda County Fire,
Alameda County Sheriff, East Bay
Regional Park, and U.S. Coast Guard).
Develop and maintain current
understanding of the resources,
locations, and capabilities.
Recommendations
During critical incidents when life safety
is at risk and resource requests are
receiving uncertain estimated arrival
times, order multiple resources that
have a reasonable probability of
arriving. It is better to cancel those that
are not needed than to fail to have
requested them.
Recommendations
Mutual Aid resource requests should be
made through the appropriate mutual
aid channels to avoid confusion and
delays in resource ordering.
Recommendations
Eliminate the use of jargon when talking
to outside agencies or persons not
familiar with language specific to your
agency.
Recommendations
Increase the number of trained
personnel within the police department
to operate the existing personal water
craft when required for emergencies.
The equipment
is currently
underutilized.
Recommendations
Direct the police chief and fire chief to
make recommendations to the City
Manager for appropriate levels of
service to support public safety
response capabilities to water
emergencies specific to the City of
Alameda.
Recommendations
Provide an identifiable and stable
budget to support the service levels
approved by the City Council.
Recommendations
Funding should include personnel
training and certification, as well as
maintenance and replacement costs of
equipment based un rea�o�c)nable life
expectancy to ensure usefulness and
safety.
Crown Beach Review
Conclusion
Discussion and questions
Incident Timeline
11:30:08 Initial call received by
Alameda Police Dispatch person in
the water threatening suicide
11:32:29 Police units dispatched
11:32:42 Alameda Police Dispatch
calls U.S. Coast Guard for response to
person in the water (Estimated Time of
Arrival 40 min)
Incident Timeline
11:33:59 Alameda Police Dispatch
contacts Alameda County Regional
Emergency Communications Center for
Fire response
11:34:58 -First police unit arrives at
scene
11:35:00 U.S. Coast Guard opens
case 204 -11
Incident Timeline
11:35:40 Alameda Police Dispatch
request for Alameda Sheriff boat NOT
AVAILABLE
11:36:25 -Fire Medic 1 arrives on
scene
11:36:39 Police have visual of subject
(approximately 150 yards out)
11:36:59 Police lieutenant requests
that dispatch call Oakland PD for their
boat
Incident Timeline
11:37:09 Alameda Police Dispatch
calls Alameda County Regional
Emergency Communications Center for
boat status, (closest boat in San
Leandro -30 min Estimated Time of
Arrival). No request for response
made.
11:37:10 Alameda Police Dispatch
calls Oakland Police Dispatch for boat
availability (Oakland Police Dispatch
will call back)
Incident Timeline
11:37:20 Police lieutenant arrives on
scene (CAD log)
11:38:20 -Fire Engine 1 arrives on
scene
11:42:14 Alameda Police Dispatch
calls U.S. Coast Guard for updated
response time (Estimated Time of
Arrival 15 min)
Incident Timeline
11:45:06 -There W a..,a
miscommunication over the use jargon
between Alameda Fire through
Alameda County Regional Emergency
Communications Center and the U.S.
Coast Guard regarding use of the term
"rib" (RHIB vs RBS)
11:47:09 Alameda County Regional
Emergency Communications Center
advises Engine 1 that U.S. Coast Guard
RH I B is on the way
Incident Timeline
11:50:00 Kitesurfer contacts subject in
water (time approximate)
11:51:00 U.S. Coast Guard Unit
25439 crew underway, helicopter
authorized also.
11:55:00 Kitesurfer reports to police
on shore that the subject says he is
"OK" and reports that the subject does
not appear to be in distress. (time
approximate)
Incident Timeline
11:59:00 -Fire Battalion Chief arrives at
scene (time approximate)
11:59:11 Police unit on scene with
U.S. Coast Guard Commander (advises
new Estimated Time of Arrival 6 min)
12:02:29 Oakland Police advise their
boat is NOT AVAILABLE
Incident Timeline
12:05:47
Police unit
on scene
advises
that they
lost sight of
subject in
water
12:06:00 -Phone call from nearby
resident to Alameda Police Dispatch
reporting subject seen face down in
water
12:10:00 U.S. Coast Guard on scene
(unable to get close due to shallow
water)
Incident Timeline
12:11:31 Alameda battalion chief
requests Truck 1
12:15:00 U.S. Coast Guard Senior
Chief notifies Fire that U.S. Coast
Guard RBS cannot enter shallow water,
U.S. Coast Guard helicopter lifts off
from SFO after refueling.
12:17:46 -Truck 1 arrives at scene
approxi (time mate)
Incident Timeline
12:18:00 U.S. Coast Guard Senior
Chief calls Oakland Fire for shallow
water boat (at Station #12
approximately 3 miles away)
12:18:01 Alameda battalion chief
establishes "Shoreline Command"
12:19:00
-East
Bay Regional
Park
Police
has
no
boat out (in
Del
Valle
near Livermore)
Incident Timeline
12:24:40 -East Bay Regional Park Police
has a small zodiac boat (at Tidewater
in
Oakland, approximately 7 miles away)
12:25:46 Oa kland Fire Dispatch calls
Alameda County Regional Emergency
Communications Center U.S. Coast
Guard requesting shallow water boat
from Oakland Fire. Boat not requested at
this time by Alameda County Regional
Emergency Communications Center.
