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Garling Report Final

Garling Report Final

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Published by KING 5 News
Garling report final
Garling report final

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Published by: KING 5 News on Feb 26, 2014
Copyright:Attribution Non-commercial


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February 19, 2014 Chuck Duffy, State Fire Marshal Washington State Patrol PO Box 42600 Olympia, WA 98504-2600 State Fire Marshal Duffy: This document is my summary of the after action investigation into the incident that occurred on October 25
, 2013 at the Fire Training Academy aircraft rescue and firefighting (AARF) prop. I appreciate the opportunity to assist your office in this investigation. In my role as a Battalion Chief for my department, and over my twenty nine year career, I have been involved with after action reviews in various roles. During my time as Training Chief for my department I was responsible for researching and conducting after action reviews. The scope of this investigation centered primarily on the actions of the crews while engaged in AARF training on October 25
. Introduction: In 1997 a consortium of aircraft firefighting agencies entered into an agreement with the state of Washington for the development, management, and use of an aircraft rescue and firefighting (ARFF) training facility located adjacent to the Washington State Fire Training Academy (WSFTA) at North Bend. The facility has been used on an annual basis since that time. The inter-local agreement signed by all parties identifies the State, through the lead agency of the Washington State Patrol (WSP) as responsible for maintenance, scheduling, and instructor development among other responsibilities.
As part of this agreement training props were installed and an engineered water and fuel recovery system was put into place to recycle the water while removing the fuel from the waste water. It is important to note that this system is independent of the water/fuel recovery system co-located at the fire training academy. Maintaining the ARFF prop has been the responsibility of the staff of the WSFTA. Since the props became operational there has been a total change over in maintenance personnel. From 1997 until 2010 the maintenance supervisor was Tracy Caldwell. The new maintenance supervisor is Mika Elo assisted by Levi Scartozzi. Elo was hired after Caldwell left and Elo has limited experience with maintenance of the ARFF prop. P
er Scartozzi’s interview he was primaril
y responsible for minor repairs while Caldwell was employed but took over a larger
role in the maintenance of the prop after Caldwell’s departure and before Elo’s
hiring. Scartozzi was instructed by Caldwell on procedures for operating the water/fuel recovery system. The scope of this investigation did not include what role this change in personnel may have had in the events that occurred in October of 2013 but there appears to be a loss of institutional knowledge after Caldwell left as well as a change in procedures. Background: The training that occurred on October 25
 was part of ongoing annual training being primarily conducted by the Port of Seattle Fire Department (POSFD) in 2013. During prior training dates there were issues of non-standard events identified by the POSFD personnel in their statements. These issues are listed associated on the dates below. October 14th After an initial routine morning of training the ARFF prop experienced an ignition failure. The maintenance staff was notified and after attempts were made to fix the issue, which was unsuccessful, training was completed using an alternative ignition method. As part of the attempt to test the ability of the prop to self-ignite a quantity of fuel was flowed that was not ignited.
 October 21
 After several training evolutions were held it was observed that there was a black sludge coming out of the hydrants being used by the crews to re-fill the crash trucks. According to the statement of Todd Starkey, a Captain with the POSFD and longtime state certified prop operator who was present, this occurrence had not been seen in the past and after a brief discussion with academy maintenance staff it was decided to halt training for the day and the water/sludge that was in the crash trucks was ordered to be processed back into the prop for recycling. Since the POSFD was going to conduct additional training in four days (October 25
) Starkey stressed to Levi Scartozzi of the academy maintenance staff that the hydrant system needed to be flushed prior to the training on the 10/25. Captain Starkey talked to Scartozzi and was assured that system would be flushed prior to that training. Prior to the 10/25 training a phone call to ARFF Training Director Rich Galtieri was made to ensure that the hydrant system was flushed and everything was operational for the training on October 25
. Galtieri confirmed that the hydrant system was flushed. With that information it was decided to hold the training on 10/25. It is unknown who Galtieri checked with to determine if the hydrants had been flushed. October 25
 At approximately 0730 Shane Hughes, William Catlow, and Starkey entered the pump house building to turn on pumps. Hughes is part of the full time staff at the academy and Catlow was the state ARFF instructor for the day. They found what they described as a large amount of fuel rich water on the floor of the building as well as a strong fuel smell inside the building. The water/fuel separator was still in operation. Hughes phoned Mika Elo, the maintenance supervisor for the academy, and Elo advised Hughes how to shut down the separator.

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