Incident Timeline
12:26:00 Bystander enters water to retrieve
subject's body. (40 -50 yards into water)
12:30:12 Oakland Fire Dispatch calls Alameda
County Regional Emergency Communications
Center back Alameda County Regional
Emergency Communications Center requests
they respond with their boat
12.30.51`3 Oakland Fire Station #12 dispatched
with shallow water boat Incident 31540
Incident Timeline
12:31:31 Alameda County Regional Emergency
Communications Center calls Oakland Fire
Dispatch cancels request for their response
12:31:34 U.S. Coast Guard calls Alameda
County Regional Emergency Communications
Center and advises them they are canceling their
response
12:32:53 Oakland Fire Station #12 cancels their
response
Program I istory
In 1993, the City of Alameda placed in
service a 1970, 31 fireboat. It was
bought from the U.S. Coast Guard for
one dollar.
In 2000, the City of Alameda placed in
service a 1994, 24 Rigid Hull Inflatable
Boat (RH I B) for use as a rescue boat.
It was bought from the U.S. Coast
Guard for one dollar.
In 2002, the fire department initiated a
Lifeguard /Rescue Swimmer Program.
Program I istory
On January 8, 2003, the fire department released
their Water Rescue Program Policy contained in
the Alameda Fire Department General Orders
Bulletin 1 -46. (Attachment 1)
In 2006, the police department evaluated personal
water craft (PWC) for use in their Harbor Patrol
Program. The evaluation equipment was on loan.
The equipment became a permanent part of their
program in 2008 when they received grant funding
to buy the equipment. Utilization was limited to
special events.
Program I istory
On March 5, 2007, the fire department
issued a Water Operations Program
Update (Bulletin 1672). The
department had 18 qualified rescue
swimmers, 2 instructors, and 2 boat
operators per shift. They were looking
to expand the program and plan for
replacements due to retirements.
(Attachment 2)
Program I istory
On January 22, 2008, the fire
department issued an Update on Water
Operations Program (Bulletin 1723).
There was a change in the program
manager. Fire department personnel
were updated on the future direction,
III of training with police and
coast guard, policy review, grant writing
for new vessel, designing maintenance
program, and revising qualifications.
(Attachment 3)
Program I istory
On April 17, 2008, the Rescue Boat (RHIB) was
limited to use for actual responses (Bulletin
#1733). The Rescue Boat was in need of
$45,000 in repairs. The fire chief was seeking
funding for repairs by June 2008, or would
reevaluate and discuss a service reduction with
the City Manager. Direction was given to
consider Oakland Fire Department for rapid
deployment of Inflatable Rescue Boats (IRB's)
on trailers. (Attachment 4)
Program I istory
On May 1, 2008, the Rescue Boat
(RHIB) was taken out of service
(Bulletin #1734) until funding could be
secured. Direction was given to contact
Oakland Fire Department for any water
rescue incident. Direction was also
given to contact U.S. Coast Guard,
Alameda County Sheriff, and Alameda
Police for mutual aid. (Attachment 5)
Program I istory
In June 2008, City Council adopted the
2008/2009 fiscal year budget in which
police and fire department operating
budgets were reduced by 4 Fire
depai t ment overti me was further
reduced through implementation of fire
truck company closures to reduce
callback overtime.
On November 14, 2008, notice was
given by the department that Alameda
fireboat would be taken out of service.
Program I istory
On December 16, 2008, a memo was sent from the fire
chief to the city manager recommending that the fireboat
be taken out of service and pursue grant funding for
personal water craft, similar to the police department.
The rescue boat was already out of service, and the
fireboat experiencing mechanical problems. The fire chief
estimated $60,000 was needed for each boat. Removing
both vessels from service would save $7,000 in marina
fees annually. The chief indicated the department would
continue to work with Oakland and San Francisco Fire for
mutual aid. He indicated the fire department's 2009 -2010
budget would include $15,000 for the rescue swimmer
program. (Attachment 6)
Program I istory
On January 6, 2009, the Fire Department
Resource Allocation report was on the Council
agenda regarding budget reductions. In
response to the report on Fire Department
Resource Allocation, Alameda Firefighters
Local 689 submitted a letter to City Council and
spoke at the Council meeting regarding budget
cuts, including the unfunded water rescue
program. The report was an informational
report and no Council action was required.
(Attachment 7)
Program I istory
On February 4, 2009, International
Association of Firefighters (1AFF) Local
689 filed a grievance with the fire chief
regarding placing the "Fire Boat
Program" out of service and indicated
the Alameda Fire Department is unable
to respond to emergencies on the
water. They argued that was a change
in working conditions and was a matter
subject to bargaining based on their
contract with the City. (Attachment 8)
Program I istory
On March 5, 2009, the fire chief denied
the grievance filed by IAFF Local 689
due to untimeliness of the grievance
being submitted, failure to allege issues
subject to the grievance procedure, and
the authority of the City to set standards
of service. (Attachment 9)
Program I istory
On March 9, 2009, the acting city
manager was notified by the fire chief
through e -mail of noncompliance issue
of the fire department rescue swimmers
training required for certification. The
fire chief received approval to use
$10,000 overtime from his existing
budget, provided he does not go over
the department's current budget.
(Attachment 10)
Program I istory
On March 16, 2009, the Water Rescue Swimmers
Program was placed on hold (Bulletin 1762) and a
policy implemented that, "Previously qualified rescue
swimmers shall not enter the water." No documented
rescue swimmer training had occurred for over 12
months. The department's training standard required
24 hours training annually to maintain certification.
Refresher training and recertification was going to be
scheduled in the next 30 to 45 days. If water rescue
incident occurs, incident commanders should request
appropriate resources such as Coast Guard, Alameda
County Fire, or Oakland Fire. (Attachment 11)
Program I istory
On May 28, 2009, The acting city
manager upheld the fire chief's denial of
the grievance filed by IAFF Local 689
after an appeals hearing on May 20,
2009, effectively ending the water
rescue program. (Attachment 12)